Liver

#cirrhosis ascites

Discontinue ace/arb

Consider avoiding beta blocker/NSAIDs

#compensated cirrhosis

SAVE score: ___ (Liu et al, AJG 2022)

Last known HVPG: ____

#Decompensated cirrhosis

Patient with hx of cirrhosis secondary to ****. Decompensated due to complication (variceal hemorrhage, ascites, hepatic encephalopathy, spontaneous bacterial peritonitis, hepatocellular carcinoma, hepatorenal syndrome, or hepatopulmonary syndrome). MELD Score of ***.

-GI consulted; appreciate recommendations

-Abdominal ultrasound and possible paracentesis

-Cefotaxime 2g q8h, Ceftriaxone 2gm IV q24hfor empiric SBP coverage (given patient has temp >100.0, abd pain/tenderness, change in mental status, PMN>250)

-Furosemide/Bumex PO daily

-Lactulose 30ml PO daily (titrate to 3-4BM's)

- Rifaxamin 550mg PO BID

-Phenergan 25mg PO Q6HR PRN for nausea

-Pain control

-Counseled on importance of routine cardiovascular exercise as tolerated (Jamali et al, AJG 2022)

#Elevated liver-associated enzymes

Elevated to ****, indicating hepatocellular/cholestatic injury. Patient with symptoms of ****. No evidence of jaundice, hypotension or mental status change to suggest intraabdominal/biliary infection. History does not support acute toxin ingestion, APAP/salicylate overdose. DDx includes viral hepatitis, DILI, shock liver, biliary obstruction; less likely autoimmune or hereditary etiology.

- Obtain RUQUS with Doppler to r/o obstructing lesions

- Obtain Iron panel, ANA panel, CT Immuno panel, Acute and Chronic Viral hepatitis panels, alpha-1 antitrypsin, Immunoglobulins, Celiac panel on admit

-LAEs qAM

- Acute Viral Hepatitis Panel, HBV DNA, HCV RNA

- CMV IgG and PCR, EBV Total IgG/IgM and PCR, HSV 1/2 IgG and DNA, HIV

- Repeat RUQUS with Dopplers

- Acetaminophen level

- Toxicology panel (UDS), pEth

- IgG, anti-smooth muscle antibodies, anti-mitochondrial antibodies

- Trend CBC, BMP, LAE and INR daily

-Monitor closely for changes in mental status/lethargy, somnolence

History of alcohol or NAFLD?

Per ACG guideline on elevation of abnormal liver chemistries 2017:

Confirm liver chemistry is abnormal with repeat test

Testing for HCV: anti-HCV antibody, confirm with HCV RNA by NAAT

Testing for HBV: HBsAg; IgM anti-HBc

Testing for HAV: IgM HAV

Testing for HEV: IgM HEV if acute hepatitis and returning from endemic area and Hepatitis A, B, C are negative

Testing for hereditary hemochromatosis: in absence of acute hepatitis, iron level, transferrin saturation, serum ferritin; if transferrin saturation >45% and/or elevated ferritin, HFE genetic analysis

Testing for AH: ANA, ASMA, globulin level

Testing for Wilson's Disease: ceruloplasmin; if low, confirmatory testing with 24h urinary copper and slit-lamp exam

Testing for a1AT deficiency: a1AT phenotype

Prescription and OTC medications as possible culprits:

Elevated alk phos without hepatocellular enzymes

Check GGT

PBC testing: anti-mitochondrial antibody

PSC testing: MRCP or ERCP, IgG4

If ALT/AST <5x ULN: assess for HBV/HCV, alcoholic and NAFLD, hemochromatosis, Wilson's disease, a1AT, autoimmune hepatitis, and consider drug/supplement related injury

If ALT/AST 5-15x ULN: assess for acute HAV, HBV, HCV in addition to all etiologies above

If ALT/AST >15x ULN: assess for acetaminophen toxicity and ischemic hepatopathy in addition to all etiologies above

#Drug Induced Liver Injury

RECAM score ___

#elevated alkaline phosphatase

Rule out pregnancy, postprandial increase

GGT

RUQUS

Dilated = MRCP/ERCP

Non dilated = AMA

#Hepatocellular carcinoma

Patients with hepatocellular carcinoma who have well-compensated cirrhosis, no symptoms referable to liver disease, no evidence of portal hypertension, and normal liver function markers should be referred for surgical resection.

Liver transplantation for hepatocellular cancer is the best therapy for patients who also have portal hypertension or features of liver dysfunction

#hereditary hemochromatosis

Hereditary hemochromatosis is suggested by the presence of an elevated serum ferritin level and transferrin saturation.

