Severe Lactic Acidosis in Decompensated Cirrhosis Despite Nondiagnostic Imaging.

Lactic acidosis is a strong predictor of mortality in cirrhosis, reflecting both impaired hepatic clearance and systemic tissue hypoxia. We describe a 38-year-old man with decompensated alcohol-associated cirrhosis who developed severe lactic acidosis despite stable hemodynamics and initially nondiagnostic vascular imaging. Repeat computed tomography demonstrated rectal wall thickening with mesenteric fat stranding, concerning for ischemic injury in the setting of a low-flow state. The patient subsequently experienced pulseless electrical activity arrest and died. This case highlights the prognostic significance of rising lactate in cirrhosis and underscores that severe hyperlactatemia should prompt urgent evaluation for occult hypoperfusion even when early imaging is nondiagnostic.