Acute liver failure
Causes	· Drugs (Acetaminophen) · Viruses · Ischemia (Shock) · Autoimmune · Infiltrative
S/S	· Acute onset of liver sx · Kidney injury
Dx	Requirements: 1. Sky high AST/ALT (>1000) 2. Encephalopathy (confusion) 3. Liver Synthetic failure (INR 🆎)
Tx	Only definitive therapy is transplant

	Cirrhosis
?	Irreversible liver damage resulting in fibrosis
S/S	· Fatigue, Hepatic Encephalopathy · Cirrhosis Stigmata
Dx	Clx → LFT
Tx	· Serial US every 6 months Tx Ascites ⤵️ Spironolactone and other diuretics. Serial paracenteses for large- volume ascites. Coagulopathy ⤵️ PLT FFP and/platelets only if bleeding occurs Encephalopathy Lactulose and rifaximin Varices Propranolol and banding via endoscopy Hepatorenal syndrome Somatostatin (octreotide), midodrine

Ascites

Dx

· Imaging: US or CT · Most important: Paracentesis. Indications: · New onset ascites · Ascites → fever, tenderness (SBP) · AMS · vitally unstable (⤵️ HR, ⤵️ BP..) Ascites fluid characteristics Color · Bloody: Trauma, malignancy, TB (rarely) · Milky: Chylous, pancreatic · Turbid: Possible infection · Straw color: Likely more benign causes Nø · <250: No peritonitis · ≥250: Peritonitis (secondary or spontaneous bacterial) Total Protein ≥2.5 g/dL (high-protein ascites) · CHF, constrictive pericarditis, TB, Budd-Chiari, fungal (coccidioidomycosis) <2.5 g/dL (low-protein ascites) · Cirrhosis, nephrotic syndrome SAAG ≥1.1 (indicates portal HTN) · Cardiac ascites, cirrhosis, Budd-Chiari syndrome <1.1 (no portal HTN) · TB, peritoneal cancer, pancreatic ascites, nephrotic

	Common causes of Ascites
Extraperitoneal	• Cirrhosis • Acute liver failure • Alcoholic hepatitis • Budd-Chiari syndrome • Heart failure • Hypoalbuminemia • Malnutrition • Nephrotic syndrome
Peritoneal	• Malignancy (ovarian, pancreatic) • Infection (tuberculosis, fungal)

	Hepatic Encephalopathy
Make it worse	· Drugs · Hypovolemia (eg, diarrhea) · Electrolyte (Hypokalemia) · ⤴️ Nitrogen load (Gl bleeding) · Infection (eg, pneumonia, UTI, SBP) · Portosystemic shunting (TIPS)
Clx	∆ (AMS / Ataxia / Asterixis)
Tx	· Correct U/C (Fluids, antibiotics, electrolytes) · ⤵️  Blood ammonia concentration (Lactulose, rifaximin)

	SBP
S/S	· T: ≥37.8 · Abdominal pain/tenderness · AMS (abnormal connect-the-numbers test) · Hypotension, hypothermia, · paralytic ileus with severe infection (seen on X-ray as air)
Dx by TAP	· PMNs >250 · ⊕ culture, often gram e organisms · Protein <1 · SAAG ≥1.1 (Indicate Portal HTN)
Tx	Empiric Abx – 30 generation cephalosporins (eg, cefotaxime) Fluoroquinolones for SBP prophylaxis

	Solid liver masses
Focal nodular hyperplasia	· Associated with anomalous arteries · Arterial flow & central scar on imaging
Hepatic adenoma	· 👩🏻 + OCPs · Possible hemorrhage or malignant transformation
Regenerative nodules	Acute or chronic liver injury (eg, cirrhosis)
Hepatocellular carcinoma	· Systemic Sx · Chronic hepatitis or cirrhosis · ⤴️ alpha-fetoprotein
Liver metastasis	· Single/multiple lesions · Known extrahepatic malignancy

	Hepatic Adenoma
Features	· Benign epithelial liver tumor · Primarily young women 👩🏻 on OCPs
S/S	· Often Asx (incidentally found) · Episodic RUQ pain
Imaging	· Solitary, solid lesion in right lobe of liver · Multiple lesions occasionally occur
Tx	· Asx & <5 cm – stop oral contraception · Sx or >5 cm – surgical resection
Comp	· Malignant transformation (10%) · Rupture & hemorrhage shock

	Ascites fluid characteristics
Color	· Bloody: Trauma, malignancy, TB (rarely) · Milky: Chylous, pancreatic · Turbid: Possible infection · Straw color: Likely more benign causes
Nø	· <250: No peritonitis · ≥250: Peritonitis (secondary or spontaneous bacterial)
Total Protein	≥2.5 g/dL (high-protein ascites) · CHF, constrictive pericarditis, TB, Budd-Chiari, fungal (coccidioidomycosis) <2.5 g/dL (low-protein ascites) · Cirrhosis, nephrotic syndrome
SAAG	≥1.1 (indicates portal HTN) · Cardiac ascites, cirrhosis, Budd-Chiari syndrome <1.1 (no portal HTN) · TB, peritoneal cancer, pancreatic ascites, nephrotic

