3.7 Cirrhosis & the Complications of Portal Hypertension

ABIM Internal Medicine Exam

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2 Chapter 1: Cardiovascular Disease (14% of Exam)

1.1 Ischemic Heart Disease & Acute Coronary Syndromes 1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI 1.3 Atrial Fibrillation, Atrial Flutter & Stroke Prevention 1.4 Supraventricular Tachycardias, Ventricular Arrhythmias & Bradycardias 1.5 Heart Failure: Classification, Staging & Guideline-Directed Medical Therapy 1.6 Device Therapy, HFpEF & the Cardiomyopathies 1.7 Valvular Heart Disease & Endocarditis Prophylaxis 1.8 Pericardial Disease & Acute Aortic Syndromes 1.9 Hypertension: Classification, Diagnosis & Secondary Causes 1.10 Hypertensive Crises & Dyslipidemia 1.11 Adult Congenital Heart Disease & Coarctation of the Aorta 1.12 Syncope: Reflex, Orthostatic & Cardiac Causes 1.13 Cardiac Physical Examination, Murmurs & Antithrombotic Selection

3 Chapter 2: Endocrinology, Diabetes & Metabolism (9% of Exam)

2.1 Diabetes Mellitus: Diagnosis, Glycemic Targets & Pharmacotherapy 2.2 Insulin Therapy, Hyperglycemic Emergencies & Chronic Complications 2.3 Thyroid Function Testing & Hypothyroidism 2.4 Thyrotoxicosis, Thyroid Storm & Thyroid Nodules 2.5 Adrenal & Pituitary Disorders 2.6 Hypercalcemia, Hypocalcemia & Disorders of Mineral Metabolism 2.7 Osteoporosis & Paget Disease of Bone 2.8 Ovarian, Testicular & Reproductive Endocrine Disorders 2.9 Hypoglycemia, Endocrine Tumors, Polyglandular Syndromes & Severe Hypertriglyceridemia

4 Chapter 3: Gastroenterology & Hepatology (9% of Exam)

3.1 Esophageal Disease 3.2 Stomach & Duodenal Disease and Gastrointestinal Hemorrhage 3.3 Inflammatory Bowel Disease 3.4 Celiac Disease & Irritable Bowel Syndrome 3.5 Diverticular Disease & Colorectal Cancer Screening 3.6 Viral Hepatitis, Steatotic & Alcohol-Associated Liver Disease 3.7 Cirrhosis & the Complications of Portal Hypertension 3.8 Acute Pancreatitis 3.9 Chronic Pancreatitis & Biliary Tract Disease 3.10 Inherited, Autoimmune & Drug-Induced Liver Disease 3.11 Small Intestinal Disease, Ischemia & Gastrointestinal Complications of HIV

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7.1 Approach to Anemia & the Microcytic Anemias 7.2 Macrocytic, Normocytic & Hemolytic Anemias 7.3 Hemoglobinopathies, Thalassemias & Paroxysmal Nocturnal Hemoglobinuria 7.4 Platelet Disorders, Thrombocytopenia & the Bleeding Patient 7.5 Coagulation Factor Disorders, Thrombophilia & Anticoagulant Reversal 7.6 Acute Leukemias, Chronic Leukemias & Myeloproliferative Neoplasms 7.7 Lymphomas & Plasma Cell Disorders 7.8 Myelodysplastic Syndrome, Myeloproliferative Neoplasms & Porphyria 7.9 Transfusion Medicine & Late Complications of Transplantation

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10 Chapter 9: Nephrology & Urology (6% of Exam)

9.1 Acute Kidney Injury: Staging, Etiology & Urine Microscopy 9.2 Glomerular Disorders & Nephrotic Syndrome 9.3 Nephritic Syndromes, RPGN & Indications for Renal Replacement Therapy 9.4 Chronic Kidney Disease: Staging & Progression Retardation 9.5 Complications of Chronic Kidney Disease: Anemia, CKD-MBD & Acidosis 9.6 Hyponatremia, Hypernatremia & Water Balance 9.7 Potassium Disorders & Systematic Acid-Base Analysis 9.8 Renal Tubular Acidosis & Nephrolithiasis 9.9 Prostate Disorders, Urinary Incontinence & Other Urologic Conditions 9.10 Cystic Kidney Disease, Obstructive Uropathy, Tubulointerstitial Disease & Hematuria

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13.1 Contraception, Preconception Care & Teratogenicity 13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes 13.3 Thyroid Disease & Venous Thromboembolism in Pregnancy 13.4 Menopause & Menopausal Hormone Therapy 13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening 13.6 Breast Disorders & Diseases of the Vulva and Vagina 13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications

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16 Chapter 15: Allergy & Immunology (2% of Exam)

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19 Chapter 18: Perioperative Medicine & Medical Consultation

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20 Chapter 19: Ophthalmology (1% of Exam)

19.1 The Acute Red Eye & Ophthalmic Emergencies 19.2 Painless Vision Loss & Chronic Ophthalmic Disease 19.3 Uveitis, Scleritis & Orbital Disease

21 Chapter 20: Otolaryngology & Dental Medicine (1% of Exam)

20.1 Dizziness, Vertigo & Epistaxis 20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections 20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders

3.7 Cirrhosis & the Complications of Portal Hypertension

Key Takeaways Explain This Topic AI

Cirrhosis, hepatocellular carcinoma screening, hepatic vein thrombosis, fulminant liver failure and liver transplantation are all enumerated liver disease topics.

