Giant Hydrocele in a Decompansated Cirrhotic Patient: Not ...
PRIMARY CARE OF THE CIRRHOTIC PATIENT
61
PRIMARY CARE OF THE CIRRHOTIC PATIENT Tara McLamb, NP-C, MSN 2017 NPSS Asheville, NC
Transcript of PRIMARY CARE OF THE CIRRHOTIC PATIENT
PRIMARY CARE OF THE
CIRRHOTIC PATIENT
Tara McLamb NP-C MSN
2017 NPSS
Asheville NC
Goals
NCNA 2017 NPSS
Strengthen the primary care providerrsquos role and comfort level in providing safe timely care to the
patients with cirrhosis
Lay the foundation for prevention of cirrhosis through ID amp minimization or elimination of risk
factors
Overview
bull PCPsrsquo role in cirrhosis management amp
prevention
bull Causes amp pathophysiology
bull Management
ndash Compensated
ndash Decompensated
bull Opportunities
ndash Research and beyond
The Lovely Liver
bull Functions
ndash Synthesis
bull Albumin and many other proteins
bull Clotting factors
bull Fatty acids triglycerides cholesterol
ndash Formation and excretion of bile during bilirubin metabolism
ndash Regulation of glucosecarbohydrate balance
ndash Metabolism amp detoxification of drugs and other foreign substances
The Conundrum
bull ldquohellipthere is no explicit reference to which aspects
of care are in the domain of specialist versus the
generalist producing uncertainty that can
contribute to frustration or resentment for either
type of [provider]rdquo ndash Fox (2015)
bull Complexity
bull Time consuming
bull Quick decompensation
bull Requires specialist for EGDs anyway
Cirrhosis by the numbers
bull 55 million Americans
bull Many more are undiagnosed (10 million)
bull Hospital discharge Dx 10 increase between
2010 amp 2011
bull $12 BILLION per year (direct + indirect costs)
Life Expectancy
bull 10-13 years if compensated
bull 2 years if decompensated
bull Alcoholic cirrhosis
ndash Abstention x 3 years = 35 still alive
ndash Continue to drink = 0 still alive
bull Metabolic
ndash Nonalcoholic
steatohepatitis
ndash Hemochromatosis
ndash Wilsons disease
ndash α1-Antitrypsin deficiency
bull Vascular
ndash Budd-Chiari syndrome
ndash Cardiac cirrhosis
ndash Veno-occlusive disease
bull Cryptogenic (dx of exclusion)
bull Infectious ndash Chronic hepatitis B
ndash Chronic hepatitis C
bull Toxins ndash alcohol methotrexate
bull Autoimmune hepatitis
bull Cholestatic ndash Primary biliary cirrhosis
ndash Primary sclerosing cholangitis
Cirrhosis Etiologies
Cirrhosis Pathophysiology
Inflammation in liver results in
cytokine-mediated
activation of hepatic stellate
cells
Stellate cells et al produce
collagen Fibrosis
RESULT Extensive porto-central fibrosis with presence of regenerative noduleshellip cirrhosis
PCP ndash Risk Factors amp Covert Signs
bull Frequently asymptomatic until hepatic function severely reduced
bull Any patient with Hepatitis C infection (duration of infection gt 20-30 years when risk for cirrhosis peaks)
bull Any patient with fatty liver especially gt 20 years
bull Any patient with obesitymetabolic syndrome (majority have NAFLD)
bull Significant ETOH intake gt 10 years
bull Low platelet count (lt160000)
bull Low serum albumin
Late Physical Signs of Liver Disease
bull Abdominal ndash Hepatomegaly (followed
by small liver span)
ndash Splenomegaly
ndash Dilated abdominal vasculature
ndash Ascites
bull HEENT ndash Scleral icterus
ndash Xanthelasma
ndash Parotid swelling
ndash Kayser-Fleischer rings
ndash Fetor hepaticus
bull Musculoskeletal ndash Muscle wasting
ndash Palmar erythema
ndash Dupuytrens contracture
bull Neurological ndash Altered mental status
ndash Asterixis
bull Skin ndash Spider telangiectasia
ndash Jaundice
ndash Bruising
ndash Leukonychia
Cirrhosis Diagnosis
bull Labs ndash Low platelet count
ndash Low serum albumin
ndash Possibly low WBC count
ndash Elevated or NORMAL transaminases (ratio of ASTALT gt 1)
ndash Elevated PTINR
bull Ultrasound ndash nodular appearance
bull Other imaging studies ndash CT MRI
bull Biopsy ndash bridging fibrosis regenerative nodules
bull Noninvasive fibrosis testing ndash Transient elastography (FibroScanreg)
ndash Noninvasive serum biomarkers (FibroSUREreg [Quest Diagnostics] FIBROSpectreg II [PROMETHEUSreg Laboratories])
Classification System Child-Turcotte-Pugh
1 point 2 points 3 points
Encephalopathy None Grade 1-2 Grade 3-4
Ascites Absent Slight Moderate
Total bilirubin mgdL
lt2 2-3 gt3
Albumin gdL gt35 28 - 35 lt28
INR lt17 17 -23 gt23
Scoring 5-6 points ndash Class A ndash 30 reduction in hepatic function 7-9 points ndash Class B ndash 50 reduction in hepatic function 10-15 points ndash Class C ndash 90 reduction in hep function
Management Overview
bull Remove offending agent minimize further harm
bull Screen for complications
bull Minimize progression of secondary
complications
bull Communication with patient amp between
providers
bull Expectations (PCP Specialist)
bull Early ID amp management of complications
bull End of life care vs Transplantation
Screening Programs
for Cirrhosis Patients
Screening in Patients with Cirrhosis
bull Portal hypertensionEsophageal Varices
ndash EGD at diagnosis of cirrhosis amp at regularly set intervals
bull No varices ndash every 3 years
bull Small varices ndash Repeat every 1 year
bull Medium to large varices ndash band ligation ndash Every 2 weeks until eradicated
ndash FU EGD 1-3 months post-eradication
ndash Every 6-12 months to assess for recurrence
Screening in Patients with Cirrhosis
bull Cancer
ndash Regular screenings unless patient is too high risk
ndash Hepatocellular carcinoma
bull Every 6 months
bull Risk Factors Cirrhosis alone smokers HCV HBV diabetes
bull AFP ndash not done alone but + imaging (false positives)
bull Ultrasound (alternate with high constrast CT or MRI)
bull Potentially curative treatments if caught in very early to
early stages (1 HCC lt 2cm or 1 HCC3 nodules lt3cm)
bull Chemo-embolization = palliative treatment
bull Preferential transplant listing if found early
Screening in Patients with Cirrhosis
bull Hepatic Encephalopathy
ndash Covert
bull Number connection test
bull Encephalapp Stroop test ndash iPhone app
ndash Overt
bull Clinical
bull Ammonia
ndash Do not routinely check it
ndash May add additional information to suspicions
ndash Do not screen compensated patients
Disease Progression
Slowing or Reversing
Alcohol Abstinence
bull Alcohol withdrawal syndrome occurs within 6-24 hrs after the last drink
bull Light to moderate AWS symptoms ndash Elevated BP amp HR
ndash Tremors
ndash Hyperreflexia
ndash Irritability anxiety
ndash HA
ndash Nausea vomiting
bull Severe symptoms of AWS ndash Delirium tremens
ndash Seizures
ndash Coma
ndash Cardiac arrest
ndash Death
Alcohol Abstinence
bull Treatment ndash Benzodiazepines (short- amp intermediate-
acting safer in liver disease ndash lorazepam)
ndash Disulfram Naltrexone or Acamprosate + counseling in pts without ALD only ndash to reduce ETOH consumption amp prevent relapse
ndash Baclofen in ALD to prevent relapse (5mg TIDx3days then 10mg TID x 90 days)
bull Alcoholic Hepatitis ndash Acute symptomatic liver failure ndash Often associated with cirrhosis but not always
Disease Progression Slowing or Preventing
bull Address obesity
bull Vitamin D supplementation
bull Many pts ask about milk thistle ndash study results have been mixed do not show any harm nor improvement
bull Avoidance of raw oysters clams shellfish ndash Exposure to fatal infection Vibrio vulnificus
bull Reversing fibrosis (amp maybe cirrhosis) ndash Hep B amp Hep C Antivirals
ndash Primary biliary cholangitis Ursodiol
ndash Hemochromatosis Phlebotomy
ndash NASH Weight loss Vitamin E
Minimizing Further Harm
bull Medication adjustments ndash The fewer drugs the betterhellip prescribe only crucial
ones stop the others
ndash Safe drugs
bull Acetaminophen (2 gramsday) amp statins
ndash Generally unsafe drugs
bull NSAIDs including diclofenac
ndash Block prostaglandin synthesis (which protects renal function) amp cause renal vasoconstriction
ndash Risk of GI bleeding
ndash Blunt response to diuretics
bull Nitrofurantoin amp aminoglycosides
bull Herbs ndash many
Minimizing Further Harm
bull Surgical Risk ndash Increased morbidity amp mortality
ndash Abdominal surgery ndash worse outcomes
ndash Childs Classification risk stratification
bull Class A 10 mortality rate
bull Class B 30 mortality rate
bull Class C 80 mortality rate
ndash MELD score ndash validated as a predictor of 30- and 90-day mortality after surgery
bull Vaccinations ndash Hep A amp B
ndash Pneumococcal
ndash Influenza yearly
Management of the
Compensated vs
Decompensated
Cirrhosis Patient
Management - Compensated
bull 15-20 will decompensate in 10-20 years
bull Nutrition ndash 1-2 gramskgday protein
ndash Well-balanced diet
ndash Frequent small meals
ndash No skipping meals
ndash No protein restriction
ndash 1 can Ensure 1-2 times daily
ndash Daily multivitamin without iron
bull Vaccinate amp DOCUMENT administration amp IMMUNITY
Management - Compensated
bull Avoid weight gain
bull Gradual weight loss to normal BMI if obese
bull Tight glucose control
bull Address any dyslipidemia (statins are safe)
bull Avoid ETOH amp hepatotoxins ndash Avoid NSAIDs even celecoxib
ndash Tylenol is fine up to 2 grams per day (unless actively drinking)
ndash Tramadol 50mg TID with severe pain (last resort)
ndash Avoid opioids
Turn for the worse Decompensation
bull 58 of compensated pts will decompensate within 10 years
bull Decompensated disease has a 50-80 5-year mortality
bull Development of any of the following complications
ndash Jaundice due to hepatic insufficiency ndash ID amp tx superimposed causes (alcoholic hepatitis sepsis drug hepatotoxicity)
ndash Variceal hemorrhage ndash most deadly
ndash Ascites ndash most common to herald onset
ndash Encephalopathy
Turn for the worse Decompensation
bull Pathophysiology of Portal Hypertension
ndash Fibrosisnodules architectural distortion
ndash Decreased production of nitric oxide by liver
ndash Increased intrahepatic vasocontriction in liver
ndash Reduced blood flow to and through liver
ndash Formation of porto-systemic collaterals (higher
resistance) = Increased resistance in the liver
ndash Hyperdynamic circulation from vasodilation in
splanchnic arterioles increased blood flow into
portal vein
Management - Decompensated
bull Average life expectancy approximately 2 years
bull Nausea ndash metoclopramide gt odansetron but rf EPS
bull Itching ndash cholestyramine most effective sertraline
bull Fatigue ndash Rest
ndash Exercise
bull Insomnia ndash Sleep hygiene
ndash Benadryl 50mg QHS hydroxyzine 25mg QHS or trazodone 50-100mg QHS (rf precipitating HE)
ndash Melatonin
ndash Rule out sleep apnea HE RLS
Management - Decompensated
bull Muscle cramps ndash Check electrolytes
bull Remember Na+ may be low do not correct unless lt120 (fluid restriction only)
bull Calcium often low ndash no need for correction
ndash Considerations bull BCAAs (4 gram granules TID)
bull Taurine 3 grams once daily
bull Vit E 200mg TID
bull Umbilical hernias ndash Repair only if symptomatic
ndash High complication rate
Management ndash Decompensated
bull Hyponatremia
ndash Common
ndash No treatment usually
unless lt 125 (free
water restriction of 1-
15 L daily)
bull Thrombocytopenia
ndash No treatment
ndash Platelet level of 50000 sufficient for most interventions
bull Coagulopathy
ndash Elevated INR
ndash No treatment usually
ndash May need FFP prior to elective intervention (dental surgical paracentesisradiological)
Hepatic Encephalopathy
bull Reversible change in mental status
bull Continuum from minimal to overt HE
bull Exclusion of other causes for brain dysfunction
bull Assessing for HE ndash Cognition
ndash Orientation
ndash Level of consciousness
ndash Asterixis
Hepatic Encephalopathy
B
Source University of Washingtons Hep C Online Module at httpwwwhepatitiscuwedugomanagement-cirrhosis-related-complicationshepatic-encephalopathy-diagnosis-managementcore-conceptall
Hepatic Encephalopathy
bull Most cases have an identifiable precipitant cause ndash GI bleed
ndash Excessive protein intake
ndash Infection (SBP UTI Pneumonia)
ndash Pre-renal azotemia
ndash Hypokalemic alkalosis
ndash Hyponatremia
ndash Constipation
ndash Hypoxia
ndash Use of sedatives tranquilizers
bull Normal protein diet
bull No driving
bull Safety in the home
Educate pts amp caregiversrelatives
regarding med compliance potential side effects
recognition of early signs of HE and measures to
prevent recurrence
Hepatic Encephalopathy
bull Lactulose 15-30mL BID titrating for 2-3 BMs per day ndash decreases blood ammonia concentration ndash Promotes elimination of toxins
ndash Reduces urease-producing bacteria
ndash Prevents absorption of bacteria
ndash Assists with any constipation - withhold for diarrhea
ndash Continued indefinitely
bull RifaximinXifaxan ndash non-absorbed broad spectrum abx ndash Change in bowel flora
ndash May cause downregulation of intestinal
glutamase activity
Ascites
bull 1-year survival rate 50 bull Usually go through a progression of diuretic response to
refractory ascites to HRS bull Ensure pt is truly adhering to dietary sodium restriction
amp avoiding NSAIDs bull Diagnostic paracentesis for all new onset ascites - ro SBP bull Sodium restriction ndash 2 grams per day - effective in 20 of
cases bull Fluid restriction - not necessary unless hyponatremia bull Diuretics bull TIPS ndash consider if requiring gt 1-2 LVPmonth
ndash 2nd line therapy
Ascites
bull Therapeutic large volume paracentesis ndash Administer with 100 grams albumin IV intraoperatively
(6-8 grams per liter removed) if gt 5 L removed
ndash Indications
bull Discomfort
bull Dyspnea
bull Tense ascites (hemodynamic improvement)
bull Refractory ascites
bull Renal insufficiency (compartment syndrome)
ndash Complications infection Post-paracentesis circulatory dysfunction
ndash Refractory Ascites stop beta blockers
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Goals
NCNA 2017 NPSS
Strengthen the primary care providerrsquos role and comfort level in providing safe timely care to the
patients with cirrhosis
Lay the foundation for prevention of cirrhosis through ID amp minimization or elimination of risk
factors
Overview
bull PCPsrsquo role in cirrhosis management amp
prevention
bull Causes amp pathophysiology
bull Management
ndash Compensated
ndash Decompensated
bull Opportunities
ndash Research and beyond
The Lovely Liver
bull Functions
ndash Synthesis
bull Albumin and many other proteins
bull Clotting factors
bull Fatty acids triglycerides cholesterol
ndash Formation and excretion of bile during bilirubin metabolism
ndash Regulation of glucosecarbohydrate balance
ndash Metabolism amp detoxification of drugs and other foreign substances
The Conundrum
bull ldquohellipthere is no explicit reference to which aspects
of care are in the domain of specialist versus the
generalist producing uncertainty that can
contribute to frustration or resentment for either
type of [provider]rdquo ndash Fox (2015)
bull Complexity
bull Time consuming
bull Quick decompensation
bull Requires specialist for EGDs anyway
Cirrhosis by the numbers
bull 55 million Americans
bull Many more are undiagnosed (10 million)
bull Hospital discharge Dx 10 increase between
2010 amp 2011
bull $12 BILLION per year (direct + indirect costs)
Life Expectancy
bull 10-13 years if compensated
bull 2 years if decompensated
bull Alcoholic cirrhosis
ndash Abstention x 3 years = 35 still alive
ndash Continue to drink = 0 still alive
bull Metabolic
ndash Nonalcoholic
steatohepatitis
ndash Hemochromatosis
ndash Wilsons disease
ndash α1-Antitrypsin deficiency
bull Vascular
ndash Budd-Chiari syndrome
ndash Cardiac cirrhosis
ndash Veno-occlusive disease
bull Cryptogenic (dx of exclusion)
bull Infectious ndash Chronic hepatitis B
ndash Chronic hepatitis C
bull Toxins ndash alcohol methotrexate
bull Autoimmune hepatitis
bull Cholestatic ndash Primary biliary cirrhosis
ndash Primary sclerosing cholangitis
Cirrhosis Etiologies
Cirrhosis Pathophysiology
Inflammation in liver results in
cytokine-mediated
activation of hepatic stellate
cells
Stellate cells et al produce
collagen Fibrosis
RESULT Extensive porto-central fibrosis with presence of regenerative noduleshellip cirrhosis
PCP ndash Risk Factors amp Covert Signs
bull Frequently asymptomatic until hepatic function severely reduced
bull Any patient with Hepatitis C infection (duration of infection gt 20-30 years when risk for cirrhosis peaks)
bull Any patient with fatty liver especially gt 20 years
bull Any patient with obesitymetabolic syndrome (majority have NAFLD)
bull Significant ETOH intake gt 10 years
bull Low platelet count (lt160000)
bull Low serum albumin
Late Physical Signs of Liver Disease
bull Abdominal ndash Hepatomegaly (followed
by small liver span)
ndash Splenomegaly
ndash Dilated abdominal vasculature
ndash Ascites
bull HEENT ndash Scleral icterus
ndash Xanthelasma
ndash Parotid swelling
ndash Kayser-Fleischer rings
ndash Fetor hepaticus
bull Musculoskeletal ndash Muscle wasting
ndash Palmar erythema
ndash Dupuytrens contracture
bull Neurological ndash Altered mental status
ndash Asterixis
bull Skin ndash Spider telangiectasia
ndash Jaundice
ndash Bruising
ndash Leukonychia
Cirrhosis Diagnosis
bull Labs ndash Low platelet count
ndash Low serum albumin
ndash Possibly low WBC count
ndash Elevated or NORMAL transaminases (ratio of ASTALT gt 1)
ndash Elevated PTINR
bull Ultrasound ndash nodular appearance
bull Other imaging studies ndash CT MRI
bull Biopsy ndash bridging fibrosis regenerative nodules
bull Noninvasive fibrosis testing ndash Transient elastography (FibroScanreg)
ndash Noninvasive serum biomarkers (FibroSUREreg [Quest Diagnostics] FIBROSpectreg II [PROMETHEUSreg Laboratories])
Classification System Child-Turcotte-Pugh
1 point 2 points 3 points
Encephalopathy None Grade 1-2 Grade 3-4
Ascites Absent Slight Moderate
Total bilirubin mgdL
lt2 2-3 gt3
Albumin gdL gt35 28 - 35 lt28
INR lt17 17 -23 gt23
Scoring 5-6 points ndash Class A ndash 30 reduction in hepatic function 7-9 points ndash Class B ndash 50 reduction in hepatic function 10-15 points ndash Class C ndash 90 reduction in hep function
Management Overview
bull Remove offending agent minimize further harm
bull Screen for complications
bull Minimize progression of secondary
complications
bull Communication with patient amp between
providers
bull Expectations (PCP Specialist)
bull Early ID amp management of complications
bull End of life care vs Transplantation
Screening Programs
for Cirrhosis Patients
Screening in Patients with Cirrhosis
bull Portal hypertensionEsophageal Varices
ndash EGD at diagnosis of cirrhosis amp at regularly set intervals
bull No varices ndash every 3 years
bull Small varices ndash Repeat every 1 year
bull Medium to large varices ndash band ligation ndash Every 2 weeks until eradicated
ndash FU EGD 1-3 months post-eradication
ndash Every 6-12 months to assess for recurrence
Screening in Patients with Cirrhosis
bull Cancer
ndash Regular screenings unless patient is too high risk
ndash Hepatocellular carcinoma
bull Every 6 months
bull Risk Factors Cirrhosis alone smokers HCV HBV diabetes
bull AFP ndash not done alone but + imaging (false positives)
bull Ultrasound (alternate with high constrast CT or MRI)
bull Potentially curative treatments if caught in very early to
early stages (1 HCC lt 2cm or 1 HCC3 nodules lt3cm)
bull Chemo-embolization = palliative treatment
bull Preferential transplant listing if found early
Screening in Patients with Cirrhosis
bull Hepatic Encephalopathy
ndash Covert
bull Number connection test
bull Encephalapp Stroop test ndash iPhone app
ndash Overt
bull Clinical
bull Ammonia
ndash Do not routinely check it
ndash May add additional information to suspicions
ndash Do not screen compensated patients
Disease Progression
Slowing or Reversing
Alcohol Abstinence
bull Alcohol withdrawal syndrome occurs within 6-24 hrs after the last drink
bull Light to moderate AWS symptoms ndash Elevated BP amp HR
ndash Tremors
ndash Hyperreflexia
ndash Irritability anxiety
ndash HA
ndash Nausea vomiting
bull Severe symptoms of AWS ndash Delirium tremens
ndash Seizures
ndash Coma
ndash Cardiac arrest
ndash Death
Alcohol Abstinence
bull Treatment ndash Benzodiazepines (short- amp intermediate-
acting safer in liver disease ndash lorazepam)
ndash Disulfram Naltrexone or Acamprosate + counseling in pts without ALD only ndash to reduce ETOH consumption amp prevent relapse
ndash Baclofen in ALD to prevent relapse (5mg TIDx3days then 10mg TID x 90 days)
bull Alcoholic Hepatitis ndash Acute symptomatic liver failure ndash Often associated with cirrhosis but not always
Disease Progression Slowing or Preventing
bull Address obesity
bull Vitamin D supplementation
bull Many pts ask about milk thistle ndash study results have been mixed do not show any harm nor improvement
bull Avoidance of raw oysters clams shellfish ndash Exposure to fatal infection Vibrio vulnificus
bull Reversing fibrosis (amp maybe cirrhosis) ndash Hep B amp Hep C Antivirals
ndash Primary biliary cholangitis Ursodiol
ndash Hemochromatosis Phlebotomy
ndash NASH Weight loss Vitamin E
Minimizing Further Harm
bull Medication adjustments ndash The fewer drugs the betterhellip prescribe only crucial
ones stop the others
ndash Safe drugs
bull Acetaminophen (2 gramsday) amp statins
ndash Generally unsafe drugs
bull NSAIDs including diclofenac
ndash Block prostaglandin synthesis (which protects renal function) amp cause renal vasoconstriction
ndash Risk of GI bleeding
ndash Blunt response to diuretics
bull Nitrofurantoin amp aminoglycosides
bull Herbs ndash many
Minimizing Further Harm
bull Surgical Risk ndash Increased morbidity amp mortality
ndash Abdominal surgery ndash worse outcomes
ndash Childs Classification risk stratification
bull Class A 10 mortality rate
bull Class B 30 mortality rate
bull Class C 80 mortality rate
ndash MELD score ndash validated as a predictor of 30- and 90-day mortality after surgery
bull Vaccinations ndash Hep A amp B
ndash Pneumococcal
ndash Influenza yearly
Management of the
Compensated vs
Decompensated
Cirrhosis Patient
Management - Compensated
bull 15-20 will decompensate in 10-20 years
bull Nutrition ndash 1-2 gramskgday protein
ndash Well-balanced diet
ndash Frequent small meals
ndash No skipping meals
ndash No protein restriction
ndash 1 can Ensure 1-2 times daily
ndash Daily multivitamin without iron
bull Vaccinate amp DOCUMENT administration amp IMMUNITY
Management - Compensated
bull Avoid weight gain
bull Gradual weight loss to normal BMI if obese
bull Tight glucose control
bull Address any dyslipidemia (statins are safe)
bull Avoid ETOH amp hepatotoxins ndash Avoid NSAIDs even celecoxib
ndash Tylenol is fine up to 2 grams per day (unless actively drinking)
ndash Tramadol 50mg TID with severe pain (last resort)
ndash Avoid opioids
Turn for the worse Decompensation
bull 58 of compensated pts will decompensate within 10 years
bull Decompensated disease has a 50-80 5-year mortality
bull Development of any of the following complications
ndash Jaundice due to hepatic insufficiency ndash ID amp tx superimposed causes (alcoholic hepatitis sepsis drug hepatotoxicity)
ndash Variceal hemorrhage ndash most deadly
ndash Ascites ndash most common to herald onset
ndash Encephalopathy
Turn for the worse Decompensation
bull Pathophysiology of Portal Hypertension
ndash Fibrosisnodules architectural distortion
ndash Decreased production of nitric oxide by liver
ndash Increased intrahepatic vasocontriction in liver
ndash Reduced blood flow to and through liver
ndash Formation of porto-systemic collaterals (higher
resistance) = Increased resistance in the liver
ndash Hyperdynamic circulation from vasodilation in
splanchnic arterioles increased blood flow into
portal vein
Management - Decompensated
bull Average life expectancy approximately 2 years
bull Nausea ndash metoclopramide gt odansetron but rf EPS
bull Itching ndash cholestyramine most effective sertraline
bull Fatigue ndash Rest
ndash Exercise
bull Insomnia ndash Sleep hygiene
ndash Benadryl 50mg QHS hydroxyzine 25mg QHS or trazodone 50-100mg QHS (rf precipitating HE)
ndash Melatonin
ndash Rule out sleep apnea HE RLS
Management - Decompensated
bull Muscle cramps ndash Check electrolytes
bull Remember Na+ may be low do not correct unless lt120 (fluid restriction only)
bull Calcium often low ndash no need for correction
ndash Considerations bull BCAAs (4 gram granules TID)
bull Taurine 3 grams once daily
bull Vit E 200mg TID
bull Umbilical hernias ndash Repair only if symptomatic
ndash High complication rate
Management ndash Decompensated
bull Hyponatremia
ndash Common
ndash No treatment usually
unless lt 125 (free
water restriction of 1-
15 L daily)
bull Thrombocytopenia
ndash No treatment
ndash Platelet level of 50000 sufficient for most interventions
bull Coagulopathy
ndash Elevated INR
ndash No treatment usually
ndash May need FFP prior to elective intervention (dental surgical paracentesisradiological)
Hepatic Encephalopathy
bull Reversible change in mental status
bull Continuum from minimal to overt HE
bull Exclusion of other causes for brain dysfunction
bull Assessing for HE ndash Cognition
ndash Orientation
ndash Level of consciousness
ndash Asterixis
Hepatic Encephalopathy
B
Source University of Washingtons Hep C Online Module at httpwwwhepatitiscuwedugomanagement-cirrhosis-related-complicationshepatic-encephalopathy-diagnosis-managementcore-conceptall
Hepatic Encephalopathy
bull Most cases have an identifiable precipitant cause ndash GI bleed
ndash Excessive protein intake
ndash Infection (SBP UTI Pneumonia)
ndash Pre-renal azotemia
ndash Hypokalemic alkalosis
ndash Hyponatremia
ndash Constipation
ndash Hypoxia
ndash Use of sedatives tranquilizers
bull Normal protein diet
bull No driving
bull Safety in the home
Educate pts amp caregiversrelatives
regarding med compliance potential side effects
recognition of early signs of HE and measures to
prevent recurrence
Hepatic Encephalopathy
bull Lactulose 15-30mL BID titrating for 2-3 BMs per day ndash decreases blood ammonia concentration ndash Promotes elimination of toxins
ndash Reduces urease-producing bacteria
ndash Prevents absorption of bacteria
ndash Assists with any constipation - withhold for diarrhea
ndash Continued indefinitely
bull RifaximinXifaxan ndash non-absorbed broad spectrum abx ndash Change in bowel flora
ndash May cause downregulation of intestinal
glutamase activity
Ascites
bull 1-year survival rate 50 bull Usually go through a progression of diuretic response to
refractory ascites to HRS bull Ensure pt is truly adhering to dietary sodium restriction
amp avoiding NSAIDs bull Diagnostic paracentesis for all new onset ascites - ro SBP bull Sodium restriction ndash 2 grams per day - effective in 20 of
cases bull Fluid restriction - not necessary unless hyponatremia bull Diuretics bull TIPS ndash consider if requiring gt 1-2 LVPmonth
ndash 2nd line therapy
Ascites
bull Therapeutic large volume paracentesis ndash Administer with 100 grams albumin IV intraoperatively
(6-8 grams per liter removed) if gt 5 L removed
ndash Indications
bull Discomfort
bull Dyspnea
bull Tense ascites (hemodynamic improvement)
bull Refractory ascites
bull Renal insufficiency (compartment syndrome)
ndash Complications infection Post-paracentesis circulatory dysfunction
ndash Refractory Ascites stop beta blockers
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Overview
bull PCPsrsquo role in cirrhosis management amp
prevention
bull Causes amp pathophysiology
bull Management
ndash Compensated
ndash Decompensated
bull Opportunities
ndash Research and beyond
The Lovely Liver
bull Functions
ndash Synthesis
bull Albumin and many other proteins
bull Clotting factors
bull Fatty acids triglycerides cholesterol
ndash Formation and excretion of bile during bilirubin metabolism
ndash Regulation of glucosecarbohydrate balance
ndash Metabolism amp detoxification of drugs and other foreign substances
The Conundrum
bull ldquohellipthere is no explicit reference to which aspects
of care are in the domain of specialist versus the
generalist producing uncertainty that can
contribute to frustration or resentment for either
type of [provider]rdquo ndash Fox (2015)
bull Complexity
bull Time consuming
bull Quick decompensation
bull Requires specialist for EGDs anyway
Cirrhosis by the numbers
bull 55 million Americans
bull Many more are undiagnosed (10 million)
bull Hospital discharge Dx 10 increase between
2010 amp 2011
bull $12 BILLION per year (direct + indirect costs)
Life Expectancy
bull 10-13 years if compensated
bull 2 years if decompensated
bull Alcoholic cirrhosis
ndash Abstention x 3 years = 35 still alive
ndash Continue to drink = 0 still alive
bull Metabolic
ndash Nonalcoholic
steatohepatitis
ndash Hemochromatosis
ndash Wilsons disease
ndash α1-Antitrypsin deficiency
bull Vascular
ndash Budd-Chiari syndrome
ndash Cardiac cirrhosis
ndash Veno-occlusive disease
bull Cryptogenic (dx of exclusion)
bull Infectious ndash Chronic hepatitis B
ndash Chronic hepatitis C
bull Toxins ndash alcohol methotrexate
bull Autoimmune hepatitis
bull Cholestatic ndash Primary biliary cirrhosis
ndash Primary sclerosing cholangitis
Cirrhosis Etiologies
Cirrhosis Pathophysiology
Inflammation in liver results in
cytokine-mediated
activation of hepatic stellate
cells
Stellate cells et al produce
collagen Fibrosis
RESULT Extensive porto-central fibrosis with presence of regenerative noduleshellip cirrhosis
PCP ndash Risk Factors amp Covert Signs
bull Frequently asymptomatic until hepatic function severely reduced
bull Any patient with Hepatitis C infection (duration of infection gt 20-30 years when risk for cirrhosis peaks)
bull Any patient with fatty liver especially gt 20 years
bull Any patient with obesitymetabolic syndrome (majority have NAFLD)
bull Significant ETOH intake gt 10 years
bull Low platelet count (lt160000)
bull Low serum albumin
Late Physical Signs of Liver Disease
bull Abdominal ndash Hepatomegaly (followed
by small liver span)
ndash Splenomegaly
ndash Dilated abdominal vasculature
ndash Ascites
bull HEENT ndash Scleral icterus
ndash Xanthelasma
ndash Parotid swelling
ndash Kayser-Fleischer rings
ndash Fetor hepaticus
bull Musculoskeletal ndash Muscle wasting
ndash Palmar erythema
ndash Dupuytrens contracture
bull Neurological ndash Altered mental status
ndash Asterixis
bull Skin ndash Spider telangiectasia
ndash Jaundice
ndash Bruising
ndash Leukonychia
Cirrhosis Diagnosis
bull Labs ndash Low platelet count
ndash Low serum albumin
ndash Possibly low WBC count
ndash Elevated or NORMAL transaminases (ratio of ASTALT gt 1)
ndash Elevated PTINR
bull Ultrasound ndash nodular appearance
bull Other imaging studies ndash CT MRI
bull Biopsy ndash bridging fibrosis regenerative nodules
bull Noninvasive fibrosis testing ndash Transient elastography (FibroScanreg)
ndash Noninvasive serum biomarkers (FibroSUREreg [Quest Diagnostics] FIBROSpectreg II [PROMETHEUSreg Laboratories])
Classification System Child-Turcotte-Pugh
1 point 2 points 3 points
Encephalopathy None Grade 1-2 Grade 3-4
Ascites Absent Slight Moderate
Total bilirubin mgdL
lt2 2-3 gt3
Albumin gdL gt35 28 - 35 lt28
INR lt17 17 -23 gt23
Scoring 5-6 points ndash Class A ndash 30 reduction in hepatic function 7-9 points ndash Class B ndash 50 reduction in hepatic function 10-15 points ndash Class C ndash 90 reduction in hep function
Management Overview
bull Remove offending agent minimize further harm
bull Screen for complications
bull Minimize progression of secondary
complications
bull Communication with patient amp between
providers
bull Expectations (PCP Specialist)
bull Early ID amp management of complications
bull End of life care vs Transplantation
Screening Programs
for Cirrhosis Patients
Screening in Patients with Cirrhosis
bull Portal hypertensionEsophageal Varices
ndash EGD at diagnosis of cirrhosis amp at regularly set intervals
bull No varices ndash every 3 years
bull Small varices ndash Repeat every 1 year
bull Medium to large varices ndash band ligation ndash Every 2 weeks until eradicated
ndash FU EGD 1-3 months post-eradication
ndash Every 6-12 months to assess for recurrence
Screening in Patients with Cirrhosis
bull Cancer
ndash Regular screenings unless patient is too high risk
ndash Hepatocellular carcinoma
bull Every 6 months
bull Risk Factors Cirrhosis alone smokers HCV HBV diabetes
bull AFP ndash not done alone but + imaging (false positives)
bull Ultrasound (alternate with high constrast CT or MRI)
bull Potentially curative treatments if caught in very early to
early stages (1 HCC lt 2cm or 1 HCC3 nodules lt3cm)
bull Chemo-embolization = palliative treatment
bull Preferential transplant listing if found early
Screening in Patients with Cirrhosis
bull Hepatic Encephalopathy
ndash Covert
bull Number connection test
bull Encephalapp Stroop test ndash iPhone app
ndash Overt
bull Clinical
bull Ammonia
ndash Do not routinely check it
ndash May add additional information to suspicions
ndash Do not screen compensated patients
Disease Progression
Slowing or Reversing
Alcohol Abstinence
bull Alcohol withdrawal syndrome occurs within 6-24 hrs after the last drink
bull Light to moderate AWS symptoms ndash Elevated BP amp HR
ndash Tremors
ndash Hyperreflexia
ndash Irritability anxiety
ndash HA
ndash Nausea vomiting
bull Severe symptoms of AWS ndash Delirium tremens
ndash Seizures
ndash Coma
ndash Cardiac arrest
ndash Death
Alcohol Abstinence
bull Treatment ndash Benzodiazepines (short- amp intermediate-
acting safer in liver disease ndash lorazepam)
ndash Disulfram Naltrexone or Acamprosate + counseling in pts without ALD only ndash to reduce ETOH consumption amp prevent relapse
ndash Baclofen in ALD to prevent relapse (5mg TIDx3days then 10mg TID x 90 days)
bull Alcoholic Hepatitis ndash Acute symptomatic liver failure ndash Often associated with cirrhosis but not always
Disease Progression Slowing or Preventing
bull Address obesity
bull Vitamin D supplementation
bull Many pts ask about milk thistle ndash study results have been mixed do not show any harm nor improvement
bull Avoidance of raw oysters clams shellfish ndash Exposure to fatal infection Vibrio vulnificus
bull Reversing fibrosis (amp maybe cirrhosis) ndash Hep B amp Hep C Antivirals
ndash Primary biliary cholangitis Ursodiol
ndash Hemochromatosis Phlebotomy
ndash NASH Weight loss Vitamin E
Minimizing Further Harm
bull Medication adjustments ndash The fewer drugs the betterhellip prescribe only crucial
ones stop the others
ndash Safe drugs
bull Acetaminophen (2 gramsday) amp statins
ndash Generally unsafe drugs
bull NSAIDs including diclofenac
ndash Block prostaglandin synthesis (which protects renal function) amp cause renal vasoconstriction
ndash Risk of GI bleeding
ndash Blunt response to diuretics
bull Nitrofurantoin amp aminoglycosides
bull Herbs ndash many
Minimizing Further Harm
bull Surgical Risk ndash Increased morbidity amp mortality
ndash Abdominal surgery ndash worse outcomes
ndash Childs Classification risk stratification
bull Class A 10 mortality rate
bull Class B 30 mortality rate
bull Class C 80 mortality rate
ndash MELD score ndash validated as a predictor of 30- and 90-day mortality after surgery
bull Vaccinations ndash Hep A amp B
ndash Pneumococcal
ndash Influenza yearly
Management of the
Compensated vs
Decompensated
Cirrhosis Patient
Management - Compensated
bull 15-20 will decompensate in 10-20 years
bull Nutrition ndash 1-2 gramskgday protein
ndash Well-balanced diet
ndash Frequent small meals
ndash No skipping meals
ndash No protein restriction
ndash 1 can Ensure 1-2 times daily
ndash Daily multivitamin without iron
bull Vaccinate amp DOCUMENT administration amp IMMUNITY
Management - Compensated
bull Avoid weight gain
bull Gradual weight loss to normal BMI if obese
bull Tight glucose control
bull Address any dyslipidemia (statins are safe)
bull Avoid ETOH amp hepatotoxins ndash Avoid NSAIDs even celecoxib
ndash Tylenol is fine up to 2 grams per day (unless actively drinking)
ndash Tramadol 50mg TID with severe pain (last resort)
ndash Avoid opioids
Turn for the worse Decompensation
bull 58 of compensated pts will decompensate within 10 years
bull Decompensated disease has a 50-80 5-year mortality
bull Development of any of the following complications
ndash Jaundice due to hepatic insufficiency ndash ID amp tx superimposed causes (alcoholic hepatitis sepsis drug hepatotoxicity)
ndash Variceal hemorrhage ndash most deadly
ndash Ascites ndash most common to herald onset
ndash Encephalopathy
Turn for the worse Decompensation
bull Pathophysiology of Portal Hypertension
ndash Fibrosisnodules architectural distortion
ndash Decreased production of nitric oxide by liver
ndash Increased intrahepatic vasocontriction in liver
ndash Reduced blood flow to and through liver
ndash Formation of porto-systemic collaterals (higher
resistance) = Increased resistance in the liver
ndash Hyperdynamic circulation from vasodilation in
splanchnic arterioles increased blood flow into
