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Gastroenterology and Hepatology Management To care for patients with cirrhosis, select: o upper endoscopy for all new patients to evaluate for varices . ultrasonography to diagnose ascites o paracentesis fbr newly discovered ascites and calculation of the serum-ascites albumin gradient (SAAG) to diagnose the cause of ascites o paracentesis with ascitic fluid granuloc,,te count and culture for any change in mental status or clinical condition to diag- nose spontaneous bacterial peritonitis . vaccination of nonimmune patients against HAV and HBV as well as other routine vaccinations STUDY TABLE: Evaluation of Ascites Ascitic Fluid Protein SAAG >1.1 SAAG <1.1 <2.5 g/dL Cirrhosis Nephrotic syndrome >2.5 g/dL Right-sided HE Budd-Chiari syndrome Malignancy, TB Ascitic fluid granulocyte count >25O/pL confirms spontaneous bacterial peritonitis. Follow-up Surueillance Patients with cirrhosis should undergo ultrasonography screening for HCC every 6 months. DON'T BE TRICKED o Although a plasma ammonia level may be helpful in diagnosing suspected cases of hepatic encephalopathy, monitoring serial ammonia values is not useful. . Head CT in patients with hepatic encephalopathy and otherwise normal neurologic examination is not warranted o Use IV, not oral, bisphosphonate therapy in patients with esophageal varices.

DON'T BE TRICKED o Although a plasma ammonia level may be helpful in diagnosing suspected cases of hepatic encephalopathy, monitoring serial ammonia values is not useful. . Head CT in patients with hepatic encephalopathy and otherwise normal neurologic examination is not warranted o Use IV, not oral, bisphosphonate therapy in patients with esophageal varices. Treatment STUDY TABLE: Treatment of Cirrhosis Complications Indications Treatment Primary prophylaxis of variceal First choice: propranolol, nadolol, or carvedilol bleeding Second choice: endoscopic band ligation if B-blocker not tolerated or contraindicated Active variceal bleeding Octreotide with endoscopic band ligation and prophylaaic ciprofloxacin or ceftriaxone Transfusion for active bleeding Hemoglobin transfusion goal 7 g/ dL Ascites not responding to Spironolactone with or without furosemide low-sodium diet Diuretic-refractory ascites Serial large-volume paracentesis (with albumin if >5 L), TIPS, or liver transplantation Prevention of spontaneous Fluoroquinolones chronically if history of spontaneous bacterial peritonitis or otherwise high risk" bacterial peritonitis Fluoroquinolones while hospitalized if ascitic fluid protein <1.5 g/dL Ciprofloxacin or ceftriaxone for 7 days if active bleeding Spontaneous bacterial peritonitis Cefotaxime; albumin infusion if kidney dysfunction or serum bilirubin level >4 mg/dL Acute hepatic encephalopathy Correct precipitating factors, lactulose; add rifaximin if unresponsive Prevention of hepatic Lactulose, titrated to 3 stools per day encephalopathy Hepatic osteodystrophy Calcium, vitamin D, and lV bisphosphonate Hepatorenal syndrome Stop diuretics, volume expansion with lV albumin; midodrine and octreotide or norepinephrine may be helpful. Dialysis bridging to livertransplantation if no response aHigh risk (1 30 mEq/l, creatinine >1 .2 mg/dl, BUN >25 mg/dL, bilirubin >3 mg/dL. = ascitic fluid total protein <1 .5 g/dL and any of the following: serum sodium

Treatment STUDY TABLE: Treatment of Cirrhosis Complications Indications Treatment Primary prophylaxis of variceal First choice: propranolol, nadolol, or carvedilol bleeding Second choice: endoscopic band ligation if B-blocker not tolerated or contraindicated Active variceal bleeding Octreotide with endoscopic band ligation and prophylaaic ciprofloxacin or ceftriaxone Transfusion for active bleeding Hemoglobin transfusion goal 7 g/ dL Ascites not responding to Spironolactone with or without furosemide low-sodium diet Diuretic-refractory ascites Serial large-volume paracentesis (with albumin if >5 L), TIPS, or liver transplantation Prevention of spontaneous Fluoroquinolones chronically if history of spontaneous bacterial peritonitis or otherwise high risk" bacterial peritonitis Fluoroquinolones while hospitalized if ascitic fluid protein <1.5 g/dL Ciprofloxacin or ceftriaxone for 7 days if active bleeding Spontaneous bacterial peritonitis Cefotaxime; albumin infusion if kidney dysfunction or serum bilirubin level >4 mg/dL Acute hepatic encephalopathy Correct precipitating factors, lactulose; add rifaximin if unresponsive Prevention of hepatic Lactulose, titrated to 3 stools per day encephalopathy Hepatic osteodystrophy Calcium, vitamin D, and lV bisphosphonate Hepatorenal syndrome Stop diuretics, volume expansion with lV albumin; midodrine and octreotide or norepinephrine may be helpful. Dialysis bridging to livertransplantation if no response aHigh risk (1 30 mEq/l, creatinine >1 .2 mg/dl, BUN >25 mg/dL, bilirubin >3 mg/dL. = ascitic fluid total protein <1 .5 g/dL and any of the following: serum sodium 107