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Core Clinical Level 1–3 Step 1–3 High Yield

Cirrhosis, Portal Hypertension & Hepatic Encephalopathy

End-stage liver disease: SAAG calculation, spontaneous bacterial peritonitis (SBP), variceal hemorrhage, and lactulose titration.

SAAG >= 1.1 g/dL

Indicates Portal Hypertension (cirrhosis, heart failure, Budd-Chiari); SAAG < 1.1 reflects peritoneal carcinomatosis, TB, nephrotic syndrome.

SBP Diagnosis

Ascitic fluid PMNs >= 250/mm3; treat emergently with IV Cefotaxime/Ceftriaxone + Albumin (prevents hepatorenal syndrome).

Acute Variceal Bleed

IV Octreotide + prophylactic Ceftriaxone + emergent Endoscopic Variceal Ligation (EVL) within 12 hours.

Hepatic Encephalopathy

Lactulose (titrated to 2-3 soft stools/day) + Rifaximin; traps NH3 as nonabsorbable NH4+ in the colon lumen.

Ascites Evaluation & The Serum-Ascites Albumin Gradient (SAAG)

Diagnostic paracentesis is mandatory for all patients with new-onset ascites or cirrhotic patients hospitalized with clinical deterioration. Calculate SAAG = Serum Albumin − Ascitic Fluid Albumin:

SAAG LevelPathophysiologic MechanismEtiologies
High Gradient (≥ 1.1 g/dL)Increased hydrostatic pressure in portal microcirculation (Portal HTN)Cirrhosis, Congestive Heart Failure, Constrictive Pericarditis, Budd-Chiari syndrome
Low Gradient (< 1.1 g/dL)Increased peritoneal capillary permeability or non-portal peritoneal pathologyPeritoneal Carcinomatosis, Peritoneal Tuberculosis, Pancreatic Ascites, Nephrotic Syndrome

Spontaneous Bacterial Peritonitis (SBP) Protocol

SBP is an acute bacterial infection of ascitic fluid without an intra-abdominal surgically treatable source. Pathogens are predominantly enteric gram-negative bacilli (E. coli, Klebsiella) or streptococci.

  • Diagnostic Criterion: Ascitic neutrophil count (PMNs) ≥ 250 cells/mm3 (0.25 × 109/L).
  • First-Line Therapy: IV Ceftriaxone 2 g/day or Cefotaxime 2 g q8h for 5 days.
  • IV Albumin Infusion: 1.5 g/kg on day 1, followed by 1.0 g/kg on day 3. Reduces the incidence of hepatorenal syndrome and improves survival by over 50%.
OMM Board Correlate: Hepatic Lymphatics & Autonomics
  • Sympathetic Innervation: T5-T9 via the greater splanchnic nerve and celiac ganglion. Normalizing thoracic hypertonicity reduces sympathetic vasoconstriction to the splanchnic bed.
  • Chapman Points: Right 5th and 6th intercostal spaces near the sternum (liver) and right 6th intercostal space (gallbladder).
  • Hepatic Lymphatic Drainage: Hepatic lymph accounts for over 50% of thoracic duct lymph flow. Thoracic pump and thoracic inlet myofascial release relieve diaphragmatic restriction and improve ascites drainage.
Board Traps & Common Distractors
  • Never give beta-blockers during an acute variceal bleed; beta-blockers worsen acute hypotension and blunts compensatory tachycardia.
  • Never perform a paracentesis through surgical scars or superficial abdominal collateral veins (caput medusae) due to bowel adhesion and hemorrhage risk.
  • Overly rapid paracentesis without albumin replacement in large-volume paracentesis (> 5 L) causes post-paracentesis circulatory dysfunction (PICD) and rapid renal failure.