portal vein
Management - Decompensated
bull Average life expectancy approximately 2 years
bull Nausea ndash metoclopramide gt odansetron but rf EPS
bull Itching ndash cholestyramine most effective sertraline
bull Fatigue ndash Rest
ndash Exercise
bull Insomnia ndash Sleep hygiene
ndash Benadryl 50mg QHS hydroxyzine 25mg QHS or trazodone 50-100mg QHS (rf precipitating HE)
ndash Melatonin
ndash Rule out sleep apnea HE RLS
Management - Decompensated
bull Muscle cramps ndash Check electrolytes
bull Remember Na+ may be low do not correct unless lt120 (fluid restriction only)
bull Calcium often low ndash no need for correction
ndash Considerations bull BCAAs (4 gram granules TID)
bull Taurine 3 grams once daily
bull Vit E 200mg TID
bull Umbilical hernias ndash Repair only if symptomatic
ndash High complication rate
Management ndash Decompensated
bull Hyponatremia
ndash Common
ndash No treatment usually
unless lt 125 (free
water restriction of 1-
15 L daily)
bull Thrombocytopenia
ndash No treatment
ndash Platelet level of 50000 sufficient for most interventions
bull Coagulopathy
ndash Elevated INR
ndash No treatment usually
ndash May need FFP prior to elective intervention (dental surgical paracentesisradiological)
Hepatic Encephalopathy
bull Reversible change in mental status
bull Continuum from minimal to overt HE
bull Exclusion of other causes for brain dysfunction
bull Assessing for HE ndash Cognition
ndash Orientation
ndash Level of consciousness
ndash Asterixis
Hepatic Encephalopathy
B
Source University of Washingtons Hep C Online Module at httpwwwhepatitiscuwedugomanagement-cirrhosis-related-complicationshepatic-encephalopathy-diagnosis-managementcore-conceptall
Hepatic Encephalopathy
bull Most cases have an identifiable precipitant cause ndash GI bleed
ndash Excessive protein intake
ndash Infection (SBP UTI Pneumonia)
ndash Pre-renal azotemia
ndash Hypokalemic alkalosis
ndash Hyponatremia
ndash Constipation
ndash Hypoxia
ndash Use of sedatives tranquilizers
bull Normal protein diet
bull No driving
bull Safety in the home
Educate pts amp caregiversrelatives
regarding med compliance potential side effects
recognition of early signs of HE and measures to
prevent recurrence
Hepatic Encephalopathy
bull Lactulose 15-30mL BID titrating for 2-3 BMs per day ndash decreases blood ammonia concentration ndash Promotes elimination of toxins
ndash Reduces urease-producing bacteria
ndash Prevents absorption of bacteria
ndash Assists with any constipation - withhold for diarrhea
ndash Continued indefinitely
bull RifaximinXifaxan ndash non-absorbed broad spectrum abx ndash Change in bowel flora
ndash May cause downregulation of intestinal
glutamase activity
Ascites
bull 1-year survival rate 50 bull Usually go through a progression of diuretic response to
refractory ascites to HRS bull Ensure pt is truly adhering to dietary sodium restriction
amp avoiding NSAIDs bull Diagnostic paracentesis for all new onset ascites - ro SBP bull Sodium restriction ndash 2 grams per day - effective in 20 of
cases bull Fluid restriction - not necessary unless hyponatremia bull Diuretics bull TIPS ndash consider if requiring gt 1-2 LVPmonth
ndash 2nd line therapy
Ascites
bull Therapeutic large volume paracentesis ndash Administer with 100 grams albumin IV intraoperatively
(6-8 grams per liter removed) if gt 5 L removed
ndash Indications
bull Discomfort
bull Dyspnea
bull Tense ascites (hemodynamic improvement)
bull Refractory ascites
bull Renal insufficiency (compartment syndrome)
ndash Complications infection Post-paracentesis circulatory dysfunction
ndash Refractory Ascites stop beta blockers
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
The Lovely Liver
bull Functions
ndash Synthesis
bull Albumin and many other proteins
bull Clotting factors
bull Fatty acids triglycerides cholesterol
ndash Formation and excretion of bile during bilirubin metabolism
ndash Regulation of glucosecarbohydrate balance
ndash Metabolism amp detoxification of drugs and other foreign substances
The Conundrum
bull ldquohellipthere is no explicit reference to which aspects
of care are in the domain of specialist versus the
generalist producing uncertainty that can
contribute to frustration or resentment for either
type of [provider]rdquo ndash Fox (2015)
bull Complexity
bull Time consuming
bull Quick decompensation
bull Requires specialist for EGDs anyway
Cirrhosis by the numbers
bull 55 million Americans
bull Many more are undiagnosed (10 million)
bull Hospital discharge Dx 10 increase between
2010 amp 2011
bull $12 BILLION per year (direct + indirect costs)
Life Expectancy
bull 10-13 years if compensated
bull 2 years if decompensated
bull Alcoholic cirrhosis
ndash Abstention x 3 years = 35 still alive
ndash Continue to drink = 0 still alive
bull Metabolic
ndash Nonalcoholic
steatohepatitis
ndash Hemochromatosis
ndash Wilsons disease
ndash α1-Antitrypsin deficiency
bull Vascular
ndash Budd-Chiari syndrome
ndash Cardiac cirrhosis
ndash Veno-occlusive disease
bull Cryptogenic (dx of exclusion)
bull Infectious ndash Chronic hepatitis B
ndash Chronic hepatitis C
bull Toxins ndash alcohol methotrexate
bull Autoimmune hepatitis
bull Cholestatic ndash Primary biliary cirrhosis
ndash Primary sclerosing cholangitis
Cirrhosis Etiologies
Cirrhosis Pathophysiology
Inflammation in liver results in
cytokine-mediated
activation of hepatic stellate
cells
Stellate cells et al produce
collagen Fibrosis
RESULT Extensive porto-central fibrosis with presence of regenerative noduleshellip cirrhosis
PCP ndash Risk Factors amp Covert Signs
bull Frequently asymptomatic until hepatic function severely reduced
bull Any patient with Hepatitis C infection (duration of infection gt 20-30 years when risk for cirrhosis peaks)
bull Any patient with fatty liver especially gt 20 years
bull Any patient with obesitymetabolic syndrome (majority have NAFLD)
bull Significant ETOH intake gt 10 years
bull Low platelet count (lt160000)
bull Low serum albumin
Late Physical Signs of Liver Disease
bull Abdominal ndash Hepatomegaly (followed
by small liver span)
ndash Splenomegaly
ndash Dilated abdominal vasculature
ndash Ascites
bull HEENT ndash Scleral icterus
ndash Xanthelasma
ndash Parotid swelling
ndash Kayser-Fleischer rings
ndash Fetor hepaticus
bull Musculoskeletal ndash Muscle wasting
ndash Palmar erythema
ndash Dupuytrens contracture
bull Neurological ndash Altered mental status
ndash Asterixis
bull Skin ndash Spider telangiectasia
ndash Jaundice
ndash Bruising
ndash Leukonychia
Cirrhosis Diagnosis
bull Labs ndash Low platelet count
ndash Low serum albumin
ndash Possibly low WBC count
ndash Elevated or NORMAL transaminases (ratio of ASTALT gt 1)
ndash Elevated PTINR
bull Ultrasound ndash nodular appearance
bull Other imaging studies ndash CT MRI
bull Biopsy ndash bridging fibrosis regenerative nodules
bull Noninvasive fibrosis testing ndash Transient elastography (FibroScanreg)
ndash Noninvasive serum biomarkers (FibroSUREreg [Quest Diagnostics] FIBROSpectreg II [PROMETHEUSreg Laboratories])
Classification System Child-Turcotte-Pugh
1 point 2 points 3 points
Encephalopathy None Grade 1-2 Grade 3-4
Ascites Absent Slight Moderate
Total bilirubin mgdL
lt2 2-3 gt3
Albumin gdL gt35 28 - 35 lt28
INR lt17 17 -23 gt23
Scoring 5-6 points ndash Class A ndash 30 reduction in hepatic function 7-9 points ndash Class B ndash 50 reduction in hepatic function 10-15 points ndash Class C ndash 90 reduction in hep function
Management Overview
bull Remove offending agent minimize further harm
bull Screen for complications
bull Minimize progression of secondary
complications
bull Communication with patient amp between
providers
bull Expectations (PCP Specialist)
bull Early ID amp management of complications
bull End of life care vs Transplantation
Screening Programs
for Cirrhosis Patients
Screening in Patients with Cirrhosis
bull Portal hypertensionEsophageal Varices
ndash EGD at diagnosis of cirrhosis amp at regularly set intervals
bull No varices ndash every 3 years
bull Small varices ndash Repeat every 1 year
bull Medium to large varices ndash band ligation ndash Every 2 weeks until eradicated
ndash FU EGD 1-3 months post-eradication
ndash Every 6-12 months to assess for recurrence
Screening in Patients with Cirrhosis
bull Cancer
ndash Regular screenings unless patient is too high risk
ndash Hepatocellular carcinoma
bull Every 6 months
bull Risk Factors Cirrhosis alone smokers HCV HBV diabetes
bull AFP ndash not done alone but + imaging (false positives)
bull Ultrasound (alternate with high constrast CT or MRI)
bull Potentially curative treatments if caught in very early to
early stages (1 HCC lt 2cm or 1 HCC3 nodules lt3cm)
bull Chemo-embolization = palliative treatment
bull Preferential transplant listing if found early
Screening in Patients with Cirrhosis
bull Hepatic Encephalopathy
ndash Covert
bull Number connection test
bull Encephalapp Stroop test ndash iPhone app
ndash Overt
bull Clinical
bull Ammonia
ndash Do not routinely check it
ndash May add additional information to suspicions
ndash Do not screen compensated patients
Disease Progression
Slowing or Reversing
Alcohol Abstinence
bull Alcohol withdrawal syndrome occurs within 6-24 hrs after the last drink
bull Light to moderate AWS symptoms ndash Elevated BP amp HR
ndash Tremors
ndash Hyperreflexia
ndash Irritability anxiety
ndash HA
ndash Nausea vomiting
bull Severe symptoms of AWS ndash Delirium tremens
ndash Seizures
ndash Coma
ndash Cardiac arrest
ndash Death
Alcohol Abstinence
bull Treatment ndash Benzodiazepines (short- amp intermediate-
acting safer in liver disease ndash lorazepam)
ndash Disulfram Naltrexone or Acamprosate + counseling in pts without ALD only ndash to reduce ETOH consumption amp prevent relapse
ndash Baclofen in ALD to prevent relapse (5mg TIDx3days then 10mg TID x 90 days)
bull Alcoholic Hepatitis ndash Acute symptomatic liver failure ndash Often associated with cirrhosis but not always
Disease Progression Slowing or Preventing
bull Address obesity
bull Vitamin D supplementation
bull Many pts ask about milk thistle ndash study results have been mixed do not show any harm nor improvement
bull Avoidance of raw oysters clams shellfish ndash Exposure to fatal infection Vibrio vulnificus
bull Reversing fibrosis (amp maybe cirrhosis) ndash Hep B amp Hep C Antivirals
ndash Primary biliary cholangitis Ursodiol
ndash Hemochromatosis Phlebotomy
ndash NASH Weight loss Vitamin E
Minimizing Further Harm
bull Medication adjustments ndash The fewer drugs the betterhellip prescribe only crucial
ones stop the others
ndash Safe drugs
bull Acetaminophen (2 gramsday) amp statins
ndash Generally unsafe drugs
bull NSAIDs including diclofenac
ndash Block prostaglandin synthesis (which protects renal function) amp cause renal vasoconstriction
ndash Risk of GI bleeding
ndash Blunt response to diuretics
bull Nitrofurantoin amp aminoglycosides
bull Herbs ndash many
Minimizing Further Harm
bull Surgical Risk ndash Increased morbidity amp mortality
ndash Abdominal surgery ndash worse outcomes
ndash Childs Classification risk stratification
bull Class A 10 mortality rate
bull Class B 30 mortality rate
bull Class C 80 mortality rate
ndash MELD score ndash validated as a predictor of 30- and 90-day mortality after surgery
bull Vaccinations ndash Hep A amp B
ndash Pneumococcal
ndash Influenza yearly
Management of the
Compensated vs
Decompensated
Cirrhosis Patient
Management - Compensated
bull 15-20 will decompensate in 10-20 years
bull Nutrition ndash 1-2 gramskgday protein
ndash Well-balanced diet
ndash Frequent small meals
ndash No skipping meals
ndash No protein restriction
ndash 1 can Ensure 1-2 times daily
ndash Daily multivitamin without iron
bull Vaccinate amp DOCUMENT administration amp IMMUNITY
Management - Compensated
bull Avoid weight gain
bull Gradual weight loss to normal BMI if obese
bull Tight glucose control
bull Address any dyslipidemia (statins are safe)
bull Avoid ETOH amp hepatotoxins ndash Avoid NSAIDs even celecoxib
ndash Tylenol is fine up to 2 grams per day (unless actively drinking)
ndash Tramadol 50mg TID with severe pain (last resort)
ndash Avoid opioids
Turn for the worse Decompensation
bull 58 of compensated pts will decompensate within 10 years
bull Decompensated disease has a 50-80 5-year mortality
bull Development of any of the following complications
ndash Jaundice due to hepatic insufficiency ndash ID amp tx superimposed causes (alcoholic hepatitis sepsis drug hepatotoxicity)
ndash Variceal hemorrhage ndash most deadly
ndash Ascites ndash most common to herald onset
ndash Encephalopathy
Turn for the worse Decompensation
bull Pathophysiology of Portal Hypertension
ndash Fibrosisnodules architectural distortion
ndash Decreased production of nitric oxide by liver
ndash Increased intrahepatic vasocontriction in liver
ndash Reduced blood flow to and through liver
ndash Formation of porto-systemic collaterals (higher
resistance) = Increased resistance in the liver
ndash Hyperdynamic circulation from vasodilation in
splanchnic arterioles increased blood flow into
portal vein
Management - Decompensated
bull Average life expectancy approximately 2 years
bull Nausea ndash metoclopramide gt odansetron but rf EPS
bull Itching ndash cholestyramine most effective sertraline
bull Fatigue ndash Rest
ndash Exercise
bull Insomnia ndash Sleep hygiene
ndash Benadryl 50mg QHS hydroxyzine 25mg QHS or trazodone 50-100mg QHS (rf precipitating HE)
ndash Melatonin
ndash Rule out sleep apnea HE RLS
Management - Decompensated
bull Muscle cramps ndash Check electrolytes
bull Remember Na+ may be low do not correct unless lt120 (fluid restriction only)
bull Calcium often low ndash no need for correction
ndash Considerations bull BCAAs (4 gram granules TID)
bull Taurine 3 grams once daily
bull Vit E 200mg TID
bull Umbilical hernias ndash Repair only if symptomatic
ndash High complication rate
Management ndash Decompensated
bull Hyponatremia
ndash Common
ndash No treatment usually
unless lt 125 (free
water restriction of 1-
15 L daily)
bull Thrombocytopenia
ndash No treatment
ndash Platelet level of 50000 sufficient for most interventions
bull Coagulopathy
ndash Elevated INR
ndash No treatment usually
ndash May need FFP prior to elective intervention (dental surgical paracentesisradiological)
Hepatic Encephalopathy
bull Reversible change in mental status
bull Continuum from minimal to overt HE
bull Exclusion of other causes for brain dysfunction
bull Assessing for HE ndash Cognition
ndash Orientation
ndash Level of consciousness
ndash Asterixis
Hepatic Encephalopathy
B
Source University of Washingtons Hep C Online Module at httpwwwhepatitiscuwedugomanagement-cirrhosis-related-complicationshepatic-encephalopathy-diagnosis-managementcore-conceptall
Hepatic Encephalopathy
bull Most cases have an identifiable precipitant cause ndash GI bleed
ndash Excessive protein intake
ndash Infection (SBP UTI Pneumonia)
ndash Pre-renal azotemia
ndash Hypokalemic alkalosis
ndash Hyponatremia
ndash Constipation
ndash Hypoxia
ndash Use of sedatives tranquilizers
bull Normal protein diet
bull No driving
bull Safety in the home
Educate pts amp caregiversrelatives
regarding med compliance potential side effects
recognition of early signs of HE and measures to
prevent recurrence
Hepatic Encephalopathy
bull Lactulose 15-30mL BID titrating for 2-3 BMs per day ndash decreases blood ammonia concentration ndash Promotes elimination of toxins
ndash Reduces urease-producing bacteria
ndash Prevents absorption of bacteria
ndash Assists with any constipation - withhold for diarrhea
ndash Continued indefinitely
bull RifaximinXifaxan ndash non-absorbed broad spectrum abx ndash Change in bowel flora
ndash May cause downregulation of intestinal
glutamase activity
Ascites
bull 1-year survival rate 50 bull Usually go through a progression of diuretic response to
refractory ascites to HRS bull Ensure pt is truly adhering to dietary sodium restriction
amp avoiding NSAIDs bull Diagnostic paracentesis for all new onset ascites - ro SBP bull Sodium restriction ndash 2 grams per day - effective in 20 of
cases bull Fluid restriction - not necessary unless hyponatremia bull Diuretics bull TIPS ndash consider if requiring gt 1-2 LVPmonth
ndash 2nd line therapy
Ascites
bull Therapeutic large volume paracentesis ndash Administer with 100 grams albumin IV intraoperatively
(6-8 grams per liter removed) if gt 5 L removed
ndash Indications
bull Discomfort
bull Dyspnea
bull Tense ascites (hemodynamic improvement)
bull Refractory ascites
bull Renal insufficiency (compartment syndrome)
ndash Complications infection Post-paracentesis circulatory dysfunction
ndash Refractory Ascites stop beta blockers
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
The Conundrum
bull ldquohellipthere is no explicit reference to which aspects
of care are in the domain of specialist versus the
generalist producing uncertainty that can
contribute to frustration or resentment for either
type of [provider]rdquo ndash Fox (2015)
bull Complexity
bull Time consuming
bull Quick decompensation
bull Requires specialist for EGDs anyway
Cirrhosis by the numbers
bull 55 million Americans
bull Many more are undiagnosed (10 million)
bull Hospital discharge Dx 10 increase between
2010 amp 2011
bull $12 BILLION per year (direct + indirect costs)
Life Expectancy
bull 10-13 years if compensated
bull 2 years if decompensated
bull Alcoholic cirrhosis
ndash Abstention x 3 years = 35 still alive
ndash Continue to drink = 0 still alive
bull Metabolic
ndash Nonalcoholic
steatohepatitis
ndash Hemochromatosis
ndash Wilsons disease
ndash α1-Antitrypsin deficiency
bull Vascular
ndash Budd-Chiari syndrome
ndash Cardiac cirrhosis
ndash Veno-occlusive disease
bull Cryptogenic (dx of exclusion)
bull Infectious ndash Chronic hepatitis B
ndash Chronic hepatitis C
bull Toxins ndash alcohol methotrexate
bull Autoimmune hepatitis
bull Cholestatic ndash Primary biliary cirrhosis
ndash Primary sclerosing cholangitis
Cirrhosis Etiologies
Cirrhosis Pathophysiology
Inflammation in liver results in
cytokine-mediated
activation of hepatic stellate
cells
Stellate cells et al produce
collagen Fibrosis
RESULT Extensive porto-central fibrosis with presence of regenerative noduleshellip cirrhosis
PCP ndash Risk Factors amp Covert Signs
bull Frequently asymptomatic until hepatic function severely reduced
bull Any patient with Hepatitis C infection (duration of infection gt 20-30 years when risk for cirrhosis peaks)
bull Any patient with fatty liver especially gt 20 years
bull Any patient with obesitymetabolic syndrome (majority have NAFLD)
bull Significant ETOH intake gt 10 years
bull Low platelet count (lt160000)
bull Low serum albumin
Late Physical Signs of Liver Disease
bull Abdominal ndash Hepatomegaly (followed
by small liver span)
ndash Splenomegaly
ndash Dilated abdominal vasculature
ndash Ascites
bull HEENT ndash Scleral icterus
ndash Xanthelasma
ndash Parotid swelling
ndash Kayser-Fleischer rings
ndash Fetor hepaticus
bull Musculoskeletal ndash Muscle wasting
ndash Palmar erythema
ndash Dupuytrens contracture
bull Neurological ndash Altered mental status
ndash Asterixis
bull Skin ndash Spider telangiectasia
ndash Jaundice
ndash Bruising
ndash Leukonychia
Cirrhosis Diagnosis
bull Labs ndash Low platelet count
ndash Low serum albumin
ndash Possibly low WBC count
ndash Elevated or NORMAL transaminases (ratio of ASTALT gt 1)
ndash Elevated PTINR
bull Ultrasound ndash nodular appearance
bull Other imaging studies ndash CT MRI
bull Biopsy ndash bridging fibrosis regenerative nodules
bull Noninvasive fibrosis testing ndash Transient elastography (FibroScanreg)
ndash Noninvasive serum biomarkers (FibroSUREreg [Quest Diagnostics] FIBROSpectreg II [PROMETHEUSreg Laboratories])
Classification System Child-Turcotte-Pugh
1 point 2 points 3 points
Encephalopathy None Grade 1-2 Grade 3-4
Ascites Absent Slight Moderate
Total bilirubin mgdL
lt2 2-3 gt3
Albumin gdL gt35 28 - 35 lt28
INR lt17 17 -23 gt23
Scoring 5-6 points ndash Class A ndash 30 reduction in hepatic function 7-9 points ndash Class B ndash 50 reduction in hepatic function 10-15 points ndash Class C ndash 90 reduction in hep function
Management Overview
bull Remove offending agent minimize further harm
bull Screen for complications
bull Minimize progression of secondary
complications
bull Communication with patient amp between
providers
bull Expectations (PCP Specialist)
bull Early ID amp management of complications
bull End of life care vs Transplantation
Screening Programs
for Cirrhosis Patients
Screening in Patients with Cirrhosis
bull Portal hypertensionEsophageal Varices
ndash EGD at diagnosis of cirrhosis amp at regularly set intervals
bull No varices ndash every 3 years
bull Small varices ndash Repeat every 1 year
bull Medium to large varices ndash band ligation ndash Every 2 weeks until eradicated
ndash FU EGD 1-3 months post-eradication
ndash Every 6-12 months to assess for recurrence
Screening in Patients with Cirrhosis
bull Cancer
ndash Regular screenings unless patient is too high risk
ndash Hepatocellular carcinoma
bull Every 6 months
bull Risk Factors Cirrhosis alone smokers HCV HBV diabetes
bull AFP ndash not done alone but + imaging (false positives)
bull Ultrasound (alternate with high constrast CT or MRI)
bull Potentially curative treatments if caught in very early to
early stages (1 HCC lt 2cm or 1 HCC3 nodules lt3cm)
bull Chemo-embolization = palliative treatment
bull Preferential transplant listing if found early
Screening in Patients with Cirrhosis
bull Hepatic Encephalopathy
ndash Covert
bull Number connection test
bull Encephalapp Stroop test ndash iPhone app
ndash Overt
bull Clinical
bull Ammonia
ndash Do not routinely check it
ndash May add additional information to suspicions
ndash Do not screen compensated patients
Disease Progression
Slowing or Reversing
Alcohol Abstinence
bull Alcohol withdrawal syndrome occurs within 6-24 hrs after the last drink
bull Light to moderate AWS symptoms ndash Elevated BP amp HR
ndash Tremors
ndash Hyperreflexia
ndash Irritability anxiety
ndash HA
ndash Nausea vomiting
bull Severe symptoms of AWS ndash Delirium tremens
ndash Seizures
ndash Coma
ndash Cardiac arrest
ndash Death
Alcohol Abstinence
bull Treatment ndash Benzodiazepines (short- amp intermediate-
acting safer in liver disease ndash lorazepam)
ndash Disulfram Naltrexone or Acamprosate + counseling in pts without ALD only ndash to reduce ETOH consumption amp prevent relapse
ndash Baclofen in ALD to prevent relapse (5mg TIDx3days then 10mg TID x 90 days)
bull Alcoholic Hepatitis ndash Acute symptomatic liver failure ndash Often associated with cirrhosis but not always
Disease Progression Slowing or Preventing
bull Address obesity
bull Vitamin D supplementation
bull Many pts ask about milk thistle ndash study results have been mixed do not show any harm nor improvement
bull Avoidance of raw oysters clams shellfish ndash Exposure to fatal infection Vibrio vulnificus
bull Reversing fibrosis (amp maybe cirrhosis) ndash Hep B amp Hep C Antivirals
ndash Primary biliary cholangitis Ursodiol
ndash Hemochromatosis Phlebotomy
ndash NASH Weight loss Vitamin E
Minimizing Further Harm
bull Medication adjustments ndash The fewer drugs the betterhellip prescribe only crucial
ones stop the others
ndash Safe drugs
bull Acetaminophen (2 gramsday) amp statins
ndash Generally unsafe drugs
bull NSAIDs including diclofenac
ndash Block prostaglandin synthesis (which protects renal function) amp cause renal vasoconstriction
ndash Risk of GI bleeding
ndash Blunt response to diuretics
bull Nitrofurantoin amp aminoglycosides
bull Herbs ndash many
Minimizing Further Harm
bull Surgical Risk ndash Increased morbidity amp mortality
ndash Abdominal surgery ndash worse outcomes
ndash Childs Classification risk stratification
bull Class A 10 mortality rate
bull Class B 30 mortality rate
bull Class C 80 mortality rate
ndash MELD score ndash validated as a predictor of 30- and 90-day mortality after surgery
bull Vaccinations ndash Hep A amp B
ndash Pneumococcal
ndash Influenza yearly
Management of the
Compensated vs
Decompensated
Cirrhosis Patient
Management - Compensated
bull 15-20 will decompensate in 10-20 years
bull Nutrition ndash 1-2 gramskgday protein
ndash Well-balanced diet
ndash Frequent small meals
ndash No skipping meals
ndash No protein restriction
ndash 1 can Ensure 1-2 times daily
ndash Daily multivitamin without iron
bull Vaccinate amp DOCUMENT administration amp IMMUNITY
Management - Compensated
bull Avoid weight gain
bull Gradual weight loss to normal BMI if obese
bull Tight glucose control
bull Address any dyslipidemia (statins are safe)
bull Avoid ETOH amp hepatotoxins ndash Avoid NSAIDs even celecoxib
ndash Tylenol is fine up to 2 grams per day (unless actively drinking)
ndash Tramadol 50mg TID with severe pain (last resort)
ndash Avoid opioids
Turn for the worse Decompensation
bull 58 of compensated pts will decompensate within 10 years
bull Decompensated disease has a 50-80 5-year mortality
bull Development of any of the following complications
ndash Jaundice due to hepatic insufficiency ndash ID amp tx superimposed causes (alcoholic hepatitis sepsis drug hepatotoxicity)
ndash Variceal hemorrhage ndash most deadly
ndash Ascites ndash most common to herald onset
ndash Encephalopathy
Turn for the worse Decompensation
bull Pathophysiology of Portal Hypertension
ndash Fibrosisnodules architectural distortion
ndash Decreased production of nitric oxide by liver
ndash Increased intrahepatic vasocontriction in liver
ndash Reduced blood flow to and through liver
ndash Formation of porto-systemic collaterals (higher
resistance) = Increased resistance in the liver
ndash Hyperdynamic circulation from vasodilation in
splanchnic arterioles increased blood flow into
portal vein
Management - Decompensated
bull Average life expectancy approximately 2 years
bull Nausea ndash metoclopramide gt odansetron but rf EPS
bull Itching ndash cholestyramine most effective sertraline
bull Fatigue ndash Rest
ndash Exercise
bull Insomnia ndash Sleep hygiene
ndash Benadryl 50mg QHS hydroxyzine 25mg QHS or trazodone 50-100mg QHS (rf precipitating HE)
ndash Melatonin
ndash Rule out sleep apnea HE RLS
Management - Decompensated
bull Muscle cramps ndash Check electrolytes
bull Remember Na+ may be low do not correct unless lt120 (fluid restriction only)
bull Calcium often low ndash no need for correction
ndash Considerations bull BCAAs (4 gram granules TID)
bull Taurine 3 grams once daily
bull Vit E 200mg TID
bull Umbilical hernias ndash Repair only if symptomatic
ndash High complication rate
Management ndash Decompensated
bull Hyponatremia
ndash Common
ndash No treatment usually
unless lt 125 (free
water restriction of 1-
15 L daily)
bull Thrombocytopenia
ndash No treatment
ndash Platelet level of 50000 sufficient for most interventions
bull Coagulopathy
ndash Elevated INR
ndash No treatment usually
ndash May need FFP prior to elective intervention (dental surgical paracentesisradiological)
Hepatic Encephalopathy
bull Reversible change in mental status
bull Continuum from minimal to overt HE
bull Exclusion of other causes for brain dysfunction
bull Assessing for HE ndash Cognition
ndash Orientation
ndash Level of consciousness
ndash Asterixis
Hepatic Encephalopathy
B
Source University of Washingtons Hep C Online Module at httpwwwhepatitiscuwedugomanagement-cirrhosis-related-complicationshepatic-encephalopathy-diagnosis-managementcore-conceptall
Hepatic Encephalopathy
bull Most cases have an identifiable precipitant cause ndash GI bleed
ndash Excessive protein intake
ndash Infection (SBP UTI Pneumonia)
ndash Pre-renal azotemia
ndash Hypokalemic alkalosis
ndash Hyponatremia
ndash Constipation
ndash Hypoxia
ndash Use of sedatives tranquilizers
bull Normal protein diet
bull No driving
bull Safety in the home
Educate pts amp caregiversrelatives
regarding med compliance potential side effects
recognition of early signs of HE and measures to
prevent recurrence
Hepatic Encephalopathy
bull Lactulose 15-30mL BID titrating for 2-3 BMs per day ndash decreases blood ammonia concentration ndash Promotes elimination of toxins
ndash Reduces urease-producing bacteria
ndash Prevents absorption of bacteria
ndash Assists with any constipation - withhold for diarrhea
ndash Continued indefinitely
bull RifaximinXifaxan ndash non-absorbed broad spectrum abx ndash Change in bowel flora
ndash May cause downregulation of intestinal
glutamase activity
Ascites
bull 1-year survival rate 50 bull Usually go through a progression of diuretic response to
refractory ascites to HRS bull Ensure pt is truly adhering to dietary sodium restriction
amp avoiding NSAIDs bull Diagnostic paracentesis for all new onset ascites - ro SBP bull Sodium restriction ndash 2 grams per day - effective in 20 of
cases bull Fluid restriction - not necessary unless hyponatremia bull Diuretics bull TIPS ndash consider if requiring gt 1-2 LVPmonth
ndash 2nd line therapy
Ascites
bull Therapeutic large volume paracentesis ndash Administer with 100 grams albumin IV intraoperatively
(6-8 grams per liter removed) if gt 5 L removed
ndash Indications
bull Discomfort
bull Dyspnea
bull Tense ascites (hemodynamic improvement)
bull Refractory ascites
bull Renal insufficiency (compartment syndrome)
ndash Complications infection Post-paracentesis circulatory dysfunction
ndash Refractory Ascites stop beta blockers
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Cirrhosis by the numbers
bull 55 million Americans
bull Many more are undiagnosed (10 million)
bull Hospital discharge Dx 10 increase between
2010 amp 2011
bull $12 BILLION per year (direct + indirect costs)
Life Expectancy
bull 10-13 years if compensated
bull 2 years if decompensated
bull Alcoholic cirrhosis
ndash Abstention x 3 years = 35 still alive
ndash Continue to drink = 0 still alive
bull Metabolic
ndash Nonalcoholic
steatohepatitis
ndash Hemochromatosis
ndash Wilsons disease
ndash α1-Antitrypsin deficiency
bull Vascular
ndash Budd-Chiari syndrome
ndash Cardiac cirrhosis
ndash Veno-occlusive disease
bull Cryptogenic (dx of exclusion)
bull Infectious ndash Chronic hepatitis B
ndash Chronic hepatitis C
bull Toxins ndash alcohol methotrexate
bull Autoimmune hepatitis
bull Cholestatic ndash Primary biliary cirrhosis
ndash Primary sclerosing cholangitis
Cirrhosis Etiologies
Cirrhosis Pathophysiology
Inflammation in liver results in
cytokine-mediated
activation of hepatic stellate
cells
Stellate cells et al produce
collagen Fibrosis
RESULT Extensive porto-central fibrosis with presence of regenerative noduleshellip cirrhosis
PCP ndash Risk Factors amp Covert Signs
bull Frequently asymptomatic until hepatic function severely reduced
bull Any patient with Hepatitis C infection (duration of infection gt 20-30 years when risk for cirrhosis peaks)
bull Any patient with fatty liver especially gt 20 years
bull Any patient with obesitymetabolic syndrome (majority have NAFLD)
bull Significant ETOH intake gt 10 years
bull Low platelet count (lt160000)
bull Low serum albumin
Late Physical Signs of Liver Disease
bull Abdominal ndash Hepatomegaly (followed
by small liver span)
ndash Splenomegaly
ndash Dilated abdominal vasculature
ndash Ascites
bull HEENT ndash Scleral icterus
ndash Xanthelasma
ndash Parotid swelling
ndash Kayser-Fleischer rings
ndash Fetor hepaticus
bull Musculoskeletal ndash Muscle wasting
ndash Palmar erythema
ndash Dupuytrens contracture
bull Neurological ndash Altered mental status
ndash Asterixis
bull Skin ndash Spider telangiectasia
ndash Jaundice
ndash Bruising
ndash Leukonychia
Cirrhosis Diagnosis
bull Labs ndash Low platelet count
ndash Low serum albumin
ndash Possibly low WBC count
ndash Elevated or NORMAL transaminases (ratio of ASTALT gt 1)
ndash Elevated PTINR
bull Ultrasound ndash nodular appearance
bull Other imaging studies ndash CT MRI
bull Biopsy ndash bridging fibrosis regenerative nodules
bull Noninvasive fibrosis testing ndash Transient elastography (FibroScanreg)
ndash Noninvasive serum biomarkers (FibroSUREreg [Quest Diagnostics] FIBROSpectreg II [PROMETHEUSreg Laboratories])
Classification System Child-Turcotte-Pugh
1 point 2 points 3 points
Encephalopathy None Grade 1-2 Grade 3-4
Ascites Absent Slight Moderate
Total bilirubin mgdL
lt2 2-3 gt3
Albumin gdL gt35 28 - 35 lt28
INR lt17 17 -23 gt23
Scoring 5-6 points ndash Class A ndash 30 reduction in hepatic function 7-9 points ndash Class B ndash 50 reduction in hepatic function 10-15 points ndash Class C ndash 90 reduction in hep function
Management Overview
bull Remove offending agent minimize further harm
bull Screen for complications
bull Minimize progression of secondary
complications
bull Communication with patient amp between
providers
bull Expectations (PCP Specialist)
bull Early ID amp management of complications
bull End of life care vs Transplantation
Screening Programs
for Cirrhosis Patients
Screening in Patients with Cirrhosis
bull Portal hypertensionEsophageal Varices
ndash EGD at diagnosis of cirrhosis amp at regularly set intervals
bull No varices ndash every 3 years
bull Small varices ndash Repeat every 1 year
bull Medium to large varices ndash band ligation ndash Every 2 weeks until eradicated
ndash FU EGD 1-3 months post-eradication
ndash Every 6-12 months to assess for recurrence
Screening in Patients with Cirrhosis
bull Cancer
ndash Regular screenings unless patient is too high risk
ndash Hepatocellular carcinoma
bull Every 6 months
bull Risk Factors Cirrhosis alone smokers HCV HBV diabetes
bull AFP ndash not done alone but + imaging (false positives)
bull Ultrasound (alternate with high constrast CT or MRI)
bull Potentially curative treatments if caught in very early to
early stages (1 HCC lt 2cm or 1 HCC3 nodules lt3cm)
bull Chemo-embolization = palliative treatment
bull Preferential transplant listing if found early
Screening in Patients with Cirrhosis
bull Hepatic Encephalopathy
ndash Covert
bull Number connection test
bull Encephalapp Stroop test ndash iPhone app
ndash Overt
bull Clinical
bull Ammonia
ndash Do not routinely check it
ndash May add additional information to suspicions
ndash Do not screen compensated patients
Disease Progression
Slowing or Reversing
Alcohol Abstinence
bull Alcohol withdrawal syndrome occurs within 6-24 hrs after the last drink
bull Light to moderate AWS symptoms ndash Elevated BP amp HR
ndash Tremors
ndash Hyperreflexia
ndash Irritability anxiety
ndash HA
ndash Nausea vomiting
bull Severe symptoms of AWS ndash Delirium tremens
ndash Seizures
ndash Coma
ndash Cardiac arrest
ndash Death
Alcohol Abstinence
bull Treatment ndash Benzodiazepines (short- amp intermediate-
acting safer in liver disease ndash lorazepam)
ndash Disulfram Naltrexone or Acamprosate + counseling in pts without ALD only ndash to reduce ETOH consumption amp prevent relapse
ndash Baclofen in ALD to prevent relapse (5mg TIDx3days then 10mg TID x 90 days)
bull Alcoholic Hepatitis ndash Acute symptomatic liver failure ndash Often associated with cirrhosis but not always
Disease Progression Slowing or Preventing
bull Address obesity
bull Vitamin D supplementation
bull Many pts ask about milk thistle ndash study results have been mixed do not show any harm nor improvement
bull Avoidance of raw oysters clams shellfish ndash Exposure to fatal infection Vibrio vulnificus
bull Reversing fibrosis (amp maybe cirrhosis) ndash Hep B amp Hep C Antivirals
ndash Primary biliary cholangitis Ursodiol
ndash Hemochromatosis Phlebotomy
ndash NASH Weight loss Vitamin E
Minimizing Further Harm
bull Medication adjustments ndash The fewer drugs the betterhellip prescribe only crucial
ones stop the others
ndash Safe drugs
bull Acetaminophen (2 gramsday) amp statins
ndash Generally unsafe drugs
bull NSAIDs including diclofenac
ndash Block prostaglandin synthesis (which protects renal function) amp cause renal vasoconstriction
ndash Risk of GI bleeding
ndash Blunt response to diuretics
bull Nitrofurantoin amp aminoglycosides
bull Herbs ndash many
Minimizing Further Harm
bull Surgical Risk ndash Increased morbidity amp mortality
ndash Abdominal surgery ndash worse outcomes
ndash Childs Classification risk stratification
bull Class A 10 mortality rate
bull Class B 30 mortality rate
bull Class C 80 mortality rate
ndash MELD score ndash validated as a predictor of 30- and 90-day mortality after surgery
bull Vaccinations ndash Hep A amp B
ndash Pneumococcal
ndash Influenza yearly
Management of the
Compensated vs
Decompensated
Cirrhosis Patient
Management - Compensated
bull 15-20 will decompensate in 10-20 years
bull Nutrition ndash 1-2 gramskgday protein
ndash Well-balanced diet
ndash Frequent small meals
ndash No skipping meals
ndash No protein restriction
ndash 1 can Ensure 1-2 times daily
ndash Daily multivitamin without iron
bull Vaccinate amp DOCUMENT administration amp IMMUNITY
Management - Compensated
bull Avoid weight gain
bull Gradual weight loss to normal BMI if obese
