=======GI/Liver Cheat Sheet=======

======Hepatology======

=====Cirrhosis=====

  * Labs: CBC, CMP, INR, Mg, Phos
  * EV Bleed
  * Hepatic Encephalopathy: Lactulose PO TID, if refractory add Rifaximin 550 mg PO BID
  * HCC: US RUQ Q6mon, AFP?
  * Ascites: Paracentesis (if >5 L removed //attending dependent//, give albumin 6-8 gm/L)
  * Diet: low Na
  * Avoid NG tubes, NSAIDs, APAP NTE 2g/d, BZDs
  * High risk for EVH? start propranolol 20 mg PO BID
  * Transplant Eval: CPT > A or elevated MELD with history of sobriety and no metastatic cancer

=====Hepatorenal Syndrome=====

  * Type 1: Portal HTN, Cr > 2x baseline, benign UA, renal US negative
  * Type 2: Portal HTN, slow rise in Cr with ascites resistant to paracentesis
  * Treatment:
    * Critically Ill:
      * vasopressin 0.5-0.3 mg/hr (goal MAP +10 mmHg)
      * albumin 1 g/kg/d (max 100g/d) for 2 d+
    * Not critically ill:
      * midodrine 7.5 PO TID (can increase to 15 mg TID)
      * octreotide 200 mcg SQ Q8H or gtt at 50 mcg/hr
      * albumin: 1 g/kg/d (max 100 g/d) x 2 days, then 50 g/d until off midodrine/octreotide
    * All:
      * Treat for two weeks or more, possible bridge to dialysis or liver transplant
      * If responsive to therapy, can continue midodrine indefinitely
  * Resolution: defined as Cr < 1.5 with no HD requirements

=====Spontaneous Bacterial Peritonitis=====

  * Cirrhosis + Ascites + any of following: ↑ T, ↓ T, ↓ BP, AP, HE, AKI, ileus, dirrhea, ↑ WBC
  * Diagnosis:
    * Paracentesis: PMNs > 250
    * Labs: CBC, CMP, BCx, Fluid Cx, TP, Alb, Glucose, LDH, Alk Phos
  * Treatment:
    * Ceftriaxone 2 g IV Q24H x 5 days (if d/c after D2, ciprofloxain 500 mg PO Q12H)
    * Albumin IV 1.5 g/kg on D1, 1.0 g/kg on D3 (only if Cr > 1.0 or BUN > 30 or TBil > 4.0)
  * Follow up:
    * If poor response, repeat diagnostic paracentesis at 48 hours
    * If <25% PMN reduction, broaden antibiotics and obtain stat CT-AP with contrast
  * Lifelong prophylaxis with ciprofloxacin 500 mg PO daily if any of following criteria:
    * Prior SBP infection
    * Ascitic fluid TP < 1.5 AND one of following:
      * Na < 130
      * Cr > 1.2
      * BUN > 25
      * TBil > 3 + Child's Score > 8
    * Ascitic fluid TP < 1.0 during hospitalization

=====Cirrhosis of unknown etiology=====

  * If no heavy EtOH, viral hepatitis negative, no evidence of fatty liver on US abdomen
  * Labs: ANA, AMA, anti-SMA, anti-LKM, IgG, alpha-1 antitrypsin, ceruloplasmin, iron studies/ferritin, TTG

=====EV Bleed=====

  * Active/unstable: ICU for scope, contact fellow
  * INR > 3: consider vitamin K, FFP
  * Octreotide 50 mcg IV + 50 mcg/hr gtt until 3 days post-EGD
  * Ceftriaxone 1 g IV Q24H until 7 days post-EGD
  * Propranolol 20 mg PO BID to start after EGD

=====Portopulmonary Hypertension=====

  * Portal hypertension + pulmonary vasoconstriction (WHO Class I)
  * If symptoms of PAH:
    * Rule out alternatives with CXR, EKG
    * If CXR/EKG negative: TTE
    * If RVSP >38 mm: RHC
  * Treatment:
    * Non-targeted: diuretics, O2, stop BB if appropriate
    * Targeted: no TIPS, CCBs, or BBs
    * Targeted WHO Class I: sildenafil per pulm

=====Severe Acute Hepatocellular Injury=====

  * Rule out acute liver failure
  * DDx: ischemic, biliary, DILI, viral, autoimmune hepatitis
    * ALT/LDH > 1.5: likely viral
    * ALT/LDH < 1.5: likely ischemic vs. toxin
  * Labs: CBC, CMP, INR, LDH, hepatitis labs, AFP, APAP level, urine tox, US abdomen with doppler

=====Acute Liver Failure=====

  * Dx: HE + INR > 1.5 + Jaundice + <26 week duration
  * Etiologies:
    * APAP (most likely)
    * HAV/HBV
    * Mushrooms
    * Autoimmune hepatitis
    * Acute fatty liver of pregnancy
    * Meds: TB, sulfa, antifungal, herbal

