Which painkiller should NOT be given?

Correct answer: B. Ibuprofen

• A. Acetaminophen is counterintuitively the SAFER choice in stable cirrhosis when the dose is limited (commonly 2 g per day or less) and alcohol has been stopped. It does not affect platelets or the GI mucosa. Note this file also contains a Day 1 item keying acetaminophen as the drug to avoid — see the note below.
• B. Correct. NSAIDs are avoided in cirrhosis for several converging reasons: they inhibit platelet aggregation in a patient who ALREADY has reduced synthesis of clotting factors and thrombocytopenia from hypersplenism; they cause GI mucosal injury in a patient at risk of variceal bleeding; and they reduce renal prostaglandins, precipitating hepatorenal syndrome and fluid retention.
• C. Opioids are used cautiously; they are metabolised hepatically and can precipitate hepatic encephalopathy, but they are not the single worst choice here.
• D. Tramadol carries the same hepatic metabolism concerns plus a seizure risk.

Note: ⚠️ THIS FILE CONTRADICTS ITSELF. Day 1 item asks 'liver cirrhosis, what analgesic should be avoided?' and lists ibuprofen first; a separate Day 1 item keys acetaminophen. THE CONSENSUS HEPATOLOGY POSITION: NSAIDs are contraindicated in cirrhosis; acetaminophen at a REDUCED dose is the preferred analgesic in stable disease. Watch the stem for ACTIVE drinking, which shifts acetaminophen toward avoidance.