** Cirrhosis - Key Points
Patients with cirrhosis are classified as having:
Compensated cirrhosis
no significant complications
esophageal or gastric varices without bleeding
Median survival more than 12 years
Decompensated cirrhosis, has the following findings:
esophageal or gastric varices with bleeding
ascites
Spontaneous Bacterial Peritonitis (SBP)
hepatic encephalopathy
Prognosis is generally worse
Three significant complications related to cirrhosis
1. Liver failure: Calculate MELD scores
2. Hepatocellular carcinoma: order liver ultrasound every 6 months
3. Variceal bleeding: order EGD. If no varices, repeat EGD in 3 years. If small varices, repeat EGD every 1-2 years.
Screen for hepatocellular carcinoma in a patient with cirrhosis from any cause
Order a liver ultrasound every six months with or without alpha-fetoprotein measurement.
Patients with hepatitis B infection can develop hepatocellular carcinoma without cirrhosis.
Main indications for liver transplantation include the following:
MELD score of at least 15
Decompensated cirrhosis
What are lab results suggestive of advanced liver disease?
Thrombocytopenia is often due to portal hypertension from cirrhosis that leads to splenic sequestration of platelets.
Also, low albumin and prolonged INR both suggest advanced liver disease.
If imaging is readily not available, is there a calculation that we can use to screen patients for cirrhosis? Yes, it’s called FIB-4 index (link: https://www.mdcalc.com/calc/2200/fibrosis-4-fib-4-index-liver-fibrosis)
** Chronic Hepatitis C disease - Key Points
Screening is indicated at least once in all persons aged over 18
Order hepatitis C antibody, if positive, then order hepatitis C viral load (RNA) testing
Hep C antibody (+) but Hep C viralload (-) = person was previously exposed to the hepatitis C virus but may or may not have an active infection.
Hep C antibody (+) & Hep C viralload (+) = presence of the virus and active HCV infection
WORK-UP
Screen for Hep B (order HBsAg, anti-HBs, and anti-HBc) and HIV (HIV 4th generation).
Order platelet count, INR, liver enzymes, BMP, and abdominal ultrasound
Evaluate the extent of liver fibrosis related to Hepatitis C
Use of clinical scores (FIB-4 and APRI) and fibrotest
Liver biopsy is no longer recommended due to being an invasive test
Abdominal ultrasound may not be necessary for all patients, though findings may suggest cirrhosis or discover tumors, nodules, or ascites.
Treatment
Glecaprevir (300 mg)/pibrentasvir (120 mg) for 8 weeks, or
Sofosbuvir (400 mg)/velpatasvir (100 mg) for 12 weeks
** Ascites - Key Points
Diagnostic paracentesis should be performed in all patients with new-onset ascites and in all patients with cirrhosis and pre-existing ascites who are admitted to the hospital.
Recommended initial peritoneal fluid tests are cell count, differential total protein, and albumin (to enable calculation of the serum albumin–ascites gradient [SAAG]).
Minimal ascites (i.e., detected only by ultrasound) do not require treatment.
Moderate ascites should be treated with dietary sodium restriction and diuretics (spironolactone, furosemide, or both), and large or tense ascites often require large-volume paracentesis (LVP).
To prevent post-paracentesis circulatory dysfunction (PPCD), a potentially dangerous complication of LVP, administer 6 to 8 g intravenous (IV) albumin per 1 L of fluid removed above 5 L. Risk for PPCD increases with an LVP of >8 L in a single session.
** Spontaneous Bacterial Peritonitis - Key Points
Is the presence of bacteria in ascites required to diagnose SBP? No, it is not necessary. The culture results can be negative due to the limited amount of ascitic sample collected compared to the overall volume.
A high cellular response is associated with SBP, even without positive culture results. A finding of >/= 250 PMNs is indicative of SBP.
What is the recommended next step if a patient does not show improvement within the first two days after initiating empiric therapy for spontaneous bacterial peritonitis?
A repeat diagnostic paracentesis.
For the treatment of SBP, a 3rd generation cephalosporin is recommended for 5 to 7 days.
