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

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

Table of Contents

GI/Liver Cheat Sheet

Hepatology

Cirrhosis

Hepatorenal Syndrome

Spontaneous Bacterial Peritonitis

Cirrhosis of unknown etiology

EV Bleed

Portopulmonary Hypertension

Severe Acute Hepatocellular Injury

Acute Liver Failure

Hepatitis C

Hepatitis B

NAFLD

TIPS

Liver Transplant Evaluation

GI

GI Bleed

Acute Pancreatitis

Chronic diarrhea

Symptom management

Nausea/Vomiting

Constipation

Diarrhea

Pain

Muscle Cramps on Diuretics