Hepatic encephalopathy and advanced transplant psychiatry — structured clinical viva

Station A — HE mislabeled as primary bipolar. Open with safety and medical ownership: this is type C HE until proven otherwise — asterixis, fluctuation, cirrhosis context. Grade using West Haven language; list precipitants including the benzodiazepine just given; stop unnecessary sedatives; lactulose pathway; consider rifaximin if this is recurrent disease after remission.^[1][2][3] Ammonia is supportive only. Capacity: decision-specific; reassess when lucid; emergency necessity if incapacity and serious harm.^[6] If valproate appears on the chart with rising ammonia, treat as possible VPA hyperammonaemic encephalopathy and stop VPA.^[7] Do not launch a lifelong bipolar label from a single organic episode.

Station B — Listing MDT. Role clarity: psychiatry contributes structured risk and optimisation, not unilateral veto theatre. Use SIPAT/ISHLT-style domains: psychopathology (depression treatment, suicide risk), substance recovery engagement and monitoring, social support, adherence (DNA pattern as modifiable signal), readiness/health literacy, and capacity for transplant consent after material disclosure.^[4][6] Cite Dew: depression/anxiety associate with worse post-transplant outcomes — treat as modifiable medical risk.^[5] Absolute vs relative barriers are programme-defined; do not invent a universal six-month abstinence statute; Mathurin early LT for select severe AH is the classic counter-example that selection, not slogans, matter.^[8] Communication script: domains assessed, optimisations underway, residual risks, monitoring plan, timestamped capacity statement — never “psych clear.”