** Acute or Acute-on-Chronic Liver Failure Patients (ACLF) - Key Points
Given his high risk of esophageal variceal bleeding, start octreotide with a PPI.
ACLF patients with upper gastrointestinal bleeding, prophylactic antibiotics, 3rd generation cephalosporin
Is there a role for albumin in a patient with ACLF and spontaneous bacterial peritonitis? Even if the patient is not experiencing volume depletion, using albumin is recommended. Administering albumin can reduce the risks of acute kidney injury and mortality.
** GERD - Key Points
Suppose a patient presents with heartburn, regurgitation, and/or non-cardiac chest pain without alarming symptoms.
Next best step is a 4 to 8-week trial of once-daily PPI dosing, and consider testing for H. pylori (either stool H. pylori antigen or urea breath test).
If there is an adequate response, taper the PPI to the lowest effective dose.
If there's no adequate response, then switch to twice-daily dosing. If there is still no adequate response, then it is recommended to proceed with an upper endoscopy.
Endoscopy should be done after 2 to 4 weeks off PPIs (to maximize the chance of documenting esophagitis).
If the patient presents with GERD and exhibits alarm symptoms such as dysphagia or weight loss, an endoscopy should be recommended immediately to consider malignancy.
If endoscopy is normal, ambulatory pH monitoring (off treatment) is the next step.
We recommend intermittent or “on-demand” (rather than indefinite) PPI therapy in patients with no history of high-grade esophagitis or Barrett's esophagus.
A patient who requires ongoing PPI therapy for symptom control should use the lowest effective dose.
Important - If a patient with no alarm symptoms and a good response to a PPI stops the drug after several months and symptoms relapse, primary care clinicians often resume PPI therapy without further evaluation.
For such patients, this guideline recommends endoscopy to identify complications that merit indefinite PPI therapy (i.e., erosive esophagitis or Barret's esophagus) and to identify alternative diagnoses (e.g., eosinophilic esophagitis).
** Dyspepsia - Key Points
Dyspepsia is defined as epigastric pain with the following
early satiety, epigastric burning, nausea, and post-prandial pain or bloating
What are the two most common conditions of dyspepsia?
Peptic ulcer disease (PUD)
GERD
note: if there is NO organic cause of dyspepsia, then it's termed functional dyspepsia
A patient who is < 60 yo and has dyspepsia symptoms, what’s the primary intervention?
H. Pylori test and treat
What are the two preferred non-invasive tests for H Pylori diagnosis?
C-urea breath test and monoclonal stool antigen
**avoid H Pylori antibody test
A patient who is > 60 yo and has dyspepsia symptoms, what’s the primary intervention? Upper endoscopy
Functional Dyspepsia [Rome 4 Diagnostic Criteria]
One or more of the following (w/o evidence of structural disease, including endoscopic findings):
Bothersome post-prandial fullness
Bothersome early satiation
Bothersome epigastric pain
Bothersome epigastric burning
If there is no symptomatic relief with once-daily PPI, the next-line options are tricyclic antidepressants (TCAs) or prokinetic agents (metoclopramide).
There are two types:
Epigastric pain syndrome - tend to benefit more from a TCA (like amitriptyline)
Post-prandial distress syndrome - consider buspirone (causes stomach relaxation)
** Acute Pancreatitis - Key Points
What are the 3 criteria for diagnosing acute pancreatitis? To diagnose acute pancreatitis, the patient must have 2 out of 3 diagnostic criteria: abdominal pain, elevated lipase >/= 3x ULN, common imaging findings (CT scan, MRI, or abdominal UTZ).
What is the most vital intervention to prevent necrotizing pancreatitis?
Early resuscitation (5-10 ml/kg/hr for the 1st 48 hours)
Is it necessary to trend lipase? There is NO role in trending lipase levels daily.
Which imaging modality is recommended to assess biliary tract etiologies, visualize gallstones, and biliary tract dilation?
Abdominal ultrasound (does not need contrast).
If the patient presents with signs of cholangitis (RUQ tenderness, jaundice, fever), which imaging modality is recommended?
MRCP