=====Hepatitis C=====

  * Acute (HCVL+) vs. chronic (HCV Ab+)
  * Dx: Hep C Ab, if (+) or suspicions get HCVL
  * Other labs: CBC, CMP, INR, Genotype, HIV, Hep D
  * HCC: abdomen US q6month +/- AFP
  * Vaccines: HAV, HBV, pneumoccocal

=====Hepatitis B=====

  * Causes acute liver failure in 0.5%
  * Resolved or immunized: HBsAb (+)
  * Chronic: HBsAg (+) for >6 months

=====NAFLD=====

  * [[http://www.NAFLDscore.com|NAFLD fibrosis score]]
  * NAFLD + inflammation = NASH -> Cirrhosis
  * Management: diet, weight loss, manage diabetes, statin

=====TIPS=====

  * Indications: refractory ascites, variceal bleeding
  * Contraindications:
    * Absolute:
      * CHF
      * Severe tricuspid regurgitatoin
      * Severe PAH
      * Multiple hepatic cysts
      * Uncontrolled infection
      * Unrelieved biliary obstruction
    * Relative
      * CPT-C and MELD > 18
      * TBil > 3.8
      * Poorly controlled HE
      * PVT
      * Obstruction of all hepatic veins
      * Platelets < 20k
      * Severe coagulopathy
      * Moderate PAH
      * Hepatoma

=====Liver Transplant Evaluation=====

  * Infectious workup:
    * HAV Ab total, HBsAb, HBsAg, HBcAb, HCV Ab, HCVL
    * EBV IgG, CMV IgG
    * Cocci Ab ID with reflexive CF
    * HIV screen
    * RPR
    * Quantiferon gold
  * Malignancy screening:
    * Mammogram
    * Pap smear
    * Colonoscopy
    * AFP
    * CT Chest without contrast
    * CT multiphase abdomen
    * US abdomen with doppler
  * Cardiac:
    * 12-lead EKG
    * TTE with bubble study
    * Stress test (if indicated)
  * Respiratory: CXR (AP and lateral) +/- ABG
  * Misc:
    * blood typing
    * iron studies, ferritin
    * Hgb A1c
    * TSH with reflexive FT4
    * PSA if >45 years

======GI======

=====GI Bleed=====

  * Consult GI fellow, consent for blood
  * Labs: type and cross, coags, CBC Q8H, CMP, diuretics
  * Diet: NPO
  * Transfuse: Hgb > 7, plt > 50, fibrinogen > 100, INR > 3
  * PPI IV BID or gtt
  * No anticoagulation, NSAIDs, or ACEi
  * Stop antiplatelet?
  * Aortic graft: CT with contrast stat
  * Post-EGD management for UGIB with lesions:
    * Low risk: observe x 24 hours, PPI qday
    * High risk: observe x 72 hours, PPI BID
  * Follow up with GI to discuss results

=====Acute Pancreatitis=====

  * Labs: lipase, CMP, Mg, Phos, lipid panel
  * Diagnostics: US abdomen, CT abdomen (?)
  * Fluids: LR at 150 cc/hr or more
  * Pain: dilaudid vs. meperidine
  * Diet: as tolerated

=====Chronic diarrhea=====

  * Stool osm gap = 290 - 2 * (Na - K)
    * secretory: <50
    * osmotic: >75
  * Differential:
    * Osmotic: laxatives, carb intolerance
    * Secretory: medications, endo, bile salt, SIBO, NI-infection
    * Steattorhea: maldigestion/malabsorption
    * Motility: vagotomy, dump, SS, DM, hyperthyroid
    * Inflammatory: IBD, infection, cancer, ischemic, rads
    * Miscellaneous: IBS, factitious, overflow

======Symptom management======

=====Nausea/Vomiting=====

  * Zofran 4-8 mg ODT/IV Q6-8H
  * Compazine 5-10 mg IV
  * Reglan 10 mg PO/IV TID (gastroparesis)
  * Ativan 0.5 mg SL (watch in borderline patients)
  * Haloperidol 0.5-1 mg PO (last-line)
  * Watch EKG for QT prolongation

=====Constipation=====

  * Lactulose 20 g QID PRN
  * Miralax + Senna qday -> BID
  * Mg citrate PO x 1 (takes 6-8 hours)
  * Bisacodyl PR
  * Fleet enema x 1-2

=====Diarrhea=====

  * Stop bowel regimen
  * Labs: C. diff, stool WBC< stool culture, ova and parasites
  * Treatment:
    * If antibiotics: lactobacillus QID
    * Lomotil (diphenoxylate/atropine) 2.5 mg PO Q4H
    * Loperamide 2 mg PO Q4H
    * IVF, replete K, Mg, Phos

=====Pain=====

  * Acetaminophen 500 mg PO Q6H PRN (NTE 2g/d)
  * Tramodol 50 mg PO Q12H PRN (if no seizure history)
  * Dilaudid 1 mg PO Q6H PRN (esp. if ESRD)

=====Muscle Cramps on Diuretics=====

  * Zinc sulfate 220 mg PO BID