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Home Books CURRENT Practice Guidelines in Primary Care 2021-2022

Chapter 31: Gastrointestinal Disorders

ABNORMAL LIVER CHEMISTRIES

Recommendations

American College of Gastroenterology 2017

ALGORITHM FOR EVALUATION OF ASPARTATE AMINOTRANSFERASE (AST) AND/OR ALANINE AMINOTRANSFERASE (ALT) LEVEL

A flowchart shows algorithm for evaluation of Aspartate Aminotransferase (AST) and/or Alanine Aminotransferase (ALT) level. Top left of the chart begins with Borderline elevation less than 2x ULN which leads to five steps. The first step reads: History and physical exam, Discontinue hepatotoxic meds, Discontinue alcohol consumption, Assess for risk factors for fatty liver and viral hepatitis. The second step reads: CBC/platelet count, AST/ALT, ALK Phos, TB, albumin, PT/INR HBsAg, HBcAb, HBsAb, HCV Ab with PCR confirmation if +, iron panel, abdominal ultrasound. The third step reads: If negative, consider observation for 3–6 mo with repeat AST/ALT, Alk Phos, TB or … The fourth step reads: If persistently elevated, continue investigation: ANA, ASMA, gamma-globulin, ceruloplasmin, alpha-1 antitrypsin phenotype and may consider additional tests based on history (eg, celiac sprue, tick-borne disease, thyroid disease, and muscle disorders). The fifth step reads: If normal, further testing at discretion of clinician or refer to hepatologist for consideration of liver biopsy. Top right of the chart begins with Mildline elevation ranging from 2 to 5x ULN which leads to four steps. The first step reads: History and physical exam, Discontinue hepatotoxic meds, Discontinue alcohol consumption, Assess for risk factors for fatty liver and viral hepatitis. The second step reads: CBC/platelet count, AST/ALT, ALK Phos, TB, albumin, PT/INR HBsAg, HBcAb, HBsAb, HCV Ab with PCR confirmation if +, iron panel, Abdominal ultrasound. The third step reads: If negative, consider observation for 3 mo with repeat AST/ALT, Alk Phos, TB or continue investigation. The fourth step reads: If persistently elevated, continue investigation: ANA, ASMA, gamma-globulin, ceruloplasmin, alpha-1 antitrypsin phenotype and may consider additional tests based on history (eg, celiac sprue, tick-borne disease, thyroid disease, and muscle disorders) If no diagnosis, consider diagnostic liver biopsy.
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A flowchart shows algorithm for evaluation of Aspartate Aminotransferase (AST) and/or Alanine Aminotransferase (ALT) level. Top left of the chart begins with Borderline elevation less than 2x ULN which leads to five steps. The first step reads: History and physical exam, Discontinue hepatotoxic meds, Discontinue alcohol consumption, Assess for risk factors for fatty liver and viral hepatitis. The second step reads: CBC/platelet count, AST/ALT, ALK Phos, TB, albumin, PT/INR HBsAg, HBcAb, HBsAb, HCV Ab with PCR confirmation if +, iron panel, abdominal ultrasound. The third step reads: If negative, consider observation for 3–6 mo with repeat AST/ALT, Alk Phos, TB or … The fourth step reads: If persistently elevated, continue investigation: ANA, ASMA, gamma-globulin, ceruloplasmin, alpha-1 antitrypsin phenotype and may consider additional tests based on history (eg, celiac sprue, tick-borne disease, thyroid disease, and muscle disorders). The fifth step reads: If normal, further testing at discretion of clinician or refer to hepatologist for consideration of liver biopsy. Top right of the chart begins with Mildline elevation ranging from 2 to 5x ULN which leads to four steps. The first step reads: History and physical exam, Discontinue hepatotoxic meds, Discontinue alcohol consumption, Assess for risk factors for fatty liver and viral hepatitis. The second step reads: CBC/platelet count, AST/ALT, ALK Phos, TB, albumin, PT/INR HBsAg, HBcAb, HBsAb, HCV Ab with PCR confirmation if +, iron panel, Abdominal ultrasound. The third step reads: If negative, consider observation for 3 mo with repeat AST/ALT, Alk Phos, TB or continue investigation. The fourth step reads: If persistently elevated, continue investigation: ANA, ASMA, gamma-globulin, ceruloplasmin, alpha-1 antitrypsin phenotype and may consider additional tests based on history (eg, celiac sprue, tick-borne disease, thyroid disease, and muscle disorders) If no diagnosis, consider diagnostic liver biopsy.

HCV, hepatitis C virus.

Source

  • – Reproduced with permission from Kwo PY, Cohen SM, Lim JK. ACG clinical guideline: evaluation of abnormal liver chemistries. Am J Gastroenterol. 2017;112(1):18-35.

