Liver

A patient with newly biopsy-confirmed fibrotic MASH is ready to start pharmacotherapy. The disagreement isn't whether to treat — it's whether an approved, purpose-built drug with a real but modest effect size should lose to an agent with bigger trial numbers and no label for this use.

Two cirrhotic patients meet criteria for hepatorenal syndrome-acute kidney injury within the same week — one already in the ICU on norepinephrine, one on the ward being considered for terlipressin. The pivot isn't which drug is better in the abstract; it's whether the setting each patient is actually in changes the right answer.

A patient meets every severity threshold for corticosteroid therapy in severe alcohol-associated hepatitis — except that he was treated for spontaneous bacterial peritonitis three days ago. The pivot is whether a treated, source-controlled infection should function as the same hard stop as an active, uncontrolled one.

A patient's day-7 Lille score confirms she isn't responding to corticosteroid therapy for severe alcohol-associated hepatitis. Stopping the drug isn't controversial. What happens in the same conversation — whether to open an early transplant evaluation that bypasses the traditional sobriety clock — is.

A patient doing well on obeticholic acid for primary biliary cholangitis needs a new second-line agent after the drug's voluntary US withdrawal. The pivot isn't whether to switch — it's which of two newer, less-established options actually fits a patient who was, until this week, a treatment success.

A patient stable on tenofovir for ten years has a hepatitis B surface antigen level low enough to make him eligible for a structured stopping trial under a recently revised guideline. The disagreement is whether that eligibility is a reason to actually stop.

A patient with three years of biochemical remission from autoimmune hepatitis wants to know whether she still needs to take azathioprine. The debate turns out to hinge less on how long she's been in remission than on what kind of remission has actually been documented.

A patient's second hepatic encephalopathy admission on lactulose alone raises the option of adding rifaximin. Before the team agrees on that, someone has to establish whether the lactulose he's been sent home on was ever actually working at the dose he was taking it.

A patient newly found to have high-risk varices needs primary bleeding prophylaxis. Carvedilol is the guideline-preferred first choice — except his blood pressure is already close to the floor a beta-blocker with real hypotensive effect could push him past.

A cirrhotic patient recovering from a first SBP episode needs indefinite antibiotic prophylaxis. The choice between norfloxacin's longer track record and rifaximin's lower resistance-selection profile turns out to depend on a culture history nobody has checked yet.

Two newly diagnosed Wilson disease patients need copper-reducing therapy in the same week. One presented with liver injury alone; the other with tremor and dysarthria. The diagnosis is identical. The first drug shouldn't be.

A hemochromatosis patient can't tolerate phlebotomy because of a concurrent anemia, and iron continues to accumulate. Before the team reaches for a chelator built for a different population, someone has to ask whether the anemia itself has actually been worked up.

A patient with compensated cirrhosis and real cardiovascular risk was told years ago to avoid statins entirely. Newer data linking statin use to reduced decompensation risk in cirrhosis reopens a question his prior care team considered closed.

A patient whose liver fully recovered from isoniazid-induced injury needs isoniazid again, and no adequate alternative exists for his specific tuberculosis exposure. The debate isn't whether rechallenge is risky — it clearly is — it's whether the alternative is actually safer.

A patient with a real, substantial tumor response to checkpoint inhibitor therapy develops steroid-refractory hepatitis from the same drug. Escalating immunosuppression is not controversial on its own. What happens to her cancer treatment in the same conversation is.

A patient presents more than a day after a large acetaminophen ingestion, well outside the window the Rumack-Matthew nomogram was built to interpret. The debate isn't really whether to treat — it's what a tool designed for early presenters should and shouldn't be asked to decide.

A liver transplant recipient whose original disease was autoimmune hepatitis is due for the standard early steroid withdrawal most recipients undergo. The disagreement is whether a diagnosis with real graft-recurrence risk should follow the same default protocol as everyone else.

A patient's hepatitis C did not clear after first-line direct-acting antiviral therapy. The retreatment regimen is not seriously in dispute. Whether resistance testing is worth sending, and whether anyone has actually asked about adherence, are.

A patient with newly diagnosed Budd-Chiari syndrome needs long-term anticoagulation, but her hepatic vein thrombosis is driven by an underlying myeloproliferative neoplasm — a population DOAC trials weren't specifically built around.

A family asks for alpha-1 proteinase augmentation therapy for a patient with liver-only alpha-1 antitrypsin disease and normal lungs, having seen it help a relative with the same genotype. The drug is real and effective — for a different organ, working through a mechanism his liver disease doesn't share.

A patient with new, moderate-volume cirrhotic ascites and no renal impairment could reasonably start on spironolactone alone or on combination therapy from day one. The team's actual disagreement turns out to be less about the drugs and more about how closely he can be watched.

A cirrhotic patient's acute-on-chronic liver failure is progressing fast enough that standard vasopressor and renal support may not be the whole plan much longer. The disagreement is about timing, and about whether the transplant conversation is keeping pace with everything else happening in the room.

A patient newly eligible for bulevirtide, the first therapy built specifically for hepatitis D, could start it alone or combined with pegylated interferon. The trial data favor combination for her disease stage. Whether she can actually tolerate what that combination asks of her hasn't been discussed yet.

A patient with unresectable hepatocellular carcinoma and a recent variceal bleed needs first-line systemic therapy. The standard first choice contains a drug with a real bleeding-risk signal that matches his history almost exactly.

A patient with primary sclerosing cholangitis feels and looks better on low-dose ursodeoxycholic acid — a drug current guidelines recommend against at high dose in this disease, and remain genuinely divided on at low dose. His own response doesn't settle the question the guideline is actually about. ---