bull Tight glucose control
bull Address any dyslipidemia (statins are safe)
bull Avoid ETOH amp hepatotoxins ndash Avoid NSAIDs even celecoxib
ndash Tylenol is fine up to 2 grams per day (unless actively drinking)
ndash Tramadol 50mg TID with severe pain (last resort)
ndash Avoid opioids
Turn for the worse Decompensation
bull 58 of compensated pts will decompensate within 10 years
bull Decompensated disease has a 50-80 5-year mortality
bull Development of any of the following complications
ndash Jaundice due to hepatic insufficiency ndash ID amp tx superimposed causes (alcoholic hepatitis sepsis drug hepatotoxicity)
ndash Variceal hemorrhage ndash most deadly
ndash Ascites ndash most common to herald onset
ndash Encephalopathy
Turn for the worse Decompensation
bull Pathophysiology of Portal Hypertension
ndash Fibrosisnodules architectural distortion
ndash Decreased production of nitric oxide by liver
ndash Increased intrahepatic vasocontriction in liver
ndash Reduced blood flow to and through liver
ndash Formation of porto-systemic collaterals (higher
resistance) = Increased resistance in the liver
ndash Hyperdynamic circulation from vasodilation in
splanchnic arterioles increased blood flow into
portal vein
Management - Decompensated
bull Average life expectancy approximately 2 years
bull Nausea ndash metoclopramide gt odansetron but rf EPS
bull Itching ndash cholestyramine most effective sertraline
bull Fatigue ndash Rest
ndash Exercise
bull Insomnia ndash Sleep hygiene
ndash Benadryl 50mg QHS hydroxyzine 25mg QHS or trazodone 50-100mg QHS (rf precipitating HE)
ndash Melatonin
ndash Rule out sleep apnea HE RLS
Management - Decompensated
bull Muscle cramps ndash Check electrolytes
bull Remember Na+ may be low do not correct unless lt120 (fluid restriction only)
bull Calcium often low ndash no need for correction
ndash Considerations bull BCAAs (4 gram granules TID)
bull Taurine 3 grams once daily
bull Vit E 200mg TID
bull Umbilical hernias ndash Repair only if symptomatic
ndash High complication rate
Management ndash Decompensated
bull Hyponatremia
ndash Common
ndash No treatment usually
unless lt 125 (free
water restriction of 1-
15 L daily)
bull Thrombocytopenia
ndash No treatment
ndash Platelet level of 50000 sufficient for most interventions
bull Coagulopathy
ndash Elevated INR
ndash No treatment usually
ndash May need FFP prior to elective intervention (dental surgical paracentesisradiological)
Hepatic Encephalopathy
bull Reversible change in mental status
bull Continuum from minimal to overt HE
bull Exclusion of other causes for brain dysfunction
bull Assessing for HE ndash Cognition
ndash Orientation
ndash Level of consciousness
ndash Asterixis
Hepatic Encephalopathy
B
Source University of Washingtons Hep C Online Module at httpwwwhepatitiscuwedugomanagement-cirrhosis-related-complicationshepatic-encephalopathy-diagnosis-managementcore-conceptall
Hepatic Encephalopathy
bull Most cases have an identifiable precipitant cause ndash GI bleed
ndash Excessive protein intake
ndash Infection (SBP UTI Pneumonia)
ndash Pre-renal azotemia
ndash Hypokalemic alkalosis
ndash Hyponatremia
ndash Constipation
ndash Hypoxia
ndash Use of sedatives tranquilizers
bull Normal protein diet
bull No driving
bull Safety in the home
Educate pts amp caregiversrelatives
regarding med compliance potential side effects
recognition of early signs of HE and measures to
prevent recurrence
Hepatic Encephalopathy
bull Lactulose 15-30mL BID titrating for 2-3 BMs per day ndash decreases blood ammonia concentration ndash Promotes elimination of toxins
ndash Reduces urease-producing bacteria
ndash Prevents absorption of bacteria
ndash Assists with any constipation - withhold for diarrhea
ndash Continued indefinitely
bull RifaximinXifaxan ndash non-absorbed broad spectrum abx ndash Change in bowel flora
ndash May cause downregulation of intestinal
glutamase activity
Ascites
bull 1-year survival rate 50 bull Usually go through a progression of diuretic response to
refractory ascites to HRS bull Ensure pt is truly adhering to dietary sodium restriction
amp avoiding NSAIDs bull Diagnostic paracentesis for all new onset ascites - ro SBP bull Sodium restriction ndash 2 grams per day - effective in 20 of
cases bull Fluid restriction - not necessary unless hyponatremia bull Diuretics bull TIPS ndash consider if requiring gt 1-2 LVPmonth
ndash 2nd line therapy
Ascites
bull Therapeutic large volume paracentesis ndash Administer with 100 grams albumin IV intraoperatively
(6-8 grams per liter removed) if gt 5 L removed
ndash Indications
bull Discomfort
bull Dyspnea
bull Tense ascites (hemodynamic improvement)
bull Refractory ascites
bull Renal insufficiency (compartment syndrome)
ndash Complications infection Post-paracentesis circulatory dysfunction
ndash Refractory Ascites stop beta blockers
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Life Expectancy
bull 10-13 years if compensated
bull 2 years if decompensated
bull Alcoholic cirrhosis
ndash Abstention x 3 years = 35 still alive
ndash Continue to drink = 0 still alive
bull Metabolic
ndash Nonalcoholic
steatohepatitis
ndash Hemochromatosis
ndash Wilsons disease
ndash α1-Antitrypsin deficiency
bull Vascular
ndash Budd-Chiari syndrome
ndash Cardiac cirrhosis
ndash Veno-occlusive disease
bull Cryptogenic (dx of exclusion)
bull Infectious ndash Chronic hepatitis B
ndash Chronic hepatitis C
bull Toxins ndash alcohol methotrexate
bull Autoimmune hepatitis
bull Cholestatic ndash Primary biliary cirrhosis
ndash Primary sclerosing cholangitis
Cirrhosis Etiologies
Cirrhosis Pathophysiology
Inflammation in liver results in
cytokine-mediated
activation of hepatic stellate
cells
Stellate cells et al produce
collagen Fibrosis
RESULT Extensive porto-central fibrosis with presence of regenerative noduleshellip cirrhosis
PCP ndash Risk Factors amp Covert Signs
bull Frequently asymptomatic until hepatic function severely reduced
bull Any patient with Hepatitis C infection (duration of infection gt 20-30 years when risk for cirrhosis peaks)
bull Any patient with fatty liver especially gt 20 years
bull Any patient with obesitymetabolic syndrome (majority have NAFLD)
bull Significant ETOH intake gt 10 years
bull Low platelet count (lt160000)
bull Low serum albumin
Late Physical Signs of Liver Disease
bull Abdominal ndash Hepatomegaly (followed
by small liver span)
ndash Splenomegaly
ndash Dilated abdominal vasculature
ndash Ascites
bull HEENT ndash Scleral icterus
ndash Xanthelasma
ndash Parotid swelling
ndash Kayser-Fleischer rings
ndash Fetor hepaticus
bull Musculoskeletal ndash Muscle wasting
ndash Palmar erythema
ndash Dupuytrens contracture
bull Neurological ndash Altered mental status
ndash Asterixis
bull Skin ndash Spider telangiectasia
ndash Jaundice
ndash Bruising
ndash Leukonychia
Cirrhosis Diagnosis
bull Labs ndash Low platelet count
ndash Low serum albumin
ndash Possibly low WBC count
ndash Elevated or NORMAL transaminases (ratio of ASTALT gt 1)
ndash Elevated PTINR
bull Ultrasound ndash nodular appearance
bull Other imaging studies ndash CT MRI
bull Biopsy ndash bridging fibrosis regenerative nodules
bull Noninvasive fibrosis testing ndash Transient elastography (FibroScanreg)
ndash Noninvasive serum biomarkers (FibroSUREreg [Quest Diagnostics] FIBROSpectreg II [PROMETHEUSreg Laboratories])
Classification System Child-Turcotte-Pugh
1 point 2 points 3 points
Encephalopathy None Grade 1-2 Grade 3-4
Ascites Absent Slight Moderate
Total bilirubin mgdL
lt2 2-3 gt3
Albumin gdL gt35 28 - 35 lt28
INR lt17 17 -23 gt23
Scoring 5-6 points ndash Class A ndash 30 reduction in hepatic function 7-9 points ndash Class B ndash 50 reduction in hepatic function 10-15 points ndash Class C ndash 90 reduction in hep function
Management Overview
bull Remove offending agent minimize further harm
bull Screen for complications
bull Minimize progression of secondary
complications
bull Communication with patient amp between
providers
bull Expectations (PCP Specialist)
bull Early ID amp management of complications
bull End of life care vs Transplantation
Screening Programs
for Cirrhosis Patients
Screening in Patients with Cirrhosis
bull Portal hypertensionEsophageal Varices
ndash EGD at diagnosis of cirrhosis amp at regularly set intervals
bull No varices ndash every 3 years
bull Small varices ndash Repeat every 1 year
bull Medium to large varices ndash band ligation ndash Every 2 weeks until eradicated
ndash FU EGD 1-3 months post-eradication
ndash Every 6-12 months to assess for recurrence
Screening in Patients with Cirrhosis
bull Cancer
ndash Regular screenings unless patient is too high risk
ndash Hepatocellular carcinoma
bull Every 6 months
bull Risk Factors Cirrhosis alone smokers HCV HBV diabetes
bull AFP ndash not done alone but + imaging (false positives)
bull Ultrasound (alternate with high constrast CT or MRI)
bull Potentially curative treatments if caught in very early to
early stages (1 HCC lt 2cm or 1 HCC3 nodules lt3cm)
bull Chemo-embolization = palliative treatment
bull Preferential transplant listing if found early
Screening in Patients with Cirrhosis
bull Hepatic Encephalopathy
ndash Covert
bull Number connection test
bull Encephalapp Stroop test ndash iPhone app
ndash Overt
bull Clinical
bull Ammonia
ndash Do not routinely check it
ndash May add additional information to suspicions
ndash Do not screen compensated patients
Disease Progression
Slowing or Reversing
Alcohol Abstinence
bull Alcohol withdrawal syndrome occurs within 6-24 hrs after the last drink
bull Light to moderate AWS symptoms ndash Elevated BP amp HR
ndash Tremors
ndash Hyperreflexia
ndash Irritability anxiety
ndash HA
ndash Nausea vomiting
bull Severe symptoms of AWS ndash Delirium tremens
ndash Seizures
ndash Coma
ndash Cardiac arrest
ndash Death
Alcohol Abstinence
bull Treatment ndash Benzodiazepines (short- amp intermediate-
acting safer in liver disease ndash lorazepam)
ndash Disulfram Naltrexone or Acamprosate + counseling in pts without ALD only ndash to reduce ETOH consumption amp prevent relapse
ndash Baclofen in ALD to prevent relapse (5mg TIDx3days then 10mg TID x 90 days)
bull Alcoholic Hepatitis ndash Acute symptomatic liver failure ndash Often associated with cirrhosis but not always
Disease Progression Slowing or Preventing
bull Address obesity
bull Vitamin D supplementation
bull Many pts ask about milk thistle ndash study results have been mixed do not show any harm nor improvement
bull Avoidance of raw oysters clams shellfish ndash Exposure to fatal infection Vibrio vulnificus
bull Reversing fibrosis (amp maybe cirrhosis) ndash Hep B amp Hep C Antivirals
ndash Primary biliary cholangitis Ursodiol
ndash Hemochromatosis Phlebotomy
ndash NASH Weight loss Vitamin E
Minimizing Further Harm
bull Medication adjustments ndash The fewer drugs the betterhellip prescribe only crucial
ones stop the others
ndash Safe drugs
bull Acetaminophen (2 gramsday) amp statins
ndash Generally unsafe drugs
bull NSAIDs including diclofenac
ndash Block prostaglandin synthesis (which protects renal function) amp cause renal vasoconstriction
ndash Risk of GI bleeding
ndash Blunt response to diuretics
bull Nitrofurantoin amp aminoglycosides
bull Herbs ndash many
Minimizing Further Harm
bull Surgical Risk ndash Increased morbidity amp mortality
ndash Abdominal surgery ndash worse outcomes
ndash Childs Classification risk stratification
bull Class A 10 mortality rate
bull Class B 30 mortality rate
bull Class C 80 mortality rate
ndash MELD score ndash validated as a predictor of 30- and 90-day mortality after surgery
bull Vaccinations ndash Hep A amp B
ndash Pneumococcal
ndash Influenza yearly
Management of the
Compensated vs
Decompensated
Cirrhosis Patient
Management - Compensated
bull 15-20 will decompensate in 10-20 years
bull Nutrition ndash 1-2 gramskgday protein
ndash Well-balanced diet
ndash Frequent small meals
ndash No skipping meals
ndash No protein restriction
ndash 1 can Ensure 1-2 times daily
ndash Daily multivitamin without iron
bull Vaccinate amp DOCUMENT administration amp IMMUNITY
Management - Compensated
bull Avoid weight gain
bull Gradual weight loss to normal BMI if obese
bull Tight glucose control
bull Address any dyslipidemia (statins are safe)
bull Avoid ETOH amp hepatotoxins ndash Avoid NSAIDs even celecoxib
ndash Tylenol is fine up to 2 grams per day (unless actively drinking)
ndash Tramadol 50mg TID with severe pain (last resort)
ndash Avoid opioids
Turn for the worse Decompensation
bull 58 of compensated pts will decompensate within 10 years
bull Decompensated disease has a 50-80 5-year mortality
bull Development of any of the following complications
ndash Jaundice due to hepatic insufficiency ndash ID amp tx superimposed causes (alcoholic hepatitis sepsis drug hepatotoxicity)
ndash Variceal hemorrhage ndash most deadly
ndash Ascites ndash most common to herald onset
ndash Encephalopathy
Turn for the worse Decompensation
bull Pathophysiology of Portal Hypertension
ndash Fibrosisnodules architectural distortion
ndash Decreased production of nitric oxide by liver
ndash Increased intrahepatic vasocontriction in liver
ndash Reduced blood flow to and through liver
ndash Formation of porto-systemic collaterals (higher
resistance) = Increased resistance in the liver
ndash Hyperdynamic circulation from vasodilation in
splanchnic arterioles increased blood flow into
portal vein
Management - Decompensated
bull Average life expectancy approximately 2 years
bull Nausea ndash metoclopramide gt odansetron but rf EPS
bull Itching ndash cholestyramine most effective sertraline
bull Fatigue ndash Rest
ndash Exercise
bull Insomnia ndash Sleep hygiene
ndash Benadryl 50mg QHS hydroxyzine 25mg QHS or trazodone 50-100mg QHS (rf precipitating HE)
ndash Melatonin
ndash Rule out sleep apnea HE RLS
Management - Decompensated
bull Muscle cramps ndash Check electrolytes
bull Remember Na+ may be low do not correct unless lt120 (fluid restriction only)
bull Calcium often low ndash no need for correction
ndash Considerations bull BCAAs (4 gram granules TID)
bull Taurine 3 grams once daily
bull Vit E 200mg TID
bull Umbilical hernias ndash Repair only if symptomatic
ndash High complication rate
Management ndash Decompensated
bull Hyponatremia
ndash Common
ndash No treatment usually
unless lt 125 (free
water restriction of 1-
15 L daily)
bull Thrombocytopenia
ndash No treatment
ndash Platelet level of 50000 sufficient for most interventions
bull Coagulopathy
ndash Elevated INR
ndash No treatment usually
ndash May need FFP prior to elective intervention (dental surgical paracentesisradiological)
Hepatic Encephalopathy
bull Reversible change in mental status
bull Continuum from minimal to overt HE
bull Exclusion of other causes for brain dysfunction
bull Assessing for HE ndash Cognition
ndash Orientation
ndash Level of consciousness
ndash Asterixis
Hepatic Encephalopathy
B
Source University of Washingtons Hep C Online Module at httpwwwhepatitiscuwedugomanagement-cirrhosis-related-complicationshepatic-encephalopathy-diagnosis-managementcore-conceptall
Hepatic Encephalopathy
bull Most cases have an identifiable precipitant cause ndash GI bleed
ndash Excessive protein intake
ndash Infection (SBP UTI Pneumonia)
ndash Pre-renal azotemia
ndash Hypokalemic alkalosis
ndash Hyponatremia
ndash Constipation
ndash Hypoxia
ndash Use of sedatives tranquilizers
bull Normal protein diet
bull No driving
bull Safety in the home
Educate pts amp caregiversrelatives
regarding med compliance potential side effects
recognition of early signs of HE and measures to
prevent recurrence
Hepatic Encephalopathy
bull Lactulose 15-30mL BID titrating for 2-3 BMs per day ndash decreases blood ammonia concentration ndash Promotes elimination of toxins
ndash Reduces urease-producing bacteria
ndash Prevents absorption of bacteria
ndash Assists with any constipation - withhold for diarrhea
ndash Continued indefinitely
bull RifaximinXifaxan ndash non-absorbed broad spectrum abx ndash Change in bowel flora
ndash May cause downregulation of intestinal
glutamase activity
Ascites
bull 1-year survival rate 50 bull Usually go through a progression of diuretic response to
refractory ascites to HRS bull Ensure pt is truly adhering to dietary sodium restriction
amp avoiding NSAIDs bull Diagnostic paracentesis for all new onset ascites - ro SBP bull Sodium restriction ndash 2 grams per day - effective in 20 of
cases bull Fluid restriction - not necessary unless hyponatremia bull Diuretics bull TIPS ndash consider if requiring gt 1-2 LVPmonth
ndash 2nd line therapy
Ascites
bull Therapeutic large volume paracentesis ndash Administer with 100 grams albumin IV intraoperatively
(6-8 grams per liter removed) if gt 5 L removed
ndash Indications
bull Discomfort
bull Dyspnea
bull Tense ascites (hemodynamic improvement)
bull Refractory ascites
bull Renal insufficiency (compartment syndrome)
ndash Complications infection Post-paracentesis circulatory dysfunction
ndash Refractory Ascites stop beta blockers
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
bull Metabolic
ndash Nonalcoholic
steatohepatitis
ndash Hemochromatosis
ndash Wilsons disease
ndash α1-Antitrypsin deficiency
bull Vascular
ndash Budd-Chiari syndrome
ndash Cardiac cirrhosis
ndash Veno-occlusive disease
bull Cryptogenic (dx of exclusion)
bull Infectious ndash Chronic hepatitis B
ndash Chronic hepatitis C
bull Toxins ndash alcohol methotrexate
bull Autoimmune hepatitis
bull Cholestatic ndash Primary biliary cirrhosis
ndash Primary sclerosing cholangitis
Cirrhosis Etiologies
Cirrhosis Pathophysiology
Inflammation in liver results in
cytokine-mediated
activation of hepatic stellate
cells
Stellate cells et al produce
collagen Fibrosis
RESULT Extensive porto-central fibrosis with presence of regenerative noduleshellip cirrhosis
PCP ndash Risk Factors amp Covert Signs
bull Frequently asymptomatic until hepatic function severely reduced
bull Any patient with Hepatitis C infection (duration of infection gt 20-30 years when risk for cirrhosis peaks)
bull Any patient with fatty liver especially gt 20 years
bull Any patient with obesitymetabolic syndrome (majority have NAFLD)
bull Significant ETOH intake gt 10 years
bull Low platelet count (lt160000)
bull Low serum albumin
Late Physical Signs of Liver Disease
bull Abdominal ndash Hepatomegaly (followed
by small liver span)
ndash Splenomegaly
ndash Dilated abdominal vasculature
ndash Ascites
bull HEENT ndash Scleral icterus
ndash Xanthelasma
ndash Parotid swelling
ndash Kayser-Fleischer rings
ndash Fetor hepaticus
bull Musculoskeletal ndash Muscle wasting
ndash Palmar erythema
ndash Dupuytrens contracture
bull Neurological ndash Altered mental status
ndash Asterixis
bull Skin ndash Spider telangiectasia
ndash Jaundice
ndash Bruising
ndash Leukonychia
Cirrhosis Diagnosis
bull Labs ndash Low platelet count
ndash Low serum albumin
ndash Possibly low WBC count
ndash Elevated or NORMAL transaminases (ratio of ASTALT gt 1)
ndash Elevated PTINR
bull Ultrasound ndash nodular appearance
bull Other imaging studies ndash CT MRI
bull Biopsy ndash bridging fibrosis regenerative nodules
bull Noninvasive fibrosis testing ndash Transient elastography (FibroScanreg)
ndash Noninvasive serum biomarkers (FibroSUREreg [Quest Diagnostics] FIBROSpectreg II [PROMETHEUSreg Laboratories])
Classification System Child-Turcotte-Pugh
1 point 2 points 3 points
Encephalopathy None Grade 1-2 Grade 3-4
Ascites Absent Slight Moderate
Total bilirubin mgdL
lt2 2-3 gt3
Albumin gdL gt35 28 - 35 lt28
INR lt17 17 -23 gt23
Scoring 5-6 points ndash Class A ndash 30 reduction in hepatic function 7-9 points ndash Class B ndash 50 reduction in hepatic function 10-15 points ndash Class C ndash 90 reduction in hep function
Management Overview
bull Remove offending agent minimize further harm
bull Screen for complications
bull Minimize progression of secondary
complications
bull Communication with patient amp between
providers
bull Expectations (PCP Specialist)
bull Early ID amp management of complications
bull End of life care vs Transplantation
Screening Programs
for Cirrhosis Patients
Screening in Patients with Cirrhosis
bull Portal hypertensionEsophageal Varices
ndash EGD at diagnosis of cirrhosis amp at regularly set intervals
bull No varices ndash every 3 years
bull Small varices ndash Repeat every 1 year
bull Medium to large varices ndash band ligation ndash Every 2 weeks until eradicated
ndash FU EGD 1-3 months post-eradication
ndash Every 6-12 months to assess for recurrence
Screening in Patients with Cirrhosis
bull Cancer
ndash Regular screenings unless patient is too high risk
ndash Hepatocellular carcinoma
bull Every 6 months
bull Risk Factors Cirrhosis alone smokers HCV HBV diabetes
bull AFP ndash not done alone but + imaging (false positives)
bull Ultrasound (alternate with high constrast CT or MRI)
bull Potentially curative treatments if caught in very early to
early stages (1 HCC lt 2cm or 1 HCC3 nodules lt3cm)
bull Chemo-embolization = palliative treatment
bull Preferential transplant listing if found early
Screening in Patients with Cirrhosis
bull Hepatic Encephalopathy
ndash Covert
bull Number connection test
bull Encephalapp Stroop test ndash iPhone app
ndash Overt
bull Clinical
bull Ammonia
ndash Do not routinely check it
ndash May add additional information to suspicions
ndash Do not screen compensated patients
Disease Progression
Slowing or Reversing
Alcohol Abstinence
bull Alcohol withdrawal syndrome occurs within 6-24 hrs after the last drink
bull Light to moderate AWS symptoms ndash Elevated BP amp HR
ndash Tremors
ndash Hyperreflexia
ndash Irritability anxiety
ndash HA
ndash Nausea vomiting
bull Severe symptoms of AWS ndash Delirium tremens
ndash Seizures
ndash Coma
ndash Cardiac arrest
ndash Death
Alcohol Abstinence
bull Treatment ndash Benzodiazepines (short- amp intermediate-
acting safer in liver disease ndash lorazepam)
ndash Disulfram Naltrexone or Acamprosate + counseling in pts without ALD only ndash to reduce ETOH consumption amp prevent relapse
ndash Baclofen in ALD to prevent relapse (5mg TIDx3days then 10mg TID x 90 days)
bull Alcoholic Hepatitis ndash Acute symptomatic liver failure ndash Often associated with cirrhosis but not always
Disease Progression Slowing or Preventing
bull Address obesity
bull Vitamin D supplementation
bull Many pts ask about milk thistle ndash study results have been mixed do not show any harm nor improvement
bull Avoidance of raw oysters clams shellfish ndash Exposure to fatal infection Vibrio vulnificus
bull Reversing fibrosis (amp maybe cirrhosis) ndash Hep B amp Hep C Antivirals
ndash Primary biliary cholangitis Ursodiol
ndash Hemochromatosis Phlebotomy
ndash NASH Weight loss Vitamin E
Minimizing Further Harm
bull Medication adjustments ndash The fewer drugs the betterhellip prescribe only crucial
ones stop the others
ndash Safe drugs
bull Acetaminophen (2 gramsday) amp statins
ndash Generally unsafe drugs
bull NSAIDs including diclofenac
ndash Block prostaglandin synthesis (which protects renal function) amp cause renal vasoconstriction
ndash Risk of GI bleeding
ndash Blunt response to diuretics
bull Nitrofurantoin amp aminoglycosides
bull Herbs ndash many
Minimizing Further Harm
bull Surgical Risk ndash Increased morbidity amp mortality
ndash Abdominal surgery ndash worse outcomes
ndash Childs Classification risk stratification
bull Class A 10 mortality rate
bull Class B 30 mortality rate
bull Class C 80 mortality rate
ndash MELD score ndash validated as a predictor of 30- and 90-day mortality after surgery
bull Vaccinations ndash Hep A amp B
ndash Pneumococcal
ndash Influenza yearly
Management of the
Compensated vs
Decompensated
Cirrhosis Patient
Management - Compensated
bull 15-20 will decompensate in 10-20 years
bull Nutrition ndash 1-2 gramskgday protein
ndash Well-balanced diet
ndash Frequent small meals
ndash No skipping meals
ndash No protein restriction
ndash 1 can Ensure 1-2 times daily
ndash Daily multivitamin without iron
bull Vaccinate amp DOCUMENT administration amp IMMUNITY
Management - Compensated
bull Avoid weight gain
bull Gradual weight loss to normal BMI if obese
bull Tight glucose control
bull Address any dyslipidemia (statins are safe)
bull Avoid ETOH amp hepatotoxins ndash Avoid NSAIDs even celecoxib
ndash Tylenol is fine up to 2 grams per day (unless actively drinking)
ndash Tramadol 50mg TID with severe pain (last resort)
ndash Avoid opioids
Turn for the worse Decompensation
bull 58 of compensated pts will decompensate within 10 years
bull Decompensated disease has a 50-80 5-year mortality
bull Development of any of the following complications
ndash Jaundice due to hepatic insufficiency ndash ID amp tx superimposed causes (alcoholic hepatitis sepsis drug hepatotoxicity)
ndash Variceal hemorrhage ndash most deadly
ndash Ascites ndash most common to herald onset
ndash Encephalopathy
Turn for the worse Decompensation
bull Pathophysiology of Portal Hypertension
ndash Fibrosisnodules architectural distortion
ndash Decreased production of nitric oxide by liver
ndash Increased intrahepatic vasocontriction in liver
ndash Reduced blood flow to and through liver
ndash Formation of porto-systemic collaterals (higher
resistance) = Increased resistance in the liver
ndash Hyperdynamic circulation from vasodilation in
splanchnic arterioles increased blood flow into
portal vein
Management - Decompensated
bull Average life expectancy approximately 2 years
bull Nausea ndash metoclopramide gt odansetron but rf EPS
bull Itching ndash cholestyramine most effective sertraline
bull Fatigue ndash Rest
ndash Exercise
bull Insomnia ndash Sleep hygiene
ndash Benadryl 50mg QHS hydroxyzine 25mg QHS or trazodone 50-100mg QHS (rf precipitating HE)
ndash Melatonin
ndash Rule out sleep apnea HE RLS
Management - Decompensated
bull Muscle cramps ndash Check electrolytes
bull Remember Na+ may be low do not correct unless lt120 (fluid restriction only)
bull Calcium often low ndash no need for correction
ndash Considerations bull BCAAs (4 gram granules TID)
bull Taurine 3 grams once daily
bull Vit E 200mg TID
bull Umbilical hernias ndash Repair only if symptomatic
ndash High complication rate
Management ndash Decompensated
bull Hyponatremia
ndash Common
ndash No treatment usually
unless lt 125 (free
water restriction of 1-
15 L daily)
bull Thrombocytopenia
ndash No treatment
ndash Platelet level of 50000 sufficient for most interventions
bull Coagulopathy
ndash Elevated INR
ndash No treatment usually
ndash May need FFP prior to elective intervention (dental surgical paracentesisradiological)
Hepatic Encephalopathy
bull Reversible change in mental status
bull Continuum from minimal to overt HE
bull Exclusion of other causes for brain dysfunction
bull Assessing for HE ndash Cognition
ndash Orientation
ndash Level of consciousness
ndash Asterixis
Hepatic Encephalopathy
B
Source University of Washingtons Hep C Online Module at httpwwwhepatitiscuwedugomanagement-cirrhosis-related-complicationshepatic-encephalopathy-diagnosis-managementcore-conceptall
Hepatic Encephalopathy
bull Most cases have an identifiable precipitant cause ndash GI bleed
ndash Excessive protein intake
ndash Infection (SBP UTI Pneumonia)
ndash Pre-renal azotemia
ndash Hypokalemic alkalosis
ndash Hyponatremia
ndash Constipation
ndash Hypoxia
ndash Use of sedatives tranquilizers
bull Normal protein diet
bull No driving
bull Safety in the home
Educate pts amp caregiversrelatives
regarding med compliance potential side effects
recognition of early signs of HE and measures to
prevent recurrence
Hepatic Encephalopathy
bull Lactulose 15-30mL BID titrating for 2-3 BMs per day ndash decreases blood ammonia concentration ndash Promotes elimination of toxins
ndash Reduces urease-producing bacteria
ndash Prevents absorption of bacteria
ndash Assists with any constipation - withhold for diarrhea
ndash Continued indefinitely
bull RifaximinXifaxan ndash non-absorbed broad spectrum abx ndash Change in bowel flora
ndash May cause downregulation of intestinal
glutamase activity
Ascites
bull 1-year survival rate 50 bull Usually go through a progression of diuretic response to
refractory ascites to HRS bull Ensure pt is truly adhering to dietary sodium restriction
amp avoiding NSAIDs bull Diagnostic paracentesis for all new onset ascites - ro SBP bull Sodium restriction ndash 2 grams per day - effective in 20 of
cases bull Fluid restriction - not necessary unless hyponatremia bull Diuretics bull TIPS ndash consider if requiring gt 1-2 LVPmonth
ndash 2nd line therapy
Ascites
bull Therapeutic large volume paracentesis ndash Administer with 100 grams albumin IV intraoperatively
(6-8 grams per liter removed) if gt 5 L removed
ndash Indications
bull Discomfort
bull Dyspnea
bull Tense ascites (hemodynamic improvement)
bull Refractory ascites
bull Renal insufficiency (compartment syndrome)
ndash Complications infection Post-paracentesis circulatory dysfunction
ndash Refractory Ascites stop beta blockers
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Cirrhosis Pathophysiology
Inflammation in liver results in
cytokine-mediated
activation of hepatic stellate
cells
Stellate cells et al produce
collagen Fibrosis
RESULT Extensive porto-central fibrosis with presence of regenerative noduleshellip cirrhosis
PCP ndash Risk Factors amp Covert Signs
bull Frequently asymptomatic until hepatic function severely reduced
bull Any patient with Hepatitis C infection (duration of infection gt 20-30 years when risk for cirrhosis peaks)
bull Any patient with fatty liver especially gt 20 years
bull Any patient with obesitymetabolic syndrome (majority have NAFLD)
bull Significant ETOH intake gt 10 years
bull Low platelet count (lt160000)
bull Low serum albumin
Late Physical Signs of Liver Disease
bull Abdominal ndash Hepatomegaly (followed
by small liver span)
ndash Splenomegaly
ndash Dilated abdominal vasculature
ndash Ascites
bull HEENT ndash Scleral icterus
ndash Xanthelasma
ndash Parotid swelling
ndash Kayser-Fleischer rings
ndash Fetor hepaticus
bull Musculoskeletal ndash Muscle wasting
ndash Palmar erythema
ndash Dupuytrens contracture
bull Neurological ndash Altered mental status
ndash Asterixis
bull Skin ndash Spider telangiectasia
ndash Jaundice
ndash Bruising
ndash Leukonychia
Cirrhosis Diagnosis
bull Labs ndash Low platelet count
ndash Low serum albumin
ndash Possibly low WBC count
ndash Elevated or NORMAL transaminases (ratio of ASTALT gt 1)
ndash Elevated PTINR
bull Ultrasound ndash nodular appearance
bull Other imaging studies ndash CT MRI
bull Biopsy ndash bridging fibrosis regenerative nodules
bull Noninvasive fibrosis testing ndash Transient elastography (FibroScanreg)
ndash Noninvasive serum biomarkers (FibroSUREreg [Quest Diagnostics] FIBROSpectreg II [PROMETHEUSreg Laboratories])
Classification System Child-Turcotte-Pugh
1 point 2 points 3 points
Encephalopathy None Grade 1-2 Grade 3-4
Ascites Absent Slight Moderate
Total bilirubin mgdL
lt2 2-3 gt3
Albumin gdL gt35 28 - 35 lt28
INR lt17 17 -23 gt23
Scoring 5-6 points ndash Class A ndash 30 reduction in hepatic function 7-9 points ndash Class B ndash 50 reduction in hepatic function 10-15 points ndash Class C ndash 90 reduction in hep function
Management Overview
bull Remove offending agent minimize further harm
bull Screen for complications
bull Minimize progression of secondary
complications
bull Communication with patient amp between
providers
bull Expectations (PCP Specialist)
bull Early ID amp management of complications
bull End of life care vs Transplantation
Screening Programs
for Cirrhosis Patients
Screening in Patients with Cirrhosis
bull Portal hypertensionEsophageal Varices
ndash EGD at diagnosis of cirrhosis amp at regularly set intervals
bull No varices ndash every 3 years
bull Small varices ndash Repeat every 1 year
bull Medium to large varices ndash band ligation ndash Every 2 weeks until eradicated
ndash FU EGD 1-3 months post-eradication
ndash Every 6-12 months to assess for recurrence
Screening in Patients with Cirrhosis
bull Cancer
ndash Regular screenings unless patient is too high risk
ndash Hepatocellular carcinoma
bull Every 6 months
bull Risk Factors Cirrhosis alone smokers HCV HBV diabetes
bull AFP ndash not done alone but + imaging (false positives)
bull Ultrasound (alternate with high constrast CT or MRI)
bull Potentially curative treatments if caught in very early to
early stages (1 HCC lt 2cm or 1 HCC3 nodules lt3cm)
bull Chemo-embolization = palliative treatment
bull Preferential transplant listing if found early
Screening in Patients with Cirrhosis
bull Hepatic Encephalopathy
ndash Covert
bull Number connection test
bull Encephalapp Stroop test ndash iPhone app
ndash Overt
bull Clinical
bull Ammonia
ndash Do not routinely check it
ndash May add additional information to suspicions
ndash Do not screen compensated patients
Disease Progression
Slowing or Reversing
Alcohol Abstinence
bull Alcohol withdrawal syndrome occurs within 6-24 hrs after the last drink
bull Light to moderate AWS symptoms ndash Elevated BP amp HR
ndash Tremors
ndash Hyperreflexia
ndash Irritability anxiety
ndash HA
ndash Nausea vomiting
bull Severe symptoms of AWS ndash Delirium tremens
ndash Seizures
ndash Coma
ndash Cardiac arrest
ndash Death
Alcohol Abstinence
bull Treatment ndash Benzodiazepines (short- amp intermediate-
acting safer in liver disease ndash lorazepam)
ndash Disulfram Naltrexone or Acamprosate + counseling in pts without ALD only ndash to reduce ETOH consumption amp prevent relapse
ndash Baclofen in ALD to prevent relapse (5mg TIDx3days then 10mg TID x 90 days)
bull Alcoholic Hepatitis ndash Acute symptomatic liver failure ndash Often associated with cirrhosis but not always
Disease Progression Slowing or Preventing
bull Address obesity
bull Vitamin D supplementation
bull Many pts ask about milk thistle ndash study results have been mixed do not show any harm nor improvement
bull Avoidance of raw oysters clams shellfish ndash Exposure to fatal infection Vibrio vulnificus
bull Reversing fibrosis (amp maybe cirrhosis) ndash Hep B amp Hep C Antivirals
ndash Primary biliary cholangitis Ursodiol
ndash Hemochromatosis Phlebotomy
ndash NASH Weight loss Vitamin E
Minimizing Further Harm
bull Medication adjustments ndash The fewer drugs the betterhellip prescribe only crucial
ones stop the others
ndash Safe drugs
bull Acetaminophen (2 gramsday) amp statins
ndash Generally unsafe drugs
bull NSAIDs including diclofenac
ndash Block prostaglandin synthesis (which protects renal function) amp cause renal vasoconstriction
ndash Risk of GI bleeding
ndash Blunt response to diuretics
bull Nitrofurantoin amp aminoglycosides
bull Herbs ndash many
Minimizing Further Harm
bull Surgical Risk ndash Increased morbidity amp mortality
ndash Abdominal surgery ndash worse outcomes
ndash Childs Classification risk stratification
bull Class A 10 mortality rate
bull Class B 30 mortality rate
bull Class C 80 mortality rate
ndash MELD score ndash validated as a predictor of 30- and 90-day mortality after surgery
bull Vaccinations ndash Hep A amp B
ndash Pneumococcal
ndash Influenza yearly
Management of the
Compensated vs
Decompensated
Cirrhosis Patient
Management - Compensated
bull 15-20 will decompensate in 10-20 years
bull Nutrition ndash 1-2 gramskgday protein
ndash Well-balanced diet
ndash Frequent small meals
ndash No skipping meals
ndash No protein restriction
ndash 1 can Ensure 1-2 times daily
ndash Daily multivitamin without iron
bull Vaccinate amp DOCUMENT administration amp IMMUNITY
Management - Compensated
bull Avoid weight gain
bull Gradual weight loss to normal BMI if obese
bull Tight glucose control
bull Address any dyslipidemia (statins are safe)
bull Avoid ETOH amp hepatotoxins ndash Avoid NSAIDs even celecoxib
ndash Tylenol is fine up to 2 grams per day (unless actively drinking)
ndash Tramadol 50mg TID with severe pain (last resort)
ndash Avoid opioids
Turn for the worse Decompensation
bull 58 of compensated pts will decompensate within 10 years
bull Decompensated disease has a 50-80 5-year mortality
bull Development of any of the following complications
ndash Jaundice due to hepatic insufficiency ndash ID amp tx superimposed causes (alcoholic hepatitis sepsis drug hepatotoxicity)
ndash Variceal hemorrhage ndash most deadly
ndash Ascites ndash most common to herald onset
ndash Encephalopathy
Turn for the worse Decompensation
bull Pathophysiology of Portal Hypertension
ndash Fibrosisnodules architectural distortion
ndash Decreased production of nitric oxide by liver
ndash Increased intrahepatic vasocontriction in liver
ndash Reduced blood flow to and through liver
ndash Formation of porto-systemic collaterals (higher
resistance) = Increased resistance in the liver
ndash Hyperdynamic circulation from vasodilation in
splanchnic arterioles increased blood flow into
portal vein
Management - Decompensated
bull Average life expectancy approximately 2 years
bull Nausea ndash metoclopramide gt odansetron but rf EPS
