Sections View Full Chapter Figures Tables Videos Full Chapter Figures Tables Videos Supplementary Content +++ ABNORMAL LIVER CHEMISTRIES +++ Recommendations +++ American College of Gastroenterology 2017 ++ ALGORITHM FOR EVALUATION OF ASPARTATE AMINOTRANSFERASE (AST) AND/OR ALANINE AMINOTRANSFERASE (ALT) LEVEL Graphic Jump LocationView Full Size|Favorite Figure|Download Slide (.ppt) ++ HCV, hepatitis C virus. +++ Source ++ ACG Clinical Guideline: Evaluation of Abnormal Liver Chemistries. Am J Gastroenterol. 2017;112:1835. ++ ALGORITHM FOR EVALUATION OF ELEVATED SERUM ALKALINE PHOSPHATASE Graphic Jump LocationView Full Size|Favorite Figure|Download Slide (.ppt) ++ ALGORITHM FOR EVALUTION OF ELEVATED SERUM TOTAL BILIRUBIN Graphic Jump LocationView Full Size|Favorite Figure|Download Slide (.ppt) +++ 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 ... GET ACCESS TO THIS RESOURCE Sign In Username Error: Please enter User Name Password Error: Please enter Password Forgot Username? Forgot Password? Sign in via OpenAthens Sign in via Shibboleth Get Free Access Through Your Institution Contact your institution's library to ask if they subscribe to McGraw-Hill Medical Products. Access My Subscription GET ACCESS TO THIS RESOURCE Subscription Options Pay Per View Timed Access to all of AccessMedicine 24 Hour $34.95 (USD) Buy Now 48 Hour $54.95 (USD) Buy Now Best Value AccessMedicine Full Site: One-Year Individual Subscription $995 USD Buy Now View All Subscription Options