The diagnosis of hereditary hemochromatosis is confirmed by testing for mutations in theHFEgene

In these patients, the diagnosis is suspected by finding elevated transferrin saturation greater than 45% (guidelines vary) and an elevated serum ferritin level; diagnosis is confirmed through genetic testing

#autoimmune hepatitis

The mainstay of treatment of autoimmune hepatitis is immunosuppression with prednisone or a combination of prednisone and azathioprine.

Because autoimmune hepatitis has a high rate of relapse, therapy is recommended for at least 2 to 3 years before discontinuation of the medications.

#hepatic sarcoidosis

The most appropriate diagnostic test to perform next is upper endoscopy (Option D). Granulomatous inflammation of the liver can result in portal hypertension, even in the absence of hepatic fibrosis. Hepatic sarcoidosis is an idiopathic condition that results in non-necrotizing granulomas. The organ most commonly affected by sarcoidosis is the lung, although the liver is also often affected. Most patients with hepatic sarcoidosis are asymptomatic; if symptoms do exist, they are typically mild and may consist of pruritus or abdominal pain due to hepatic capsule stretch. It is unclear whether immunosuppressive therapy affects the clinical course of hepatic sarcoidosis, and treatment is usually not initiated unless symptoms are severe or markers of liver inflammation are significantly abnormal. Conditions such as tuberculosis, fungal infections, brucellosis, Q fever, Hodgkin lymphoma, and drug toxicity can also cause granulomatous lesions in the liver, and steps should be undertaken to exclude these conditions before a diagnosis of sarcoidosis is accepted. The presence of skin or chest imaging findings typical of sarcoidosis also supports the diagnosis of hepatic sarcoidosis. Hepatic sarcoidosis rarely results in liver failure, but portal hypertension is common. Therefore, upper endoscopy to evaluate for esophageal varices is warranted, particularly in this patient with splenomegaly and thrombocytopenia

#drug induced liver injury

Drug-induced liver disease can result from exposure to prescription and nonprescription drugs as well as herbal and dietary supplements, even if the exposure occurred 6 months before symptom onset.

The most common cause of cholestatic hepatitis is drug-induced liver injury.

#concern for hepatorenal syndrome

The initial management of acute kidney injury in patients with cirrhosis is to stop diuretic therapy.

In patients with hepatorenal syndrome, β-blocker therapy should be discontinued

Consider terlipressin per CONFIRM trial; NNT HRS of ~6, NNH at 90 day mortality ~20

#sbp

Spontaneous bacterial peritonitis is diagnosed by an ascitic fluid neutrophil count of 250/μL (0.25 × 109/L) or higher.

Treatment of spontaneous bacterial peritonitis includes a third-generation cephalosporin; albumin is infused in the presence of hepatic (bilirubin level >4 mg/dL [68.4 μmol/L]) or kidney dysfunction

#Budd Chiari

Budd-Chiari syndrome is suggested by right-upper-quadrant abdominal discomfort, hepatomegaly, and ascites.

Budd-Chiari syndrome can be diagnosed with Doppler ultrasonography of the abdomen; it demonstrates absence of flow in the hepatic veins as well as hepatic congestion

Long-term anticoagulation is required in patients with Budd-Chiari syndrome, although bleeding risks are significant in patients with acute or chronic liver disease, portal hypertension, and esophageal varices. Angioplasty of the hepatic veins and/or placement of a transjugular intrahepatic portosystemic shunt (TIPS) can be used to reestablish adequate hepatic venous drainage. If liver failure develops, liver transplantation may be considered.

#Alcoholic hepatitis

fever, jaundice, tender hepatomegaly, and leukocytosis

Maddrey score:

Prednisolone is the treatment for severe alcoholic hepatitis, defined as a Maddrey discriminant function score of 32 or greater or the presence of hepatic encephalopathy.

Patients with alcoholic hepatitis treated with prednisolone who do not respond after 7 days should have the prednisolone discontinued; otherwise, prednisolone should be continued for 28 days.

The 2018 American College of Gastroenterology guideline on alcoholic liver disease makes a conditional recommendation against the use of pentoxifylline

#pyogenic liver abscess

In patients with pyogenic liver abscess, empiric broad-spectrum parenteral antibiotics that cover streptococci, enteric gram-negative bacilli, and anaerobes should be initiated.

Hepatic abscesses 3 cm or greater in diameter typically do not resolve with antibiotic therapy alone, and aspiration of the abscess by percutaneous needle approach is warranted.

CTX + flagyl

Serology for entameba histolytica

#HCC screening and cirrhosis

Patients with cirrhosis who have undergone virologic cure for hepatitis C virus infection should undergo surveillance for hepatocellular carcinoma every 6 months with ultrasonography.

No information indicates that the addition of α-fetoprotein (AFP) to ultrasonography screening for hepatocellular carcinoma leads to improved survival; therefore, surveillance using ultrasonography may be performed with or without AFP measurement every 6 months