Chronic Liver Disease (Cirrhosis)

Pt with h/o alcoholism, chronic viral hepatitis, NAFLD, DM type 2, autoimmune disease presents to establish care. Reports recent anorexia, weight loss, weakness, fatigue, abdominal fullness, pruritus. Fever, confusion, gynecomastia, abdominal distention, caput medusa, flank dullness with percussion, splenomegaly, Dupuytren's contracture, jaundice, spider angiomata, palmar erythema, asterixis on exam.

  • Labs

    • Liver function

      • Obtain CBC, CMP, GGT, PT, PTT, INR

      • CMP shows AST and ALT 2x ULN (consistent with values 6 months prior), elevated bilirubin

    • Hepatitis B screening

      • Obtain hepatitis B surface antigen (HBsAg)

      • If HBsAg positive: Obtain HBsAg antibodies (anti-HBs) and hepatitis B core antigen (anti-HBc)

    • Hepatitis C screening: Obtain HCV antibody test; if positive, obtain HCV RNA test

    • Concern for hepatic encephalopathy: Obtain ammonia level

  • Imaging

    • Ultrasound

      • RUQ U/S shows liver nodularity, irregularity, increased echogenicity, atrophy

      • Abdominal U/S shows abdominal ascites

      • Consider Doppler U/S of portal and hepatic veins

    • Consider abdominal CT to establish baseline assessment of hepatic nodules

    • Consider EGD to assess for esophageal varices

  • Treatment

    • Hepatic encephalopathy (hypersomnia, asterixis): Start lactulose 20 mg TID and titrate to 4 bowel movements daily

    • Beta blockers

      • Esophageal varices on EGD: Start nadolol 40 mg daily

      • Stop beta-blockers for MAP < 82 mmHg

    • Ascites

      • Limit sodium intake to < 2,000 mg daily

      • Start Bumex 1 mg daily

      • Paracentesis with > 5L fluid removed: Administer 6g albumin for each liter of fluid removed

    • Spontaneous bacterial peritonitis: Admit to hospital

      • Obtain ascitic fluid culture and PMN count

      • Obtain blood, urine, sputum culture

      • Start IV cefotaxime 2g q 8 hours

      • Administer IV albumin 1.5 g/kg for BUN > 30 mg/dL, Cr > 1 mg/dL, and/or bilirubin > 4 mg/dL

  • Referral

    • Consider liver biopsy to definitively establish diagnosis

    • Refer to GI to establish care

    • Concern for esophageal varices: Refer for EGD

    • MELD score ≥ 15: Consider referral to transplant center

  • Counseling

    • Stop drinking alcohol

    • Three month mortality rate per MELD score

    • Risk for ascites, spontaneous bacterial peritonitis, portal HTN leading to variceal bleeding and/or hepatorenal syndrome, hepatic encephalopathy

Notes

  • DM type 2 is a risk factor for NAFLD

  • Labs

    • Liver enzymes 2x ULN for 6 months is strongly correlated with cirrhosis on biopsy

    • If liver enzymes are normal and cirrhosis is suspected, consider ANA, anti-smooth muscle antibody

    • Anti-smooth muscle antibody is correlated with autoimmune hepatitis

    • Ammonia levels

      • Should only be obtained in the setting of altered mental status

      • Are not sufficient for the diagnosis if hepatic encephalopathy

  • Protein-restricted diets do not improve encephalopathy