Work through each vignette, select your answer, then reveal the explanation.
Case 1Cirrhosis Complications
A 52-year-old man with alcohol use disorder presents with increasing abdominal distension and weight gain over 3 weeks. He has not consumed alcohol in 6 months. Exam: jaundice, spider angiomata, caput medusae, shifting dullness, and bilateral pitting edema. Labs: Na 128, albumin 2.1, total bilirubin 4.8, INR 1.9, creatinine 1.0. Paracentesis: SAAG 1.3 g/dL, total protein 1.5 g/dL, WBC 150 cells/mm³ (70% PMNs).
What is the most appropriate next management step?
A. Broad-spectrum antibiotics (cefotaxime IV)
B. Add spironolactone and furosemide
C. TIPS procedure
D. Repeat paracentesis in 48 hours
✅ Answer: A – Cefotaxime IV
PMN count ≥250 cells/mm³ on paracentesis = spontaneous bacterial peritonitis (SBP) — treat immediately with cefotaxime 2g IV q8h for 5 days OR ceftriaxone 1g IV daily. Also give IV albumin 1.5 g/kg on day 1 and 1 g/kg on day 3 to prevent hepatorenal syndrome (reduces mortality). The low total protein (<1.5 g/dL) and hyponatremia are consistent with advanced cirrhosis. After SBP treatment, start norfloxacin or TMP-SMX prophylaxis to prevent recurrence. TIPS is reserved for refractory ascites after diuretic optimization.
Case 2Hepatitis B Serology
A 34-year-old Vietnamese immigrant presents for a routine physical. He feels well and denies symptoms. Labs reveal: HBsAg positive, HBeAg positive, anti-HBc IgG positive, anti-HBs negative, HBV DNA 2,500,000 IU/mL, ALT 82 U/L (normal <40), AST 64 U/L. Liver biopsy shows moderate fibrosis (Metavir F2).
What is the most appropriate management?
A. Reassurance and repeat labs in 1 year
B. Initiate tenofovir (TDF or TAF)
C. Interferon-alpha monotherapy
D. Liver transplant evaluation
✅ Answer: B – Tenofovir
This patient has HBeAg-positive chronic active hepatitis B with elevated HBV DNA (>20,000 IU/mL), elevated aminotransferases, and moderate fibrosis (F2) — treatment is indicated. Tenofovir disoproxil fumarate (TDF) or tenofovir alafenamide (TAF — preferred if renal/bone concerns) are first-line nucleotide analogues. Entecavir is an alternative. Treatment suppresses viral replication, normalizes ALT, and prevents cirrhosis progression. HBeAg+ with high viral load and elevated liver enzymes = immune-active phase → treat. The pattern (HBsAg+, HBeAg+, no anti-HBs) confirms chronic active infection, not resolved disease or vaccination.
Case 3Hepatic Encephalopathy
A 61-year-old woman with known cirrhosis (Child-Pugh C) is brought in by her family for confusion and asterixis over 2 days. She takes lactulose and spironolactone. Her family reports she ran out of lactulose 5 days ago. Vitals: T 37.2°C, BP 100/65, HR 92. Exam: oriented to person only, asterixis present, no fever. Ammonia 142 μmol/L. UA shows nitrites and leukocyte esterase positive.
What is the most likely precipitant and best next step?
A. Gastrointestinal bleed — perform EGD
B. UTI as precipitant — treat infection and restart lactulose
C. Worsening liver failure — refer for transplant urgently
D. Benzodiazepine toxicity — give flumazenil
✅ Answer: B – UTI precipitant, treat and restart lactulose
Hepatic encephalopathy (HE) precipitants: GI bleed, infection (most common — UTI, SBP), constipation/lactulose non-compliance, hypokalemia, protein overload, sedatives, renal failure, portosystemic shunt. This patient has UTI (positive UA) PLUS lactulose non-compliance — both are contributing. Treatment: antibiotics for UTI + restart lactulose (titrate to 2–3 soft stools/day) + consider adding rifaximin 550mg BID for recurrent HE prevention. Rifaximin is highly effective at preventing HE recurrence. Ammonia levels correlate poorly with grade of encephalopathy; treatment is clinical.
Case 4NAFLD/NASH
A 48-year-old woman with T2DM and BMI 38 is referred for evaluation of elevated liver enzymes (ALT 68, AST 54). She drinks alcohol rarely (<1 drink/week). RUQ ultrasound shows echogenic liver consistent with steatosis. Hepatitis B and C serologies are negative. She denies use of hepatotoxic medications. FIB-4 score is 1.8.
What is the most appropriate next step in management?
A. Liver biopsy immediately to stage fibrosis
B. Start pioglitazone and refer for weight loss program
C. Advanced fibrosis assessment (elastography or FIB-4/ELF) and lifestyle modification
D. Start metformin for liver protection
✅ Answer: C – Fibrosis staging + lifestyle modification
NAFLD diagnosis of exclusion (no alcohol, no other liver disease, positive steatosis imaging). FIB-4 score 1.8 is in the indeterminate range (1.3–2.67 = indeterminate → refer for elastography, e.g., FibroScan). For confirmed NASH: cornerstone of treatment is weight loss (≥5–10% body weight → improves steatosis/inflammation). GLP-1 agonists (semaglutide) have shown efficacy in NASH and promote weight loss. Pioglitazone improves NASH histology but causes weight gain/fluid retention. The only FDA-approved drug for NASH with fibrosis is resmetirom (Rezdiffra) as of 2024. Metformin does NOT improve liver histology in NASH.