bull Itching ndash cholestyramine most effective sertraline
bull Fatigue ndash Rest
ndash Exercise
bull Insomnia ndash Sleep hygiene
ndash Benadryl 50mg QHS hydroxyzine 25mg QHS or trazodone 50-100mg QHS (rf precipitating HE)
ndash Melatonin
ndash Rule out sleep apnea HE RLS
Management - Decompensated
bull Muscle cramps ndash Check electrolytes
bull Remember Na+ may be low do not correct unless lt120 (fluid restriction only)
bull Calcium often low ndash no need for correction
ndash Considerations bull BCAAs (4 gram granules TID)
bull Taurine 3 grams once daily
bull Vit E 200mg TID
bull Umbilical hernias ndash Repair only if symptomatic
ndash High complication rate
Management ndash Decompensated
bull Hyponatremia
ndash Common
ndash No treatment usually
unless lt 125 (free
water restriction of 1-
15 L daily)
bull Thrombocytopenia
ndash No treatment
ndash Platelet level of 50000 sufficient for most interventions
bull Coagulopathy
ndash Elevated INR
ndash No treatment usually
ndash May need FFP prior to elective intervention (dental surgical paracentesisradiological)
Hepatic Encephalopathy
bull Reversible change in mental status
bull Continuum from minimal to overt HE
bull Exclusion of other causes for brain dysfunction
bull Assessing for HE ndash Cognition
ndash Orientation
ndash Level of consciousness
ndash Asterixis
Hepatic Encephalopathy
B
Source University of Washingtons Hep C Online Module at httpwwwhepatitiscuwedugomanagement-cirrhosis-related-complicationshepatic-encephalopathy-diagnosis-managementcore-conceptall
Hepatic Encephalopathy
bull Most cases have an identifiable precipitant cause ndash GI bleed
ndash Excessive protein intake
ndash Infection (SBP UTI Pneumonia)
ndash Pre-renal azotemia
ndash Hypokalemic alkalosis
ndash Hyponatremia
ndash Constipation
ndash Hypoxia
ndash Use of sedatives tranquilizers
bull Normal protein diet
bull No driving
bull Safety in the home
Educate pts amp caregiversrelatives
regarding med compliance potential side effects
recognition of early signs of HE and measures to
prevent recurrence
Hepatic Encephalopathy
bull Lactulose 15-30mL BID titrating for 2-3 BMs per day ndash decreases blood ammonia concentration ndash Promotes elimination of toxins
ndash Reduces urease-producing bacteria
ndash Prevents absorption of bacteria
ndash Assists with any constipation - withhold for diarrhea
ndash Continued indefinitely
bull RifaximinXifaxan ndash non-absorbed broad spectrum abx ndash Change in bowel flora
ndash May cause downregulation of intestinal
glutamase activity
Ascites
bull 1-year survival rate 50 bull Usually go through a progression of diuretic response to
refractory ascites to HRS bull Ensure pt is truly adhering to dietary sodium restriction
amp avoiding NSAIDs bull Diagnostic paracentesis for all new onset ascites - ro SBP bull Sodium restriction ndash 2 grams per day - effective in 20 of
cases bull Fluid restriction - not necessary unless hyponatremia bull Diuretics bull TIPS ndash consider if requiring gt 1-2 LVPmonth
ndash 2nd line therapy
Ascites
bull Therapeutic large volume paracentesis ndash Administer with 100 grams albumin IV intraoperatively
(6-8 grams per liter removed) if gt 5 L removed
ndash Indications
bull Discomfort
bull Dyspnea
bull Tense ascites (hemodynamic improvement)
bull Refractory ascites
bull Renal insufficiency (compartment syndrome)
ndash Complications infection Post-paracentesis circulatory dysfunction
ndash Refractory Ascites stop beta blockers
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
PCP ndash Risk Factors amp Covert Signs
bull Frequently asymptomatic until hepatic function severely reduced
bull Any patient with Hepatitis C infection (duration of infection gt 20-30 years when risk for cirrhosis peaks)
bull Any patient with fatty liver especially gt 20 years
bull Any patient with obesitymetabolic syndrome (majority have NAFLD)
bull Significant ETOH intake gt 10 years
bull Low platelet count (lt160000)
bull Low serum albumin
Late Physical Signs of Liver Disease
bull Abdominal ndash Hepatomegaly (followed
by small liver span)
ndash Splenomegaly
ndash Dilated abdominal vasculature
ndash Ascites
bull HEENT ndash Scleral icterus
ndash Xanthelasma
ndash Parotid swelling
ndash Kayser-Fleischer rings
ndash Fetor hepaticus
bull Musculoskeletal ndash Muscle wasting
ndash Palmar erythema
ndash Dupuytrens contracture
bull Neurological ndash Altered mental status
ndash Asterixis
bull Skin ndash Spider telangiectasia
ndash Jaundice
ndash Bruising
ndash Leukonychia
Cirrhosis Diagnosis
bull Labs ndash Low platelet count
ndash Low serum albumin
ndash Possibly low WBC count
ndash Elevated or NORMAL transaminases (ratio of ASTALT gt 1)
ndash Elevated PTINR
bull Ultrasound ndash nodular appearance
bull Other imaging studies ndash CT MRI
bull Biopsy ndash bridging fibrosis regenerative nodules
bull Noninvasive fibrosis testing ndash Transient elastography (FibroScanreg)
ndash Noninvasive serum biomarkers (FibroSUREreg [Quest Diagnostics] FIBROSpectreg II [PROMETHEUSreg Laboratories])
Classification System Child-Turcotte-Pugh
1 point 2 points 3 points
Encephalopathy None Grade 1-2 Grade 3-4
Ascites Absent Slight Moderate
Total bilirubin mgdL
lt2 2-3 gt3
Albumin gdL gt35 28 - 35 lt28
INR lt17 17 -23 gt23
Scoring 5-6 points ndash Class A ndash 30 reduction in hepatic function 7-9 points ndash Class B ndash 50 reduction in hepatic function 10-15 points ndash Class C ndash 90 reduction in hep function
Management Overview
bull Remove offending agent minimize further harm
bull Screen for complications
bull Minimize progression of secondary
complications
bull Communication with patient amp between
providers
bull Expectations (PCP Specialist)
bull Early ID amp management of complications
bull End of life care vs Transplantation
Screening Programs
for Cirrhosis Patients
Screening in Patients with Cirrhosis
bull Portal hypertensionEsophageal Varices
ndash EGD at diagnosis of cirrhosis amp at regularly set intervals
bull No varices ndash every 3 years
bull Small varices ndash Repeat every 1 year
bull Medium to large varices ndash band ligation ndash Every 2 weeks until eradicated
ndash FU EGD 1-3 months post-eradication
ndash Every 6-12 months to assess for recurrence
Screening in Patients with Cirrhosis
bull Cancer
ndash Regular screenings unless patient is too high risk
ndash Hepatocellular carcinoma
bull Every 6 months
bull Risk Factors Cirrhosis alone smokers HCV HBV diabetes
bull AFP ndash not done alone but + imaging (false positives)
bull Ultrasound (alternate with high constrast CT or MRI)
bull Potentially curative treatments if caught in very early to
early stages (1 HCC lt 2cm or 1 HCC3 nodules lt3cm)
bull Chemo-embolization = palliative treatment
bull Preferential transplant listing if found early
Screening in Patients with Cirrhosis
bull Hepatic Encephalopathy
ndash Covert
bull Number connection test
bull Encephalapp Stroop test ndash iPhone app
ndash Overt
bull Clinical
bull Ammonia
ndash Do not routinely check it
ndash May add additional information to suspicions
ndash Do not screen compensated patients
Disease Progression
Slowing or Reversing
Alcohol Abstinence
bull Alcohol withdrawal syndrome occurs within 6-24 hrs after the last drink
bull Light to moderate AWS symptoms ndash Elevated BP amp HR
ndash Tremors
ndash Hyperreflexia
ndash Irritability anxiety
ndash HA
ndash Nausea vomiting
bull Severe symptoms of AWS ndash Delirium tremens
ndash Seizures
ndash Coma
ndash Cardiac arrest
ndash Death
Alcohol Abstinence
bull Treatment ndash Benzodiazepines (short- amp intermediate-
acting safer in liver disease ndash lorazepam)
ndash Disulfram Naltrexone or Acamprosate + counseling in pts without ALD only ndash to reduce ETOH consumption amp prevent relapse
ndash Baclofen in ALD to prevent relapse (5mg TIDx3days then 10mg TID x 90 days)
bull Alcoholic Hepatitis ndash Acute symptomatic liver failure ndash Often associated with cirrhosis but not always
Disease Progression Slowing or Preventing
bull Address obesity
bull Vitamin D supplementation
bull Many pts ask about milk thistle ndash study results have been mixed do not show any harm nor improvement
bull Avoidance of raw oysters clams shellfish ndash Exposure to fatal infection Vibrio vulnificus
bull Reversing fibrosis (amp maybe cirrhosis) ndash Hep B amp Hep C Antivirals
ndash Primary biliary cholangitis Ursodiol
ndash Hemochromatosis Phlebotomy
ndash NASH Weight loss Vitamin E
Minimizing Further Harm
bull Medication adjustments ndash The fewer drugs the betterhellip prescribe only crucial
ones stop the others
ndash Safe drugs
bull Acetaminophen (2 gramsday) amp statins
ndash Generally unsafe drugs
bull NSAIDs including diclofenac
ndash Block prostaglandin synthesis (which protects renal function) amp cause renal vasoconstriction
ndash Risk of GI bleeding
ndash Blunt response to diuretics
bull Nitrofurantoin amp aminoglycosides
bull Herbs ndash many
Minimizing Further Harm
bull Surgical Risk ndash Increased morbidity amp mortality
ndash Abdominal surgery ndash worse outcomes
ndash Childs Classification risk stratification
bull Class A 10 mortality rate
bull Class B 30 mortality rate
bull Class C 80 mortality rate
ndash MELD score ndash validated as a predictor of 30- and 90-day mortality after surgery
bull Vaccinations ndash Hep A amp B
ndash Pneumococcal
ndash Influenza yearly
Management of the
Compensated vs
Decompensated
Cirrhosis Patient
Management - Compensated
bull 15-20 will decompensate in 10-20 years
bull Nutrition ndash 1-2 gramskgday protein
ndash Well-balanced diet
ndash Frequent small meals
ndash No skipping meals
ndash No protein restriction
ndash 1 can Ensure 1-2 times daily
ndash Daily multivitamin without iron
bull Vaccinate amp DOCUMENT administration amp IMMUNITY
Management - Compensated
bull Avoid weight gain
bull Gradual weight loss to normal BMI if obese
bull Tight glucose control
bull Address any dyslipidemia (statins are safe)
bull Avoid ETOH amp hepatotoxins ndash Avoid NSAIDs even celecoxib
ndash Tylenol is fine up to 2 grams per day (unless actively drinking)
ndash Tramadol 50mg TID with severe pain (last resort)
ndash Avoid opioids
Turn for the worse Decompensation
bull 58 of compensated pts will decompensate within 10 years
bull Decompensated disease has a 50-80 5-year mortality
bull Development of any of the following complications
ndash Jaundice due to hepatic insufficiency ndash ID amp tx superimposed causes (alcoholic hepatitis sepsis drug hepatotoxicity)
ndash Variceal hemorrhage ndash most deadly
ndash Ascites ndash most common to herald onset
ndash Encephalopathy
Turn for the worse Decompensation
bull Pathophysiology of Portal Hypertension
ndash Fibrosisnodules architectural distortion
ndash Decreased production of nitric oxide by liver
ndash Increased intrahepatic vasocontriction in liver
ndash Reduced blood flow to and through liver
ndash Formation of porto-systemic collaterals (higher
resistance) = Increased resistance in the liver
ndash Hyperdynamic circulation from vasodilation in
splanchnic arterioles increased blood flow into
portal vein
Management - Decompensated
bull Average life expectancy approximately 2 years
bull Nausea ndash metoclopramide gt odansetron but rf EPS
bull Itching ndash cholestyramine most effective sertraline
bull Fatigue ndash Rest
ndash Exercise
bull Insomnia ndash Sleep hygiene
ndash Benadryl 50mg QHS hydroxyzine 25mg QHS or trazodone 50-100mg QHS (rf precipitating HE)
ndash Melatonin
ndash Rule out sleep apnea HE RLS
Management - Decompensated
bull Muscle cramps ndash Check electrolytes
bull Remember Na+ may be low do not correct unless lt120 (fluid restriction only)
bull Calcium often low ndash no need for correction
ndash Considerations bull BCAAs (4 gram granules TID)
bull Taurine 3 grams once daily
bull Vit E 200mg TID
bull Umbilical hernias ndash Repair only if symptomatic
ndash High complication rate
Management ndash Decompensated
bull Hyponatremia
ndash Common
ndash No treatment usually
unless lt 125 (free
water restriction of 1-
15 L daily)
bull Thrombocytopenia
ndash No treatment
ndash Platelet level of 50000 sufficient for most interventions
bull Coagulopathy
ndash Elevated INR
ndash No treatment usually
ndash May need FFP prior to elective intervention (dental surgical paracentesisradiological)
Hepatic Encephalopathy
bull Reversible change in mental status
bull Continuum from minimal to overt HE
bull Exclusion of other causes for brain dysfunction
bull Assessing for HE ndash Cognition
ndash Orientation
ndash Level of consciousness
ndash Asterixis
Hepatic Encephalopathy
B
Source University of Washingtons Hep C Online Module at httpwwwhepatitiscuwedugomanagement-cirrhosis-related-complicationshepatic-encephalopathy-diagnosis-managementcore-conceptall
Hepatic Encephalopathy
bull Most cases have an identifiable precipitant cause ndash GI bleed
ndash Excessive protein intake
ndash Infection (SBP UTI Pneumonia)
ndash Pre-renal azotemia
ndash Hypokalemic alkalosis
ndash Hyponatremia
ndash Constipation
ndash Hypoxia
ndash Use of sedatives tranquilizers
bull Normal protein diet
bull No driving
bull Safety in the home
Educate pts amp caregiversrelatives
regarding med compliance potential side effects
recognition of early signs of HE and measures to
prevent recurrence
Hepatic Encephalopathy
bull Lactulose 15-30mL BID titrating for 2-3 BMs per day ndash decreases blood ammonia concentration ndash Promotes elimination of toxins
ndash Reduces urease-producing bacteria
ndash Prevents absorption of bacteria
ndash Assists with any constipation - withhold for diarrhea
ndash Continued indefinitely
bull RifaximinXifaxan ndash non-absorbed broad spectrum abx ndash Change in bowel flora
ndash May cause downregulation of intestinal
glutamase activity
Ascites
bull 1-year survival rate 50 bull Usually go through a progression of diuretic response to
refractory ascites to HRS bull Ensure pt is truly adhering to dietary sodium restriction
amp avoiding NSAIDs bull Diagnostic paracentesis for all new onset ascites - ro SBP bull Sodium restriction ndash 2 grams per day - effective in 20 of
cases bull Fluid restriction - not necessary unless hyponatremia bull Diuretics bull TIPS ndash consider if requiring gt 1-2 LVPmonth
ndash 2nd line therapy
Ascites
bull Therapeutic large volume paracentesis ndash Administer with 100 grams albumin IV intraoperatively
(6-8 grams per liter removed) if gt 5 L removed
ndash Indications
bull Discomfort
bull Dyspnea
bull Tense ascites (hemodynamic improvement)
bull Refractory ascites
bull Renal insufficiency (compartment syndrome)
ndash Complications infection Post-paracentesis circulatory dysfunction
ndash Refractory Ascites stop beta blockers
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Late Physical Signs of Liver Disease
bull Abdominal ndash Hepatomegaly (followed
by small liver span)
ndash Splenomegaly
ndash Dilated abdominal vasculature
ndash Ascites
bull HEENT ndash Scleral icterus
ndash Xanthelasma
ndash Parotid swelling
ndash Kayser-Fleischer rings
ndash Fetor hepaticus
bull Musculoskeletal ndash Muscle wasting
ndash Palmar erythema
ndash Dupuytrens contracture
bull Neurological ndash Altered mental status
ndash Asterixis
bull Skin ndash Spider telangiectasia
ndash Jaundice
ndash Bruising
ndash Leukonychia
Cirrhosis Diagnosis
bull Labs ndash Low platelet count
ndash Low serum albumin
ndash Possibly low WBC count
ndash Elevated or NORMAL transaminases (ratio of ASTALT gt 1)
ndash Elevated PTINR
bull Ultrasound ndash nodular appearance
bull Other imaging studies ndash CT MRI
bull Biopsy ndash bridging fibrosis regenerative nodules
bull Noninvasive fibrosis testing ndash Transient elastography (FibroScanreg)
ndash Noninvasive serum biomarkers (FibroSUREreg [Quest Diagnostics] FIBROSpectreg II [PROMETHEUSreg Laboratories])
Classification System Child-Turcotte-Pugh
1 point 2 points 3 points
Encephalopathy None Grade 1-2 Grade 3-4
Ascites Absent Slight Moderate
Total bilirubin mgdL
lt2 2-3 gt3
Albumin gdL gt35 28 - 35 lt28
INR lt17 17 -23 gt23
Scoring 5-6 points ndash Class A ndash 30 reduction in hepatic function 7-9 points ndash Class B ndash 50 reduction in hepatic function 10-15 points ndash Class C ndash 90 reduction in hep function
Management Overview
bull Remove offending agent minimize further harm
bull Screen for complications
bull Minimize progression of secondary
complications
bull Communication with patient amp between
providers
bull Expectations (PCP Specialist)
bull Early ID amp management of complications
bull End of life care vs Transplantation
Screening Programs
for Cirrhosis Patients
Screening in Patients with Cirrhosis
bull Portal hypertensionEsophageal Varices
ndash EGD at diagnosis of cirrhosis amp at regularly set intervals
bull No varices ndash every 3 years
bull Small varices ndash Repeat every 1 year
bull Medium to large varices ndash band ligation ndash Every 2 weeks until eradicated
ndash FU EGD 1-3 months post-eradication
ndash Every 6-12 months to assess for recurrence
Screening in Patients with Cirrhosis
bull Cancer
ndash Regular screenings unless patient is too high risk
ndash Hepatocellular carcinoma
bull Every 6 months
bull Risk Factors Cirrhosis alone smokers HCV HBV diabetes
bull AFP ndash not done alone but + imaging (false positives)
bull Ultrasound (alternate with high constrast CT or MRI)
bull Potentially curative treatments if caught in very early to
early stages (1 HCC lt 2cm or 1 HCC3 nodules lt3cm)
bull Chemo-embolization = palliative treatment
bull Preferential transplant listing if found early
Screening in Patients with Cirrhosis
bull Hepatic Encephalopathy
ndash Covert
bull Number connection test
bull Encephalapp Stroop test ndash iPhone app
ndash Overt
bull Clinical
bull Ammonia
ndash Do not routinely check it
ndash May add additional information to suspicions
ndash Do not screen compensated patients
Disease Progression
Slowing or Reversing
Alcohol Abstinence
bull Alcohol withdrawal syndrome occurs within 6-24 hrs after the last drink
bull Light to moderate AWS symptoms ndash Elevated BP amp HR
ndash Tremors
ndash Hyperreflexia
ndash Irritability anxiety
ndash HA
ndash Nausea vomiting
bull Severe symptoms of AWS ndash Delirium tremens
ndash Seizures
ndash Coma
ndash Cardiac arrest
ndash Death
Alcohol Abstinence
bull Treatment ndash Benzodiazepines (short- amp intermediate-
acting safer in liver disease ndash lorazepam)
ndash Disulfram Naltrexone or Acamprosate + counseling in pts without ALD only ndash to reduce ETOH consumption amp prevent relapse
ndash Baclofen in ALD to prevent relapse (5mg TIDx3days then 10mg TID x 90 days)
bull Alcoholic Hepatitis ndash Acute symptomatic liver failure ndash Often associated with cirrhosis but not always
Disease Progression Slowing or Preventing
bull Address obesity
bull Vitamin D supplementation
bull Many pts ask about milk thistle ndash study results have been mixed do not show any harm nor improvement
bull Avoidance of raw oysters clams shellfish ndash Exposure to fatal infection Vibrio vulnificus
bull Reversing fibrosis (amp maybe cirrhosis) ndash Hep B amp Hep C Antivirals
ndash Primary biliary cholangitis Ursodiol
ndash Hemochromatosis Phlebotomy
ndash NASH Weight loss Vitamin E
Minimizing Further Harm
bull Medication adjustments ndash The fewer drugs the betterhellip prescribe only crucial
ones stop the others
ndash Safe drugs
bull Acetaminophen (2 gramsday) amp statins
ndash Generally unsafe drugs
bull NSAIDs including diclofenac
ndash Block prostaglandin synthesis (which protects renal function) amp cause renal vasoconstriction
ndash Risk of GI bleeding
ndash Blunt response to diuretics
bull Nitrofurantoin amp aminoglycosides
bull Herbs ndash many
Minimizing Further Harm
bull Surgical Risk ndash Increased morbidity amp mortality
ndash Abdominal surgery ndash worse outcomes
ndash Childs Classification risk stratification
bull Class A 10 mortality rate
bull Class B 30 mortality rate
bull Class C 80 mortality rate
ndash MELD score ndash validated as a predictor of 30- and 90-day mortality after surgery
bull Vaccinations ndash Hep A amp B
ndash Pneumococcal
ndash Influenza yearly
Management of the
Compensated vs
Decompensated
Cirrhosis Patient
Management - Compensated
bull 15-20 will decompensate in 10-20 years
bull Nutrition ndash 1-2 gramskgday protein
ndash Well-balanced diet
ndash Frequent small meals
ndash No skipping meals
ndash No protein restriction
ndash 1 can Ensure 1-2 times daily
ndash Daily multivitamin without iron
bull Vaccinate amp DOCUMENT administration amp IMMUNITY
Management - Compensated
bull Avoid weight gain
bull Gradual weight loss to normal BMI if obese
bull Tight glucose control
bull Address any dyslipidemia (statins are safe)
bull Avoid ETOH amp hepatotoxins ndash Avoid NSAIDs even celecoxib
ndash Tylenol is fine up to 2 grams per day (unless actively drinking)
ndash Tramadol 50mg TID with severe pain (last resort)
ndash Avoid opioids
Turn for the worse Decompensation
bull 58 of compensated pts will decompensate within 10 years
bull Decompensated disease has a 50-80 5-year mortality
bull Development of any of the following complications
ndash Jaundice due to hepatic insufficiency ndash ID amp tx superimposed causes (alcoholic hepatitis sepsis drug hepatotoxicity)
ndash Variceal hemorrhage ndash most deadly
ndash Ascites ndash most common to herald onset
ndash Encephalopathy
Turn for the worse Decompensation
bull Pathophysiology of Portal Hypertension
ndash Fibrosisnodules architectural distortion
ndash Decreased production of nitric oxide by liver
ndash Increased intrahepatic vasocontriction in liver
ndash Reduced blood flow to and through liver
ndash Formation of porto-systemic collaterals (higher
resistance) = Increased resistance in the liver
ndash Hyperdynamic circulation from vasodilation in
splanchnic arterioles increased blood flow into
portal vein
Management - Decompensated
bull Average life expectancy approximately 2 years
bull Nausea ndash metoclopramide gt odansetron but rf EPS
bull Itching ndash cholestyramine most effective sertraline
bull Fatigue ndash Rest
ndash Exercise
bull Insomnia ndash Sleep hygiene
ndash Benadryl 50mg QHS hydroxyzine 25mg QHS or trazodone 50-100mg QHS (rf precipitating HE)
ndash Melatonin
ndash Rule out sleep apnea HE RLS
Management - Decompensated
bull Muscle cramps ndash Check electrolytes
bull Remember Na+ may be low do not correct unless lt120 (fluid restriction only)
bull Calcium often low ndash no need for correction
ndash Considerations bull BCAAs (4 gram granules TID)
bull Taurine 3 grams once daily
bull Vit E 200mg TID
bull Umbilical hernias ndash Repair only if symptomatic
ndash High complication rate
Management ndash Decompensated
bull Hyponatremia
ndash Common
ndash No treatment usually
unless lt 125 (free
water restriction of 1-
15 L daily)
bull Thrombocytopenia
ndash No treatment
ndash Platelet level of 50000 sufficient for most interventions
bull Coagulopathy
ndash Elevated INR
ndash No treatment usually
ndash May need FFP prior to elective intervention (dental surgical paracentesisradiological)
Hepatic Encephalopathy
bull Reversible change in mental status
bull Continuum from minimal to overt HE
bull Exclusion of other causes for brain dysfunction
bull Assessing for HE ndash Cognition
ndash Orientation
ndash Level of consciousness
ndash Asterixis
Hepatic Encephalopathy
B
Source University of Washingtons Hep C Online Module at httpwwwhepatitiscuwedugomanagement-cirrhosis-related-complicationshepatic-encephalopathy-diagnosis-managementcore-conceptall
Hepatic Encephalopathy
bull Most cases have an identifiable precipitant cause ndash GI bleed
ndash Excessive protein intake
ndash Infection (SBP UTI Pneumonia)
ndash Pre-renal azotemia
ndash Hypokalemic alkalosis
ndash Hyponatremia
ndash Constipation
ndash Hypoxia
ndash Use of sedatives tranquilizers
bull Normal protein diet
bull No driving
bull Safety in the home
Educate pts amp caregiversrelatives
regarding med compliance potential side effects
recognition of early signs of HE and measures to
prevent recurrence
Hepatic Encephalopathy
bull Lactulose 15-30mL BID titrating for 2-3 BMs per day ndash decreases blood ammonia concentration ndash Promotes elimination of toxins
ndash Reduces urease-producing bacteria
ndash Prevents absorption of bacteria
ndash Assists with any constipation - withhold for diarrhea
ndash Continued indefinitely
bull RifaximinXifaxan ndash non-absorbed broad spectrum abx ndash Change in bowel flora
ndash May cause downregulation of intestinal
glutamase activity
Ascites
bull 1-year survival rate 50 bull Usually go through a progression of diuretic response to
refractory ascites to HRS bull Ensure pt is truly adhering to dietary sodium restriction
amp avoiding NSAIDs bull Diagnostic paracentesis for all new onset ascites - ro SBP bull Sodium restriction ndash 2 grams per day - effective in 20 of
cases bull Fluid restriction - not necessary unless hyponatremia bull Diuretics bull TIPS ndash consider if requiring gt 1-2 LVPmonth
ndash 2nd line therapy
Ascites
bull Therapeutic large volume paracentesis ndash Administer with 100 grams albumin IV intraoperatively
(6-8 grams per liter removed) if gt 5 L removed
ndash Indications
bull Discomfort
bull Dyspnea
bull Tense ascites (hemodynamic improvement)
bull Refractory ascites
bull Renal insufficiency (compartment syndrome)
ndash Complications infection Post-paracentesis circulatory dysfunction
ndash Refractory Ascites stop beta blockers
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Cirrhosis Diagnosis
bull Labs ndash Low platelet count
ndash Low serum albumin
ndash Possibly low WBC count
ndash Elevated or NORMAL transaminases (ratio of ASTALT gt 1)
ndash Elevated PTINR
bull Ultrasound ndash nodular appearance
bull Other imaging studies ndash CT MRI
bull Biopsy ndash bridging fibrosis regenerative nodules
bull Noninvasive fibrosis testing ndash Transient elastography (FibroScanreg)
ndash Noninvasive serum biomarkers (FibroSUREreg [Quest Diagnostics] FIBROSpectreg II [PROMETHEUSreg Laboratories])
Classification System Child-Turcotte-Pugh
1 point 2 points 3 points
Encephalopathy None Grade 1-2 Grade 3-4
Ascites Absent Slight Moderate
Total bilirubin mgdL
lt2 2-3 gt3
Albumin gdL gt35 28 - 35 lt28
INR lt17 17 -23 gt23
Scoring 5-6 points ndash Class A ndash 30 reduction in hepatic function 7-9 points ndash Class B ndash 50 reduction in hepatic function 10-15 points ndash Class C ndash 90 reduction in hep function
Management Overview
bull Remove offending agent minimize further harm
bull Screen for complications
bull Minimize progression of secondary
complications
bull Communication with patient amp between
providers
bull Expectations (PCP Specialist)
bull Early ID amp management of complications
bull End of life care vs Transplantation
Screening Programs
for Cirrhosis Patients
Screening in Patients with Cirrhosis
bull Portal hypertensionEsophageal Varices
ndash EGD at diagnosis of cirrhosis amp at regularly set intervals
bull No varices ndash every 3 years
bull Small varices ndash Repeat every 1 year
bull Medium to large varices ndash band ligation ndash Every 2 weeks until eradicated
ndash FU EGD 1-3 months post-eradication
ndash Every 6-12 months to assess for recurrence
Screening in Patients with Cirrhosis
bull Cancer
ndash Regular screenings unless patient is too high risk
ndash Hepatocellular carcinoma
bull Every 6 months
bull Risk Factors Cirrhosis alone smokers HCV HBV diabetes
bull AFP ndash not done alone but + imaging (false positives)
bull Ultrasound (alternate with high constrast CT or MRI)
bull Potentially curative treatments if caught in very early to
early stages (1 HCC lt 2cm or 1 HCC3 nodules lt3cm)
bull Chemo-embolization = palliative treatment
bull Preferential transplant listing if found early
Screening in Patients with Cirrhosis
bull Hepatic Encephalopathy
ndash Covert
bull Number connection test
bull Encephalapp Stroop test ndash iPhone app
ndash Overt
bull Clinical
bull Ammonia
ndash Do not routinely check it
ndash May add additional information to suspicions
ndash Do not screen compensated patients
Disease Progression
Slowing or Reversing
Alcohol Abstinence
bull Alcohol withdrawal syndrome occurs within 6-24 hrs after the last drink
bull Light to moderate AWS symptoms ndash Elevated BP amp HR
ndash Tremors
ndash Hyperreflexia
ndash Irritability anxiety
ndash HA
ndash Nausea vomiting
bull Severe symptoms of AWS ndash Delirium tremens
ndash Seizures
ndash Coma
ndash Cardiac arrest
ndash Death
Alcohol Abstinence
bull Treatment ndash Benzodiazepines (short- amp intermediate-
acting safer in liver disease ndash lorazepam)
ndash Disulfram Naltrexone or Acamprosate + counseling in pts without ALD only ndash to reduce ETOH consumption amp prevent relapse
ndash Baclofen in ALD to prevent relapse (5mg TIDx3days then 10mg TID x 90 days)
bull Alcoholic Hepatitis ndash Acute symptomatic liver failure ndash Often associated with cirrhosis but not always
Disease Progression Slowing or Preventing
bull Address obesity
bull Vitamin D supplementation
bull Many pts ask about milk thistle ndash study results have been mixed do not show any harm nor improvement
bull Avoidance of raw oysters clams shellfish ndash Exposure to fatal infection Vibrio vulnificus
bull Reversing fibrosis (amp maybe cirrhosis) ndash Hep B amp Hep C Antivirals
ndash Primary biliary cholangitis Ursodiol
ndash Hemochromatosis Phlebotomy
ndash NASH Weight loss Vitamin E
Minimizing Further Harm
bull Medication adjustments ndash The fewer drugs the betterhellip prescribe only crucial
ones stop the others
ndash Safe drugs
bull Acetaminophen (2 gramsday) amp statins
ndash Generally unsafe drugs
bull NSAIDs including diclofenac
ndash Block prostaglandin synthesis (which protects renal function) amp cause renal vasoconstriction
ndash Risk of GI bleeding
ndash Blunt response to diuretics
bull Nitrofurantoin amp aminoglycosides
bull Herbs ndash many
Minimizing Further Harm
bull Surgical Risk ndash Increased morbidity amp mortality
ndash Abdominal surgery ndash worse outcomes
ndash Childs Classification risk stratification
bull Class A 10 mortality rate
bull Class B 30 mortality rate
bull Class C 80 mortality rate
ndash MELD score ndash validated as a predictor of 30- and 90-day mortality after surgery
bull Vaccinations ndash Hep A amp B
ndash Pneumococcal
ndash Influenza yearly
Management of the
Compensated vs
Decompensated
Cirrhosis Patient
Management - Compensated
bull 15-20 will decompensate in 10-20 years
bull Nutrition ndash 1-2 gramskgday protein
ndash Well-balanced diet
ndash Frequent small meals
ndash No skipping meals
ndash No protein restriction
ndash 1 can Ensure 1-2 times daily
ndash Daily multivitamin without iron
bull Vaccinate amp DOCUMENT administration amp IMMUNITY
Management - Compensated
bull Avoid weight gain
bull Gradual weight loss to normal BMI if obese
bull Tight glucose control
bull Address any dyslipidemia (statins are safe)
bull Avoid ETOH amp hepatotoxins ndash Avoid NSAIDs even celecoxib
ndash Tylenol is fine up to 2 grams per day (unless actively drinking)
ndash Tramadol 50mg TID with severe pain (last resort)
ndash Avoid opioids
Turn for the worse Decompensation
bull 58 of compensated pts will decompensate within 10 years
bull Decompensated disease has a 50-80 5-year mortality
bull Development of any of the following complications
ndash Jaundice due to hepatic insufficiency ndash ID amp tx superimposed causes (alcoholic hepatitis sepsis drug hepatotoxicity)
ndash Variceal hemorrhage ndash most deadly
ndash Ascites ndash most common to herald onset
ndash Encephalopathy
Turn for the worse Decompensation
bull Pathophysiology of Portal Hypertension
ndash Fibrosisnodules architectural distortion
ndash Decreased production of nitric oxide by liver
ndash Increased intrahepatic vasocontriction in liver
ndash Reduced blood flow to and through liver
ndash Formation of porto-systemic collaterals (higher
resistance) = Increased resistance in the liver
ndash Hyperdynamic circulation from vasodilation in
splanchnic arterioles increased blood flow into
portal vein
Management - Decompensated
bull Average life expectancy approximately 2 years
bull Nausea ndash metoclopramide gt odansetron but rf EPS
bull Itching ndash cholestyramine most effective sertraline
bull Fatigue ndash Rest
ndash Exercise
bull Insomnia ndash Sleep hygiene
ndash Benadryl 50mg QHS hydroxyzine 25mg QHS or trazodone 50-100mg QHS (rf precipitating HE)
ndash Melatonin
ndash Rule out sleep apnea HE RLS
Management - Decompensated
bull Muscle cramps ndash Check electrolytes
bull Remember Na+ may be low do not correct unless lt120 (fluid restriction only)
bull Calcium often low ndash no need for correction
ndash Considerations bull BCAAs (4 gram granules TID)
bull Taurine 3 grams once daily
bull Vit E 200mg TID
bull Umbilical hernias ndash Repair only if symptomatic
ndash High complication rate
Management ndash Decompensated
bull Hyponatremia
ndash Common
ndash No treatment usually
unless lt 125 (free
water restriction of 1-
15 L daily)
bull Thrombocytopenia
ndash No treatment
ndash Platelet level of 50000 sufficient for most interventions
bull Coagulopathy
ndash Elevated INR
ndash No treatment usually
ndash May need FFP prior to elective intervention (dental surgical paracentesisradiological)
Hepatic Encephalopathy
bull Reversible change in mental status
bull Continuum from minimal to overt HE
bull Exclusion of other causes for brain dysfunction
bull Assessing for HE ndash Cognition
ndash Orientation
ndash Level of consciousness
ndash Asterixis
Hepatic Encephalopathy
B
Source University of Washingtons Hep C Online Module at httpwwwhepatitiscuwedugomanagement-cirrhosis-related-complicationshepatic-encephalopathy-diagnosis-managementcore-conceptall
Hepatic Encephalopathy
bull Most cases have an identifiable precipitant cause ndash GI bleed
ndash Excessive protein intake
ndash Infection (SBP UTI Pneumonia)
ndash Pre-renal azotemia
ndash Hypokalemic alkalosis
ndash Hyponatremia
ndash Constipation
ndash Hypoxia
ndash Use of sedatives tranquilizers
bull Normal protein diet
bull No driving
bull Safety in the home
Educate pts amp caregiversrelatives
regarding med compliance potential side effects
recognition of early signs of HE and measures to
prevent recurrence
Hepatic Encephalopathy
bull Lactulose 15-30mL BID titrating for 2-3 BMs per day ndash decreases blood ammonia concentration ndash Promotes elimination of toxins
ndash Reduces urease-producing bacteria
ndash Prevents absorption of bacteria
ndash Assists with any constipation - withhold for diarrhea
ndash Continued indefinitely
bull RifaximinXifaxan ndash non-absorbed broad spectrum abx ndash Change in bowel flora
ndash May cause downregulation of intestinal
glutamase activity
Ascites
bull 1-year survival rate 50 bull Usually go through a progression of diuretic response to
refractory ascites to HRS bull Ensure pt is truly adhering to dietary sodium restriction
amp avoiding NSAIDs bull Diagnostic paracentesis for all new onset ascites - ro SBP bull Sodium restriction ndash 2 grams per day - effective in 20 of
cases bull Fluid restriction - not necessary unless hyponatremia bull Diuretics bull TIPS ndash consider if requiring gt 1-2 LVPmonth
ndash 2nd line therapy
Ascites
bull Therapeutic large volume paracentesis ndash Administer with 100 grams albumin IV intraoperatively
(6-8 grams per liter removed) if gt 5 L removed
ndash Indications
bull Discomfort
bull Dyspnea
bull Tense ascites (hemodynamic improvement)
bull Refractory ascites
bull Renal insufficiency (compartment syndrome)
ndash Complications infection Post-paracentesis circulatory dysfunction
ndash Refractory Ascites stop beta blockers
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Classification System Child-Turcotte-Pugh
1 point 2 points 3 points
Encephalopathy None Grade 1-2 Grade 3-4
Ascites Absent Slight Moderate
Total bilirubin mgdL
lt2 2-3 gt3
Albumin gdL gt35 28 - 35 lt28
INR lt17 17 -23 gt23
Scoring 5-6 points ndash Class A ndash 30 reduction in hepatic function 7-9 points ndash Class B ndash 50 reduction in hepatic function 10-15 points ndash Class C ndash 90 reduction in hep function
Management Overview
bull Remove offending agent minimize further harm
bull Screen for complications
bull Minimize progression of secondary
complications
bull Communication with patient amp between
providers
bull Expectations (PCP Specialist)
bull Early ID amp management of complications
bull End of life care vs Transplantation
Screening Programs
for Cirrhosis Patients
Screening in Patients with Cirrhosis
bull Portal hypertensionEsophageal Varices
ndash EGD at diagnosis of cirrhosis amp at regularly set intervals
bull No varices ndash every 3 years
bull Small varices ndash Repeat every 1 year
bull Medium to large varices ndash band ligation ndash Every 2 weeks until eradicated
ndash FU EGD 1-3 months post-eradication
ndash Every 6-12 months to assess for recurrence
