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ABNORMAL LIVER CHEMISTRIES

Recommendations

American College of Gastroenterology 2017

FIGURE 31-1

Algorithm for Evaluation of Aspartate Aminotransferase (Ast) and/or Alanine Aminotransferase (Alt) Level

HCV, hepatitis C virus.

FIGURE 31-2

Algorithm for Evaluation of Elevated Serum Alkaline Phosphatase

FIGURE 31-3

Algorithm for Evalution of Elevated Serum Total Bilirubin

Source

  • –ACG Clinical Guideline: evaluation of abnormal liver chemistries. Am J Gastroenterol. 2017;112:18–35.

ASCITES, DUE TO CIRRHOSIS

Population

  • –Adults with cirrhosis.

Recommendations

AASLD 2013

  • –Diagnostic paracentesis is recommended for all patients with new-onset ascites.

  • –The routine use of platelets or fresh frozen plasma prior to a paracentesis is not recommended.

  • –Ascitic fluid analysis:

    • Cell count with differential.

    • Albumin.

    • Protein.

    • Bedside inoculation of aerobic and anaerobic culture bottles.

  • –Management of cirrhotic ascites:

    • Alcohol cessation.

      • Baclofen can be given to reduce alcohol craving and alcohol consumption.

    • <2 g sodium/d.

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

    • Fluid restriction not necessary unless serum sodium <125 mmol/L.

    • All patients with cirrhosis and ascites should be considered for liver transplantation.

    • Avoid NSAIDs.

    • Cautious use of ACEI, ARB, and even beta-blockers.

      • If used, should be accompanied by careful monitoring of arterial blood pressure as it is an independent predictor of survival in patients with cirrhosis.

  • –Management of refractory cirrhotic ascites:

    • Avoid propranolol.

    • Avoid ACEI or ARB.

    • Consider use of oral midodrine.

    • Serial therapeutic paracentesis is a treatment option.

    • Transjugular intrahepatic portosystemic shunt (TIPSS) is a therapeutic option in carefully selected patients.

    • Albumin 6–8 g/L ascitic fluid removed indicated for large volume paracentesis >5 L.

  • –Management of spontaneous bacterial peritonitis (SBP):

    • Recommend cefotaxime 2 g IV q8h.

    • Alternative is ofloxacin 400 mg PO bid.

    • 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 mg/dL, or bilirubin >4 mg/dL.

  • –SBP prophylaxis

    • Cefotaxime or oral norfloxacin for 7 d in patients admitted for upper gastrointestinal bleed.

    • Long-term oral trimethoprim-sulfamethoxazole or norfloxacin for any patient with a history of SBP.

    • Consider SBP prophylaxis if ascitic fluid protein <1.5 g/dL in association with creatinine >1.2 mg/dL or sodium <130 mmol/L or bilirubin >3 mg/dL.

  • –Hepatorenal syndrome options for treatment:

    • Midodrine + SQ Octreotide + albumin.

    • Norepinephrine infusion + albumin.

    • Referral for liver transplantation.

  • –Hepatic hydrothorax:

    • Chest tube is contraindicated.

    • Dietary sodium restriction and diuretics is first-line therapy.

    • TIPSS is an option for refractory cases.

  • –Avoid percutaneous gastrostomy tube placement in patients with ascites.

Source

BARRETT ESOPHAGUS

Population

  • –Patients with biopsy diagnosis of Barrett esophagus (metaplastic columnar epithelium in distal esophagus).

Recommendations

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