22.2 Complications of Cirrhosis: Alcohol-Associated Hepatitis, Hepatorenal Syndrome & Pulmonary Vascular Syndromes

ABIM Critical Care Medicine Study Guide Exam

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1 Chapter 1: Exam Orientation: Format, Blueprint & Study Strategy

1.1 ABIM Critical Care Medicine Exam: Format, Blueprint & Study Strategy

2 Chapter 2: Acute Respiratory Failure & ARDS

2.1 ARDS Definition, Pathophysiology & Phenotypes 2.2 Lung-Protective Mechanical Ventilation 2.3 Refractory ARDS: Prone Positioning, Neuromuscular Blockade & VV-ECMO

3 Chapter 3: Obstructive Airways, Pulmonary Vascular & Pleural Emergencies

3.1 Severe Asthma & COPD Exacerbations in the ICU 3.2 Massive & Submassive Pulmonary Embolism 3.3 Pulmonary Hypertension & Right Ventricular Failure in the ICU 3.4 Massive Hemoptysis, Complex Pleural Effusions & Thoracic Drainage

4 Chapter 4: Airway, Parenchymal & Nonthrombotic Pulmonary Emergencies

4.1 Airway Management, Upper-Airway Obstruction & Artificial-Airway Complications 4.2 Diffuse Alveolar Hemorrhage, Interstitial Lung Disease, Pulmonary Vasculitis & Noncardiogenic Edema 4.3 Severe Community-Acquired & Viral Pneumonia 4.4 Nonthrombotic Embolism (Air, Fat, Amniotic Fluid, Tumor, Septic) & Acute Chest Syndrome

5 Chapter 5: Mechanical Ventilation Modes, Dyssynchrony & Liberation

5.1 Mechanical Ventilator Modes & Advanced Breath Delivery 5.2 Patient-Ventilator Dyssynchrony & Waveform Analysis 5.3 Ventilator Liberation, Spontaneous Breathing Trials & Post-Extubation Support

6 Chapter 6: Shock Syndromes & Hemodynamic Principles

6.1 Shock Classification, Cellular Pathophysiology & Biomarkers 6.2 Hemodynamic Monitoring: Arterial Lines, CVP & Pulmonary Artery Catheter 6.3 Dynamic Assessment of Fluid Responsiveness & Resuscitation Targets

7 Chapter 7: Vasoactive Therapies & Mechanical Circulatory Support

7.1 Vasopressors & Inotropes: Pharmacology & Clinical Titration 7.2 Temporary Mechanical Circulatory Support: IABP, Impella & TandemHeart 7.3 Venoarterial ECMO (VA-ECMO) & Differential Hypoxemia 7.4 Post-Cardiac Arrest Care, Targeted Temperature Management & Neuroprognostication

8 Chapter 8: Acute Kidney Injury & Renal Replacement Therapy

8.1 KDIGO AKI Classification, Etiologies & Diagnostic Evaluation 8.2 Continuous Renal Replacement Therapy (CRRT) vs Intermittent Hemodialysis 8.3 Indications & Timing for RRT in Critical Illness: AKIKI & STARRT-AKI

9 Chapter 9: Electrolyte, Acid-Base & Endocrine Emergencies

9.1 Severe Dysnatremias: Hyponatremia, Hypernatremia & Osmotic Demyelination 9.2 Potassium, Calcium, Magnesium & Phosphate Disorders 9.3 Complex & Mixed Acid-Base Disorders: Boston vs Copenhagen vs Stewart 9.4 Endocrine Crises: DKA, HHS, Thyroid Storm, Myxedema Coma & Adrenal Crisis

10 Chapter 10: Glycemic Control, Hyperammonemia, Pituitary & Adrenal Disorders

10.1 ICU Glycemic Control & Severe Hypoglycemia 10.2 Non-Hepatic Hyperammonemia & Metabolic Encephalopathy 10.3 Pituitary Emergencies, Adrenal Excess & Critical Illness-Related Corticosteroid Insufficiency

11 Chapter 11: Acute Coronary Syndromes & Cardiac Arrhythmias

11.1 Acute Coronary Syndromes & Mechanical Complications of Myocardial Infarction 11.2 Critical Tachyarrhythmias: Atrial Fibrillation with RVR, VT & VF 11.3 Critical Bradyarrhythmias, Conduction Blocks & Temporary Cardiac Pacing

12 Chapter 12: Acute Heart Failure, Valvular & Pericardial Emergencies

12.1 Acute Decompensated Heart Failure & Cardiogenic Pulmonary Edema 12.2 Acute Valvular Regurgitation & Prosthetic Valve Emergencies 12.3 Pericardial Tamponade & Acute Aortic Syndromes