Screening in Patients with Cirrhosis
bull Cancer
ndash Regular screenings unless patient is too high risk
ndash Hepatocellular carcinoma
bull Every 6 months
bull Risk Factors Cirrhosis alone smokers HCV HBV diabetes
bull AFP ndash not done alone but + imaging (false positives)
bull Ultrasound (alternate with high constrast CT or MRI)
bull Potentially curative treatments if caught in very early to
early stages (1 HCC lt 2cm or 1 HCC3 nodules lt3cm)
bull Chemo-embolization = palliative treatment
bull Preferential transplant listing if found early
Screening in Patients with Cirrhosis
bull Hepatic Encephalopathy
ndash Covert
bull Number connection test
bull Encephalapp Stroop test ndash iPhone app
ndash Overt
bull Clinical
bull Ammonia
ndash Do not routinely check it
ndash May add additional information to suspicions
ndash Do not screen compensated patients
Disease Progression
Slowing or Reversing
Alcohol Abstinence
bull Alcohol withdrawal syndrome occurs within 6-24 hrs after the last drink
bull Light to moderate AWS symptoms ndash Elevated BP amp HR
ndash Tremors
ndash Hyperreflexia
ndash Irritability anxiety
ndash HA
ndash Nausea vomiting
bull Severe symptoms of AWS ndash Delirium tremens
ndash Seizures
ndash Coma
ndash Cardiac arrest
ndash Death
Alcohol Abstinence
bull Treatment ndash Benzodiazepines (short- amp intermediate-
acting safer in liver disease ndash lorazepam)
ndash Disulfram Naltrexone or Acamprosate + counseling in pts without ALD only ndash to reduce ETOH consumption amp prevent relapse
ndash Baclofen in ALD to prevent relapse (5mg TIDx3days then 10mg TID x 90 days)
bull Alcoholic Hepatitis ndash Acute symptomatic liver failure ndash Often associated with cirrhosis but not always
Disease Progression Slowing or Preventing
bull Address obesity
bull Vitamin D supplementation
bull Many pts ask about milk thistle ndash study results have been mixed do not show any harm nor improvement
bull Avoidance of raw oysters clams shellfish ndash Exposure to fatal infection Vibrio vulnificus
bull Reversing fibrosis (amp maybe cirrhosis) ndash Hep B amp Hep C Antivirals
ndash Primary biliary cholangitis Ursodiol
ndash Hemochromatosis Phlebotomy
ndash NASH Weight loss Vitamin E
Minimizing Further Harm
bull Medication adjustments ndash The fewer drugs the betterhellip prescribe only crucial
ones stop the others
ndash Safe drugs
bull Acetaminophen (2 gramsday) amp statins
ndash Generally unsafe drugs
bull NSAIDs including diclofenac
ndash Block prostaglandin synthesis (which protects renal function) amp cause renal vasoconstriction
ndash Risk of GI bleeding
ndash Blunt response to diuretics
bull Nitrofurantoin amp aminoglycosides
bull Herbs ndash many
Minimizing Further Harm
bull Surgical Risk ndash Increased morbidity amp mortality
ndash Abdominal surgery ndash worse outcomes
ndash Childs Classification risk stratification
bull Class A 10 mortality rate
bull Class B 30 mortality rate
bull Class C 80 mortality rate
ndash MELD score ndash validated as a predictor of 30- and 90-day mortality after surgery
bull Vaccinations ndash Hep A amp B
ndash Pneumococcal
ndash Influenza yearly
Management of the
Compensated vs
Decompensated
Cirrhosis Patient
Management - Compensated
bull 15-20 will decompensate in 10-20 years
bull Nutrition ndash 1-2 gramskgday protein
ndash Well-balanced diet
ndash Frequent small meals
ndash No skipping meals
ndash No protein restriction
ndash 1 can Ensure 1-2 times daily
ndash Daily multivitamin without iron
bull Vaccinate amp DOCUMENT administration amp IMMUNITY
Management - Compensated
bull Avoid weight gain
bull Gradual weight loss to normal BMI if obese
bull Tight glucose control
bull Address any dyslipidemia (statins are safe)
bull Avoid ETOH amp hepatotoxins ndash Avoid NSAIDs even celecoxib
ndash Tylenol is fine up to 2 grams per day (unless actively drinking)
ndash Tramadol 50mg TID with severe pain (last resort)
ndash Avoid opioids
Turn for the worse Decompensation
bull 58 of compensated pts will decompensate within 10 years
bull Decompensated disease has a 50-80 5-year mortality
bull Development of any of the following complications
ndash Jaundice due to hepatic insufficiency ndash ID amp tx superimposed causes (alcoholic hepatitis sepsis drug hepatotoxicity)
ndash Variceal hemorrhage ndash most deadly
ndash Ascites ndash most common to herald onset
ndash Encephalopathy
Turn for the worse Decompensation
bull Pathophysiology of Portal Hypertension
ndash Fibrosisnodules architectural distortion
ndash Decreased production of nitric oxide by liver
ndash Increased intrahepatic vasocontriction in liver
ndash Reduced blood flow to and through liver
ndash Formation of porto-systemic collaterals (higher
resistance) = Increased resistance in the liver
ndash Hyperdynamic circulation from vasodilation in
splanchnic arterioles increased blood flow into
portal vein
Management - Decompensated
bull Average life expectancy approximately 2 years
bull Nausea ndash metoclopramide gt odansetron but rf EPS
bull Itching ndash cholestyramine most effective sertraline
bull Fatigue ndash Rest
ndash Exercise
bull Insomnia ndash Sleep hygiene
ndash Benadryl 50mg QHS hydroxyzine 25mg QHS or trazodone 50-100mg QHS (rf precipitating HE)
ndash Melatonin
ndash Rule out sleep apnea HE RLS
Management - Decompensated
bull Muscle cramps ndash Check electrolytes
bull Remember Na+ may be low do not correct unless lt120 (fluid restriction only)
bull Calcium often low ndash no need for correction
ndash Considerations bull BCAAs (4 gram granules TID)
bull Taurine 3 grams once daily
bull Vit E 200mg TID
bull Umbilical hernias ndash Repair only if symptomatic
ndash High complication rate
Management ndash Decompensated
bull Hyponatremia
ndash Common
ndash No treatment usually
unless lt 125 (free
water restriction of 1-
15 L daily)
bull Thrombocytopenia
ndash No treatment
ndash Platelet level of 50000 sufficient for most interventions
bull Coagulopathy
ndash Elevated INR
ndash No treatment usually
ndash May need FFP prior to elective intervention (dental surgical paracentesisradiological)
Hepatic Encephalopathy
bull Reversible change in mental status
bull Continuum from minimal to overt HE
bull Exclusion of other causes for brain dysfunction
bull Assessing for HE ndash Cognition
ndash Orientation
ndash Level of consciousness
ndash Asterixis
Hepatic Encephalopathy
B
Source University of Washingtons Hep C Online Module at httpwwwhepatitiscuwedugomanagement-cirrhosis-related-complicationshepatic-encephalopathy-diagnosis-managementcore-conceptall
Hepatic Encephalopathy
bull Most cases have an identifiable precipitant cause ndash GI bleed
ndash Excessive protein intake
ndash Infection (SBP UTI Pneumonia)
ndash Pre-renal azotemia
ndash Hypokalemic alkalosis
ndash Hyponatremia
ndash Constipation
ndash Hypoxia
ndash Use of sedatives tranquilizers
bull Normal protein diet
bull No driving
bull Safety in the home
Educate pts amp caregiversrelatives
regarding med compliance potential side effects
recognition of early signs of HE and measures to
prevent recurrence
Hepatic Encephalopathy
bull Lactulose 15-30mL BID titrating for 2-3 BMs per day ndash decreases blood ammonia concentration ndash Promotes elimination of toxins
ndash Reduces urease-producing bacteria
ndash Prevents absorption of bacteria
ndash Assists with any constipation - withhold for diarrhea
ndash Continued indefinitely
bull RifaximinXifaxan ndash non-absorbed broad spectrum abx ndash Change in bowel flora
ndash May cause downregulation of intestinal
glutamase activity
Ascites
bull 1-year survival rate 50 bull Usually go through a progression of diuretic response to
refractory ascites to HRS bull Ensure pt is truly adhering to dietary sodium restriction
amp avoiding NSAIDs bull Diagnostic paracentesis for all new onset ascites - ro SBP bull Sodium restriction ndash 2 grams per day - effective in 20 of
cases bull Fluid restriction - not necessary unless hyponatremia bull Diuretics bull TIPS ndash consider if requiring gt 1-2 LVPmonth
ndash 2nd line therapy
Ascites
bull Therapeutic large volume paracentesis ndash Administer with 100 grams albumin IV intraoperatively
(6-8 grams per liter removed) if gt 5 L removed
ndash Indications
bull Discomfort
bull Dyspnea
bull Tense ascites (hemodynamic improvement)
bull Refractory ascites
bull Renal insufficiency (compartment syndrome)
ndash Complications infection Post-paracentesis circulatory dysfunction
ndash Refractory Ascites stop beta blockers
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Management Overview
bull Remove offending agent minimize further harm
bull Screen for complications
bull Minimize progression of secondary
complications
bull Communication with patient amp between
providers
bull Expectations (PCP Specialist)
bull Early ID amp management of complications
bull End of life care vs Transplantation
Screening Programs
for Cirrhosis Patients
Screening in Patients with Cirrhosis
bull Portal hypertensionEsophageal Varices
ndash EGD at diagnosis of cirrhosis amp at regularly set intervals
bull No varices ndash every 3 years
bull Small varices ndash Repeat every 1 year
bull Medium to large varices ndash band ligation ndash Every 2 weeks until eradicated
ndash FU EGD 1-3 months post-eradication
ndash Every 6-12 months to assess for recurrence
Screening in Patients with Cirrhosis
bull Cancer
ndash Regular screenings unless patient is too high risk
ndash Hepatocellular carcinoma
bull Every 6 months
bull Risk Factors Cirrhosis alone smokers HCV HBV diabetes
bull AFP ndash not done alone but + imaging (false positives)
bull Ultrasound (alternate with high constrast CT or MRI)
bull Potentially curative treatments if caught in very early to
early stages (1 HCC lt 2cm or 1 HCC3 nodules lt3cm)
bull Chemo-embolization = palliative treatment
bull Preferential transplant listing if found early
Screening in Patients with Cirrhosis
bull Hepatic Encephalopathy
ndash Covert
bull Number connection test
bull Encephalapp Stroop test ndash iPhone app
ndash Overt
bull Clinical
bull Ammonia
ndash Do not routinely check it
ndash May add additional information to suspicions
ndash Do not screen compensated patients
Disease Progression
Slowing or Reversing
Alcohol Abstinence
bull Alcohol withdrawal syndrome occurs within 6-24 hrs after the last drink
bull Light to moderate AWS symptoms ndash Elevated BP amp HR
ndash Tremors
ndash Hyperreflexia
ndash Irritability anxiety
ndash HA
ndash Nausea vomiting
bull Severe symptoms of AWS ndash Delirium tremens
ndash Seizures
ndash Coma
ndash Cardiac arrest
ndash Death
Alcohol Abstinence
bull Treatment ndash Benzodiazepines (short- amp intermediate-
acting safer in liver disease ndash lorazepam)
ndash Disulfram Naltrexone or Acamprosate + counseling in pts without ALD only ndash to reduce ETOH consumption amp prevent relapse
ndash Baclofen in ALD to prevent relapse (5mg TIDx3days then 10mg TID x 90 days)
bull Alcoholic Hepatitis ndash Acute symptomatic liver failure ndash Often associated with cirrhosis but not always
Disease Progression Slowing or Preventing
bull Address obesity
bull Vitamin D supplementation
bull Many pts ask about milk thistle ndash study results have been mixed do not show any harm nor improvement
bull Avoidance of raw oysters clams shellfish ndash Exposure to fatal infection Vibrio vulnificus
bull Reversing fibrosis (amp maybe cirrhosis) ndash Hep B amp Hep C Antivirals
ndash Primary biliary cholangitis Ursodiol
ndash Hemochromatosis Phlebotomy
ndash NASH Weight loss Vitamin E
Minimizing Further Harm
bull Medication adjustments ndash The fewer drugs the betterhellip prescribe only crucial
ones stop the others
ndash Safe drugs
bull Acetaminophen (2 gramsday) amp statins
ndash Generally unsafe drugs
bull NSAIDs including diclofenac
ndash Block prostaglandin synthesis (which protects renal function) amp cause renal vasoconstriction
ndash Risk of GI bleeding
ndash Blunt response to diuretics
bull Nitrofurantoin amp aminoglycosides
bull Herbs ndash many
Minimizing Further Harm
bull Surgical Risk ndash Increased morbidity amp mortality
ndash Abdominal surgery ndash worse outcomes
ndash Childs Classification risk stratification
bull Class A 10 mortality rate
bull Class B 30 mortality rate
bull Class C 80 mortality rate
ndash MELD score ndash validated as a predictor of 30- and 90-day mortality after surgery
bull Vaccinations ndash Hep A amp B
ndash Pneumococcal
ndash Influenza yearly
Management of the
Compensated vs
Decompensated
Cirrhosis Patient
Management - Compensated
bull 15-20 will decompensate in 10-20 years
bull Nutrition ndash 1-2 gramskgday protein
ndash Well-balanced diet
ndash Frequent small meals
ndash No skipping meals
ndash No protein restriction
ndash 1 can Ensure 1-2 times daily
ndash Daily multivitamin without iron
bull Vaccinate amp DOCUMENT administration amp IMMUNITY
Management - Compensated
bull Avoid weight gain
bull Gradual weight loss to normal BMI if obese
bull Tight glucose control
bull Address any dyslipidemia (statins are safe)
bull Avoid ETOH amp hepatotoxins ndash Avoid NSAIDs even celecoxib
ndash Tylenol is fine up to 2 grams per day (unless actively drinking)
ndash Tramadol 50mg TID with severe pain (last resort)
ndash Avoid opioids
Turn for the worse Decompensation
bull 58 of compensated pts will decompensate within 10 years
bull Decompensated disease has a 50-80 5-year mortality
bull Development of any of the following complications
ndash Jaundice due to hepatic insufficiency ndash ID amp tx superimposed causes (alcoholic hepatitis sepsis drug hepatotoxicity)
ndash Variceal hemorrhage ndash most deadly
ndash Ascites ndash most common to herald onset
ndash Encephalopathy
Turn for the worse Decompensation
bull Pathophysiology of Portal Hypertension
ndash Fibrosisnodules architectural distortion
ndash Decreased production of nitric oxide by liver
ndash Increased intrahepatic vasocontriction in liver
ndash Reduced blood flow to and through liver
ndash Formation of porto-systemic collaterals (higher
resistance) = Increased resistance in the liver
ndash Hyperdynamic circulation from vasodilation in
splanchnic arterioles increased blood flow into
portal vein
Management - Decompensated
bull Average life expectancy approximately 2 years
bull Nausea ndash metoclopramide gt odansetron but rf EPS
bull Itching ndash cholestyramine most effective sertraline
bull Fatigue ndash Rest
ndash Exercise
bull Insomnia ndash Sleep hygiene
ndash Benadryl 50mg QHS hydroxyzine 25mg QHS or trazodone 50-100mg QHS (rf precipitating HE)
ndash Melatonin
ndash Rule out sleep apnea HE RLS
Management - Decompensated
bull Muscle cramps ndash Check electrolytes
bull Remember Na+ may be low do not correct unless lt120 (fluid restriction only)
bull Calcium often low ndash no need for correction
ndash Considerations bull BCAAs (4 gram granules TID)
bull Taurine 3 grams once daily
bull Vit E 200mg TID
bull Umbilical hernias ndash Repair only if symptomatic
ndash High complication rate
Management ndash Decompensated
bull Hyponatremia
ndash Common
ndash No treatment usually
unless lt 125 (free
water restriction of 1-
15 L daily)
bull Thrombocytopenia
ndash No treatment
ndash Platelet level of 50000 sufficient for most interventions
bull Coagulopathy
ndash Elevated INR
ndash No treatment usually
ndash May need FFP prior to elective intervention (dental surgical paracentesisradiological)
Hepatic Encephalopathy
bull Reversible change in mental status
bull Continuum from minimal to overt HE
bull Exclusion of other causes for brain dysfunction
bull Assessing for HE ndash Cognition
ndash Orientation
ndash Level of consciousness
ndash Asterixis
Hepatic Encephalopathy
B
Source University of Washingtons Hep C Online Module at httpwwwhepatitiscuwedugomanagement-cirrhosis-related-complicationshepatic-encephalopathy-diagnosis-managementcore-conceptall
Hepatic Encephalopathy
bull Most cases have an identifiable precipitant cause ndash GI bleed
ndash Excessive protein intake
ndash Infection (SBP UTI Pneumonia)
ndash Pre-renal azotemia
ndash Hypokalemic alkalosis
ndash Hyponatremia
ndash Constipation
ndash Hypoxia
ndash Use of sedatives tranquilizers
bull Normal protein diet
bull No driving
bull Safety in the home
Educate pts amp caregiversrelatives
regarding med compliance potential side effects
recognition of early signs of HE and measures to
prevent recurrence
Hepatic Encephalopathy
bull Lactulose 15-30mL BID titrating for 2-3 BMs per day ndash decreases blood ammonia concentration ndash Promotes elimination of toxins
ndash Reduces urease-producing bacteria
ndash Prevents absorption of bacteria
ndash Assists with any constipation - withhold for diarrhea
ndash Continued indefinitely
bull RifaximinXifaxan ndash non-absorbed broad spectrum abx ndash Change in bowel flora
ndash May cause downregulation of intestinal
glutamase activity
Ascites
bull 1-year survival rate 50 bull Usually go through a progression of diuretic response to
refractory ascites to HRS bull Ensure pt is truly adhering to dietary sodium restriction
amp avoiding NSAIDs bull Diagnostic paracentesis for all new onset ascites - ro SBP bull Sodium restriction ndash 2 grams per day - effective in 20 of
cases bull Fluid restriction - not necessary unless hyponatremia bull Diuretics bull TIPS ndash consider if requiring gt 1-2 LVPmonth
ndash 2nd line therapy
Ascites
bull Therapeutic large volume paracentesis ndash Administer with 100 grams albumin IV intraoperatively
(6-8 grams per liter removed) if gt 5 L removed
ndash Indications
bull Discomfort
bull Dyspnea
bull Tense ascites (hemodynamic improvement)
bull Refractory ascites
bull Renal insufficiency (compartment syndrome)
ndash Complications infection Post-paracentesis circulatory dysfunction
ndash Refractory Ascites stop beta blockers
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Screening Programs
for Cirrhosis Patients
Screening in Patients with Cirrhosis
bull Portal hypertensionEsophageal Varices
ndash EGD at diagnosis of cirrhosis amp at regularly set intervals
bull No varices ndash every 3 years
bull Small varices ndash Repeat every 1 year
bull Medium to large varices ndash band ligation ndash Every 2 weeks until eradicated
ndash FU EGD 1-3 months post-eradication
ndash Every 6-12 months to assess for recurrence
Screening in Patients with Cirrhosis
bull Cancer
ndash Regular screenings unless patient is too high risk
ndash Hepatocellular carcinoma
bull Every 6 months
bull Risk Factors Cirrhosis alone smokers HCV HBV diabetes
bull AFP ndash not done alone but + imaging (false positives)
bull Ultrasound (alternate with high constrast CT or MRI)
bull Potentially curative treatments if caught in very early to
early stages (1 HCC lt 2cm or 1 HCC3 nodules lt3cm)
bull Chemo-embolization = palliative treatment
bull Preferential transplant listing if found early
Screening in Patients with Cirrhosis
bull Hepatic Encephalopathy
ndash Covert
bull Number connection test
bull Encephalapp Stroop test ndash iPhone app
ndash Overt
bull Clinical
bull Ammonia
ndash Do not routinely check it
ndash May add additional information to suspicions
ndash Do not screen compensated patients
Disease Progression
Slowing or Reversing
Alcohol Abstinence
bull Alcohol withdrawal syndrome occurs within 6-24 hrs after the last drink
bull Light to moderate AWS symptoms ndash Elevated BP amp HR
ndash Tremors
ndash Hyperreflexia
ndash Irritability anxiety
ndash HA
ndash Nausea vomiting
bull Severe symptoms of AWS ndash Delirium tremens
ndash Seizures
ndash Coma
ndash Cardiac arrest
ndash Death
Alcohol Abstinence
bull Treatment ndash Benzodiazepines (short- amp intermediate-
acting safer in liver disease ndash lorazepam)
ndash Disulfram Naltrexone or Acamprosate + counseling in pts without ALD only ndash to reduce ETOH consumption amp prevent relapse
ndash Baclofen in ALD to prevent relapse (5mg TIDx3days then 10mg TID x 90 days)
bull Alcoholic Hepatitis ndash Acute symptomatic liver failure ndash Often associated with cirrhosis but not always
Disease Progression Slowing or Preventing
bull Address obesity
bull Vitamin D supplementation
bull Many pts ask about milk thistle ndash study results have been mixed do not show any harm nor improvement
bull Avoidance of raw oysters clams shellfish ndash Exposure to fatal infection Vibrio vulnificus
bull Reversing fibrosis (amp maybe cirrhosis) ndash Hep B amp Hep C Antivirals
ndash Primary biliary cholangitis Ursodiol
ndash Hemochromatosis Phlebotomy
ndash NASH Weight loss Vitamin E
Minimizing Further Harm
bull Medication adjustments ndash The fewer drugs the betterhellip prescribe only crucial
ones stop the others
ndash Safe drugs
bull Acetaminophen (2 gramsday) amp statins
ndash Generally unsafe drugs
bull NSAIDs including diclofenac
ndash Block prostaglandin synthesis (which protects renal function) amp cause renal vasoconstriction
ndash Risk of GI bleeding
ndash Blunt response to diuretics
bull Nitrofurantoin amp aminoglycosides
bull Herbs ndash many
Minimizing Further Harm
bull Surgical Risk ndash Increased morbidity amp mortality
ndash Abdominal surgery ndash worse outcomes
ndash Childs Classification risk stratification
bull Class A 10 mortality rate
bull Class B 30 mortality rate
bull Class C 80 mortality rate
ndash MELD score ndash validated as a predictor of 30- and 90-day mortality after surgery
bull Vaccinations ndash Hep A amp B
ndash Pneumococcal
ndash Influenza yearly
Management of the
Compensated vs
Decompensated
Cirrhosis Patient
Management - Compensated
bull 15-20 will decompensate in 10-20 years
bull Nutrition ndash 1-2 gramskgday protein
ndash Well-balanced diet
ndash Frequent small meals
ndash No skipping meals
ndash No protein restriction
ndash 1 can Ensure 1-2 times daily
ndash Daily multivitamin without iron
bull Vaccinate amp DOCUMENT administration amp IMMUNITY
Management - Compensated
bull Avoid weight gain
bull Gradual weight loss to normal BMI if obese
bull Tight glucose control
bull Address any dyslipidemia (statins are safe)
bull Avoid ETOH amp hepatotoxins ndash Avoid NSAIDs even celecoxib
ndash Tylenol is fine up to 2 grams per day (unless actively drinking)
ndash Tramadol 50mg TID with severe pain (last resort)
ndash Avoid opioids
Turn for the worse Decompensation
bull 58 of compensated pts will decompensate within 10 years
bull Decompensated disease has a 50-80 5-year mortality
bull Development of any of the following complications
ndash Jaundice due to hepatic insufficiency ndash ID amp tx superimposed causes (alcoholic hepatitis sepsis drug hepatotoxicity)
ndash Variceal hemorrhage ndash most deadly
ndash Ascites ndash most common to herald onset
ndash Encephalopathy
Turn for the worse Decompensation
bull Pathophysiology of Portal Hypertension
ndash Fibrosisnodules architectural distortion
ndash Decreased production of nitric oxide by liver
ndash Increased intrahepatic vasocontriction in liver
ndash Reduced blood flow to and through liver
ndash Formation of porto-systemic collaterals (higher
resistance) = Increased resistance in the liver
ndash Hyperdynamic circulation from vasodilation in
splanchnic arterioles increased blood flow into
portal vein
Management - Decompensated
bull Average life expectancy approximately 2 years
bull Nausea ndash metoclopramide gt odansetron but rf EPS
bull Itching ndash cholestyramine most effective sertraline
bull Fatigue ndash Rest
ndash Exercise
bull Insomnia ndash Sleep hygiene
ndash Benadryl 50mg QHS hydroxyzine 25mg QHS or trazodone 50-100mg QHS (rf precipitating HE)
ndash Melatonin
ndash Rule out sleep apnea HE RLS
Management - Decompensated
bull Muscle cramps ndash Check electrolytes
bull Remember Na+ may be low do not correct unless lt120 (fluid restriction only)
bull Calcium often low ndash no need for correction
ndash Considerations bull BCAAs (4 gram granules TID)
bull Taurine 3 grams once daily
bull Vit E 200mg TID
bull Umbilical hernias ndash Repair only if symptomatic
ndash High complication rate
Management ndash Decompensated
bull Hyponatremia
ndash Common
ndash No treatment usually
unless lt 125 (free
water restriction of 1-
15 L daily)
bull Thrombocytopenia
ndash No treatment
ndash Platelet level of 50000 sufficient for most interventions
bull Coagulopathy
ndash Elevated INR
ndash No treatment usually
ndash May need FFP prior to elective intervention (dental surgical paracentesisradiological)
Hepatic Encephalopathy
bull Reversible change in mental status
bull Continuum from minimal to overt HE
bull Exclusion of other causes for brain dysfunction
bull Assessing for HE ndash Cognition
ndash Orientation
ndash Level of consciousness
ndash Asterixis
Hepatic Encephalopathy
B
Source University of Washingtons Hep C Online Module at httpwwwhepatitiscuwedugomanagement-cirrhosis-related-complicationshepatic-encephalopathy-diagnosis-managementcore-conceptall
Hepatic Encephalopathy
bull Most cases have an identifiable precipitant cause ndash GI bleed
ndash Excessive protein intake
ndash Infection (SBP UTI Pneumonia)
ndash Pre-renal azotemia
ndash Hypokalemic alkalosis
ndash Hyponatremia
ndash Constipation
ndash Hypoxia
ndash Use of sedatives tranquilizers
bull Normal protein diet
bull No driving
bull Safety in the home
Educate pts amp caregiversrelatives
regarding med compliance potential side effects
recognition of early signs of HE and measures to
prevent recurrence
Hepatic Encephalopathy
bull Lactulose 15-30mL BID titrating for 2-3 BMs per day ndash decreases blood ammonia concentration ndash Promotes elimination of toxins
ndash Reduces urease-producing bacteria
ndash Prevents absorption of bacteria
ndash Assists with any constipation - withhold for diarrhea
ndash Continued indefinitely
bull RifaximinXifaxan ndash non-absorbed broad spectrum abx ndash Change in bowel flora
ndash May cause downregulation of intestinal
glutamase activity
Ascites
bull 1-year survival rate 50 bull Usually go through a progression of diuretic response to
refractory ascites to HRS bull Ensure pt is truly adhering to dietary sodium restriction
amp avoiding NSAIDs bull Diagnostic paracentesis for all new onset ascites - ro SBP bull Sodium restriction ndash 2 grams per day - effective in 20 of
cases bull Fluid restriction - not necessary unless hyponatremia bull Diuretics bull TIPS ndash consider if requiring gt 1-2 LVPmonth
ndash 2nd line therapy
Ascites
bull Therapeutic large volume paracentesis ndash Administer with 100 grams albumin IV intraoperatively
(6-8 grams per liter removed) if gt 5 L removed
ndash Indications
bull Discomfort
bull Dyspnea
bull Tense ascites (hemodynamic improvement)
bull Refractory ascites
bull Renal insufficiency (compartment syndrome)
ndash Complications infection Post-paracentesis circulatory dysfunction
ndash Refractory Ascites stop beta blockers
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Screening in Patients with Cirrhosis
bull Portal hypertensionEsophageal Varices
ndash EGD at diagnosis of cirrhosis amp at regularly set intervals
bull No varices ndash every 3 years
bull Small varices ndash Repeat every 1 year
bull Medium to large varices ndash band ligation ndash Every 2 weeks until eradicated
ndash FU EGD 1-3 months post-eradication
ndash Every 6-12 months to assess for recurrence
Screening in Patients with Cirrhosis
bull Cancer
ndash Regular screenings unless patient is too high risk
ndash Hepatocellular carcinoma
bull Every 6 months
bull Risk Factors Cirrhosis alone smokers HCV HBV diabetes
bull AFP ndash not done alone but + imaging (false positives)
bull Ultrasound (alternate with high constrast CT or MRI)
bull Potentially curative treatments if caught in very early to
early stages (1 HCC lt 2cm or 1 HCC3 nodules lt3cm)
bull Chemo-embolization = palliative treatment
bull Preferential transplant listing if found early
Screening in Patients with Cirrhosis
bull Hepatic Encephalopathy
ndash Covert
bull Number connection test
bull Encephalapp Stroop test ndash iPhone app
ndash Overt
bull Clinical
bull Ammonia
ndash Do not routinely check it
ndash May add additional information to suspicions
ndash Do not screen compensated patients
Disease Progression
Slowing or Reversing
Alcohol Abstinence
bull Alcohol withdrawal syndrome occurs within 6-24 hrs after the last drink
bull Light to moderate AWS symptoms ndash Elevated BP amp HR
ndash Tremors
ndash Hyperreflexia
ndash Irritability anxiety
ndash HA
ndash Nausea vomiting
bull Severe symptoms of AWS ndash Delirium tremens
ndash Seizures
ndash Coma
ndash Cardiac arrest
ndash Death
Alcohol Abstinence
bull Treatment ndash Benzodiazepines (short- amp intermediate-
acting safer in liver disease ndash lorazepam)
ndash Disulfram Naltrexone or Acamprosate + counseling in pts without ALD only ndash to reduce ETOH consumption amp prevent relapse
ndash Baclofen in ALD to prevent relapse (5mg TIDx3days then 10mg TID x 90 days)
bull Alcoholic Hepatitis ndash Acute symptomatic liver failure ndash Often associated with cirrhosis but not always
Disease Progression Slowing or Preventing
bull Address obesity
bull Vitamin D supplementation
bull Many pts ask about milk thistle ndash study results have been mixed do not show any harm nor improvement
bull Avoidance of raw oysters clams shellfish ndash Exposure to fatal infection Vibrio vulnificus
bull Reversing fibrosis (amp maybe cirrhosis) ndash Hep B amp Hep C Antivirals
ndash Primary biliary cholangitis Ursodiol
ndash Hemochromatosis Phlebotomy
ndash NASH Weight loss Vitamin E
Minimizing Further Harm
bull Medication adjustments ndash The fewer drugs the betterhellip prescribe only crucial
ones stop the others
ndash Safe drugs
bull Acetaminophen (2 gramsday) amp statins
ndash Generally unsafe drugs
bull NSAIDs including diclofenac
ndash Block prostaglandin synthesis (which protects renal function) amp cause renal vasoconstriction
ndash Risk of GI bleeding
ndash Blunt response to diuretics
bull Nitrofurantoin amp aminoglycosides
bull Herbs ndash many
Minimizing Further Harm
bull Surgical Risk ndash Increased morbidity amp mortality
ndash Abdominal surgery ndash worse outcomes
ndash Childs Classification risk stratification
bull Class A 10 mortality rate
bull Class B 30 mortality rate
bull Class C 80 mortality rate
ndash MELD score ndash validated as a predictor of 30- and 90-day mortality after surgery
bull Vaccinations ndash Hep A amp B
ndash Pneumococcal
ndash Influenza yearly
Management of the
Compensated vs
Decompensated
Cirrhosis Patient
Management - Compensated
bull 15-20 will decompensate in 10-20 years
bull Nutrition ndash 1-2 gramskgday protein
ndash Well-balanced diet
ndash Frequent small meals
ndash No skipping meals
ndash No protein restriction
ndash 1 can Ensure 1-2 times daily
ndash Daily multivitamin without iron
bull Vaccinate amp DOCUMENT administration amp IMMUNITY
Management - Compensated
bull Avoid weight gain
bull Gradual weight loss to normal BMI if obese
bull Tight glucose control
bull Address any dyslipidemia (statins are safe)
bull Avoid ETOH amp hepatotoxins ndash Avoid NSAIDs even celecoxib
ndash Tylenol is fine up to 2 grams per day (unless actively drinking)
ndash Tramadol 50mg TID with severe pain (last resort)
ndash Avoid opioids
Turn for the worse Decompensation
bull 58 of compensated pts will decompensate within 10 years
bull Decompensated disease has a 50-80 5-year mortality
bull Development of any of the following complications
ndash Jaundice due to hepatic insufficiency ndash ID amp tx superimposed causes (alcoholic hepatitis sepsis drug hepatotoxicity)
ndash Variceal hemorrhage ndash most deadly
ndash Ascites ndash most common to herald onset
ndash Encephalopathy
Turn for the worse Decompensation
bull Pathophysiology of Portal Hypertension
ndash Fibrosisnodules architectural distortion
ndash Decreased production of nitric oxide by liver
ndash Increased intrahepatic vasocontriction in liver
ndash Reduced blood flow to and through liver
ndash Formation of porto-systemic collaterals (higher
resistance) = Increased resistance in the liver
ndash Hyperdynamic circulation from vasodilation in
splanchnic arterioles increased blood flow into
portal vein
Management - Decompensated
bull Average life expectancy approximately 2 years
bull Nausea ndash metoclopramide gt odansetron but rf EPS
bull Itching ndash cholestyramine most effective sertraline
bull Fatigue ndash Rest
ndash Exercise
bull Insomnia ndash Sleep hygiene
ndash Benadryl 50mg QHS hydroxyzine 25mg QHS or trazodone 50-100mg QHS (rf precipitating HE)
ndash Melatonin
ndash Rule out sleep apnea HE RLS
Management - Decompensated
bull Muscle cramps ndash Check electrolytes
bull Remember Na+ may be low do not correct unless lt120 (fluid restriction only)
bull Calcium often low ndash no need for correction
ndash Considerations bull BCAAs (4 gram granules TID)
bull Taurine 3 grams once daily
bull Vit E 200mg TID
bull Umbilical hernias ndash Repair only if symptomatic
ndash High complication rate
Management ndash Decompensated
bull Hyponatremia
ndash Common
ndash No treatment usually
unless lt 125 (free
water restriction of 1-
15 L daily)
bull Thrombocytopenia
ndash No treatment
ndash Platelet level of 50000 sufficient for most interventions
bull Coagulopathy
ndash Elevated INR
ndash No treatment usually
ndash May need FFP prior to elective intervention (dental surgical paracentesisradiological)
Hepatic Encephalopathy
bull Reversible change in mental status
bull Continuum from minimal to overt HE
bull Exclusion of other causes for brain dysfunction
bull Assessing for HE ndash Cognition
ndash Orientation
ndash Level of consciousness
ndash Asterixis
Hepatic Encephalopathy
B
Source University of Washingtons Hep C Online Module at httpwwwhepatitiscuwedugomanagement-cirrhosis-related-complicationshepatic-encephalopathy-diagnosis-managementcore-conceptall
Hepatic Encephalopathy
bull Most cases have an identifiable precipitant cause ndash GI bleed
ndash Excessive protein intake
ndash Infection (SBP UTI Pneumonia)
ndash Pre-renal azotemia
ndash Hypokalemic alkalosis
ndash Hyponatremia
ndash Constipation
ndash Hypoxia
ndash Use of sedatives tranquilizers
bull Normal protein diet
bull No driving
bull Safety in the home
Educate pts amp caregiversrelatives
regarding med compliance potential side effects
recognition of early signs of HE and measures to
prevent recurrence
Hepatic Encephalopathy
bull Lactulose 15-30mL BID titrating for 2-3 BMs per day ndash decreases blood ammonia concentration ndash Promotes elimination of toxins
ndash Reduces urease-producing bacteria
ndash Prevents absorption of bacteria
ndash Assists with any constipation - withhold for diarrhea
ndash Continued indefinitely
bull RifaximinXifaxan ndash non-absorbed broad spectrum abx ndash Change in bowel flora
ndash May cause downregulation of intestinal
glutamase activity
Ascites
bull 1-year survival rate 50 bull Usually go through a progression of diuretic response to
refractory ascites to HRS bull Ensure pt is truly adhering to dietary sodium restriction
amp avoiding NSAIDs bull Diagnostic paracentesis for all new onset ascites - ro SBP bull Sodium restriction ndash 2 grams per day - effective in 20 of
cases bull Fluid restriction - not necessary unless hyponatremia bull Diuretics bull TIPS ndash consider if requiring gt 1-2 LVPmonth
ndash 2nd line therapy
Ascites
bull Therapeutic large volume paracentesis ndash Administer with 100 grams albumin IV intraoperatively
(6-8 grams per liter removed) if gt 5 L removed
ndash Indications
bull Discomfort
bull Dyspnea
bull Tense ascites (hemodynamic improvement)
bull Refractory ascites
bull Renal insufficiency (compartment syndrome)
ndash Complications infection Post-paracentesis circulatory dysfunction
ndash Refractory Ascites stop beta blockers
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Screening in Patients with Cirrhosis
bull Cancer
ndash Regular screenings unless patient is too high risk
ndash Hepatocellular carcinoma
bull Every 6 months
bull Risk Factors Cirrhosis alone smokers HCV HBV diabetes
bull AFP ndash not done alone but + imaging (false positives)
bull Ultrasound (alternate with high constrast CT or MRI)
bull Potentially curative treatments if caught in very early to
early stages (1 HCC lt 2cm or 1 HCC3 nodules lt3cm)
bull Chemo-embolization = palliative treatment
bull Preferential transplant listing if found early
Screening in Patients with Cirrhosis
bull Hepatic Encephalopathy
ndash Covert
bull Number connection test
bull Encephalapp Stroop test ndash iPhone app
ndash Overt
bull Clinical
bull Ammonia
ndash Do not routinely check it
ndash May add additional information to suspicions
ndash Do not screen compensated patients
Disease Progression
Slowing or Reversing
Alcohol Abstinence
bull Alcohol withdrawal syndrome occurs within 6-24 hrs after the last drink
bull Light to moderate AWS symptoms ndash Elevated BP amp HR
ndash Tremors
ndash Hyperreflexia
ndash Irritability anxiety
ndash HA
ndash Nausea vomiting
bull Severe symptoms of AWS ndash Delirium tremens
ndash Seizures
ndash Coma
ndash Cardiac arrest
ndash Death