	Hereditary Hemochromatosis
Skin	Bronze (bronze diabetes)
MSK	Joint / Chondrocalcinosis
GI	⊕ LFT / Cirrhosis (Late) HCC
Endo	DM, 2˚ hypogonadism & hypothyroidism
Cardio	Restrictive or dilated cardiomyopathy
Infections	· Listeria, · Vibrio vulnificus & · Yersinia enterocolitica

	Hepatorenal Syndrome
RF	Advanced cirrhosis with portal hypertension & edema
Precepitators	· ⤵️ Renal perfusion · Gl bleed, vomiting, sepsis, excessive diuretic use, SBP · ⤵️ Glomerular pressure & GFR – NSAID (constricts afferent arterioles)
Dx	· Renal hypoperfusion · FeNa <1% (or urine Na <1) · Absence of tubular injury · No RBC, protein, or granular casts in urine · No improvement in renal function with fluids
Tx	· Address precipitating factors (Hypovolemia, anemia, infection) · Splanchnic vasoconstrictors (midodrine, octreotide, norepinephrine) · Liver transplantation

	Acute Liver Failure
Causes	· Viral hepatitis · Drugs (Acetaminophen overdose) · Ischemia (Shhock liver, Budd-Chiari) · Autoimmune · Wilson disease · Malignant infiltration
Clx	· Generalized Sx (fatigue, lethargy, anorexia, nausea) · RUQ abdominal pain · Pruritus & jaundice due to hyperbilirubinemia · Renal insufficiency · ⤵️ PLTs · ⤵️ Glu
Dx Req	· Severe acute liver injury (ALT & AST <1000) · Signs of hepatic encephalopathy (Confusion, asterixis) · Synthetic liver dysfunction (INR ≥1.5)

	Carcinoid Syndrome
Clx	· Skin: flushing, telangiectasias, cyanosis · GI: diarrhea, cramping · Cardiac: valvular lesions (right > left side) · Pulmonary: bronchospasm · Miscellaneous: Niacin deficiency (dermatitis, diarrhea & dementia)
Dx	· ⤴️ 24-hour urinary excretion of 5-HIAA · CT/MRI of abdomen & pelvis to localize tumor · OctreoScan to detect metastases · Echo (if sx of carcinoid heart disease are ⊕)
Tx	· Octreotide for sx pts · Surgery for liver metastases

	Alcoholic Hepatitis
Clx	· Jaundice, anorexia, fever · RUQ pain · Abdominal distension · Proximal muscle weakness from muscle wasting (if malnourished) · Hepatic encephalopathy
Dx	· Elevated AST & ALT, usually <300 · AST:ALT ≥2 · ⤴️ GGT  bilirubin, INR · ⤴️ WBCs (mainly neutrophils) · ⤵️ albumin if malnourished · Abdominal imaging may show fatty liver

	Nonalcoholic fatty liver disease
?	· Hepatic steatosis on imaging or biopsy · Exclusion of significant alcohol use · Exclusion of other causes of fatty liver
S/S	· Mostly Asx · Metabolic syndrome · ± Steatohepatitis (AST/ALT ratio <1) · Hyperechoic texture on US
Tx	· Diet & exercise · Consider bariatric surgery if BMI ≥35

	Wilson disease
Path	· AR · ATP7B · Hepatic copper accumulation → leak from damaged hepatocytes → deposits in tissues (basal ganglia, cornea)
Clx	· Hepatic (acute liver failure, chronic hepatitis, cirrhosis) · Neurologic (parkinsonism, gait disturbance, dysarthria) · Psychiatric (depression, personality changes, psychosis)
Dx	· ⤵️ Ceruloplasmin & ⤴️ urinary copper excretion · Kayser-FIeischer rings · ⤴️ Copper content on liver bx
Tx	· Chelators (D-penicillamine, trientine) · Zinc (interferes with copper absorption)

	Budd-Chiari Syndrome
Features	Hepatic venous outflow obstruction Usually due to: · Myeloproliferative disorder (PV) · Malignancy (HCC) · Oral contraception use/pregnancy
S/S	Acute · Jaundice, hepatic encephalopathy, variceal bleeding · Prolonged INR/PTT; ⤴️ transaminases Subacute/chronic · Vague, progressive abdominal pain · Hepatomegaly, splenomegaly, ascites · Mild/moderate ⤴️ in bilirubin, transaminases
Dx	· Abdominal Doppler US – ⤵️  hepatic vein flow · Investigation for underlying disorders (JAK2 testing for PV)