A serum-ascites albumin gradient of 1.1 g/dL or greater establishes portal hypertension as the cause of ascites.

Spontaneous bacterial peritonitis is diagnosed by an ascitic polymorphonuclear count of at least 250 cells per microliter and is treated with a third-generation cephalosporin plus albumin.

Albumin infusion in spontaneous bacterial peritonitis reduces hepatorenal syndrome and mortality and is not optional supportive care.

Hepatocellular carcinoma surveillance with abdominal ultrasound every six months continues in cirrhotic patients even after hepatitis C is cured.

Last updated: August 2026

• 1. Cirrhosis & Complications of Portal Hypertension
• Diagnostic Paracentesis & Ascites Evaluation

Every patient with new-onset ascites or cirrhosis admitted with clinical deterioration must undergo diagnostic paracentesis .

Serum-Ascites Albumin Gradient (SAAG): SAAG = Serum Albumin (g/dL) − Ascitic Fluid Albumin (g/dL) \text{SAAG} = \text{Serum Albumin (g/dL)} - \text{Ascitic Fluid Albumin (g/dL)} SAAG = Serum Albumin (g/dL) − Ascitic Fluid Albumin (g/dL)

SAAG ≥ 1.1 g/dL \ge 1.1\text{ g/dL} ≥ 1.1 g/dL (High Gradient → \rightarrow → Portal Hypertension Present):

Ascitic Protein < 2.5 g/dL < 2.5\text{ g/dL} < 2.5 g/dL : Cirrhosis (~80% of cases), late Budd-Chiari syndrome.

Ascitic Protein ≥ 2.5 g/dL \ge 2.5\text{ g/dL} ≥ 2.5 g/dL : Heart Failure (Cardiac Ascites) , Constrictive Pericarditis, early Budd-Chiari, Sinusoidal Obstruction Syndrome.

SAAG < 1.1 g/dL < 1.1\text{ g/dL} < 1.1 g/dL (Low Gradient → \rightarrow → Normal Portal Pressure / Peritoneal Disease):

Peritoneal Carcinomatosis (positive cytology), Peritoneal Tuberculosis (elevated Adenosine Deaminase [ADA]), Pancreatic Ascites (ascitic amylase > 1 , 000 U/L >1,000\text{ U/L} > 1 , 000 U/L ), Nephrotic Syndrome.

Spontaneous Bacterial Peritonitis (SBP)

Diagnostic Criterion: Ascitic fluid Absolute Polymorphonuclear (PMN) Count ≥ 250 cells/mm 3 \ge 250\text{ cells/mm}^3 ≥ 250 cells/mm 3 (calculated as Total WBC × % neutrophils \text{Total WBC} \times \%\text{ neutrophils} Total WBC × % neutrophils ).

Bacteriology: Monomicrobial infection, most commonly enteric gram-negative bacilli ( Escherichia coli , Klebsiella pneumoniae ) or Streptococcus pneumoniae .

Treatment Protocol:

IV Antibiotic: Empiric IV 3rd-generation cephalosporin (Ceftriaxone 2 g IV daily or Cefotaxime 2 g IV q8h) for 5 to 7 days .

IV Albumin Infusion (Mandatory): Proven to reduce the incidence of hepatorenal syndrome from 30% to 10% and significantly reduce in-hospital mortality. Administer 1.5 g/kg 1.5\text{ g/kg} 1.5 g/kg IV within 6 hours of diagnosis (Day 1) , followed by 1.0 g/kg 1.0\text{ g/kg} 1.0 g/kg IV on Day 3 .

Secondary Prophylaxis: Indefinite oral antibiotic prophylaxis ( Ciprofloxacin 500 mg daily or TMP-SMX 1 DS daily ) following recovery from an index episode of SBP until liver transplantation.

Gastroesophageal Variceal Hemorrhage Screening EGD at Cirrhosis Diagnosis ➔ Small/Medium/Large Varices Identified

Primary Prophylaxis: Non-Selective Beta-Blocker (Nadolol / Propranolol / Carvedilol) OR Endoscopic Variceal Ligation (EVL)

Acute Variceal Bleed Emergency Protocol

Hemodynamic Resuscitation: Restrictive transfusion threshold targeting Hb 7.0 − 8.0 g/dL \text{Hb } 7.0-8.0\text{ g/dL} Hb 7.0 − 8.0 g/dL .

