Episode two follows the splanchnic vasodilation cluster, where one upstream physiology produces four complications, each with its own bundle, threshold, and drug sequence. Portal hypertension drives splanchnic vasodilation, the kidney reads effective hypovolemia and retains sodium, and from that single mismatch flow ascites, spontaneous bacterial peritonitis, hepatorenal syndrome, and hepatic encephalopathy. The episode anchors ascites on the serum-ascites albumin gradient and the fixed spironolactone-to-furosemide ratio, then moves through the TIPS-versus-paracentesis decision, hyponatremia thresholds, the peritonitis antibiotic-plus-albumin bundle, terlipressin for hepatorenal syndrome, and lactulose plus rifaximin for encephalopathy. Every threshold is mechanism-derived rather than arbitrary. Topics covered One physiology, four complications Ascites and the serum-ascites albumin gradient Diuretic management and the spironolactone-furosemide ratio Large-volume paracentesis and albumin replacement Refractory ascites: TIPS versus serial paracentesis Hyponatremia thresholds Spontaneous bacterial peritonitis bundle Hepatorenal syndrome and terlipressin Hepatic encephalopathy: lactulose plus rifaximin Key decisions A serum-ascites albumin gradient over one point one supports portal hypertension while a gradient under one point one points toward carcinomatosis, tuberculous, or pancreatic ascites; low ascitic protein under two and a half fits cirrhotic ascites while high protein with a high gradient suggests heart failure or constrictive pericarditis. The diuretic backbone is spironolactone plus furosemide in a fixed hundred-to-forty ratio, starting at a hundred plus forty and maxing at four hundred plus one hundred sixty, and large-volume paracentesis above five liters needs albumin at six to eight grams per liter removed. An ascitic neutrophil count over two hundred fifty diagnoses spontaneous bacterial peritonitis; treat empirically with a third-generation cephalosporin and give albumin one and a half grams per kilogram on day one and one gram per kilogram on day three. Secondary peritonitis prophylaxis is mandatory after a first episode because one-year recurrence exceeds seventy percent, using daily norfloxacin, ciprofloxacin, or trimethoprim-sulfamethoxazole indefinitely. Hepatorenal syndrome is diagnosed after no improvement following two days of diuretic withdrawal plus albumin at a gram per kilogram, and first-line therapy is terlipressin plus albumin continued up to fourteen days or to creatinine response. Hyponatremia thresholds are concrete: reduce diuretics under one hundred thirty, stop them and fluid-restrict under one hundred twenty-five, admit for saline under one hundred twenty, correcting no faster than eight to ten per twenty-four hours. Hepatic encephalopathy is treated with lactulose titrated to two to three soft stools a day plus rifaximin after a first overt episode, and protein restriction is forbidden because muscle is the largest extra-hepatic ammonia detoxifier. For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com. Questions or feedback: [email protected]. (00:00) - Introduction and the splanchnic cluster (00:32) - One physiology, four complications (01:31) - Ascites and the albumin gradient (02:50) - Diuretics and the fixed ratio (04:41) - Refractory ascites and the TIPS decision (07:31) - Hyponatremia thresholds (09:01) - Spontaneous bacterial peritonitis (13:04) - Hepatorenal syndrome and terlipressin (16:15) - Hepatic encephalopathy

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“What did the council decide on item 42?” — answered with the speaker and the moment.

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