Alcohol Abstinence
bull Treatment ndash Benzodiazepines (short- amp intermediate-
acting safer in liver disease ndash lorazepam)
ndash Disulfram Naltrexone or Acamprosate + counseling in pts without ALD only ndash to reduce ETOH consumption amp prevent relapse
ndash Baclofen in ALD to prevent relapse (5mg TIDx3days then 10mg TID x 90 days)
bull Alcoholic Hepatitis ndash Acute symptomatic liver failure ndash Often associated with cirrhosis but not always
Disease Progression Slowing or Preventing
bull Address obesity
bull Vitamin D supplementation
bull Many pts ask about milk thistle ndash study results have been mixed do not show any harm nor improvement
bull Avoidance of raw oysters clams shellfish ndash Exposure to fatal infection Vibrio vulnificus
bull Reversing fibrosis (amp maybe cirrhosis) ndash Hep B amp Hep C Antivirals
ndash Primary biliary cholangitis Ursodiol
ndash Hemochromatosis Phlebotomy
ndash NASH Weight loss Vitamin E
Minimizing Further Harm
bull Medication adjustments ndash The fewer drugs the betterhellip prescribe only crucial
ones stop the others
ndash Safe drugs
bull Acetaminophen (2 gramsday) amp statins
ndash Generally unsafe drugs
bull NSAIDs including diclofenac
ndash Block prostaglandin synthesis (which protects renal function) amp cause renal vasoconstriction
ndash Risk of GI bleeding
ndash Blunt response to diuretics
bull Nitrofurantoin amp aminoglycosides
bull Herbs ndash many
Minimizing Further Harm
bull Surgical Risk ndash Increased morbidity amp mortality
ndash Abdominal surgery ndash worse outcomes
ndash Childs Classification risk stratification
bull Class A 10 mortality rate
bull Class B 30 mortality rate
bull Class C 80 mortality rate
ndash MELD score ndash validated as a predictor of 30- and 90-day mortality after surgery
bull Vaccinations ndash Hep A amp B
ndash Pneumococcal
ndash Influenza yearly
Management of the
Compensated vs
Decompensated
Cirrhosis Patient
Management - Compensated
bull 15-20 will decompensate in 10-20 years
bull Nutrition ndash 1-2 gramskgday protein
ndash Well-balanced diet
ndash Frequent small meals
ndash No skipping meals
ndash No protein restriction
ndash 1 can Ensure 1-2 times daily
ndash Daily multivitamin without iron
bull Vaccinate amp DOCUMENT administration amp IMMUNITY
Management - Compensated
bull Avoid weight gain
bull Gradual weight loss to normal BMI if obese
bull Tight glucose control
bull Address any dyslipidemia (statins are safe)
bull Avoid ETOH amp hepatotoxins ndash Avoid NSAIDs even celecoxib
ndash Tylenol is fine up to 2 grams per day (unless actively drinking)
ndash Tramadol 50mg TID with severe pain (last resort)
ndash Avoid opioids
Turn for the worse Decompensation
bull 58 of compensated pts will decompensate within 10 years
bull Decompensated disease has a 50-80 5-year mortality
bull Development of any of the following complications
ndash Jaundice due to hepatic insufficiency ndash ID amp tx superimposed causes (alcoholic hepatitis sepsis drug hepatotoxicity)
ndash Variceal hemorrhage ndash most deadly
ndash Ascites ndash most common to herald onset
ndash Encephalopathy
Turn for the worse Decompensation
bull Pathophysiology of Portal Hypertension
ndash Fibrosisnodules architectural distortion
ndash Decreased production of nitric oxide by liver
ndash Increased intrahepatic vasocontriction in liver
ndash Reduced blood flow to and through liver
ndash Formation of porto-systemic collaterals (higher
resistance) = Increased resistance in the liver
ndash Hyperdynamic circulation from vasodilation in
splanchnic arterioles increased blood flow into
portal vein
Management - Decompensated
bull Average life expectancy approximately 2 years
bull Nausea ndash metoclopramide gt odansetron but rf EPS
bull Itching ndash cholestyramine most effective sertraline
bull Fatigue ndash Rest
ndash Exercise
bull Insomnia ndash Sleep hygiene
ndash Benadryl 50mg QHS hydroxyzine 25mg QHS or trazodone 50-100mg QHS (rf precipitating HE)
ndash Melatonin
ndash Rule out sleep apnea HE RLS
Management - Decompensated
bull Muscle cramps ndash Check electrolytes
bull Remember Na+ may be low do not correct unless lt120 (fluid restriction only)
bull Calcium often low ndash no need for correction
ndash Considerations bull BCAAs (4 gram granules TID)
bull Taurine 3 grams once daily
bull Vit E 200mg TID
bull Umbilical hernias ndash Repair only if symptomatic
ndash High complication rate
Management ndash Decompensated
bull Hyponatremia
ndash Common
ndash No treatment usually
unless lt 125 (free
water restriction of 1-
15 L daily)
bull Thrombocytopenia
ndash No treatment
ndash Platelet level of 50000 sufficient for most interventions
bull Coagulopathy
ndash Elevated INR
ndash No treatment usually
ndash May need FFP prior to elective intervention (dental surgical paracentesisradiological)
Hepatic Encephalopathy
bull Reversible change in mental status
bull Continuum from minimal to overt HE
bull Exclusion of other causes for brain dysfunction
bull Assessing for HE ndash Cognition
ndash Orientation
ndash Level of consciousness
ndash Asterixis
Hepatic Encephalopathy
B
Source University of Washingtons Hep C Online Module at httpwwwhepatitiscuwedugomanagement-cirrhosis-related-complicationshepatic-encephalopathy-diagnosis-managementcore-conceptall
Hepatic Encephalopathy
bull Most cases have an identifiable precipitant cause ndash GI bleed
ndash Excessive protein intake
ndash Infection (SBP UTI Pneumonia)
ndash Pre-renal azotemia
ndash Hypokalemic alkalosis
ndash Hyponatremia
ndash Constipation
ndash Hypoxia
ndash Use of sedatives tranquilizers
bull Normal protein diet
bull No driving
bull Safety in the home
Educate pts amp caregiversrelatives
regarding med compliance potential side effects
recognition of early signs of HE and measures to
prevent recurrence
Hepatic Encephalopathy
bull Lactulose 15-30mL BID titrating for 2-3 BMs per day ndash decreases blood ammonia concentration ndash Promotes elimination of toxins
ndash Reduces urease-producing bacteria
ndash Prevents absorption of bacteria
ndash Assists with any constipation - withhold for diarrhea
ndash Continued indefinitely
bull RifaximinXifaxan ndash non-absorbed broad spectrum abx ndash Change in bowel flora
ndash May cause downregulation of intestinal
glutamase activity
Ascites
bull 1-year survival rate 50 bull Usually go through a progression of diuretic response to
refractory ascites to HRS bull Ensure pt is truly adhering to dietary sodium restriction
amp avoiding NSAIDs bull Diagnostic paracentesis for all new onset ascites - ro SBP bull Sodium restriction ndash 2 grams per day - effective in 20 of
cases bull Fluid restriction - not necessary unless hyponatremia bull Diuretics bull TIPS ndash consider if requiring gt 1-2 LVPmonth
ndash 2nd line therapy
Ascites
bull Therapeutic large volume paracentesis ndash Administer with 100 grams albumin IV intraoperatively
(6-8 grams per liter removed) if gt 5 L removed
ndash Indications
bull Discomfort
bull Dyspnea
bull Tense ascites (hemodynamic improvement)
bull Refractory ascites
bull Renal insufficiency (compartment syndrome)
ndash Complications infection Post-paracentesis circulatory dysfunction
ndash Refractory Ascites stop beta blockers
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Screening in Patients with Cirrhosis
bull Hepatic Encephalopathy
ndash Covert
bull Number connection test
bull Encephalapp Stroop test ndash iPhone app
ndash Overt
bull Clinical
bull Ammonia
ndash Do not routinely check it
ndash May add additional information to suspicions
ndash Do not screen compensated patients
Disease Progression
Slowing or Reversing
Alcohol Abstinence
bull Alcohol withdrawal syndrome occurs within 6-24 hrs after the last drink
bull Light to moderate AWS symptoms ndash Elevated BP amp HR
ndash Tremors
ndash Hyperreflexia
ndash Irritability anxiety
ndash HA
ndash Nausea vomiting
bull Severe symptoms of AWS ndash Delirium tremens
ndash Seizures
ndash Coma
ndash Cardiac arrest
ndash Death
Alcohol Abstinence
bull Treatment ndash Benzodiazepines (short- amp intermediate-
acting safer in liver disease ndash lorazepam)
ndash Disulfram Naltrexone or Acamprosate + counseling in pts without ALD only ndash to reduce ETOH consumption amp prevent relapse
ndash Baclofen in ALD to prevent relapse (5mg TIDx3days then 10mg TID x 90 days)
bull Alcoholic Hepatitis ndash Acute symptomatic liver failure ndash Often associated with cirrhosis but not always
Disease Progression Slowing or Preventing
bull Address obesity
bull Vitamin D supplementation
bull Many pts ask about milk thistle ndash study results have been mixed do not show any harm nor improvement
bull Avoidance of raw oysters clams shellfish ndash Exposure to fatal infection Vibrio vulnificus
bull Reversing fibrosis (amp maybe cirrhosis) ndash Hep B amp Hep C Antivirals
ndash Primary biliary cholangitis Ursodiol
ndash Hemochromatosis Phlebotomy
ndash NASH Weight loss Vitamin E
Minimizing Further Harm
bull Medication adjustments ndash The fewer drugs the betterhellip prescribe only crucial
ones stop the others
ndash Safe drugs
bull Acetaminophen (2 gramsday) amp statins
ndash Generally unsafe drugs
bull NSAIDs including diclofenac
ndash Block prostaglandin synthesis (which protects renal function) amp cause renal vasoconstriction
ndash Risk of GI bleeding
ndash Blunt response to diuretics
bull Nitrofurantoin amp aminoglycosides
bull Herbs ndash many
Minimizing Further Harm
bull Surgical Risk ndash Increased morbidity amp mortality
ndash Abdominal surgery ndash worse outcomes
ndash Childs Classification risk stratification
bull Class A 10 mortality rate
bull Class B 30 mortality rate
bull Class C 80 mortality rate
ndash MELD score ndash validated as a predictor of 30- and 90-day mortality after surgery
bull Vaccinations ndash Hep A amp B
ndash Pneumococcal
ndash Influenza yearly
Management of the
Compensated vs
Decompensated
Cirrhosis Patient
Management - Compensated
bull 15-20 will decompensate in 10-20 years
bull Nutrition ndash 1-2 gramskgday protein
ndash Well-balanced diet
ndash Frequent small meals
ndash No skipping meals
ndash No protein restriction
ndash 1 can Ensure 1-2 times daily
ndash Daily multivitamin without iron
bull Vaccinate amp DOCUMENT administration amp IMMUNITY
Management - Compensated
bull Avoid weight gain
bull Gradual weight loss to normal BMI if obese
bull Tight glucose control
bull Address any dyslipidemia (statins are safe)
bull Avoid ETOH amp hepatotoxins ndash Avoid NSAIDs even celecoxib
ndash Tylenol is fine up to 2 grams per day (unless actively drinking)
ndash Tramadol 50mg TID with severe pain (last resort)
ndash Avoid opioids
Turn for the worse Decompensation
bull 58 of compensated pts will decompensate within 10 years
bull Decompensated disease has a 50-80 5-year mortality
bull Development of any of the following complications
ndash Jaundice due to hepatic insufficiency ndash ID amp tx superimposed causes (alcoholic hepatitis sepsis drug hepatotoxicity)
ndash Variceal hemorrhage ndash most deadly
ndash Ascites ndash most common to herald onset
ndash Encephalopathy
Turn for the worse Decompensation
bull Pathophysiology of Portal Hypertension
ndash Fibrosisnodules architectural distortion
ndash Decreased production of nitric oxide by liver
ndash Increased intrahepatic vasocontriction in liver
ndash Reduced blood flow to and through liver
ndash Formation of porto-systemic collaterals (higher
resistance) = Increased resistance in the liver
ndash Hyperdynamic circulation from vasodilation in
splanchnic arterioles increased blood flow into
portal vein
Management - Decompensated
bull Average life expectancy approximately 2 years
bull Nausea ndash metoclopramide gt odansetron but rf EPS
bull Itching ndash cholestyramine most effective sertraline
bull Fatigue ndash Rest
ndash Exercise
bull Insomnia ndash Sleep hygiene
ndash Benadryl 50mg QHS hydroxyzine 25mg QHS or trazodone 50-100mg QHS (rf precipitating HE)
ndash Melatonin
ndash Rule out sleep apnea HE RLS
Management - Decompensated
bull Muscle cramps ndash Check electrolytes
bull Remember Na+ may be low do not correct unless lt120 (fluid restriction only)
bull Calcium often low ndash no need for correction
ndash Considerations bull BCAAs (4 gram granules TID)
bull Taurine 3 grams once daily
bull Vit E 200mg TID
bull Umbilical hernias ndash Repair only if symptomatic
ndash High complication rate
Management ndash Decompensated
bull Hyponatremia
ndash Common
ndash No treatment usually
unless lt 125 (free
water restriction of 1-
15 L daily)
bull Thrombocytopenia
ndash No treatment
ndash Platelet level of 50000 sufficient for most interventions
bull Coagulopathy
ndash Elevated INR
ndash No treatment usually
ndash May need FFP prior to elective intervention (dental surgical paracentesisradiological)
Hepatic Encephalopathy
bull Reversible change in mental status
bull Continuum from minimal to overt HE
bull Exclusion of other causes for brain dysfunction
bull Assessing for HE ndash Cognition
ndash Orientation
ndash Level of consciousness
ndash Asterixis
Hepatic Encephalopathy
B
Source University of Washingtons Hep C Online Module at httpwwwhepatitiscuwedugomanagement-cirrhosis-related-complicationshepatic-encephalopathy-diagnosis-managementcore-conceptall
Hepatic Encephalopathy
bull Most cases have an identifiable precipitant cause ndash GI bleed
ndash Excessive protein intake
ndash Infection (SBP UTI Pneumonia)
ndash Pre-renal azotemia
ndash Hypokalemic alkalosis
ndash Hyponatremia
ndash Constipation
ndash Hypoxia
ndash Use of sedatives tranquilizers
bull Normal protein diet
bull No driving
bull Safety in the home
Educate pts amp caregiversrelatives
regarding med compliance potential side effects
recognition of early signs of HE and measures to
prevent recurrence
Hepatic Encephalopathy
bull Lactulose 15-30mL BID titrating for 2-3 BMs per day ndash decreases blood ammonia concentration ndash Promotes elimination of toxins
ndash Reduces urease-producing bacteria
ndash Prevents absorption of bacteria
ndash Assists with any constipation - withhold for diarrhea
ndash Continued indefinitely
bull RifaximinXifaxan ndash non-absorbed broad spectrum abx ndash Change in bowel flora
ndash May cause downregulation of intestinal
glutamase activity
Ascites
bull 1-year survival rate 50 bull Usually go through a progression of diuretic response to
refractory ascites to HRS bull Ensure pt is truly adhering to dietary sodium restriction
amp avoiding NSAIDs bull Diagnostic paracentesis for all new onset ascites - ro SBP bull Sodium restriction ndash 2 grams per day - effective in 20 of
cases bull Fluid restriction - not necessary unless hyponatremia bull Diuretics bull TIPS ndash consider if requiring gt 1-2 LVPmonth
ndash 2nd line therapy
Ascites
bull Therapeutic large volume paracentesis ndash Administer with 100 grams albumin IV intraoperatively
(6-8 grams per liter removed) if gt 5 L removed
ndash Indications
bull Discomfort
bull Dyspnea
bull Tense ascites (hemodynamic improvement)
bull Refractory ascites
bull Renal insufficiency (compartment syndrome)
ndash Complications infection Post-paracentesis circulatory dysfunction
ndash Refractory Ascites stop beta blockers
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Disease Progression
Slowing or Reversing
Alcohol Abstinence
bull Alcohol withdrawal syndrome occurs within 6-24 hrs after the last drink
bull Light to moderate AWS symptoms ndash Elevated BP amp HR
ndash Tremors
ndash Hyperreflexia
ndash Irritability anxiety
ndash HA
ndash Nausea vomiting
bull Severe symptoms of AWS ndash Delirium tremens
ndash Seizures
ndash Coma
ndash Cardiac arrest
ndash Death
Alcohol Abstinence
bull Treatment ndash Benzodiazepines (short- amp intermediate-
acting safer in liver disease ndash lorazepam)
ndash Disulfram Naltrexone or Acamprosate + counseling in pts without ALD only ndash to reduce ETOH consumption amp prevent relapse
ndash Baclofen in ALD to prevent relapse (5mg TIDx3days then 10mg TID x 90 days)
bull Alcoholic Hepatitis ndash Acute symptomatic liver failure ndash Often associated with cirrhosis but not always
Disease Progression Slowing or Preventing
bull Address obesity
bull Vitamin D supplementation
bull Many pts ask about milk thistle ndash study results have been mixed do not show any harm nor improvement
bull Avoidance of raw oysters clams shellfish ndash Exposure to fatal infection Vibrio vulnificus
bull Reversing fibrosis (amp maybe cirrhosis) ndash Hep B amp Hep C Antivirals
ndash Primary biliary cholangitis Ursodiol
ndash Hemochromatosis Phlebotomy
ndash NASH Weight loss Vitamin E
Minimizing Further Harm
bull Medication adjustments ndash The fewer drugs the betterhellip prescribe only crucial
ones stop the others
ndash Safe drugs
bull Acetaminophen (2 gramsday) amp statins
ndash Generally unsafe drugs
bull NSAIDs including diclofenac
ndash Block prostaglandin synthesis (which protects renal function) amp cause renal vasoconstriction
ndash Risk of GI bleeding
ndash Blunt response to diuretics
bull Nitrofurantoin amp aminoglycosides
bull Herbs ndash many
Minimizing Further Harm
bull Surgical Risk ndash Increased morbidity amp mortality
ndash Abdominal surgery ndash worse outcomes
ndash Childs Classification risk stratification
bull Class A 10 mortality rate
bull Class B 30 mortality rate
bull Class C 80 mortality rate
ndash MELD score ndash validated as a predictor of 30- and 90-day mortality after surgery
bull Vaccinations ndash Hep A amp B
ndash Pneumococcal
ndash Influenza yearly
Management of the
Compensated vs
Decompensated
Cirrhosis Patient
Management - Compensated
bull 15-20 will decompensate in 10-20 years
bull Nutrition ndash 1-2 gramskgday protein
ndash Well-balanced diet
ndash Frequent small meals
ndash No skipping meals
ndash No protein restriction
ndash 1 can Ensure 1-2 times daily
ndash Daily multivitamin without iron
bull Vaccinate amp DOCUMENT administration amp IMMUNITY
Management - Compensated
bull Avoid weight gain
bull Gradual weight loss to normal BMI if obese
bull Tight glucose control
bull Address any dyslipidemia (statins are safe)
bull Avoid ETOH amp hepatotoxins ndash Avoid NSAIDs even celecoxib
ndash Tylenol is fine up to 2 grams per day (unless actively drinking)
ndash Tramadol 50mg TID with severe pain (last resort)
ndash Avoid opioids
Turn for the worse Decompensation
bull 58 of compensated pts will decompensate within 10 years
bull Decompensated disease has a 50-80 5-year mortality
bull Development of any of the following complications
ndash Jaundice due to hepatic insufficiency ndash ID amp tx superimposed causes (alcoholic hepatitis sepsis drug hepatotoxicity)
ndash Variceal hemorrhage ndash most deadly
ndash Ascites ndash most common to herald onset
ndash Encephalopathy
Turn for the worse Decompensation
bull Pathophysiology of Portal Hypertension
ndash Fibrosisnodules architectural distortion
ndash Decreased production of nitric oxide by liver
ndash Increased intrahepatic vasocontriction in liver
ndash Reduced blood flow to and through liver
ndash Formation of porto-systemic collaterals (higher
resistance) = Increased resistance in the liver
ndash Hyperdynamic circulation from vasodilation in
splanchnic arterioles increased blood flow into
portal vein
Management - Decompensated
bull Average life expectancy approximately 2 years
bull Nausea ndash metoclopramide gt odansetron but rf EPS
bull Itching ndash cholestyramine most effective sertraline
bull Fatigue ndash Rest
ndash Exercise
bull Insomnia ndash Sleep hygiene
ndash Benadryl 50mg QHS hydroxyzine 25mg QHS or trazodone 50-100mg QHS (rf precipitating HE)
ndash Melatonin
ndash Rule out sleep apnea HE RLS
Management - Decompensated
bull Muscle cramps ndash Check electrolytes
bull Remember Na+ may be low do not correct unless lt120 (fluid restriction only)
bull Calcium often low ndash no need for correction
ndash Considerations bull BCAAs (4 gram granules TID)
bull Taurine 3 grams once daily
bull Vit E 200mg TID
bull Umbilical hernias ndash Repair only if symptomatic
ndash High complication rate
Management ndash Decompensated
bull Hyponatremia
ndash Common
ndash No treatment usually
unless lt 125 (free
water restriction of 1-
15 L daily)
bull Thrombocytopenia
ndash No treatment
ndash Platelet level of 50000 sufficient for most interventions
bull Coagulopathy
ndash Elevated INR
ndash No treatment usually
ndash May need FFP prior to elective intervention (dental surgical paracentesisradiological)
Hepatic Encephalopathy
bull Reversible change in mental status
bull Continuum from minimal to overt HE
bull Exclusion of other causes for brain dysfunction
bull Assessing for HE ndash Cognition
ndash Orientation
ndash Level of consciousness
ndash Asterixis
Hepatic Encephalopathy
B
Source University of Washingtons Hep C Online Module at httpwwwhepatitiscuwedugomanagement-cirrhosis-related-complicationshepatic-encephalopathy-diagnosis-managementcore-conceptall
Hepatic Encephalopathy
bull Most cases have an identifiable precipitant cause ndash GI bleed
ndash Excessive protein intake
ndash Infection (SBP UTI Pneumonia)
ndash Pre-renal azotemia
ndash Hypokalemic alkalosis
ndash Hyponatremia
ndash Constipation
ndash Hypoxia
ndash Use of sedatives tranquilizers
bull Normal protein diet
bull No driving
bull Safety in the home
Educate pts amp caregiversrelatives
regarding med compliance potential side effects
recognition of early signs of HE and measures to
prevent recurrence
Hepatic Encephalopathy
bull Lactulose 15-30mL BID titrating for 2-3 BMs per day ndash decreases blood ammonia concentration ndash Promotes elimination of toxins
ndash Reduces urease-producing bacteria
ndash Prevents absorption of bacteria
ndash Assists with any constipation - withhold for diarrhea
ndash Continued indefinitely
bull RifaximinXifaxan ndash non-absorbed broad spectrum abx ndash Change in bowel flora
ndash May cause downregulation of intestinal
glutamase activity
Ascites
bull 1-year survival rate 50 bull Usually go through a progression of diuretic response to
refractory ascites to HRS bull Ensure pt is truly adhering to dietary sodium restriction
amp avoiding NSAIDs bull Diagnostic paracentesis for all new onset ascites - ro SBP bull Sodium restriction ndash 2 grams per day - effective in 20 of
cases bull Fluid restriction - not necessary unless hyponatremia bull Diuretics bull TIPS ndash consider if requiring gt 1-2 LVPmonth
ndash 2nd line therapy
Ascites
bull Therapeutic large volume paracentesis ndash Administer with 100 grams albumin IV intraoperatively
(6-8 grams per liter removed) if gt 5 L removed
ndash Indications
bull Discomfort
bull Dyspnea
bull Tense ascites (hemodynamic improvement)
bull Refractory ascites
bull Renal insufficiency (compartment syndrome)
ndash Complications infection Post-paracentesis circulatory dysfunction
ndash Refractory Ascites stop beta blockers
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Alcohol Abstinence
bull Alcohol withdrawal syndrome occurs within 6-24 hrs after the last drink
bull Light to moderate AWS symptoms ndash Elevated BP amp HR
ndash Tremors
ndash Hyperreflexia
ndash Irritability anxiety
ndash HA
ndash Nausea vomiting
bull Severe symptoms of AWS ndash Delirium tremens
ndash Seizures
ndash Coma
ndash Cardiac arrest
ndash Death
Alcohol Abstinence
bull Treatment ndash Benzodiazepines (short- amp intermediate-
acting safer in liver disease ndash lorazepam)
ndash Disulfram Naltrexone or Acamprosate + counseling in pts without ALD only ndash to reduce ETOH consumption amp prevent relapse
ndash Baclofen in ALD to prevent relapse (5mg TIDx3days then 10mg TID x 90 days)
bull Alcoholic Hepatitis ndash Acute symptomatic liver failure ndash Often associated with cirrhosis but not always
Disease Progression Slowing or Preventing
bull Address obesity
bull Vitamin D supplementation
bull Many pts ask about milk thistle ndash study results have been mixed do not show any harm nor improvement
bull Avoidance of raw oysters clams shellfish ndash Exposure to fatal infection Vibrio vulnificus
bull Reversing fibrosis (amp maybe cirrhosis) ndash Hep B amp Hep C Antivirals
ndash Primary biliary cholangitis Ursodiol
ndash Hemochromatosis Phlebotomy
ndash NASH Weight loss Vitamin E
Minimizing Further Harm
bull Medication adjustments ndash The fewer drugs the betterhellip prescribe only crucial
ones stop the others
ndash Safe drugs
bull Acetaminophen (2 gramsday) amp statins
ndash Generally unsafe drugs
bull NSAIDs including diclofenac
ndash Block prostaglandin synthesis (which protects renal function) amp cause renal vasoconstriction
ndash Risk of GI bleeding
ndash Blunt response to diuretics
bull Nitrofurantoin amp aminoglycosides
bull Herbs ndash many
Minimizing Further Harm
bull Surgical Risk ndash Increased morbidity amp mortality
ndash Abdominal surgery ndash worse outcomes
ndash Childs Classification risk stratification
bull Class A 10 mortality rate
bull Class B 30 mortality rate
bull Class C 80 mortality rate
ndash MELD score ndash validated as a predictor of 30- and 90-day mortality after surgery
bull Vaccinations ndash Hep A amp B
ndash Pneumococcal
ndash Influenza yearly
Management of the
Compensated vs
Decompensated
Cirrhosis Patient
Management - Compensated
bull 15-20 will decompensate in 10-20 years
bull Nutrition ndash 1-2 gramskgday protein
ndash Well-balanced diet
ndash Frequent small meals
ndash No skipping meals
ndash No protein restriction
ndash 1 can Ensure 1-2 times daily
ndash Daily multivitamin without iron
bull Vaccinate amp DOCUMENT administration amp IMMUNITY
Management - Compensated
bull Avoid weight gain
bull Gradual weight loss to normal BMI if obese
bull Tight glucose control
bull Address any dyslipidemia (statins are safe)
bull Avoid ETOH amp hepatotoxins ndash Avoid NSAIDs even celecoxib
ndash Tylenol is fine up to 2 grams per day (unless actively drinking)
ndash Tramadol 50mg TID with severe pain (last resort)
ndash Avoid opioids
Turn for the worse Decompensation
bull 58 of compensated pts will decompensate within 10 years
bull Decompensated disease has a 50-80 5-year mortality
bull Development of any of the following complications
ndash Jaundice due to hepatic insufficiency ndash ID amp tx superimposed causes (alcoholic hepatitis sepsis drug hepatotoxicity)
ndash Variceal hemorrhage ndash most deadly
ndash Ascites ndash most common to herald onset
ndash Encephalopathy
Turn for the worse Decompensation
bull Pathophysiology of Portal Hypertension
ndash Fibrosisnodules architectural distortion
ndash Decreased production of nitric oxide by liver
ndash Increased intrahepatic vasocontriction in liver
ndash Reduced blood flow to and through liver
ndash Formation of porto-systemic collaterals (higher
resistance) = Increased resistance in the liver
ndash Hyperdynamic circulation from vasodilation in
splanchnic arterioles increased blood flow into
portal vein
Management - Decompensated
bull Average life expectancy approximately 2 years
bull Nausea ndash metoclopramide gt odansetron but rf EPS
bull Itching ndash cholestyramine most effective sertraline
bull Fatigue ndash Rest
ndash Exercise
bull Insomnia ndash Sleep hygiene
ndash Benadryl 50mg QHS hydroxyzine 25mg QHS or trazodone 50-100mg QHS (rf precipitating HE)
ndash Melatonin
ndash Rule out sleep apnea HE RLS
Management - Decompensated
bull Muscle cramps ndash Check electrolytes
bull Remember Na+ may be low do not correct unless lt120 (fluid restriction only)
bull Calcium often low ndash no need for correction
ndash Considerations bull BCAAs (4 gram granules TID)
bull Taurine 3 grams once daily
bull Vit E 200mg TID
bull Umbilical hernias ndash Repair only if symptomatic
ndash High complication rate
Management ndash Decompensated
bull Hyponatremia
ndash Common
ndash No treatment usually
unless lt 125 (free
water restriction of 1-
15 L daily)
bull Thrombocytopenia
ndash No treatment
ndash Platelet level of 50000 sufficient for most interventions
bull Coagulopathy
ndash Elevated INR
ndash No treatment usually
ndash May need FFP prior to elective intervention (dental surgical paracentesisradiological)
Hepatic Encephalopathy
bull Reversible change in mental status
bull Continuum from minimal to overt HE
bull Exclusion of other causes for brain dysfunction
bull Assessing for HE ndash Cognition
ndash Orientation
ndash Level of consciousness
ndash Asterixis
Hepatic Encephalopathy
B
Source University of Washingtons Hep C Online Module at httpwwwhepatitiscuwedugomanagement-cirrhosis-related-complicationshepatic-encephalopathy-diagnosis-managementcore-conceptall
Hepatic Encephalopathy
bull Most cases have an identifiable precipitant cause ndash GI bleed
ndash Excessive protein intake
ndash Infection (SBP UTI Pneumonia)
ndash Pre-renal azotemia
ndash Hypokalemic alkalosis
ndash Hyponatremia
ndash Constipation
ndash Hypoxia
ndash Use of sedatives tranquilizers
bull Normal protein diet
bull No driving
bull Safety in the home
Educate pts amp caregiversrelatives
regarding med compliance potential side effects
recognition of early signs of HE and measures to
prevent recurrence
Hepatic Encephalopathy
bull Lactulose 15-30mL BID titrating for 2-3 BMs per day ndash decreases blood ammonia concentration ndash Promotes elimination of toxins
ndash Reduces urease-producing bacteria
ndash Prevents absorption of bacteria
ndash Assists with any constipation - withhold for diarrhea
ndash Continued indefinitely
bull RifaximinXifaxan ndash non-absorbed broad spectrum abx ndash Change in bowel flora
ndash May cause downregulation of intestinal
glutamase activity
Ascites
bull 1-year survival rate 50 bull Usually go through a progression of diuretic response to
refractory ascites to HRS bull Ensure pt is truly adhering to dietary sodium restriction
amp avoiding NSAIDs bull Diagnostic paracentesis for all new onset ascites - ro SBP bull Sodium restriction ndash 2 grams per day - effective in 20 of
cases bull Fluid restriction - not necessary unless hyponatremia bull Diuretics bull TIPS ndash consider if requiring gt 1-2 LVPmonth
ndash 2nd line therapy
Ascites
bull Therapeutic large volume paracentesis ndash Administer with 100 grams albumin IV intraoperatively
(6-8 grams per liter removed) if gt 5 L removed
ndash Indications
bull Discomfort
bull Dyspnea
bull Tense ascites (hemodynamic improvement)
bull Refractory ascites
bull Renal insufficiency (compartment syndrome)
ndash Complications infection Post-paracentesis circulatory dysfunction
ndash Refractory Ascites stop beta blockers
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Alcohol Abstinence
bull Treatment ndash Benzodiazepines (short- amp intermediate-
acting safer in liver disease ndash lorazepam)
ndash Disulfram Naltrexone or Acamprosate + counseling in pts without ALD only ndash to reduce ETOH consumption amp prevent relapse
ndash Baclofen in ALD to prevent relapse (5mg TIDx3days then 10mg TID x 90 days)
bull Alcoholic Hepatitis ndash Acute symptomatic liver failure ndash Often associated with cirrhosis but not always
Disease Progression Slowing or Preventing
bull Address obesity
bull Vitamin D supplementation
bull Many pts ask about milk thistle ndash study results have been mixed do not show any harm nor improvement
bull Avoidance of raw oysters clams shellfish ndash Exposure to fatal infection Vibrio vulnificus
bull Reversing fibrosis (amp maybe cirrhosis) ndash Hep B amp Hep C Antivirals
ndash Primary biliary cholangitis Ursodiol
ndash Hemochromatosis Phlebotomy
ndash NASH Weight loss Vitamin E
Minimizing Further Harm
bull Medication adjustments ndash The fewer drugs the betterhellip prescribe only crucial
ones stop the others
ndash Safe drugs
bull Acetaminophen (2 gramsday) amp statins
ndash Generally unsafe drugs
bull NSAIDs including diclofenac
ndash Block prostaglandin synthesis (which protects renal function) amp cause renal vasoconstriction
ndash Risk of GI bleeding
ndash Blunt response to diuretics
bull Nitrofurantoin amp aminoglycosides
bull Herbs ndash many
Minimizing Further Harm
bull Surgical Risk ndash Increased morbidity amp mortality
ndash Abdominal surgery ndash worse outcomes
ndash Childs Classification risk stratification
bull Class A 10 mortality rate
bull Class B 30 mortality rate
bull Class C 80 mortality rate
ndash MELD score ndash validated as a predictor of 30- and 90-day mortality after surgery
bull Vaccinations ndash Hep A amp B
ndash Pneumococcal
ndash Influenza yearly
Management of the
Compensated vs
Decompensated
Cirrhosis Patient
Management - Compensated
bull 15-20 will decompensate in 10-20 years
bull Nutrition ndash 1-2 gramskgday protein
ndash Well-balanced diet
ndash Frequent small meals
ndash No skipping meals
ndash No protein restriction
ndash 1 can Ensure 1-2 times daily
ndash Daily multivitamin without iron
bull Vaccinate amp DOCUMENT administration amp IMMUNITY
Management - Compensated
bull Avoid weight gain
bull Gradual weight loss to normal BMI if obese
bull Tight glucose control
bull Address any dyslipidemia (statins are safe)
bull Avoid ETOH amp hepatotoxins ndash Avoid NSAIDs even celecoxib
ndash Tylenol is fine up to 2 grams per day (unless actively drinking)
ndash Tramadol 50mg TID with severe pain (last resort)
ndash Avoid opioids
Turn for the worse Decompensation
bull 58 of compensated pts will decompensate within 10 years
bull Decompensated disease has a 50-80 5-year mortality
bull Development of any of the following complications
ndash Jaundice due to hepatic insufficiency ndash ID amp tx superimposed causes (alcoholic hepatitis sepsis drug hepatotoxicity)
ndash Variceal hemorrhage ndash most deadly
ndash Ascites ndash most common to herald onset
ndash Encephalopathy
Turn for the worse Decompensation
bull Pathophysiology of Portal Hypertension
ndash Fibrosisnodules architectural distortion
ndash Decreased production of nitric oxide by liver
ndash Increased intrahepatic vasocontriction in liver
ndash Reduced blood flow to and through liver
ndash Formation of porto-systemic collaterals (higher
resistance) = Increased resistance in the liver
ndash Hyperdynamic circulation from vasodilation in
splanchnic arterioles increased blood flow into
portal vein
Management - Decompensated
bull Average life expectancy approximately 2 years
bull Nausea ndash metoclopramide gt odansetron but rf EPS
bull Itching ndash cholestyramine most effective sertraline
bull Fatigue ndash Rest
ndash Exercise
bull Insomnia ndash Sleep hygiene
ndash Benadryl 50mg QHS hydroxyzine 25mg QHS or trazodone 50-100mg QHS (rf precipitating HE)
ndash Melatonin
ndash Rule out sleep apnea HE RLS
Management - Decompensated
bull Muscle cramps ndash Check electrolytes
bull Remember Na+ may be low do not correct unless lt120 (fluid restriction only)
bull Calcium often low ndash no need for correction
ndash Considerations bull BCAAs (4 gram granules TID)
bull Taurine 3 grams once daily
bull Vit E 200mg TID
bull Umbilical hernias ndash Repair only if symptomatic
ndash High complication rate
Management ndash Decompensated
bull Hyponatremia
ndash Common
ndash No treatment usually
unless lt 125 (free
water restriction of 1-
15 L daily)
bull Thrombocytopenia
ndash No treatment
ndash Platelet level of 50000 sufficient for most interventions
bull Coagulopathy
ndash Elevated INR
ndash No treatment usually
ndash May need FFP prior to elective intervention (dental surgical paracentesisradiological)
Hepatic Encephalopathy
bull Reversible change in mental status
bull Continuum from minimal to overt HE
bull Exclusion of other causes for brain dysfunction
bull Assessing for HE ndash Cognition
ndash Orientation
ndash Level of consciousness
ndash Asterixis
Hepatic Encephalopathy
B
Source University of Washingtons Hep C Online Module at httpwwwhepatitiscuwedugomanagement-cirrhosis-related-complicationshepatic-encephalopathy-diagnosis-managementcore-conceptall
Hepatic Encephalopathy
bull Most cases have an identifiable precipitant cause ndash GI bleed
ndash Excessive protein intake
ndash Infection (SBP UTI Pneumonia)
ndash Pre-renal azotemia
ndash Hypokalemic alkalosis
ndash Hyponatremia
ndash Constipation
ndash Hypoxia
ndash Use of sedatives tranquilizers
bull Normal protein diet
bull No driving
bull Safety in the home
Educate pts amp caregiversrelatives
regarding med compliance potential side effects
recognition of early signs of HE and measures to
prevent recurrence
Hepatic Encephalopathy
bull Lactulose 15-30mL BID titrating for 2-3 BMs per day ndash decreases blood ammonia concentration ndash Promotes elimination of toxins
ndash Reduces urease-producing bacteria
ndash Prevents absorption of bacteria
ndash Assists with any constipation - withhold for diarrhea
ndash Continued indefinitely
bull RifaximinXifaxan ndash non-absorbed broad spectrum abx ndash Change in bowel flora
ndash May cause downregulation of intestinal
glutamase activity
Ascites
bull 1-year survival rate 50 bull Usually go through a progression of diuretic response to
refractory ascites to HRS bull Ensure pt is truly adhering to dietary sodium restriction
