Preview Mode Links will not work in preview mode

The Curbsiders Internal Medicine Podcast

Supercharge your learning as these board-certified Internists interview the experts to bring you clinical pearls, practice changing knowledge, and a healthy dose of humor. 

Mar 11, 2019

Cirrhosis TIPS for the decompensated cirrhotic & acute on chronic liver failure from expert hepatologist and keto-practitioner Scott Matherly MD, @liverprof and chief hepatologist at @KashlakHospital. We walk through acute management of variceal bleeds, when to suspect SBP in decompensated cirrhosis (all the time, it turns out), how much fluid to remove in paracentesis, and some definitions about what decompensated cirrhosis and acute on chronic liver failure really mean.

Take our pretest on cirrhosis!

Full show notes available at Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at


Written and produced by: Nora Taranto MS4, Matthew Watto MD

Pretest by: Cyrus Askin MD

Hosts: Matthew Watto MD, Paul Williams MD,

Images and infographics: Hannah Abrams MS3

Edited by: Matthew Watto MD

Guest: Scott Matherly MD


Get your ACP membership today and use the code CURB100 to save $100 when you join by March 31, 2019.

Time Stamps

  • 00:00 NephMadness teaser
  • 00:50 Sponsor - Become an ACP Member today!
  • 01:25 Intro, guest bio
  • 03:45 Guest one-liner, keto diet
  • 07:40 Picks of the week from Paul, Matt and Scott
  • 11:50 Sponsor - Become an ACP Member today!
  • 13:26 Clinical case of bleeding and altered mental status in cirrhosis
  • 16:10 Interpretation of our patient’s labs and physical exam
  • 18:53 Defining terminology in cirrhosis (decompensated vs compensated vs acute on chronic liver failure)
  • 24:48 Initial workup, resuscitation and stabilization in variceal bleeding
  • 26:10 Why occult blood and ammonia levels are unhelpful in cirrhosis
  • 29:00 Fluid choice for the cirrhotic patient with hypotension; octreotide (or terlipressin); antibiotics prophylaxis
  • 33:10 Proton pump inhibitors and ulcers from variceal banding
  • 34:00 Mechanism of action for octreotide and terlipressin
  • 35:54 Prevention of recurrent bleeding with TIPS, or nonselective beta blockers
  • 40:40 Scores for prognostication in the acute setting
  • 44:00 Coagulopathy of cirrhosis and should DVT prophylaxis be used
  • 48:38 Elevated INR and procedures
  • 56:55 Paracentesis in the acute setting and interpretation of fluid studies:cell count, total protein, SAAG, blood culture vial; pathophysiology of ascites
  • 67:30 Treatment of SBP: antibiotics, IV albumin; plus, Hepatorenal physiology explained
  • 79:04 Hepatic encephalopathy is a shunt phenomen; how to evaluate for causes; treatment of HE
  • 87:58 Rifaximin
  • 89:10 Take home points
  • 91:02 Outro