13 Chapter 13: Myocardial Disease, Hypertensive & Cardiac Device Emergencies

13.1 Fulminant Myocarditis, Stress & Peripartum Cardiomyopathy, and Hypertrophic Cardiomyopathy 13.2 Hypertensive Emergencies & Ruptured Abdominal Aortic Aneurysm 13.3 Implanted Cardiac Devices, LVAD Emergencies & Electrical Storm

14 Chapter 14: Sepsis & Systemic Infectious Diseases

14.1 Sepsis-3 Definitions & Surviving Sepsis Campaign 2026 Guidelines 14.2 Refractory Septic Shock & Adjunctive Therapies 14.3 Multidrug-Resistant Pathogens & Antimicrobial Stewardship in the ICU

15 Chapter 15: ICU-Acquired & Severe Focal Infections

15.1 Hospital-Acquired & Ventilator-Associated Pneumonia 15.2 Central Line-Associated Bloodstream Infections & Catheter-Associated UTIs 15.3 Intra-Abdominal Sepsis, Necrotizing Soft Tissue Infections & CNS Infections

16 Chapter 16: Focal, Special-Host & Systemic Infections

16.1 CNS Infections Beyond Bacterial Meningitis: Encephalitis, Brain Abscess & Epidural Abscess 16.2 Infections in the Immunocompromised Host, Tropical & Bioterror Infections 16.3 Infective Endocarditis, Device Infections & Other Focal Cardiovascular Infections 16.4 Antimicrobial Pharmacokinetics, Allergy, Toxicity & Infection Prevention 16.5 Gastrointestinal & Hepatobiliary Infections: Fulminant C. difficile, Typhlitis, CMV Colitis & Abscesses

17 Chapter 17: Neurocritical Care & Coma

17.1 Coma, Altered Mental Status & Acute Delirium in the ICU 17.2 Status Epilepticus & Non-Convulsive Status Epilepticus 17.3 Acute Ischemic Stroke & Intracranial Hemorrhage

18 Chapter 18: Cerebrovascular Syndromes, Encephalopathy & Withdrawal States

18.1 Cerebral Venous Sinus Thrombosis, PRES & Reversible Cerebral Vasoconstriction Syndrome 18.2 Alcohol & Sedative Withdrawal, Wernicke Encephalopathy & Drug-Induced Encephalopathy

19 Chapter 19: Intracranial Hypertension & Neuromuscular Weakness

19.1 Intracranial Pressure Monitoring, Cerebral Perfusion & Tiered ICP Management 19.2 Acute Neuromuscular Respiratory Failure, ICU-Acquired Weakness & Brain Death Determination

20 Chapter 20: Traumatic Brain Injury, Spinal Cord Injury & Toxin-Mediated Paralysis

20.1 Traumatic Brain Injury Management & Paroxysmal Sympathetic Hyperactivity 20.2 Acute Spinal Cord Injury, Neurogenic Shock & Autonomic Dysreflexia 20.3 Toxin-Mediated Paralysis & Neuromuscular Crises: Botulism, Tetanus, Tick Paralysis & Myasthenic Crisis

21 Chapter 21: Gastrointestinal, Hepatic & Abdominal Emergencies

21.1 Acute Upper & Lower Gastrointestinal Bleeding in the ICU 21.2 Acute Liver Failure & Severe Acute Pancreatitis 21.3 Abdominal Compartment Syndrome & Acute Mesenteric Ischemia

22 Chapter 22: Luminal GI Emergencies & Complications of Cirrhosis

22.1 Esophageal, Gastric & Bowel Emergencies: Perforation, Obstruction, Ogilvie Syndrome & Colonic Ischemia 22.2 Complications of Cirrhosis: Alcohol-Associated Hepatitis, Hepatorenal Syndrome & Pulmonary Vascular Syndromes

23 Chapter 23: Trauma, Burns & Perioperative Critical Care

23.1 Polytrauma Resuscitation, Damage Control & Massive Transfusion 23.2 Severe Burn Injury, Inhalation Injury & Environmental Emergencies 23.3 Perioperative Critical Care for High-Risk Surgical Patients

24 Chapter 24: Thoracic Trauma, Environmental Injury & Obstetric Critical Care

24.1 Thoracic Trauma: Flail Chest, Pulmonary Contusion, Great Vessel & Tracheobronchial Injury 24.2 Environmental Injury: Drowning, Diving, Altitude, Heat, Cold, Electrical & Radiation 24.3 Obstetric & Genitourinary Emergencies and the Physiology of Pregnancy

25 Chapter 25: Transplantation, Donor Management & Post-Cardiac Surgery Care

25.1 Solid Organ Transplant Recipients & Deceased Donor Management 25.2 Post-Cardiac Surgery Critical Care: Bleeding, Tamponade, Low Output & Vasoplegia

