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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
shared/gi-liver/cheatsheet.txt · Last modified: 2020/12/09 11:38 by 127.0.0.1