1. CIRRHOSIS MANAGEMENT FOR HOSPITALISTS Madhav Devani 6/7/16

2. We will talk about: 1. When to suspect cirrhosis? 2. How to diagnose cirrhosis? 3. What to do once you made the diagnosis? 4. What complications to be aware of ? 5. How to manage complications/when to call consults?

3. When to suspect cirrhosis? Most common causes of cirrhosis: 1. Alcoholic 2. Chronic hepatitis C and hepatitis B 3. NASH (Obese, diabetic, high cholesterol) 4. Tylenol overdose

4. Cirrhosis is a silent disease. Diagnosed mostly when patients are decompensated HISTORYPHYSICAL EXAM FatigueNORMAL IN EARLY CIRRHOSIS AnemiaAscites JaundiceCachexia RashJaundice AscitesConfusion Asterisks Leg SwellingHepatomegaly AKITesticular atrophy Easy bruisingGynecomastia Loss of appetiteSpider veins

5. How to diagnose cirrhosis? Labs CBC (anemia, low platelets) CMP (elevated LFTs, elevated bilirubin) PT/INR elevated Low albumin without any other causes Imaging US Liver- quite sensitive, cheap, quick- DO IT! CT abdomen MRI

6. What to do once you diagnose cirrhosis? Depends on : 1. Compensated cirrhosis 2. Decompensated cirrhosis 3. Acute on chronic liver failure

7. Compensated Cirrhosis Asymptomatic cirrhosis noted on Ultrasound or CT 1. Follow up with hepatology as outpatient Decompensated Cirrhosis Cirrhosis + symptoms (ascites, varices/GI bleed, encephalopathy) 1. Most of our patients 2. Inpatient treatment of symptoms 3. Hepatology consult and/or follow up

8. Acute on chronic liver failure Decompensated cirrhosis+ end organ damage 1. Liver (Bilirubin>12) 2. Kidney(creatinine >2 or 50% above baseline ) 3. Coagulopathy (INR >2.5, platelets <20) 4. Circulatory (BP<80) 5. Respiratory failure Many of our patients 1 month mortality range 4 to 78% depending on number of organs involved Hepatology, nephrology, ICU

9. What complications to be aware of ? 1. Hepatic encephalopathy 2. Spontaneous Bacterial Peritonitis (SBP) 3. Hepatorenal syndrome 4. Esophageal Varices 5. Hypotension

10. 1. Hepatic Encephalopathy Diagnosis: altered mentation + high ammonia Treatment: Low protein diet (all cirrhotics don’t need to be on low protein diet) Lactulose po and/or lactulose enema (3 loose stools/day) Severe or resistant encephalopathy: flagyl or rifaximin

11. Hepatic Encephalopathy (contd.) Precipitating factors Stable cirrhotics who take meds don’t have encephalopathy unless GI bleed Infections (UTI, SBP, cellulitis) Electrolyte imbalance Dehydrations or over diuresis Medications (benzos, opiates) Constipation

12. 2. Spontaneous Bacterial Peritonitis Diagnosis: Suspect when a cirrhotic has abdominal pain, GI bleed, encephalopathy But 50% are asymptomatic Diagnostic paracentesis: >250 neutrophils in ascites fluid Low threshold for paracentesis on all cirrhotics who get admitted “If you are sick enough to have cirrhosis and be in the hospital, then you are going to need a needle in your belly” -not me

13. Spontaneous Bacterial Peritonitis (cont.) Treatment Antibiotics- rocephin, cipro, levofloxacin for at least 5 days If not getting better- repeat paracentesis to see if neutrophils going down Watch out for AKI (common in patients with SPB)- give iv albumin Consider long term antibiotics if recurrent SBP (cipro, bactrim ds once a day)

14. 3. Hepatorenal Syndrome Diagnosis: 1. Someone with normal or stable CKD 2. Abrupt jump in creatinine (>50% up from baseline) 3. No usual causes of AKI like antibiotics, hydronephrosis, contrast 4. Worsening of renal function despite stopping diuretics or giving fluids+albumin

15. Hepatorenal Syndrome (contd) Treatment: 1. Start iv albumin 1g/kg 2. If not super volume overloaded- fluid challenge (always with iv albumin) 3. If has ascites, r/o or treat SBP 4. Liver/Nephrology consult- octreotide, midodrine, TIPS

16. 4. Esophageal Varices Diagnosis: GI bleed in cirrhotic Treatment 1. PRBC- Goal Hb 8, over transfusion -> more bleeding 2. Antibiotics (rocephin) for 5 days (reduce mortality) 3. Octreotide drip (3-4 days) 4. GI consult: EGD, banding, TIPS 5. Prapronolol bid or nadolol daily

17. 5. Hypotension Most cirrhotics will have low BP (90 sys) - nature of cirrhosis - Diuresis - beta blockers - If called for BP lower than usual or symptomatic hypotension 1. Hold bb and/or diuresis 2. IV fluids+albumin 3. Think about GI bleed, SBP/sepsis if BP still low

18. At the time of discharge.. Hepatology follow up (HCC and varices screening, paracentesis, medications) Medications 1. Lasix + Aldactone 2. Propranolol or nadolol if has varices 3. Lactulose, instruction to titrate 4. Rifaxmin or flagly if lactulose not effective (recurrent admissions for hepatic encephalopathy) 5. Can do statins if LFTs stable and h/o CAD, some studies show improved outcomes in cirrhotics from statins

19. SUMMARY Think of cirrhosis in chronic hep C or NASH suspects Unexplained lab abnormalities (platelets, anemia, bilirubin, INR) or BP tends to be low Get an US abdomen Stages of cirrhosis Treatment of usual complications Hepatic encephalopathy Variceal bleeding SBP Hypotension Heparorenal syndrome Discharge

20. KEY POINTS 1.Cirrhosis is a silent disease. Diagnosed mostly when patients are decompensated 2.US liver when in doubt (cheap, easy, non invasive) 3.Low threshold for diagnostic paracentesis on all pts 4.Stable cirrhotics who take meds don’t get hepatic encephalopathy (look for medications, infection, constipation, dehydration, GI bleed etc) 5.IV albumin is your friend- use it when AKI, hypotension, GI bleed, just about anything with cirrhosis 6.IV antibiotics reduces mortality in cirrhotics, start them soon