amp avoiding NSAIDs bull Diagnostic paracentesis for all new onset ascites - ro SBP bull Sodium restriction ndash 2 grams per day - effective in 20 of
cases bull Fluid restriction - not necessary unless hyponatremia bull Diuretics bull TIPS ndash consider if requiring gt 1-2 LVPmonth
ndash 2nd line therapy
Ascites
bull Therapeutic large volume paracentesis ndash Administer with 100 grams albumin IV intraoperatively
(6-8 grams per liter removed) if gt 5 L removed
ndash Indications
bull Discomfort
bull Dyspnea
bull Tense ascites (hemodynamic improvement)
bull Refractory ascites
bull Renal insufficiency (compartment syndrome)
ndash Complications infection Post-paracentesis circulatory dysfunction
ndash Refractory Ascites stop beta blockers
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Disease Progression Slowing or Preventing
bull Address obesity
bull Vitamin D supplementation
bull Many pts ask about milk thistle ndash study results have been mixed do not show any harm nor improvement
bull Avoidance of raw oysters clams shellfish ndash Exposure to fatal infection Vibrio vulnificus
bull Reversing fibrosis (amp maybe cirrhosis) ndash Hep B amp Hep C Antivirals
ndash Primary biliary cholangitis Ursodiol
ndash Hemochromatosis Phlebotomy
ndash NASH Weight loss Vitamin E
Minimizing Further Harm
bull Medication adjustments ndash The fewer drugs the betterhellip prescribe only crucial
ones stop the others
ndash Safe drugs
bull Acetaminophen (2 gramsday) amp statins
ndash Generally unsafe drugs
bull NSAIDs including diclofenac
ndash Block prostaglandin synthesis (which protects renal function) amp cause renal vasoconstriction
ndash Risk of GI bleeding
ndash Blunt response to diuretics
bull Nitrofurantoin amp aminoglycosides
bull Herbs ndash many
Minimizing Further Harm
bull Surgical Risk ndash Increased morbidity amp mortality
ndash Abdominal surgery ndash worse outcomes
ndash Childs Classification risk stratification
bull Class A 10 mortality rate
bull Class B 30 mortality rate
bull Class C 80 mortality rate
ndash MELD score ndash validated as a predictor of 30- and 90-day mortality after surgery
bull Vaccinations ndash Hep A amp B
ndash Pneumococcal
ndash Influenza yearly
Management of the
Compensated vs
Decompensated
Cirrhosis Patient
Management - Compensated
bull 15-20 will decompensate in 10-20 years
bull Nutrition ndash 1-2 gramskgday protein
ndash Well-balanced diet
ndash Frequent small meals
ndash No skipping meals
ndash No protein restriction
ndash 1 can Ensure 1-2 times daily
ndash Daily multivitamin without iron
bull Vaccinate amp DOCUMENT administration amp IMMUNITY
Management - Compensated
bull Avoid weight gain
bull Gradual weight loss to normal BMI if obese
bull Tight glucose control
bull Address any dyslipidemia (statins are safe)
bull Avoid ETOH amp hepatotoxins ndash Avoid NSAIDs even celecoxib
ndash Tylenol is fine up to 2 grams per day (unless actively drinking)
ndash Tramadol 50mg TID with severe pain (last resort)
ndash Avoid opioids
Turn for the worse Decompensation
bull 58 of compensated pts will decompensate within 10 years
bull Decompensated disease has a 50-80 5-year mortality
bull Development of any of the following complications
ndash Jaundice due to hepatic insufficiency ndash ID amp tx superimposed causes (alcoholic hepatitis sepsis drug hepatotoxicity)
ndash Variceal hemorrhage ndash most deadly
ndash Ascites ndash most common to herald onset
ndash Encephalopathy
Turn for the worse Decompensation
bull Pathophysiology of Portal Hypertension
ndash Fibrosisnodules architectural distortion
ndash Decreased production of nitric oxide by liver
ndash Increased intrahepatic vasocontriction in liver
ndash Reduced blood flow to and through liver
ndash Formation of porto-systemic collaterals (higher
resistance) = Increased resistance in the liver
ndash Hyperdynamic circulation from vasodilation in
splanchnic arterioles increased blood flow into
portal vein
Management - Decompensated
bull Average life expectancy approximately 2 years
bull Nausea ndash metoclopramide gt odansetron but rf EPS
bull Itching ndash cholestyramine most effective sertraline
bull Fatigue ndash Rest
ndash Exercise
bull Insomnia ndash Sleep hygiene
ndash Benadryl 50mg QHS hydroxyzine 25mg QHS or trazodone 50-100mg QHS (rf precipitating HE)
ndash Melatonin
ndash Rule out sleep apnea HE RLS
Management - Decompensated
bull Muscle cramps ndash Check electrolytes
bull Remember Na+ may be low do not correct unless lt120 (fluid restriction only)
bull Calcium often low ndash no need for correction
ndash Considerations bull BCAAs (4 gram granules TID)
bull Taurine 3 grams once daily
bull Vit E 200mg TID
bull Umbilical hernias ndash Repair only if symptomatic
ndash High complication rate
Management ndash Decompensated
bull Hyponatremia
ndash Common
ndash No treatment usually
unless lt 125 (free
water restriction of 1-
15 L daily)
bull Thrombocytopenia
ndash No treatment
ndash Platelet level of 50000 sufficient for most interventions
bull Coagulopathy
ndash Elevated INR
ndash No treatment usually
ndash May need FFP prior to elective intervention (dental surgical paracentesisradiological)
Hepatic Encephalopathy
bull Reversible change in mental status
bull Continuum from minimal to overt HE
bull Exclusion of other causes for brain dysfunction
bull Assessing for HE ndash Cognition
ndash Orientation
ndash Level of consciousness
ndash Asterixis
Hepatic Encephalopathy
B
Source University of Washingtons Hep C Online Module at httpwwwhepatitiscuwedugomanagement-cirrhosis-related-complicationshepatic-encephalopathy-diagnosis-managementcore-conceptall
Hepatic Encephalopathy
bull Most cases have an identifiable precipitant cause ndash GI bleed
ndash Excessive protein intake
ndash Infection (SBP UTI Pneumonia)
ndash Pre-renal azotemia
ndash Hypokalemic alkalosis
ndash Hyponatremia
ndash Constipation
ndash Hypoxia
ndash Use of sedatives tranquilizers
bull Normal protein diet
bull No driving
bull Safety in the home
Educate pts amp caregiversrelatives
regarding med compliance potential side effects
recognition of early signs of HE and measures to
prevent recurrence
Hepatic Encephalopathy
bull Lactulose 15-30mL BID titrating for 2-3 BMs per day ndash decreases blood ammonia concentration ndash Promotes elimination of toxins
ndash Reduces urease-producing bacteria
ndash Prevents absorption of bacteria
ndash Assists with any constipation - withhold for diarrhea
ndash Continued indefinitely
bull RifaximinXifaxan ndash non-absorbed broad spectrum abx ndash Change in bowel flora
ndash May cause downregulation of intestinal
glutamase activity
Ascites
bull 1-year survival rate 50 bull Usually go through a progression of diuretic response to
refractory ascites to HRS bull Ensure pt is truly adhering to dietary sodium restriction
amp avoiding NSAIDs bull Diagnostic paracentesis for all new onset ascites - ro SBP bull Sodium restriction ndash 2 grams per day - effective in 20 of
cases bull Fluid restriction - not necessary unless hyponatremia bull Diuretics bull TIPS ndash consider if requiring gt 1-2 LVPmonth
ndash 2nd line therapy
Ascites
bull Therapeutic large volume paracentesis ndash Administer with 100 grams albumin IV intraoperatively
(6-8 grams per liter removed) if gt 5 L removed
ndash Indications
bull Discomfort
bull Dyspnea
bull Tense ascites (hemodynamic improvement)
bull Refractory ascites
bull Renal insufficiency (compartment syndrome)
ndash Complications infection Post-paracentesis circulatory dysfunction
ndash Refractory Ascites stop beta blockers
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Minimizing Further Harm
bull Medication adjustments ndash The fewer drugs the betterhellip prescribe only crucial
ones stop the others
ndash Safe drugs
bull Acetaminophen (2 gramsday) amp statins
ndash Generally unsafe drugs
bull NSAIDs including diclofenac
ndash Block prostaglandin synthesis (which protects renal function) amp cause renal vasoconstriction
ndash Risk of GI bleeding
ndash Blunt response to diuretics
bull Nitrofurantoin amp aminoglycosides
bull Herbs ndash many
Minimizing Further Harm
bull Surgical Risk ndash Increased morbidity amp mortality
ndash Abdominal surgery ndash worse outcomes
ndash Childs Classification risk stratification
bull Class A 10 mortality rate
bull Class B 30 mortality rate
bull Class C 80 mortality rate
ndash MELD score ndash validated as a predictor of 30- and 90-day mortality after surgery
bull Vaccinations ndash Hep A amp B
ndash Pneumococcal
ndash Influenza yearly
Management of the
Compensated vs
Decompensated
Cirrhosis Patient
Management - Compensated
bull 15-20 will decompensate in 10-20 years
bull Nutrition ndash 1-2 gramskgday protein
ndash Well-balanced diet
ndash Frequent small meals
ndash No skipping meals
ndash No protein restriction
ndash 1 can Ensure 1-2 times daily
ndash Daily multivitamin without iron
bull Vaccinate amp DOCUMENT administration amp IMMUNITY
Management - Compensated
bull Avoid weight gain
bull Gradual weight loss to normal BMI if obese
bull Tight glucose control
bull Address any dyslipidemia (statins are safe)
bull Avoid ETOH amp hepatotoxins ndash Avoid NSAIDs even celecoxib
ndash Tylenol is fine up to 2 grams per day (unless actively drinking)
ndash Tramadol 50mg TID with severe pain (last resort)
ndash Avoid opioids
Turn for the worse Decompensation
bull 58 of compensated pts will decompensate within 10 years
bull Decompensated disease has a 50-80 5-year mortality
bull Development of any of the following complications
ndash Jaundice due to hepatic insufficiency ndash ID amp tx superimposed causes (alcoholic hepatitis sepsis drug hepatotoxicity)
ndash Variceal hemorrhage ndash most deadly
ndash Ascites ndash most common to herald onset
ndash Encephalopathy
Turn for the worse Decompensation
bull Pathophysiology of Portal Hypertension
ndash Fibrosisnodules architectural distortion
ndash Decreased production of nitric oxide by liver
ndash Increased intrahepatic vasocontriction in liver
ndash Reduced blood flow to and through liver
ndash Formation of porto-systemic collaterals (higher
resistance) = Increased resistance in the liver
ndash Hyperdynamic circulation from vasodilation in
splanchnic arterioles increased blood flow into
portal vein
Management - Decompensated
bull Average life expectancy approximately 2 years
bull Nausea ndash metoclopramide gt odansetron but rf EPS
bull Itching ndash cholestyramine most effective sertraline
bull Fatigue ndash Rest
ndash Exercise
bull Insomnia ndash Sleep hygiene
ndash Benadryl 50mg QHS hydroxyzine 25mg QHS or trazodone 50-100mg QHS (rf precipitating HE)
ndash Melatonin
ndash Rule out sleep apnea HE RLS
Management - Decompensated
bull Muscle cramps ndash Check electrolytes
bull Remember Na+ may be low do not correct unless lt120 (fluid restriction only)
bull Calcium often low ndash no need for correction
ndash Considerations bull BCAAs (4 gram granules TID)
bull Taurine 3 grams once daily
bull Vit E 200mg TID
bull Umbilical hernias ndash Repair only if symptomatic
ndash High complication rate
Management ndash Decompensated
bull Hyponatremia
ndash Common
ndash No treatment usually
unless lt 125 (free
water restriction of 1-
15 L daily)
bull Thrombocytopenia
ndash No treatment
ndash Platelet level of 50000 sufficient for most interventions
bull Coagulopathy
ndash Elevated INR
ndash No treatment usually
ndash May need FFP prior to elective intervention (dental surgical paracentesisradiological)
Hepatic Encephalopathy
bull Reversible change in mental status
bull Continuum from minimal to overt HE
bull Exclusion of other causes for brain dysfunction
bull Assessing for HE ndash Cognition
ndash Orientation
ndash Level of consciousness
ndash Asterixis
Hepatic Encephalopathy
B
Source University of Washingtons Hep C Online Module at httpwwwhepatitiscuwedugomanagement-cirrhosis-related-complicationshepatic-encephalopathy-diagnosis-managementcore-conceptall
Hepatic Encephalopathy
bull Most cases have an identifiable precipitant cause ndash GI bleed
ndash Excessive protein intake
ndash Infection (SBP UTI Pneumonia)
ndash Pre-renal azotemia
ndash Hypokalemic alkalosis
ndash Hyponatremia
ndash Constipation
ndash Hypoxia
ndash Use of sedatives tranquilizers
bull Normal protein diet
bull No driving
bull Safety in the home
Educate pts amp caregiversrelatives
regarding med compliance potential side effects
recognition of early signs of HE and measures to
prevent recurrence
Hepatic Encephalopathy
bull Lactulose 15-30mL BID titrating for 2-3 BMs per day ndash decreases blood ammonia concentration ndash Promotes elimination of toxins
ndash Reduces urease-producing bacteria
ndash Prevents absorption of bacteria
ndash Assists with any constipation - withhold for diarrhea
ndash Continued indefinitely
bull RifaximinXifaxan ndash non-absorbed broad spectrum abx ndash Change in bowel flora
ndash May cause downregulation of intestinal
glutamase activity
Ascites
bull 1-year survival rate 50 bull Usually go through a progression of diuretic response to
refractory ascites to HRS bull Ensure pt is truly adhering to dietary sodium restriction
amp avoiding NSAIDs bull Diagnostic paracentesis for all new onset ascites - ro SBP bull Sodium restriction ndash 2 grams per day - effective in 20 of
cases bull Fluid restriction - not necessary unless hyponatremia bull Diuretics bull TIPS ndash consider if requiring gt 1-2 LVPmonth
ndash 2nd line therapy
Ascites
bull Therapeutic large volume paracentesis ndash Administer with 100 grams albumin IV intraoperatively
(6-8 grams per liter removed) if gt 5 L removed
ndash Indications
bull Discomfort
bull Dyspnea
bull Tense ascites (hemodynamic improvement)
bull Refractory ascites
bull Renal insufficiency (compartment syndrome)
ndash Complications infection Post-paracentesis circulatory dysfunction
ndash Refractory Ascites stop beta blockers
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Minimizing Further Harm
bull Surgical Risk ndash Increased morbidity amp mortality
ndash Abdominal surgery ndash worse outcomes
ndash Childs Classification risk stratification
bull Class A 10 mortality rate
bull Class B 30 mortality rate
bull Class C 80 mortality rate
ndash MELD score ndash validated as a predictor of 30- and 90-day mortality after surgery
bull Vaccinations ndash Hep A amp B
ndash Pneumococcal
ndash Influenza yearly
Management of the
Compensated vs
Decompensated
Cirrhosis Patient
Management - Compensated
bull 15-20 will decompensate in 10-20 years
bull Nutrition ndash 1-2 gramskgday protein
ndash Well-balanced diet
ndash Frequent small meals
ndash No skipping meals
ndash No protein restriction
ndash 1 can Ensure 1-2 times daily
ndash Daily multivitamin without iron
bull Vaccinate amp DOCUMENT administration amp IMMUNITY
Management - Compensated
bull Avoid weight gain
bull Gradual weight loss to normal BMI if obese
bull Tight glucose control
bull Address any dyslipidemia (statins are safe)
bull Avoid ETOH amp hepatotoxins ndash Avoid NSAIDs even celecoxib
ndash Tylenol is fine up to 2 grams per day (unless actively drinking)
ndash Tramadol 50mg TID with severe pain (last resort)
ndash Avoid opioids
Turn for the worse Decompensation
bull 58 of compensated pts will decompensate within 10 years
bull Decompensated disease has a 50-80 5-year mortality
bull Development of any of the following complications
ndash Jaundice due to hepatic insufficiency ndash ID amp tx superimposed causes (alcoholic hepatitis sepsis drug hepatotoxicity)
ndash Variceal hemorrhage ndash most deadly
ndash Ascites ndash most common to herald onset
ndash Encephalopathy
Turn for the worse Decompensation
bull Pathophysiology of Portal Hypertension
ndash Fibrosisnodules architectural distortion
ndash Decreased production of nitric oxide by liver
ndash Increased intrahepatic vasocontriction in liver
ndash Reduced blood flow to and through liver
ndash Formation of porto-systemic collaterals (higher
resistance) = Increased resistance in the liver
ndash Hyperdynamic circulation from vasodilation in
splanchnic arterioles increased blood flow into
portal vein
Management - Decompensated
bull Average life expectancy approximately 2 years
bull Nausea ndash metoclopramide gt odansetron but rf EPS
bull Itching ndash cholestyramine most effective sertraline
bull Fatigue ndash Rest
ndash Exercise
bull Insomnia ndash Sleep hygiene
ndash Benadryl 50mg QHS hydroxyzine 25mg QHS or trazodone 50-100mg QHS (rf precipitating HE)
ndash Melatonin
ndash Rule out sleep apnea HE RLS
Management - Decompensated
bull Muscle cramps ndash Check electrolytes
bull Remember Na+ may be low do not correct unless lt120 (fluid restriction only)
bull Calcium often low ndash no need for correction
ndash Considerations bull BCAAs (4 gram granules TID)
bull Taurine 3 grams once daily
bull Vit E 200mg TID
bull Umbilical hernias ndash Repair only if symptomatic
ndash High complication rate
Management ndash Decompensated
bull Hyponatremia
ndash Common
ndash No treatment usually
unless lt 125 (free
water restriction of 1-
15 L daily)
bull Thrombocytopenia
ndash No treatment
ndash Platelet level of 50000 sufficient for most interventions
bull Coagulopathy
ndash Elevated INR
ndash No treatment usually
ndash May need FFP prior to elective intervention (dental surgical paracentesisradiological)
Hepatic Encephalopathy
bull Reversible change in mental status
bull Continuum from minimal to overt HE
bull Exclusion of other causes for brain dysfunction
bull Assessing for HE ndash Cognition
ndash Orientation
ndash Level of consciousness
ndash Asterixis
Hepatic Encephalopathy
B
Source University of Washingtons Hep C Online Module at httpwwwhepatitiscuwedugomanagement-cirrhosis-related-complicationshepatic-encephalopathy-diagnosis-managementcore-conceptall
Hepatic Encephalopathy
bull Most cases have an identifiable precipitant cause ndash GI bleed
ndash Excessive protein intake
ndash Infection (SBP UTI Pneumonia)
ndash Pre-renal azotemia
ndash Hypokalemic alkalosis
ndash Hyponatremia
ndash Constipation
ndash Hypoxia
ndash Use of sedatives tranquilizers
bull Normal protein diet
bull No driving
bull Safety in the home
Educate pts amp caregiversrelatives
regarding med compliance potential side effects
recognition of early signs of HE and measures to
prevent recurrence
Hepatic Encephalopathy
bull Lactulose 15-30mL BID titrating for 2-3 BMs per day ndash decreases blood ammonia concentration ndash Promotes elimination of toxins
ndash Reduces urease-producing bacteria
ndash Prevents absorption of bacteria
ndash Assists with any constipation - withhold for diarrhea
ndash Continued indefinitely
bull RifaximinXifaxan ndash non-absorbed broad spectrum abx ndash Change in bowel flora
ndash May cause downregulation of intestinal
glutamase activity
Ascites
bull 1-year survival rate 50 bull Usually go through a progression of diuretic response to
refractory ascites to HRS bull Ensure pt is truly adhering to dietary sodium restriction
amp avoiding NSAIDs bull Diagnostic paracentesis for all new onset ascites - ro SBP bull Sodium restriction ndash 2 grams per day - effective in 20 of
cases bull Fluid restriction - not necessary unless hyponatremia bull Diuretics bull TIPS ndash consider if requiring gt 1-2 LVPmonth
ndash 2nd line therapy
Ascites
bull Therapeutic large volume paracentesis ndash Administer with 100 grams albumin IV intraoperatively
(6-8 grams per liter removed) if gt 5 L removed
ndash Indications
bull Discomfort
bull Dyspnea
bull Tense ascites (hemodynamic improvement)
bull Refractory ascites
bull Renal insufficiency (compartment syndrome)
ndash Complications infection Post-paracentesis circulatory dysfunction
ndash Refractory Ascites stop beta blockers
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Management of the
Compensated vs
Decompensated
Cirrhosis Patient
Management - Compensated
bull 15-20 will decompensate in 10-20 years
bull Nutrition ndash 1-2 gramskgday protein
ndash Well-balanced diet
ndash Frequent small meals
ndash No skipping meals
ndash No protein restriction
ndash 1 can Ensure 1-2 times daily
ndash Daily multivitamin without iron
bull Vaccinate amp DOCUMENT administration amp IMMUNITY
Management - Compensated
bull Avoid weight gain
bull Gradual weight loss to normal BMI if obese
bull Tight glucose control
bull Address any dyslipidemia (statins are safe)
bull Avoid ETOH amp hepatotoxins ndash Avoid NSAIDs even celecoxib
ndash Tylenol is fine up to 2 grams per day (unless actively drinking)
ndash Tramadol 50mg TID with severe pain (last resort)
ndash Avoid opioids
Turn for the worse Decompensation
bull 58 of compensated pts will decompensate within 10 years
bull Decompensated disease has a 50-80 5-year mortality
bull Development of any of the following complications
ndash Jaundice due to hepatic insufficiency ndash ID amp tx superimposed causes (alcoholic hepatitis sepsis drug hepatotoxicity)
ndash Variceal hemorrhage ndash most deadly
ndash Ascites ndash most common to herald onset
ndash Encephalopathy
Turn for the worse Decompensation
bull Pathophysiology of Portal Hypertension
ndash Fibrosisnodules architectural distortion
ndash Decreased production of nitric oxide by liver
ndash Increased intrahepatic vasocontriction in liver
ndash Reduced blood flow to and through liver
ndash Formation of porto-systemic collaterals (higher
resistance) = Increased resistance in the liver
ndash Hyperdynamic circulation from vasodilation in
splanchnic arterioles increased blood flow into
portal vein
Management - Decompensated
bull Average life expectancy approximately 2 years
bull Nausea ndash metoclopramide gt odansetron but rf EPS
bull Itching ndash cholestyramine most effective sertraline
bull Fatigue ndash Rest
ndash Exercise
bull Insomnia ndash Sleep hygiene
ndash Benadryl 50mg QHS hydroxyzine 25mg QHS or trazodone 50-100mg QHS (rf precipitating HE)
ndash Melatonin
ndash Rule out sleep apnea HE RLS
Management - Decompensated
bull Muscle cramps ndash Check electrolytes
bull Remember Na+ may be low do not correct unless lt120 (fluid restriction only)
bull Calcium often low ndash no need for correction
ndash Considerations bull BCAAs (4 gram granules TID)
bull Taurine 3 grams once daily
bull Vit E 200mg TID
bull Umbilical hernias ndash Repair only if symptomatic
ndash High complication rate
Management ndash Decompensated
bull Hyponatremia
ndash Common
ndash No treatment usually
unless lt 125 (free
water restriction of 1-
15 L daily)
bull Thrombocytopenia
ndash No treatment
ndash Platelet level of 50000 sufficient for most interventions
bull Coagulopathy
ndash Elevated INR
ndash No treatment usually
ndash May need FFP prior to elective intervention (dental surgical paracentesisradiological)
Hepatic Encephalopathy
bull Reversible change in mental status
bull Continuum from minimal to overt HE
bull Exclusion of other causes for brain dysfunction
bull Assessing for HE ndash Cognition
ndash Orientation
ndash Level of consciousness
ndash Asterixis
Hepatic Encephalopathy
B
Source University of Washingtons Hep C Online Module at httpwwwhepatitiscuwedugomanagement-cirrhosis-related-complicationshepatic-encephalopathy-diagnosis-managementcore-conceptall
Hepatic Encephalopathy
bull Most cases have an identifiable precipitant cause ndash GI bleed
ndash Excessive protein intake
ndash Infection (SBP UTI Pneumonia)
ndash Pre-renal azotemia
ndash Hypokalemic alkalosis
ndash Hyponatremia
ndash Constipation
ndash Hypoxia
ndash Use of sedatives tranquilizers
bull Normal protein diet
bull No driving
bull Safety in the home
Educate pts amp caregiversrelatives
regarding med compliance potential side effects
recognition of early signs of HE and measures to
prevent recurrence
Hepatic Encephalopathy
bull Lactulose 15-30mL BID titrating for 2-3 BMs per day ndash decreases blood ammonia concentration ndash Promotes elimination of toxins
ndash Reduces urease-producing bacteria
ndash Prevents absorption of bacteria
ndash Assists with any constipation - withhold for diarrhea
ndash Continued indefinitely
bull RifaximinXifaxan ndash non-absorbed broad spectrum abx ndash Change in bowel flora
ndash May cause downregulation of intestinal
glutamase activity
Ascites
bull 1-year survival rate 50 bull Usually go through a progression of diuretic response to
refractory ascites to HRS bull Ensure pt is truly adhering to dietary sodium restriction
amp avoiding NSAIDs bull Diagnostic paracentesis for all new onset ascites - ro SBP bull Sodium restriction ndash 2 grams per day - effective in 20 of
cases bull Fluid restriction - not necessary unless hyponatremia bull Diuretics bull TIPS ndash consider if requiring gt 1-2 LVPmonth
ndash 2nd line therapy
Ascites
bull Therapeutic large volume paracentesis ndash Administer with 100 grams albumin IV intraoperatively
(6-8 grams per liter removed) if gt 5 L removed
ndash Indications
bull Discomfort
bull Dyspnea
bull Tense ascites (hemodynamic improvement)
bull Refractory ascites
bull Renal insufficiency (compartment syndrome)
ndash Complications infection Post-paracentesis circulatory dysfunction
ndash Refractory Ascites stop beta blockers
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Management - Compensated
bull 15-20 will decompensate in 10-20 years
bull Nutrition ndash 1-2 gramskgday protein
ndash Well-balanced diet
ndash Frequent small meals
ndash No skipping meals
ndash No protein restriction
ndash 1 can Ensure 1-2 times daily
ndash Daily multivitamin without iron
bull Vaccinate amp DOCUMENT administration amp IMMUNITY
Management - Compensated
bull Avoid weight gain
bull Gradual weight loss to normal BMI if obese
bull Tight glucose control
bull Address any dyslipidemia (statins are safe)
bull Avoid ETOH amp hepatotoxins ndash Avoid NSAIDs even celecoxib
ndash Tylenol is fine up to 2 grams per day (unless actively drinking)
ndash Tramadol 50mg TID with severe pain (last resort)
ndash Avoid opioids
Turn for the worse Decompensation
bull 58 of compensated pts will decompensate within 10 years
bull Decompensated disease has a 50-80 5-year mortality
bull Development of any of the following complications
ndash Jaundice due to hepatic insufficiency ndash ID amp tx superimposed causes (alcoholic hepatitis sepsis drug hepatotoxicity)
ndash Variceal hemorrhage ndash most deadly
ndash Ascites ndash most common to herald onset
ndash Encephalopathy
Turn for the worse Decompensation
bull Pathophysiology of Portal Hypertension
ndash Fibrosisnodules architectural distortion
ndash Decreased production of nitric oxide by liver
ndash Increased intrahepatic vasocontriction in liver
ndash Reduced blood flow to and through liver
ndash Formation of porto-systemic collaterals (higher
resistance) = Increased resistance in the liver
ndash Hyperdynamic circulation from vasodilation in
splanchnic arterioles increased blood flow into
portal vein
Management - Decompensated
bull Average life expectancy approximately 2 years
bull Nausea ndash metoclopramide gt odansetron but rf EPS
bull Itching ndash cholestyramine most effective sertraline
bull Fatigue ndash Rest
ndash Exercise
bull Insomnia ndash Sleep hygiene
ndash Benadryl 50mg QHS hydroxyzine 25mg QHS or trazodone 50-100mg QHS (rf precipitating HE)
ndash Melatonin
ndash Rule out sleep apnea HE RLS
Management - Decompensated
bull Muscle cramps ndash Check electrolytes
bull Remember Na+ may be low do not correct unless lt120 (fluid restriction only)
bull Calcium often low ndash no need for correction
ndash Considerations bull BCAAs (4 gram granules TID)
bull Taurine 3 grams once daily
bull Vit E 200mg TID
bull Umbilical hernias ndash Repair only if symptomatic
ndash High complication rate
Management ndash Decompensated
bull Hyponatremia
ndash Common
ndash No treatment usually
unless lt 125 (free
water restriction of 1-
15 L daily)
bull Thrombocytopenia
ndash No treatment
ndash Platelet level of 50000 sufficient for most interventions
bull Coagulopathy
ndash Elevated INR
ndash No treatment usually
ndash May need FFP prior to elective intervention (dental surgical paracentesisradiological)
Hepatic Encephalopathy
bull Reversible change in mental status
bull Continuum from minimal to overt HE
bull Exclusion of other causes for brain dysfunction
bull Assessing for HE ndash Cognition
ndash Orientation
ndash Level of consciousness
ndash Asterixis
Hepatic Encephalopathy
B
Source University of Washingtons Hep C Online Module at httpwwwhepatitiscuwedugomanagement-cirrhosis-related-complicationshepatic-encephalopathy-diagnosis-managementcore-conceptall
Hepatic Encephalopathy
bull Most cases have an identifiable precipitant cause ndash GI bleed
ndash Excessive protein intake
ndash Infection (SBP UTI Pneumonia)
ndash Pre-renal azotemia
ndash Hypokalemic alkalosis
ndash Hyponatremia
ndash Constipation
ndash Hypoxia
ndash Use of sedatives tranquilizers
bull Normal protein diet
bull No driving
bull Safety in the home
Educate pts amp caregiversrelatives
regarding med compliance potential side effects
recognition of early signs of HE and measures to
prevent recurrence
Hepatic Encephalopathy
bull Lactulose 15-30mL BID titrating for 2-3 BMs per day ndash decreases blood ammonia concentration ndash Promotes elimination of toxins
ndash Reduces urease-producing bacteria
ndash Prevents absorption of bacteria
ndash Assists with any constipation - withhold for diarrhea
ndash Continued indefinitely
bull RifaximinXifaxan ndash non-absorbed broad spectrum abx ndash Change in bowel flora
ndash May cause downregulation of intestinal
glutamase activity
Ascites
bull 1-year survival rate 50 bull Usually go through a progression of diuretic response to
refractory ascites to HRS bull Ensure pt is truly adhering to dietary sodium restriction
amp avoiding NSAIDs bull Diagnostic paracentesis for all new onset ascites - ro SBP bull Sodium restriction ndash 2 grams per day - effective in 20 of
cases bull Fluid restriction - not necessary unless hyponatremia bull Diuretics bull TIPS ndash consider if requiring gt 1-2 LVPmonth
ndash 2nd line therapy
Ascites
bull Therapeutic large volume paracentesis ndash Administer with 100 grams albumin IV intraoperatively
(6-8 grams per liter removed) if gt 5 L removed
ndash Indications
bull Discomfort
bull Dyspnea
bull Tense ascites (hemodynamic improvement)
bull Refractory ascites
bull Renal insufficiency (compartment syndrome)
ndash Complications infection Post-paracentesis circulatory dysfunction
ndash Refractory Ascites stop beta blockers
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Management - Compensated
bull Avoid weight gain
bull Gradual weight loss to normal BMI if obese
bull Tight glucose control
bull Address any dyslipidemia (statins are safe)
bull Avoid ETOH amp hepatotoxins ndash Avoid NSAIDs even celecoxib
ndash Tylenol is fine up to 2 grams per day (unless actively drinking)
ndash Tramadol 50mg TID with severe pain (last resort)
ndash Avoid opioids
Turn for the worse Decompensation
bull 58 of compensated pts will decompensate within 10 years
bull Decompensated disease has a 50-80 5-year mortality
bull Development of any of the following complications
ndash Jaundice due to hepatic insufficiency ndash ID amp tx superimposed causes (alcoholic hepatitis sepsis drug hepatotoxicity)
ndash Variceal hemorrhage ndash most deadly
ndash Ascites ndash most common to herald onset
ndash Encephalopathy
Turn for the worse Decompensation
bull Pathophysiology of Portal Hypertension
ndash Fibrosisnodules architectural distortion
ndash Decreased production of nitric oxide by liver
ndash Increased intrahepatic vasocontriction in liver
ndash Reduced blood flow to and through liver
ndash Formation of porto-systemic collaterals (higher
resistance) = Increased resistance in the liver
ndash Hyperdynamic circulation from vasodilation in
splanchnic arterioles increased blood flow into
portal vein
Management - Decompensated
bull Average life expectancy approximately 2 years
bull Nausea ndash metoclopramide gt odansetron but rf EPS
bull Itching ndash cholestyramine most effective sertraline
bull Fatigue ndash Rest
ndash Exercise
bull Insomnia ndash Sleep hygiene
ndash Benadryl 50mg QHS hydroxyzine 25mg QHS or trazodone 50-100mg QHS (rf precipitating HE)
ndash Melatonin
ndash Rule out sleep apnea HE RLS
Management - Decompensated
bull Muscle cramps ndash Check electrolytes
bull Remember Na+ may be low do not correct unless lt120 (fluid restriction only)
bull Calcium often low ndash no need for correction
ndash Considerations bull BCAAs (4 gram granules TID)
bull Taurine 3 grams once daily
bull Vit E 200mg TID
bull Umbilical hernias ndash Repair only if symptomatic
ndash High complication rate
Management ndash Decompensated
bull Hyponatremia
ndash Common
ndash No treatment usually
unless lt 125 (free
water restriction of 1-
15 L daily)
bull Thrombocytopenia
ndash No treatment
ndash Platelet level of 50000 sufficient for most interventions
bull Coagulopathy
ndash Elevated INR
ndash No treatment usually
ndash May need FFP prior to elective intervention (dental surgical paracentesisradiological)
Hepatic Encephalopathy
bull Reversible change in mental status
bull Continuum from minimal to overt HE
bull Exclusion of other causes for brain dysfunction
bull Assessing for HE ndash Cognition
ndash Orientation
ndash Level of consciousness
ndash Asterixis
Hepatic Encephalopathy
B
Source University of Washingtons Hep C Online Module at httpwwwhepatitiscuwedugomanagement-cirrhosis-related-complicationshepatic-encephalopathy-diagnosis-managementcore-conceptall
Hepatic Encephalopathy
bull Most cases have an identifiable precipitant cause ndash GI bleed
ndash Excessive protein intake
ndash Infection (SBP UTI Pneumonia)
ndash Pre-renal azotemia
ndash Hypokalemic alkalosis
ndash Hyponatremia
ndash Constipation
ndash Hypoxia
ndash Use of sedatives tranquilizers
bull Normal protein diet
bull No driving
bull Safety in the home
Educate pts amp caregiversrelatives
regarding med compliance potential side effects
recognition of early signs of HE and measures to
prevent recurrence
Hepatic Encephalopathy
bull Lactulose 15-30mL BID titrating for 2-3 BMs per day ndash decreases blood ammonia concentration ndash Promotes elimination of toxins
ndash Reduces urease-producing bacteria
ndash Prevents absorption of bacteria
ndash Assists with any constipation - withhold for diarrhea
ndash Continued indefinitely
bull RifaximinXifaxan ndash non-absorbed broad spectrum abx ndash Change in bowel flora
ndash May cause downregulation of intestinal
glutamase activity
Ascites
bull 1-year survival rate 50 bull Usually go through a progression of diuretic response to
refractory ascites to HRS bull Ensure pt is truly adhering to dietary sodium restriction
amp avoiding NSAIDs bull Diagnostic paracentesis for all new onset ascites - ro SBP bull Sodium restriction ndash 2 grams per day - effective in 20 of
cases bull Fluid restriction - not necessary unless hyponatremia bull Diuretics bull TIPS ndash consider if requiring gt 1-2 LVPmonth
ndash 2nd line therapy
Ascites
bull Therapeutic large volume paracentesis ndash Administer with 100 grams albumin IV intraoperatively
(6-8 grams per liter removed) if gt 5 L removed
ndash Indications
bull Discomfort
bull Dyspnea
bull Tense ascites (hemodynamic improvement)
bull Refractory ascites
bull Renal insufficiency (compartment syndrome)
ndash Complications infection Post-paracentesis circulatory dysfunction
ndash Refractory Ascites stop beta blockers
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Turn for the worse Decompensation
bull 58 of compensated pts will decompensate within 10 years
bull Decompensated disease has a 50-80 5-year mortality
bull Development of any of the following complications
ndash Jaundice due to hepatic insufficiency ndash ID amp tx superimposed causes (alcoholic hepatitis sepsis drug hepatotoxicity)
ndash Variceal hemorrhage ndash most deadly
ndash Ascites ndash most common to herald onset
ndash Encephalopathy
Turn for the worse Decompensation
bull Pathophysiology of Portal Hypertension
ndash Fibrosisnodules architectural distortion
ndash Decreased production of nitric oxide by liver
ndash Increased intrahepatic vasocontriction in liver
ndash Reduced blood flow to and through liver
ndash Formation of porto-systemic collaterals (higher
resistance) = Increased resistance in the liver
ndash Hyperdynamic circulation from vasodilation in
splanchnic arterioles increased blood flow into
portal vein
Management - Decompensated
bull Average life expectancy approximately 2 years
bull Nausea ndash metoclopramide gt odansetron but rf EPS
bull Itching ndash cholestyramine most effective sertraline
bull Fatigue ndash Rest
ndash Exercise
bull Insomnia ndash Sleep hygiene
ndash Benadryl 50mg QHS hydroxyzine 25mg QHS or trazodone 50-100mg QHS (rf precipitating HE)
ndash Melatonin
ndash Rule out sleep apnea HE RLS
Management - Decompensated
bull Muscle cramps ndash Check electrolytes
bull Remember Na+ may be low do not correct unless lt120 (fluid restriction only)