26 Chapter 26: Hematologic Emergencies, Toxicology, Critical Ultrasound & ICU Liberation

26.1 Hematologic Emergencies in the ICU: HIT, DIC, TMA & Anticoagulant Reversal 26.2 Critical Care Toxicology, Toxidromes & Specific Antidotes 26.3 Critical Care Point-of-Care Ultrasound (POCUS) 26.4 ICU Liberation, Analgosedation, Goals of Care & Critical Care Ethics

27 Chapter 27: Transfusion Medicine, Hematologic & Oncologic Disorders

27.1 Transfusion Medicine: Products, Thresholds, Reactions & Apheresis 27.2 Red and White Cell Disorders, Hemoglobinopathies, Factor Deficiencies & Hypercoagulable States 27.3 Oncologic Emergencies, Hematopoietic Cell Transplant Complications & Cellular Therapy Toxicity

28 Chapter 28: Clinical Pharmacology, Adverse Drug Reactions & Specific Poisonings

28.1 Pharmacokinetic Principles, Dose Adjustment & Drug Interactions in Critical Illness 28.2 Adverse Drug Reactions: Anaphylaxis, Severe Cutaneous Reactions & Hyperthermic Syndromes 28.3 Specific Poisonings: Sodium-Channel Blockers, Lithium, Valproate, Theophylline, Iron, Sulfonylureas & Methemoglobinemia

29 Chapter 29: Ethics, Research Methods, Administration & Abdominal Ultrasound

29.1 Advance Care Planning, Nonbeneficial Treatment, Informed Consent & Confidentiality 29.2 Critical Care Research Methods, Statistics, IRB Oversight & Quality Improvement 29.3 Abdominal, Vascular & Procedural Point-of-Care Ultrasound

22.2 Complications of Cirrhosis: Alcohol-Associated Hepatitis, Hepatorenal Syndrome & Pulmonary Vascular Syndromes

Key Takeaways Explain This Topic AI

A Maddrey discriminant function of 32 or more defines severe alcohol-associated hepatitis and is the threshold for corticosteroid therapy with prednisolone 40 mg daily.

A Lille score above 0.45 after 7 days of corticosteroids indicates non-response, and steroids should be stopped.

In the CONFIRM trial, terlipressin improved reversal of hepatorenal syndrome compared with placebo but caused more respiratory failure, so volume status must be assessed carefully.

Hepatopulmonary syndrome causes intrapulmonary vascular dilatation with orthodeoxia and platypnea, and liver transplantation is the only definitive treatment.

Portopulmonary hypertension with a mean pulmonary artery pressure of 35 mmHg or more requires treatment before transplantation because perioperative mortality is high.

Last updated: October 2026

Alcohol-Associated Hepatitis

Presentation : jaundice developing over weeks in a patient with heavy recent alcohol use, with tender hepatomegaly, fever, leukocytosis, AST above ALT (usually with AST below 400 U/L), and a rising bilirubin and INR.

Severity scores :

Maddrey discriminant function = 4.6 × ( patient PT − control PT ) + total bilirubin (mg/dL) = 4.6 \times (\text{patient PT} - \text{control PT}) + \text{total bilirubin (mg/dL)} = 4.6 × ( patient PT − control PT ) + total bilirubin (mg/dL) . A value of 32 or more indicates severe disease with high short-term mortality.

MELD and the Glasgow alcoholic hepatitis score are alternatives.

Treatment :

Prednisolone 40 mg daily for 28 days (prednisolone rather than prednisone, which requires hepatic conversion) for severe disease without contraindications. In the STOPAH trial, prednisolone showed a borderline 28-day mortality benefit without longer-term benefit, and pentoxifylline did not help .

Assess response at day 7 with the Lille score : a value above 0.45 indicates non-response, and steroids are stopped to limit infection risk.

Contraindications or cautions : uncontrolled infection, active gastrointestinal bleeding, acute kidney injury, and multiorgan failure.

Infection surveillance is essential: these patients have impaired immunity, and steroids add risk.

Nutrition : aggressive enteral nutrition, thiamine and other vitamins, and treatment of alcohol withdrawal.

N-acetylcysteine combined with steroids has shown benefit in some trials.

Early liver transplantation in carefully selected patients with a first episode and good psychosocial support produces survival far better than medical therapy; fixed abstinence intervals are no longer universally required.

Mimics to exclude : acetaminophen injury, ischemic hepatitis, biliary obstruction, drug-induced liver injury, and Budd-Chiari syndrome.

Hepatorenal Syndrome-AKI

Concept : splanchnic vasodilation reduces effective arterial volume, which activates the renin-angiotensin and sympathetic systems and constricts the renal circulation. The kidneys are structurally normal.