Vasoactive Infusion: IV Octreotide ( 50 μ g 50\;\mu\text{g} 50 μ g IV bolus followed by 50 μ g/hr 50\;\mu\text{g/hr} 50 μ g/hr continuous IV infusion for 2 to 5 days ) to induce selective splanchnic vasoconstriction and decrease portal inflow pressure.

Prophylactic Antibiotics (Mandatory): IV Ceftriaxone 1 g daily for up to 7 days (reduces bacteremia, rebleeding rates, and overall mortality).

Urgent Endoscopy: EGD within 12 hours of presentation with Endoscopic Variceal Ligation (EVL / Banding) .

Refractory / High-Risk Bleeding: Preemptive Transjugular Intrahepatic Portosystemic Shunt (TIPS) within 72 hours for high-risk patients (Child-Pugh C score 10–13 or Child-Pugh B with active spurting bleeding). Balloon tamponade (Sengstaken-Blakemore tube) as temporary bridge ( < 24 hours <24\text{ hours} < 24 hours ) if uncontrollable.

Hepatic Encephalopathy (HE)

Pathophysiology: Neuropsychiatric syndrome caused by neurotoxin (ammonia) accumulation and portosystemic shunting.

Precipitating Triggers (Must Identify and Treat):

Gastrointestinal bleeding (increased protein load in gut lumen).

Infection (SBP, UTI, pneumonia, bacteremia).

Electrolyte derangements (hypokalemia, metabolic alkalosis, hyponatremia; hypokalemia increases renal ammonia production).

Constipation , dehydration/overdiuresis, sedatives/opioids, or TIPS placement.

Medical Therapy:

First-Line: Lactulose (non-absorbable disaccharide converted by gut flora into lactic/acetic acid, trapping ammonia as unabsorbable ammonium NH 4 + \text{NH}_4^+ NH 4 + ​ ). Administer 20–30 g PO TID–QID, titrated to achieve 2 to 3 soft bowel movements per day .

Second-Line / Add-On: Rifaximin 550 mg PO BID (non-absorbable antibiotic targeting urease-producing gut bacteria; added after a second breakthrough episode of HE while on lactulose).

Hepatorenal Syndrome (HRS-AKI)

Pathophysiology: Extreme splanchnic arterial vasodilation mediated by nitric oxide, leading to profound renal arterial vasoconstriction, hypoperfusion, and functional renal failure.

Diagnostic Criteria (ICA 2015):

Cirrhosis with ascites.

Acute Kidney Injury (KDIGO criteria: increase in Cr ≥ 0.3 mg/dL \text{Cr} \ge 0.3\text{ mg/dL} Cr ≥ 0.3 mg/dL within 48h or ≥ 50 % \ge 50\% ≥ 50% from baseline).

No response after at least 48 hours of diuretic withdrawal and IV albumin volume expansion ( 1 g/kg/day 1\text{ g/kg/day} 1 g/kg/day , max 100 g/day) .

Absence of shock, nephrotoxic medications, and intrinsic renal parenchymal disease (proteinuria < 500 mg/day <500\text{ mg/day} < 500 mg/day , microhematuria < 50 RBCs/HPF <50\text{ RBCs/HPF} < 50 RBCs/HPF , normal renal ultrasound).

First-Line Pharmacotherapy: Terlipressin (vasopressin V1a receptor agonist, 0.85–1.7 mg IV q6h) combined with IV Albumin (20–40 g/day). (Alternative: IV Norepinephrine infusion + Albumin in ICU, or oral Midodrine + subcutaneous Octreotide + Albumin).

Definitive Treatment: Orthotopic Liver Transplantation (OLT) .

Hepatocellular Carcinoma (HCC) Surveillance & MELD-Na

Surveillance Protocol: Abdominal Ultrasound with or without Alpha-Fetoprotein (AFP) every 6 months in all patients with cirrhosis (regardless of etiology) and in high-risk non-cirrhotic chronic HBV carriers.

Diagnostic Imaging (LI-RADS Criteria): If a nodule ≥ 1 cm \ge 1\text{ cm} ≥ 1 cm is detected on ultrasound, proceed to Multiphasic Contrast-Enhanced CT or MRI . The classic hallmark of HCC is Arterial Phase Hyperenhancement (APHE) followed by "washout" on portal venous/delayed phases with an enhancing capsule ( LI-RADS 5 ). In a cirrhotic liver, classic imaging findings are diagnostic of HCC without requiring tissue biopsy.

MELD-Na Score: Used to calculate 90-day mortality in cirrhosis and prioritize donor liver allocation (Scores 6–40). Incorporates Serum Bilirubin, Serum Creatinine, INR, and Serum Sodium .