bull Calcium often low ndash no need for correction
ndash Considerations bull BCAAs (4 gram granules TID)
bull Taurine 3 grams once daily
bull Vit E 200mg TID
bull Umbilical hernias ndash Repair only if symptomatic
ndash High complication rate
Management ndash Decompensated
bull Hyponatremia
ndash Common
ndash No treatment usually
unless lt 125 (free
water restriction of 1-
15 L daily)
bull Thrombocytopenia
ndash No treatment
ndash Platelet level of 50000 sufficient for most interventions
bull Coagulopathy
ndash Elevated INR
ndash No treatment usually
ndash May need FFP prior to elective intervention (dental surgical paracentesisradiological)
Hepatic Encephalopathy
bull Reversible change in mental status
bull Continuum from minimal to overt HE
bull Exclusion of other causes for brain dysfunction
bull Assessing for HE ndash Cognition
ndash Orientation
ndash Level of consciousness
ndash Asterixis
Hepatic Encephalopathy
B
Source University of Washingtons Hep C Online Module at httpwwwhepatitiscuwedugomanagement-cirrhosis-related-complicationshepatic-encephalopathy-diagnosis-managementcore-conceptall
Hepatic Encephalopathy
bull Most cases have an identifiable precipitant cause ndash GI bleed
ndash Excessive protein intake
ndash Infection (SBP UTI Pneumonia)
ndash Pre-renal azotemia
ndash Hypokalemic alkalosis
ndash Hyponatremia
ndash Constipation
ndash Hypoxia
ndash Use of sedatives tranquilizers
bull Normal protein diet
bull No driving
bull Safety in the home
Educate pts amp caregiversrelatives
regarding med compliance potential side effects
recognition of early signs of HE and measures to
prevent recurrence
Hepatic Encephalopathy
bull Lactulose 15-30mL BID titrating for 2-3 BMs per day ndash decreases blood ammonia concentration ndash Promotes elimination of toxins
ndash Reduces urease-producing bacteria
ndash Prevents absorption of bacteria
ndash Assists with any constipation - withhold for diarrhea
ndash Continued indefinitely
bull RifaximinXifaxan ndash non-absorbed broad spectrum abx ndash Change in bowel flora
ndash May cause downregulation of intestinal
glutamase activity
Ascites
bull 1-year survival rate 50 bull Usually go through a progression of diuretic response to
refractory ascites to HRS bull Ensure pt is truly adhering to dietary sodium restriction
amp avoiding NSAIDs bull Diagnostic paracentesis for all new onset ascites - ro SBP bull Sodium restriction ndash 2 grams per day - effective in 20 of
cases bull Fluid restriction - not necessary unless hyponatremia bull Diuretics bull TIPS ndash consider if requiring gt 1-2 LVPmonth
ndash 2nd line therapy
Ascites
bull Therapeutic large volume paracentesis ndash Administer with 100 grams albumin IV intraoperatively
(6-8 grams per liter removed) if gt 5 L removed
ndash Indications
bull Discomfort
bull Dyspnea
bull Tense ascites (hemodynamic improvement)
bull Refractory ascites
bull Renal insufficiency (compartment syndrome)
ndash Complications infection Post-paracentesis circulatory dysfunction
ndash Refractory Ascites stop beta blockers
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Turn for the worse Decompensation
bull Pathophysiology of Portal Hypertension
ndash Fibrosisnodules architectural distortion
ndash Decreased production of nitric oxide by liver
ndash Increased intrahepatic vasocontriction in liver
ndash Reduced blood flow to and through liver
ndash Formation of porto-systemic collaterals (higher
resistance) = Increased resistance in the liver
ndash Hyperdynamic circulation from vasodilation in
splanchnic arterioles increased blood flow into
portal vein
Management - Decompensated
bull Average life expectancy approximately 2 years
bull Nausea ndash metoclopramide gt odansetron but rf EPS
bull Itching ndash cholestyramine most effective sertraline
bull Fatigue ndash Rest
ndash Exercise
bull Insomnia ndash Sleep hygiene
ndash Benadryl 50mg QHS hydroxyzine 25mg QHS or trazodone 50-100mg QHS (rf precipitating HE)
ndash Melatonin
ndash Rule out sleep apnea HE RLS
Management - Decompensated
bull Muscle cramps ndash Check electrolytes
bull Remember Na+ may be low do not correct unless lt120 (fluid restriction only)
bull Calcium often low ndash no need for correction
ndash Considerations bull BCAAs (4 gram granules TID)
bull Taurine 3 grams once daily
bull Vit E 200mg TID
bull Umbilical hernias ndash Repair only if symptomatic
ndash High complication rate
Management ndash Decompensated
bull Hyponatremia
ndash Common
ndash No treatment usually
unless lt 125 (free
water restriction of 1-
15 L daily)
bull Thrombocytopenia
ndash No treatment
ndash Platelet level of 50000 sufficient for most interventions
bull Coagulopathy
ndash Elevated INR
ndash No treatment usually
ndash May need FFP prior to elective intervention (dental surgical paracentesisradiological)
Hepatic Encephalopathy
bull Reversible change in mental status
bull Continuum from minimal to overt HE
bull Exclusion of other causes for brain dysfunction
bull Assessing for HE ndash Cognition
ndash Orientation
ndash Level of consciousness
ndash Asterixis
Hepatic Encephalopathy
B
Source University of Washingtons Hep C Online Module at httpwwwhepatitiscuwedugomanagement-cirrhosis-related-complicationshepatic-encephalopathy-diagnosis-managementcore-conceptall
Hepatic Encephalopathy
bull Most cases have an identifiable precipitant cause ndash GI bleed
ndash Excessive protein intake
ndash Infection (SBP UTI Pneumonia)
ndash Pre-renal azotemia
ndash Hypokalemic alkalosis
ndash Hyponatremia
ndash Constipation
ndash Hypoxia
ndash Use of sedatives tranquilizers
bull Normal protein diet
bull No driving
bull Safety in the home
Educate pts amp caregiversrelatives
regarding med compliance potential side effects
recognition of early signs of HE and measures to
prevent recurrence
Hepatic Encephalopathy
bull Lactulose 15-30mL BID titrating for 2-3 BMs per day ndash decreases blood ammonia concentration ndash Promotes elimination of toxins
ndash Reduces urease-producing bacteria
ndash Prevents absorption of bacteria
ndash Assists with any constipation - withhold for diarrhea
ndash Continued indefinitely
bull RifaximinXifaxan ndash non-absorbed broad spectrum abx ndash Change in bowel flora
ndash May cause downregulation of intestinal
glutamase activity
Ascites
bull 1-year survival rate 50 bull Usually go through a progression of diuretic response to
refractory ascites to HRS bull Ensure pt is truly adhering to dietary sodium restriction
amp avoiding NSAIDs bull Diagnostic paracentesis for all new onset ascites - ro SBP bull Sodium restriction ndash 2 grams per day - effective in 20 of
cases bull Fluid restriction - not necessary unless hyponatremia bull Diuretics bull TIPS ndash consider if requiring gt 1-2 LVPmonth
ndash 2nd line therapy
Ascites
bull Therapeutic large volume paracentesis ndash Administer with 100 grams albumin IV intraoperatively
(6-8 grams per liter removed) if gt 5 L removed
ndash Indications
bull Discomfort
bull Dyspnea
bull Tense ascites (hemodynamic improvement)
bull Refractory ascites
bull Renal insufficiency (compartment syndrome)
ndash Complications infection Post-paracentesis circulatory dysfunction
ndash Refractory Ascites stop beta blockers
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Management - Decompensated
bull Average life expectancy approximately 2 years
bull Nausea ndash metoclopramide gt odansetron but rf EPS
bull Itching ndash cholestyramine most effective sertraline
bull Fatigue ndash Rest
ndash Exercise
bull Insomnia ndash Sleep hygiene
ndash Benadryl 50mg QHS hydroxyzine 25mg QHS or trazodone 50-100mg QHS (rf precipitating HE)
ndash Melatonin
ndash Rule out sleep apnea HE RLS
Management - Decompensated
bull Muscle cramps ndash Check electrolytes
bull Remember Na+ may be low do not correct unless lt120 (fluid restriction only)
bull Calcium often low ndash no need for correction
ndash Considerations bull BCAAs (4 gram granules TID)
bull Taurine 3 grams once daily
bull Vit E 200mg TID
bull Umbilical hernias ndash Repair only if symptomatic
ndash High complication rate
Management ndash Decompensated
bull Hyponatremia
ndash Common
ndash No treatment usually
unless lt 125 (free
water restriction of 1-
15 L daily)
bull Thrombocytopenia
ndash No treatment
ndash Platelet level of 50000 sufficient for most interventions
bull Coagulopathy
ndash Elevated INR
ndash No treatment usually
ndash May need FFP prior to elective intervention (dental surgical paracentesisradiological)
Hepatic Encephalopathy
bull Reversible change in mental status
bull Continuum from minimal to overt HE
bull Exclusion of other causes for brain dysfunction
bull Assessing for HE ndash Cognition
ndash Orientation
ndash Level of consciousness
ndash Asterixis
Hepatic Encephalopathy
B
Source University of Washingtons Hep C Online Module at httpwwwhepatitiscuwedugomanagement-cirrhosis-related-complicationshepatic-encephalopathy-diagnosis-managementcore-conceptall
Hepatic Encephalopathy
bull Most cases have an identifiable precipitant cause ndash GI bleed
ndash Excessive protein intake
ndash Infection (SBP UTI Pneumonia)
ndash Pre-renal azotemia
ndash Hypokalemic alkalosis
ndash Hyponatremia
ndash Constipation
ndash Hypoxia
ndash Use of sedatives tranquilizers
bull Normal protein diet
bull No driving
bull Safety in the home
Educate pts amp caregiversrelatives
regarding med compliance potential side effects
recognition of early signs of HE and measures to
prevent recurrence
Hepatic Encephalopathy
bull Lactulose 15-30mL BID titrating for 2-3 BMs per day ndash decreases blood ammonia concentration ndash Promotes elimination of toxins
ndash Reduces urease-producing bacteria
ndash Prevents absorption of bacteria
ndash Assists with any constipation - withhold for diarrhea
ndash Continued indefinitely
bull RifaximinXifaxan ndash non-absorbed broad spectrum abx ndash Change in bowel flora
ndash May cause downregulation of intestinal
glutamase activity
Ascites
bull 1-year survival rate 50 bull Usually go through a progression of diuretic response to
refractory ascites to HRS bull Ensure pt is truly adhering to dietary sodium restriction
amp avoiding NSAIDs bull Diagnostic paracentesis for all new onset ascites - ro SBP bull Sodium restriction ndash 2 grams per day - effective in 20 of
cases bull Fluid restriction - not necessary unless hyponatremia bull Diuretics bull TIPS ndash consider if requiring gt 1-2 LVPmonth
ndash 2nd line therapy
Ascites
bull Therapeutic large volume paracentesis ndash Administer with 100 grams albumin IV intraoperatively
(6-8 grams per liter removed) if gt 5 L removed
ndash Indications
bull Discomfort
bull Dyspnea
bull Tense ascites (hemodynamic improvement)
bull Refractory ascites
bull Renal insufficiency (compartment syndrome)
ndash Complications infection Post-paracentesis circulatory dysfunction
ndash Refractory Ascites stop beta blockers
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Management - Decompensated
bull Muscle cramps ndash Check electrolytes
bull Remember Na+ may be low do not correct unless lt120 (fluid restriction only)
bull Calcium often low ndash no need for correction
ndash Considerations bull BCAAs (4 gram granules TID)
bull Taurine 3 grams once daily
bull Vit E 200mg TID
bull Umbilical hernias ndash Repair only if symptomatic
ndash High complication rate
Management ndash Decompensated
bull Hyponatremia
ndash Common
ndash No treatment usually
unless lt 125 (free
water restriction of 1-
15 L daily)
bull Thrombocytopenia
ndash No treatment
ndash Platelet level of 50000 sufficient for most interventions
bull Coagulopathy
ndash Elevated INR
ndash No treatment usually
ndash May need FFP prior to elective intervention (dental surgical paracentesisradiological)
Hepatic Encephalopathy
bull Reversible change in mental status
bull Continuum from minimal to overt HE
bull Exclusion of other causes for brain dysfunction
bull Assessing for HE ndash Cognition
ndash Orientation
ndash Level of consciousness
ndash Asterixis
Hepatic Encephalopathy
B
Source University of Washingtons Hep C Online Module at httpwwwhepatitiscuwedugomanagement-cirrhosis-related-complicationshepatic-encephalopathy-diagnosis-managementcore-conceptall
Hepatic Encephalopathy
bull Most cases have an identifiable precipitant cause ndash GI bleed
ndash Excessive protein intake
ndash Infection (SBP UTI Pneumonia)
ndash Pre-renal azotemia
ndash Hypokalemic alkalosis
ndash Hyponatremia
ndash Constipation
ndash Hypoxia
ndash Use of sedatives tranquilizers
bull Normal protein diet
bull No driving
bull Safety in the home
Educate pts amp caregiversrelatives
regarding med compliance potential side effects
recognition of early signs of HE and measures to
prevent recurrence
Hepatic Encephalopathy
bull Lactulose 15-30mL BID titrating for 2-3 BMs per day ndash decreases blood ammonia concentration ndash Promotes elimination of toxins
ndash Reduces urease-producing bacteria
ndash Prevents absorption of bacteria
ndash Assists with any constipation - withhold for diarrhea
ndash Continued indefinitely
bull RifaximinXifaxan ndash non-absorbed broad spectrum abx ndash Change in bowel flora
ndash May cause downregulation of intestinal
glutamase activity
Ascites
bull 1-year survival rate 50 bull Usually go through a progression of diuretic response to
refractory ascites to HRS bull Ensure pt is truly adhering to dietary sodium restriction
amp avoiding NSAIDs bull Diagnostic paracentesis for all new onset ascites - ro SBP bull Sodium restriction ndash 2 grams per day - effective in 20 of
cases bull Fluid restriction - not necessary unless hyponatremia bull Diuretics bull TIPS ndash consider if requiring gt 1-2 LVPmonth
ndash 2nd line therapy
Ascites
bull Therapeutic large volume paracentesis ndash Administer with 100 grams albumin IV intraoperatively
(6-8 grams per liter removed) if gt 5 L removed
ndash Indications
bull Discomfort
bull Dyspnea
bull Tense ascites (hemodynamic improvement)
bull Refractory ascites
bull Renal insufficiency (compartment syndrome)
ndash Complications infection Post-paracentesis circulatory dysfunction
ndash Refractory Ascites stop beta blockers
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Management ndash Decompensated
bull Hyponatremia
ndash Common
ndash No treatment usually
unless lt 125 (free
water restriction of 1-
15 L daily)
bull Thrombocytopenia
ndash No treatment
ndash Platelet level of 50000 sufficient for most interventions
bull Coagulopathy
ndash Elevated INR
ndash No treatment usually
ndash May need FFP prior to elective intervention (dental surgical paracentesisradiological)
Hepatic Encephalopathy
bull Reversible change in mental status
bull Continuum from minimal to overt HE
bull Exclusion of other causes for brain dysfunction
bull Assessing for HE ndash Cognition
ndash Orientation
ndash Level of consciousness
ndash Asterixis
Hepatic Encephalopathy
B
Source University of Washingtons Hep C Online Module at httpwwwhepatitiscuwedugomanagement-cirrhosis-related-complicationshepatic-encephalopathy-diagnosis-managementcore-conceptall
Hepatic Encephalopathy
bull Most cases have an identifiable precipitant cause ndash GI bleed
ndash Excessive protein intake
ndash Infection (SBP UTI Pneumonia)
ndash Pre-renal azotemia
ndash Hypokalemic alkalosis
ndash Hyponatremia
ndash Constipation
ndash Hypoxia
ndash Use of sedatives tranquilizers
bull Normal protein diet
bull No driving
bull Safety in the home
Educate pts amp caregiversrelatives
regarding med compliance potential side effects
recognition of early signs of HE and measures to
prevent recurrence
Hepatic Encephalopathy
bull Lactulose 15-30mL BID titrating for 2-3 BMs per day ndash decreases blood ammonia concentration ndash Promotes elimination of toxins
ndash Reduces urease-producing bacteria
ndash Prevents absorption of bacteria
ndash Assists with any constipation - withhold for diarrhea
ndash Continued indefinitely
bull RifaximinXifaxan ndash non-absorbed broad spectrum abx ndash Change in bowel flora
ndash May cause downregulation of intestinal
glutamase activity
Ascites
bull 1-year survival rate 50 bull Usually go through a progression of diuretic response to
refractory ascites to HRS bull Ensure pt is truly adhering to dietary sodium restriction
amp avoiding NSAIDs bull Diagnostic paracentesis for all new onset ascites - ro SBP bull Sodium restriction ndash 2 grams per day - effective in 20 of
cases bull Fluid restriction - not necessary unless hyponatremia bull Diuretics bull TIPS ndash consider if requiring gt 1-2 LVPmonth
ndash 2nd line therapy
Ascites
bull Therapeutic large volume paracentesis ndash Administer with 100 grams albumin IV intraoperatively
(6-8 grams per liter removed) if gt 5 L removed
ndash Indications
bull Discomfort
bull Dyspnea
bull Tense ascites (hemodynamic improvement)
bull Refractory ascites
bull Renal insufficiency (compartment syndrome)
ndash Complications infection Post-paracentesis circulatory dysfunction
ndash Refractory Ascites stop beta blockers
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Hepatic Encephalopathy
bull Reversible change in mental status
bull Continuum from minimal to overt HE
bull Exclusion of other causes for brain dysfunction
bull Assessing for HE ndash Cognition
ndash Orientation
ndash Level of consciousness
ndash Asterixis
Hepatic Encephalopathy
B
Source University of Washingtons Hep C Online Module at httpwwwhepatitiscuwedugomanagement-cirrhosis-related-complicationshepatic-encephalopathy-diagnosis-managementcore-conceptall
Hepatic Encephalopathy
bull Most cases have an identifiable precipitant cause ndash GI bleed
ndash Excessive protein intake
ndash Infection (SBP UTI Pneumonia)
ndash Pre-renal azotemia
ndash Hypokalemic alkalosis
ndash Hyponatremia
ndash Constipation
ndash Hypoxia
ndash Use of sedatives tranquilizers
bull Normal protein diet
bull No driving
bull Safety in the home
Educate pts amp caregiversrelatives
regarding med compliance potential side effects
recognition of early signs of HE and measures to
prevent recurrence
Hepatic Encephalopathy
bull Lactulose 15-30mL BID titrating for 2-3 BMs per day ndash decreases blood ammonia concentration ndash Promotes elimination of toxins
ndash Reduces urease-producing bacteria
ndash Prevents absorption of bacteria
ndash Assists with any constipation - withhold for diarrhea
ndash Continued indefinitely
bull RifaximinXifaxan ndash non-absorbed broad spectrum abx ndash Change in bowel flora
ndash May cause downregulation of intestinal
glutamase activity
Ascites
bull 1-year survival rate 50 bull Usually go through a progression of diuretic response to
refractory ascites to HRS bull Ensure pt is truly adhering to dietary sodium restriction
amp avoiding NSAIDs bull Diagnostic paracentesis for all new onset ascites - ro SBP bull Sodium restriction ndash 2 grams per day - effective in 20 of
cases bull Fluid restriction - not necessary unless hyponatremia bull Diuretics bull TIPS ndash consider if requiring gt 1-2 LVPmonth
ndash 2nd line therapy
Ascites
bull Therapeutic large volume paracentesis ndash Administer with 100 grams albumin IV intraoperatively
(6-8 grams per liter removed) if gt 5 L removed
ndash Indications
bull Discomfort
bull Dyspnea
bull Tense ascites (hemodynamic improvement)
bull Refractory ascites
bull Renal insufficiency (compartment syndrome)
ndash Complications infection Post-paracentesis circulatory dysfunction
ndash Refractory Ascites stop beta blockers
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Hepatic Encephalopathy
B
Source University of Washingtons Hep C Online Module at httpwwwhepatitiscuwedugomanagement-cirrhosis-related-complicationshepatic-encephalopathy-diagnosis-managementcore-conceptall
Hepatic Encephalopathy
bull Most cases have an identifiable precipitant cause ndash GI bleed
ndash Excessive protein intake
ndash Infection (SBP UTI Pneumonia)
ndash Pre-renal azotemia
ndash Hypokalemic alkalosis
ndash Hyponatremia
ndash Constipation
ndash Hypoxia
ndash Use of sedatives tranquilizers
bull Normal protein diet
bull No driving
bull Safety in the home
Educate pts amp caregiversrelatives
regarding med compliance potential side effects
recognition of early signs of HE and measures to
prevent recurrence
Hepatic Encephalopathy
bull Lactulose 15-30mL BID titrating for 2-3 BMs per day ndash decreases blood ammonia concentration ndash Promotes elimination of toxins
ndash Reduces urease-producing bacteria
ndash Prevents absorption of bacteria
ndash Assists with any constipation - withhold for diarrhea
ndash Continued indefinitely
bull RifaximinXifaxan ndash non-absorbed broad spectrum abx ndash Change in bowel flora
ndash May cause downregulation of intestinal
glutamase activity
Ascites
bull 1-year survival rate 50 bull Usually go through a progression of diuretic response to
refractory ascites to HRS bull Ensure pt is truly adhering to dietary sodium restriction
amp avoiding NSAIDs bull Diagnostic paracentesis for all new onset ascites - ro SBP bull Sodium restriction ndash 2 grams per day - effective in 20 of
cases bull Fluid restriction - not necessary unless hyponatremia bull Diuretics bull TIPS ndash consider if requiring gt 1-2 LVPmonth
ndash 2nd line therapy
Ascites
bull Therapeutic large volume paracentesis ndash Administer with 100 grams albumin IV intraoperatively
(6-8 grams per liter removed) if gt 5 L removed
ndash Indications
bull Discomfort
bull Dyspnea
bull Tense ascites (hemodynamic improvement)
bull Refractory ascites
bull Renal insufficiency (compartment syndrome)
ndash Complications infection Post-paracentesis circulatory dysfunction
ndash Refractory Ascites stop beta blockers
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Hepatic Encephalopathy
bull Most cases have an identifiable precipitant cause ndash GI bleed
ndash Excessive protein intake
ndash Infection (SBP UTI Pneumonia)
ndash Pre-renal azotemia
ndash Hypokalemic alkalosis
ndash Hyponatremia
ndash Constipation
ndash Hypoxia
ndash Use of sedatives tranquilizers
bull Normal protein diet
bull No driving
bull Safety in the home
Educate pts amp caregiversrelatives
regarding med compliance potential side effects
recognition of early signs of HE and measures to
prevent recurrence
Hepatic Encephalopathy
bull Lactulose 15-30mL BID titrating for 2-3 BMs per day ndash decreases blood ammonia concentration ndash Promotes elimination of toxins
ndash Reduces urease-producing bacteria
ndash Prevents absorption of bacteria
ndash Assists with any constipation - withhold for diarrhea
ndash Continued indefinitely
bull RifaximinXifaxan ndash non-absorbed broad spectrum abx ndash Change in bowel flora
ndash May cause downregulation of intestinal
glutamase activity
Ascites
bull 1-year survival rate 50 bull Usually go through a progression of diuretic response to
refractory ascites to HRS bull Ensure pt is truly adhering to dietary sodium restriction
amp avoiding NSAIDs bull Diagnostic paracentesis for all new onset ascites - ro SBP bull Sodium restriction ndash 2 grams per day - effective in 20 of
cases bull Fluid restriction - not necessary unless hyponatremia bull Diuretics bull TIPS ndash consider if requiring gt 1-2 LVPmonth
ndash 2nd line therapy
Ascites
bull Therapeutic large volume paracentesis ndash Administer with 100 grams albumin IV intraoperatively
(6-8 grams per liter removed) if gt 5 L removed
ndash Indications
bull Discomfort
bull Dyspnea
bull Tense ascites (hemodynamic improvement)
bull Refractory ascites
bull Renal insufficiency (compartment syndrome)
ndash Complications infection Post-paracentesis circulatory dysfunction
ndash Refractory Ascites stop beta blockers
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Hepatic Encephalopathy
bull Lactulose 15-30mL BID titrating for 2-3 BMs per day ndash decreases blood ammonia concentration ndash Promotes elimination of toxins
ndash Reduces urease-producing bacteria
ndash Prevents absorption of bacteria
ndash Assists with any constipation - withhold for diarrhea
ndash Continued indefinitely
bull RifaximinXifaxan ndash non-absorbed broad spectrum abx ndash Change in bowel flora
ndash May cause downregulation of intestinal
glutamase activity
Ascites
bull 1-year survival rate 50 bull Usually go through a progression of diuretic response to
refractory ascites to HRS bull Ensure pt is truly adhering to dietary sodium restriction
amp avoiding NSAIDs bull Diagnostic paracentesis for all new onset ascites - ro SBP bull Sodium restriction ndash 2 grams per day - effective in 20 of
cases bull Fluid restriction - not necessary unless hyponatremia bull Diuretics bull TIPS ndash consider if requiring gt 1-2 LVPmonth
ndash 2nd line therapy
Ascites
bull Therapeutic large volume paracentesis ndash Administer with 100 grams albumin IV intraoperatively
(6-8 grams per liter removed) if gt 5 L removed
ndash Indications
bull Discomfort
bull Dyspnea
bull Tense ascites (hemodynamic improvement)
bull Refractory ascites
bull Renal insufficiency (compartment syndrome)
ndash Complications infection Post-paracentesis circulatory dysfunction
ndash Refractory Ascites stop beta blockers
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Ascites
bull 1-year survival rate 50 bull Usually go through a progression of diuretic response to
refractory ascites to HRS bull Ensure pt is truly adhering to dietary sodium restriction
amp avoiding NSAIDs bull Diagnostic paracentesis for all new onset ascites - ro SBP bull Sodium restriction ndash 2 grams per day - effective in 20 of
cases bull Fluid restriction - not necessary unless hyponatremia bull Diuretics bull TIPS ndash consider if requiring gt 1-2 LVPmonth
ndash 2nd line therapy
Ascites
bull Therapeutic large volume paracentesis ndash Administer with 100 grams albumin IV intraoperatively
(6-8 grams per liter removed) if gt 5 L removed
ndash Indications
bull Discomfort
bull Dyspnea
bull Tense ascites (hemodynamic improvement)
bull Refractory ascites
bull Renal insufficiency (compartment syndrome)
ndash Complications infection Post-paracentesis circulatory dysfunction
ndash Refractory Ascites stop beta blockers
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Ascites
bull Therapeutic large volume paracentesis ndash Administer with 100 grams albumin IV intraoperatively
(6-8 grams per liter removed) if gt 5 L removed
ndash Indications
bull Discomfort
bull Dyspnea
bull Tense ascites (hemodynamic improvement)
bull Refractory ascites
bull Renal insufficiency (compartment syndrome)
ndash Complications infection Post-paracentesis circulatory dysfunction
ndash Refractory Ascites stop beta blockers
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Ascites bull Diuretics
ndash Maximal weight loss in patients with edema 2 lbsday ndash Start with furosemide 20mg daily amp spironolactone 50mg dailyhellip
do not use furosemide alone ndash Progressive increase in doses every 3-7 days as needed
bull Follow Creatinine K+ Na+ bull Max spironolactone 400mgday (usually 200mgday) bull Max furosemide 160mgday (usually 80-120mgday)
ndash Side effects ndash Beware of increased HE risk amp HRS
bull Discontinue if SCr increases by gt50 or over 15 gdL) bull Hyponatremia (lt 125-130) Decrease dose + fluid restriction
bull Clonidine Further studies needed but looks promising
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Spontaneous Bacterial Peritonitis
bull Early dx is key
bull Signs amp symptoms ndash Abdominal pain or tenderness on palpation
ndash Fever andor chills
ndash Hepatic encephalopathy
bull Diagnostic paracentesis should be performed in any patient ndash Admitted to hospital with cirrhosis and ascites
ndash With cirrhosis and ascites who develops ss of SBP
ndash Send fluid for bull Albumin
bull Cell count
bull Culture
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Spontaneous Bacterial Peritonitis
bull Prophylaxis
ndash Indications
bull Previous episode of SBP (up to 70 recurrence rate
within 1 year)
bull Ascites total protein lt 1gdL (up to 40 recurrence 1yr)
bull Bilirubin gt 25 mgdL (43 recurrence rate in 1 year)
ndash Outpatient antibiotics of choice for prevention ndash
norfloxacin 400mg daily ciprofloxacin 500mg daily
TMPSMX daily vs 5 daysweek
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Portal Vein Thrombosis
bull Almost considered diagnostic for cirrhosis if
found incidentally because its prevalence in
cirrhosis is up to 26
bull No increased mortality
bull CT or MRI ndash usually dxd incidentally
bull Screen for underlying genetic
thrombophilic condition
ndash Anticoagulate if present
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Portal Vein Thrombosis
bull Chronic
ndash Obstructed portal vein replaced by collaterals
ndash Documented gt 6 months
ndash Consider anticoagulation after evaluating risks of GI bleeding
ndash Treat until transplant
ndash Possible referral to tertiary center for consideration of surgical options
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Esophageal Varices bull Develop at a rate of 8 per year in general rate of
progression from small to large varices also 8year
bull 50 have varices at diagnosis
bull Class A 40 Class C 85
bull Hemorrhage ndash Deadliest complication ndash 20 mortality rate within 6 weeks of initial
event
ndash Higher risk for developing SBP amp other infections
ndash Expect short-term Abx prophylaxis on discharge
ndash Start NSBB after 24 hours of no evidence of hemorrhage (discharge)
bull Teach patient to monitor stools for melena amp report to the ER with any hematemesis or coffee ground emesis
ndash Untreated 33 mortality rate
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Esophageal Varices
bull Hemoglobin ndash monitor closely for trendsacute drops
ndash Maintain Hgb of 8 GdL during acute event
ndash Avoid overtransfusion or vigorous IV rehydration ndash
increases portal pressure and significantly increases
bleeding risk
ndash Hgb 10 GdL maximum in our practice
bull Non-selective Beta Blocker (not unless indicated)
ndash Nadolol 40mg daily or Propranolol 20mg BID
ndash Continued indefinitely
ndash Switch selective BB (metoprolol atenolol for other reasons) to
nonselective BB
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Esophageal Varices
bull Esophageal Band Ligation prevents variceal hemorrhage
amp treats it
ndash Most common complaints transient dysphagia amp chest
discomfort
ndash Also start PPI
ndash Once initiated
o Repeat every 1-2 weeks until obliteration
o 1-3 months after obliteration
o Every 6-12 months to check for recurrence
bull TIPS for refractory varices ndash higher rates of HE
ndash New covered stents ndash lower occlusion rate
lower HE rates ndash promising
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Hepatorenal Syndrome
bull Renal failure in pts with cirrhosissevere liver dysfunction
bull Serum creatinine gt 15 gdL
ndash Increase in serum creatinine of gt= 03 mgdl or 15-2-fold increase from
baseline
bull Usually occurs in refractory ascites
bull Rapidly progressive (median survival ~2 weeks) or slower type of
failure (median survival ~6 mo)
bull Discontinue diuretics
bull Expand intravascular volume with IV albumin
bull ID amp address underlying factors known to precipitate renal failure
(infection fluid loss blood loss)
bull Only choice for definitive therapy is liver transplant
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Liver Transplant
bull Childrsquos score of 7 or greater
bull MELD score gt= 16 (10+ - begin referral) ndash Exceptions
bull Familial amyloidosis
bull Hepatopulmonary syndrome ndash screen with SaO2 dx with bubble echocardiogram referral before resting PaO2 lt 50 mm Hg
bull Portopulmonary HTN ndash screen with echocardiogram confirm with right heart cath referral before pulmonary pressure gt 45-50 mm Hg
bull HCC ndash Single tumor lt 5cm OR up to 3 tumors (none gt 3cm) PLUS no macroscopic vascular invasion or extrahepatic spread
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
MELD Score
Source University of Washington Hepatitis C Online Modules MELD Calculator page at httpwwwhepatitiscuwedupageclinical-
calculatorsmeld
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Excellent calculators for all areas of practice wwwMDCalccom
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Liver Transplant
bull Contraindications ndash Active ETOH andor substance abuse ndash Cigarette smoking ndash Morbid obesity ndash Psychiatric or social concerns ndash Recent malignancy (lt5 yrs except non-melanoma skin
CA) ndash Significant co-morbidities
bull CAD bull Stroke bull DM
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Opportunities
bull Updated Guidelines
bull Communication between generalists and specialists Continuity of Care
bull Communication with patients
bull Research ndash Role in noninvasive diagnosis of varices amp
hemorrhage (capsule endoscopy)
ndash Noninvasive markers
ndash Fundalgastric varices
bull Prevention amp early detection
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
Summary
bull Primary Care Providers need a hepatologist or a gastroenterologist with training in hepatology in their back pocket
bull Communication is key ndash send labs notes any other pertinent information to specialist ndash and expect the same from them
bull Encourage patients to remain aware of key factors amp to maintain regular follow-up appointments with specialist and with you
bull Be realistic in prognosis bull Be caring in your approach
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
CONTACT INFO
Tara McLamb NP-C
Taramclambwaynehealthorg
Taramclambgmailcom
919-587-3700
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Bernstein B (2016) Cirrhotics are people too Primary care for the cirrhotic patient Presentation at the ACG 2016 Southern Regional Postgraduate Course
Castera L amp Chang HLY (2015) EASL-ALEH Clinical practice guidelines Non-invasive tests for evaluation of liver disease severity and prognosis J of Hepat 63 237-264 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(15)00259-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Fox R (2015) Toward the effective co-management of patients with cirrhosis by primary care providers and specialists [Editorial] Dig Dis Sci 60 (2576-2578) Retrieved 013017 from httplinkspringercomarticle101007s10620-015-3704-y
Garcia-Tsao G et al (2007) Practice Guidelines Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis Amer J Gastroenterology 102 (2086-2102) Retrieved 010917 from httpgiorgguidelineprevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Garcia-Tsao G et al (2009) Management and treatment of patients with cirrhosis and portal hypertension Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Amer J of Gastroenterology 104 1802-1829 Accessed 01092017 from wwwhepatitisvagovpdf2009cirrhosis-guidelinespdf
Gines P et al (2010) EASL clinical practice guidelines on the management of ascites spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis J of Hepatology 53 397-417 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(10)00478-2fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Grattagliano I et al (2011) Management of liver cirrhosis between primary care and specialists World J of Gastroenterology 17(18) 2273-2282 Accessed 01092017 at httpswwwresearchgatenetpublication51184866_Management_of_liver_cirrhosis_between_primary_care_and_specialists
Ingram K amp Zaman A (2008 Nov) Primary care management of the patient with cirrhosis J Of Clinical Outcomes Management 15(11) 554-561 Accessed 01092017 at wwwturner-whitecompdfjcom_nov08_cirrhosispdf
Mathurin P et al (2012) EASL Clinical Practical Guidelines Management of alcoholic liver disease J of Hepatology 57 399-420 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(12)00288-7fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
REFERENCES
OShea RS Dasarathy S amp McCullough AJ (2010) Alcoholic liver disease Amer J of Gastroenterology 105 14-32 Accessed 13117 at httpsgiorgguidelinealcoholic-liver-disease
Runyon BA (2011) A primer on detecting cirrhosis and caring for these patients without causing harm Internat J of Hepatology 2011 np Accessed 01092017 at httpswwwhindawicomjournalsijh2011801983
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Starr SP amp Raines D (2011) Cirrhosis Diagnosis management and prevention Amer Fam Physician 84(12) 1353-1359 Accessed 01092017 at httpwwwaafporgafp20111215p1353html
Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver disease 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases J Of Hepatology 61 642-659 Accessed 01092017 at httpwwwjournal-of-hepatologyeuarticleS0168-8278(14)00390-0fulltext
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
REFERENCES
Voigt MD (2015) Best practice Care of the cirrhotic in primary care 2015 Powerpoint presentation accessed 01092017 from httpiruiowaeducgiviewcontentcgiarticle=1063ampcontext=fmrc
Yadav A amp Vargas HE (2015) Care of the patient with cirrhosis Clinical Liver Disease 5(4) 100-104 Accessed 13017 at httponlinelibrarywileycomdoi101002cld462full
2017 NPSS ndash ASHEVILLE NC