Diagnosis (current terminology): acute kidney injury in cirrhosis with ascites, no improvement after withdrawal of diuretics and volume expansion with albumin (1 g/kg daily for 2 days) , absence of shock, no recent nephrotoxins, and no evidence of structural kidney disease (no significant proteinuria, hematuria, or abnormal renal ultrasound).

Differential : hypovolemia from diuresis, lactulose-induced losses or bleeding (responds to volume), acute tubular necrosis (often with granular casts and a higher urine sodium), abdominal compartment syndrome, and glomerular disease (IgA nephropathy in cirrhosis, hepatitis-associated nephropathy).

Treatment :

Vasoconstrictor plus albumin :

Terlipressin plus albumin is the most effective option. In CONFIRM , terlipressin improved reversal of hepatorenal syndrome compared with placebo, but respiratory failure was more common , so avoid it in patients with hypoxemia or volume overload and monitor closely.

Norepinephrine plus albumin in the ICU is an effective alternative requiring central access.

Midodrine with octreotide and albumin is a weaker outpatient option.

Treat precipitants: spontaneous bacterial peritonitis (with albumin), bleeding, and overdiuresis.

Avoid NSAIDs, aminoglycosides, and contrast when possible, and reconsider beta-blockers in severe circulatory dysfunction.

Kidney replacement therapy as a bridge in transplant candidates; TIPS in selected patients.

Liver transplantation is the definitive therapy; combined liver-kidney transplantation is considered with prolonged dialysis dependence.

Other Complications of Portal Hypertension

Complication Key features Management

Hepatic encephalopathy Precipitated by infection, bleeding, constipation, dehydration, hypokalemia, sedatives, and TIPS Treat the precipitant, lactulose, rifaximin; avoid protein restriction; intubate for airway protection in grade 3 or 4

Refractory ascites Needs repeated paracentesis Large-volume paracentesis with albumin (6 to 8 g per liter removed above 5 liters), TIPS in suitable patients, consider transplantation

Hepatic hydrothorax Usually right-sided; can cause respiratory failure Sodium restriction and diuretics, thoracentesis, TIPS; avoid chest tubes , which cause protein and fluid loss and infection

Hepatopulmonary syndrome Hypoxemia with an elevated alveolar-arterial gradient from intrapulmonary vascular dilatation ; platypnea and orthodeoxia (desaturation when upright); positive contrast echocardiography with late left atrial opacification Oxygen; liver transplantation is the only definitive treatment , and severe hypoxemia gives MELD exception points

Portopulmonary hypertension Pulmonary arterial hypertension with portal hypertension: a mean pulmonary artery pressure above 20 mmHg with a pulmonary vascular resistance above 2 Wood units and a wedge pressure of 15 mmHg or less (2022 ESC/ERS definition) Pulmonary vasodilators (phosphodiesterase-5 inhibitors, endothelin antagonists, prostacyclins); a mean pressure of 35 mmHg or more or high resistance carries prohibitive transplant risk until treated

Cirrhotic cardiomyopathy Blunted contractile response to stress, diastolic dysfunction, QT prolongation Recognized when a patient fails to respond to vasopressors or decompensates after TIPS or transplant

Budd-Chiari syndrome Hepatic venous outflow obstruction: ascites, painful hepatomegaly, often with myeloproliferative neoplasm (JAK2) or antiphospholipid syndrome Anticoagulation , treat the underlying thrombophilia, angioplasty or stenting, TIPS, then transplantation; the caudate lobe is spared and hypertrophies

Ischemic hepatitis ("shock liver") Transaminases in the thousands after hypotension, resolving within days; LDH rises in parallel Restore perfusion; the liver injury itself is not treated

Acute-on-chronic liver failure Organ failures with high short-term mortality, graded by CLIF-C scores Organ support, treat precipitants, early transplant assessment, and timely goals-of-care discussion when futility becomes clear

Severe Pancreatitis Variants Worth Separating

Hypertriglyceridemia-induced pancreatitis : suspect it when triglycerides exceed 1,000 mg/dL. Treat with nil by mouth, an insulin infusion (which activates lipoprotein lipase) with dextrose to prevent hypoglycemia, fibrates once enteral intake resumes, and plasmapheresis in severe or refractory cases. Note that marked hypertriglyceridemia can cause spuriously low sodium and amylase measurements.

Gallstone pancreatitis : urgent ERCP within 24 hours only for concurrent cholangitis or persistent biliary obstruction; otherwise early cholecystectomy during the same admission for mild disease.

Drug-induced pancreatitis : azathioprine, valproate, didanosine, GLP-1 receptor agonists, and others.

Fluid strategy : the WATERFALL trial found that aggressive fluid resuscitation caused more fluid overload without benefit compared with moderate resuscitation, so moderate goal-directed fluids are now preferred.