#Cirrhosis Brief Hx

Etiology: alcohol, HBsAg, anti-HBs, Anti-HCV, HCV RNA, HCV genotype, Autoimmune (ANA, anti-smooth muscle Ab, AMA, anti-LKM, anti-SLA), hemochromatosis (iron studies), Wilson's (serum ceruloplasmin/serum and urine Cu, Ophtho consult), A1AT def, biliary (MRCP, AMA), R-sided CHF/pericarditis (echo), budd-chiari (Abd U/S), NAFLD (lipid panel, A1C, liver bx), cancer (CEA, AFP, U/S)

Prior EGD

Tylenol

IVDU

Alcohol: ***

IVDU: ***

Amateur tattoos or piercings: ***

Herbal supplements: ***

FamHx of liver disease of autoimmune conditions: ***

Blood transfusions prior to 1992: ***

#Cirrhosis Brief Recs

>Please perform paracentesis and send fluid studies, rule out SBP (cell count, albumin, total protein, gram stain/culture, cytology)

>Send Hepatitis labs: HAV IgM/IgG, HBsAg, HBcAb, HBV DNA, HCV RNA, HCV Ab

>Send HIV, if immunocompromised will consider further infectious work-up

>Send Fe studies (including Ferritin)

>Send AFP

>Send Lipid Panel, A1c

>Send ANA

Volume:

-Obtain baseline urine Na, urine K

-If paracentesis is negative for SBP, Diuretic regimen includes: Spironolactone 100mg (with close monitoring of K) and Lasix 40mg (with close monitoring of Cr)

-Na restricted diet (1.5g/daily)

-avoid NSAIDs - interferes with diuretics and can cause renal failure

-stop diuresis if serum Na < 120, uncontrolled encephalopathy, Cr > 2

-No indication for fluid restriction, unless Na<125

Infection:

***SBP Ppx with ciprofloxacin 500 mg orally daily or 160/800 mg orally daily

***If bleeding with ascites, SBP Ppx with ceftriaxone 1 gm IV daily for 7 days

***Begin if ascitic fluid protein level < 1.5 g/dL and severe liver disease (Child-Pugh score ≥ 9 points with serum bilirubin level ≥ 3 mg/dL) or impaired renal function (creatinine ≥ 1.2 mg/dL, blood urea nitrogen ≥ 25 mg/dL, or serum sodium ≤ 130 mEq/L)

***If SBP--1.5g/kg albumin day 1, 1g/kg albumin day 3 for HRS PPx

Bleeding:

***-Last EGD showed ***

*** Beta blockers: carvedilol at 3.125mg BID or nadolol 40mg daily for goal HR between 55-60 (avoided in Hepatorenal syndrome, SBP , and hypotension)

Encephalopathy:

***- lactulose goal BM's 2-3 daily

Please ask patient to implement the following lifestyle interventions:

-Avoid raw shellfish

-Alcohol cessation (involve addiction medicine if necessary)

-High protein diet

-Low sodium diet given ascites

-Vaccines: HepA, HepB, Pneumonia, Flu Vaccine

Outpatient:

-Will need RUQUS q6 months

>Outpatient EGD to evaluate for varices

>Criteria for liver transplant: recurrent encephalopathy, refractory ascites, SBP, recurrent variceal bleeding, HRS, HPS, HCC (if limited), acute liver failure