In a patient with end-stage liver disease undergoing hepatic resection, the most likely cause of a high-anion-gap metabolic acidosis is:

In a patient with end-stage liver disease undergoing hepatic resection, the most likely cause of a high-anion-gap metabolic acidosis is:

• A. Ureteroenteric fistula
• B. Renal tubular acidosis
• C. Propofol infusion syndrome
• D. Diabetic ketoacidosis

Answer: (C)

Propofol infusion syndrome is the likely cause because it produces lactic acidosis, which creates a high-anion-gap metabolic acidosis. Propofol, especially when given in high doses or for a prolonged period, can disrupt mitochondrial fatty acid oxidation and oxidative phosphorylation. The result is increased anaerobic metabolism and lactate accumulation. In a patient with end-stage liver disease undergoing hepatic resection, propofol clearance is already reduced, increasing exposure and the risk of PRIS. The other options don’t fit this intraoperative setting well: a ureteroenteric fistula would cause urinary-type disturbances rather than a focal lactic acidosis; renal tubular acidosis causes a non–anion gap acidosis; and diabetic ketoacidosis is driven by insulin deficiency or counterregulatory hormones and is not the typical cause of this scenario.

Propofol infusion syndrome is the likely cause because it produces lactic acidosis, which creates a high-anion-gap metabolic acidosis. Propofol, especially when given in high doses or for a prolonged period, can disrupt mitochondrial fatty acid oxidation and oxidative phosphorylation. The result is increased anaerobic metabolism and lactate accumulation. In a patient with end-stage liver disease undergoing hepatic resection, propofol clearance is already reduced, increasing exposure and the risk of PRIS. The other options don’t fit this intraoperative setting well: a ureteroenteric fistula would cause urinary-type disturbances rather than a focal lactic acidosis; renal tubular acidosis causes a non–anion gap acidosis; and diabetic ketoacidosis is driven by insulin deficiency or counterregulatory hormones and is not the typical cause of this scenario.