ALGORITHM FOR EVALUATION OF ELEVATED SERUM ALKALINE PHOSPHATASE

A flowchart shows algorithm for evaluation of elevated serum alkaline phosphatase. Top left of the chart begins with Normal total bilirubin and serum transaminases, which leads to four steps. The first step reads: History and physical exam confirm with serum GGT. The second step reads: If GGT is normal, evaluate for non-hepatobiliary etiologies; if GGT is abnormal, obtain right upper quadrant ultrasound, evaluate for potential hepatotoxic medications, check AMA, ANA, and SMA. The third step reads: If evaluation negative and alkaline phosphatase is 2x ULN, it leads to consider liver biopsy; if evaluation negative and alkaline phosphatase is 1 to 2x ULN leads to observation; If ductal dilatation identified leads to ERCP or MRCP. If AMA positive leads to evaluate for primary biliary cirrhosis/cholangitis. The fourth step reads: If persistent elevation of serum alkaline phosphatase after 6 mo observation leads to consider liver biopsy. Top right of the chart begins with elevated serum transaminases plus or minus elevated bilirubin, which leads to four steps. The first step reads: History and physical exam, Check right upper quadrant ultrasound. The second step reads: If ductal dilatation leads to ERCP, MRCP; If no ductal dilatation leads to check AMA, ANA, SMA. The third step reads: If AMA positive leads to evaluate for primary biliary cirrhosis/cholangitis. If AMA negative and alkaline phosphatase leads to 2x ULN leads to consider liver biopsy or MRCP. If AMA negative and alkaline phosphatase 1 to 2x ULN leads to consider observation. The fourth step reads: If persistent elevation of serum alkaline phosphatase after 6 mo observation leads to consider liver biopsy or MRCP.
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A flowchart shows algorithm for evaluation of elevated serum alkaline phosphatase. Top left of the chart begins with Normal total bilirubin and serum transaminases, which leads to four steps. The first step reads: History and physical exam confirm with serum GGT. The second step reads: If GGT is normal, evaluate for non-hepatobiliary etiologies; if GGT is abnormal, obtain right upper quadrant ultrasound, evaluate for potential hepatotoxic medications, check AMA, ANA, and SMA. The third step reads: If evaluation negative and alkaline phosphatase is 2x ULN, it leads to consider liver biopsy; if evaluation negative and alkaline phosphatase is 1 to 2x ULN leads to observation; If ductal dilatation identified leads to ERCP or MRCP. If AMA positive leads to evaluate for primary biliary cirrhosis/cholangitis. The fourth step reads: If persistent elevation of serum alkaline phosphatase after 6 mo observation leads to consider liver biopsy. Top right of the chart begins with elevated serum transaminases plus or minus elevated bilirubin, which leads to four steps. The first step reads: History and physical exam, Check right upper quadrant ultrasound. The second step reads: If ductal dilatation leads to ERCP, MRCP; If no ductal dilatation leads to check AMA, ANA, SMA. The third step reads: If AMA positive leads to evaluate for primary biliary cirrhosis/cholangitis. If AMA negative and alkaline phosphatase leads to 2x ULN leads to consider liver biopsy or MRCP. If AMA negative and alkaline phosphatase 1 to 2x ULN leads to consider observation. The fourth step reads: If persistent elevation of serum alkaline phosphatase after 6 mo observation leads to consider liver biopsy or MRCP.

ALGORITHM FOR EVALUTION OF ELEVATED SERUM TOTAL BILIRUBIN

A flowchart shows algorithm for evaluation of elevated serum total bilirubin. Top left of the chart begins with Elevated total bilirubin (predominant unconjugated) which leads to four steps. The first step reads: History and physical exam, Assess liver transaminases and serum alkaline phosphatase. The second step reads: Review medications, Evaluate for hemolysis, Evaluate for Gilbert’s syndrome. The third step reads: If persistent elevation is otherwise unexplained, may consider diagnostic testing for Gilbert’s syndrome (UGT1A1 genotype) and evaluate for uncommon etiologies in Table 6. The fourth step reads: If persistent elevation is otherwise unexplained, is symptomatic, is worsening over time, and/or associated with abnormal transaminases leads to consider liver biopsy.
View Full Size||Download Slide (.ppt)
A flowchart shows algorithm for evaluation of elevated serum total bilirubin. Top left of the chart begins with Elevated total bilirubin (predominant unconjugated) which leads to four steps. The first step reads: History and physical exam, Assess liver transaminases and serum alkaline phosphatase. The second step reads: Review medications, Evaluate for hemolysis, Evaluate for Gilbert’s syndrome. The third step reads: If persistent elevation is otherwise unexplained, may consider diagnostic testing for Gilbert’s syndrome (UGT1A1 genotype) and evaluate for uncommon etiologies in Table 6. The fourth step reads: If persistent elevation is otherwise unexplained, is symptomatic, is worsening over time, and/or associated with abnormal transaminases leads to consider liver biopsy.

CIRRHOSIS: ASCITES

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.

    • 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, ...

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