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ABNORMAL LIVER CHEMISTRIES

Recommendations

American College of Gastroenterology 2017

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

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

ALGORITHM FOR EVALUTION OF ELEVATED SERUM TOTAL BILIRUBIN

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 mg/dL, or bilirubin >4 mg/dL.

    • Consider diagnosis of ...

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