Chapter 31: Gastrointestinal Disorders

ABNORMAL LIVER CHEMISTRIES

Recommendations

American College of Gastroenterology 2017

HCV, hepatitis C virus.

Source

• ACG Clinical Guideline: Evaluation of Abnormal Liver Chemistries. Am J Gastroenterol. 2017;112:1835.

ASCITES, FROM CIRRHOSIS

Population

• Adults with cirrhosis.

Recommendations

AASLD 2013, EASL 2018

• Perform diagnostic paracentesis for all patients with new-onset ascites.

• Do not routinely give platelets or fresh frozen plasma prior to a paracentesis.

• Ascitic fluid analysis:

  • Cell count with differential.

  • Albumin.

  • Protein.

  • Bedside inoculation of aerobic and anaerobic culture bottles.

• Management of cirrhotic ascites:

  • Alcohol cessation.

    • Consider baclofen to reduce alcohol craving and alcohol consumption.

  • Recommend low sodium diet.^a

  • Give furosemide and spironolactone in a 2:5 ratio.

  • During the first episode of ascites, start spironolactone at 100 mg/d and increase q3 d in 100-mg steps until at 400 mg/d if no response to lower dosage. If not responding to spironolactone alone (defined as <2 kg/wk weight loss or patients developing hyperkalemia) add furosemide starting at 40 mg/d increasing in 40-mg steps to a maximum of 160 mg/d (EASL).

  • Consider substituting other loop diuretics if furosemide is not effective (EASL).

  • Target maximum weight loss per day of 0.5 kg/d if no edema or 1 kg/d if edema.

  • Restrict fluid intake if serum sodium is low (AASLD <125 mmol/L; EASL <130 mmol/L).

  • Consider liver transplantation for all patients with cirrhosis and ascites.

  • Avoid NSAIDs.

  • Cautious use of ACEI, ARB, and even beta-blockers. If used, monitor blood pressure carefully as an independent predictor of survival in patients with cirrhosis.

  • Avoid aminoglycosides (EASL).

• Management of refractory cirrhotic ascites:

  • Avoid propranolol.

  • Avoid ACEI or ARB.

  • Consider oral midodrine.

  • Consider serial therapeutic paracentesis.

  • Consider transjugular intrahepatic portosystemic shunt (TIPSS) in carefully selected patients.

  • Give albumin for large volume paracentesis (AASLD: give 6–8 g/L of ascitic fluid removed if >5 L; EASL: give 8 g/L ascitic fluid removed and consider even when <5 L).

• Management of spontaneous bacterial peritonitis (SBP):

  • Give cefotaxime 2 g IV q8h for 5–7 d.

  • Alternative is ofloxacin 400 mg PO bid.

  • For locations with high bacterial resistance piperacillin/tazobactam or carbapenem should be used (EASL).

  • Repeat paracentesis in 48 h to assess for reduction in leukocyte count of >25% (EASL).

  • Add albumin 1.5 g/kg/d on day 1 and 1 g/kg/d on day 3 if creatinine >1 mg/dL, BUN >30 ...