# *** [Compensated/Decompensated] Cirrhosis Due to *** [Alcoholic, Hepatitis B/C, NASH, Autoimmune, PBC, PSC]
-- ABC's: life-threatening decompensations include SBP/sepsis, EV bleed, severe HE - ICU for pressor need, intubation, or close monitoring of bleed
-- Chart Check: prior decompensations, last para and studies, meds
-- HPI Intake: EtOH use, adherence to meds, constipation, bleeding
-- Can't Miss: variceal bleed, severe HE, SBP leading to sepsis
-- Admission Orders: Labs - CBC, CMP, coag, infectious workup; RUQUS if c/f clotting, underlying HCC; If AKI, send urine Na; new cirrhosis and transplant workup - viral hepatitis panels, iron studies, ANA, ASMA, AMA, a1aT, ceruloplasmin, SPEP
-- Initial Treatment to Consider: abx, GI bleed from varices pathway (EGD, octreotide, PPI, CTX), lactulose/rifaximin; all decompensations should at least get diagnostic para
Transplant: *** (listed, Hepatologist, prior workup)
MELD Score: ***
Decompensation Hx: (VIBES)
-- Volume/Ascites: *** prior LVP, frequency, salt restriction on lasix/spironolactone
-- Infection/SBP: *** prior infections, h/o low protein ascites, on ppx
-- Bleeding/EV: *** last EGD, prior bleeds, banding, on nadolol/PPI
-- Encephalopathy/HE: *** prior decompensation, on lactulose/rifaximin, BM/day
-- Screening/HCC: *** last screen, AFP; if nodule >1cm get multiphase CT or MRI
-- Clinical: *** pruritis, distention, anorexia, AMS, fatigue
-- Exam: *** hypotension, jaundice, cachexia, temporal wasting, gynecomastia, asterixis/milkmaid's, ascites, AMS, spider angioma, palmar erythema, petechiae/eccymoses, caput medusa, edema, Terry's nails
-- Data: *** serum Na, Creatinine, TBili, INR, albumin; para - albumin, protein, cell counts, cultures; RUQUS
-- Trigger: *** infection, med adherence, bleed, constipation, new clot, sedative, dehydration, alcohol, procedure, hypokalemia, AKI, metabolic alkalosis
The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.
-- f/u *** CBC, CMP, coags, UA, ascitic studies - PMN, SAAG, GS/Cx
-- Consider RUQUS to rule out portal vein thrombosis
-- If AKI, send urine Na
-- If c/f EtOH use - sent PEth
-- If first presentation of cirrhosis - to discuss full workup inpatient vs outpatient (viral hepatitis panels, iron studies, ANA, ASMA, AMA, a1aT, ceruloplasmin, SPEP)
-- Volume/Ascites: *** diagnostic vs LVP - albumin 8-10 g/L if >5L, diuresis 100mg spironolactone, 40mg furosemide (5:2 ratio); Refractory ascites - midodrine TID, serial LVPs q2 weeks, or TIPS as a bridge to OLT
-- Infection/SBP: *** CTX 2g/day for 5 days and albumin 1.5g/kg day 1; ppx cipro 500mg BID or bactrim SS daily if h/o SBP, ascitic total protein <1.5 AND impaired renal fx (defined by 1 of: Cr >1.2, BUN >25, Na <130, Tbili >3); ciproflax 400mg q12 is alternative; discontinue BB indefinitely
-- Bleed/EV: *** prior bleed or EV w/ risk bleed - nadolol 20-40mg BID ppx with goal HR 55-60, SBP >90; if c/f bleed - octreotide 50mcg load/gtt 50mcg/hr for 3 days, PPI 80mg load/drip 8mg/hr, CTX 1g for 7 days
-- Encephalopathy/HE: *** infectious w/u; lactulose 30g titrated to 3 BMs/day, rifaximin 550mg BID; maintain K >4
-- HRS: *** 100g albumin, followed by 20-40g daily, midodrine 7.5mg to 15mg TID, octreotide 100mcg TID
-- Nutrition: *** Dobhoff with TEN if altered, consult nutrition, low Na/high protein diet
-- Palliative: *** serna lotion (menthol, camphor) for itching
-- If hyponatremic <125, fluid restrict 1.5L/day; Na restrict >2g/day
-- If AKI, hold diuretics, send urine Na (<10 c/f HRS - volume challenge 1g/kg albumin)
-- If suspect vitamin K deficiency, give vitamin K 10mg x3d to correct nutritional component
-- If c/f portal vein thrombosis, DOAC for 3-6 months
-- Transfuse for hgb > 7, plt > 50, fibrinogen >100
*** with a history of Cirrhosis due to *** [EtOH, NASH, HCV, Autoimmune, PSC, PBC, etc.] decompensated by *** [HE, EV, Ascites, SBP, HCC] with MELD score on admission of ***, currently [listed/not listed] for transplant at ***, followed by *** [Hepatologist] who presents with *** concerning for ***.
The patient’s current volume exam suggests they are ***. We should [hold/continue/initiate] diuretics ***.
Based on Na level of ***, this patient should have a Na diet and fluid restriction.
There is currently *** concern for SBP based on history/exam, and ascitic fluid showing ***. Based on this, we should treat with *** (CTX 2g for 5 days), or treat prophylactically with ***.
The patient [does/does not] have a history of esophageal varices, with bleeding history of ***. There is currently *** concern for a GI bleed based on ***. Based on this, we should treat with *** (PPI, octreotide), plan for EGD ***, treat for SBP prophylaxis with CTX 1g daily, and transfuse as needed for Hgb >7.
The patient [is/is not] currently altered with an exam showing ***, concerning for hepatic encephalopathy. The etiology of this decompensation is likely ***. We should treat with (lactulose, rifaximin) with a goal of *** BM’s (or 500cc stool) per day.
Based on patient’s MELD of , they [are/are not] a candidate for transplant and [are/are not] currently listed for transplant at ***. Limitations for transplant include (HCC, sobriety, etc).
PDF coming soon!
The most common etiologies of cirrhosis are EtOH, HCV, NAFLD/NASH. MELD uses Cr, Tbili, INR, and Na to calculate - ranges from 6-40. Decompensations are ascites, SBP, EV, HE, HCC. Common triggers for decompensation include infection, medication non-adherence, constipation, bleeding, and dehydration from diuretic use. All decompensated patients admitted should have a diagnostic paracentesis. SAAG (serum ascites albumin gradient) > 1.1 suggests the etiology of ascites is related to portal hypertension (if there is a big difference, would be more explained by oncotic pressure)