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Dos and Don'ts in the Management of Cirrhosis: a View from the 21St

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Dos and Don'ts in the Management of Cirrhosis: a View from the 21St THE RED SECTION 1 see related editorial on page x Dos and Don’ts in the Management of Cirrhosis: IT H A View from the 21st Century C A Mary J. Tomson, MD1,2, Elliot B. Tapper, MD1,2,3 and Anna S.F. Lok, MD1,2 Am J Gastroenterol https://doi.org/10.1038/s41395-018-0028-5 Cirrhosis is a morbid, multisystem disease associated with fre- (creatinine ≥1.2 or sodium ≤130 mmol/L) and an ascitic fuid quent hospitalizations and high mortality rates. Te number of total protein <1.5 g/dL [4]. afected people is rising in the United States, refected in a 59% HOW I APPRO increase in patients with cirrhosis seeking medical care in the past decade [1]. Anticipating and preventing many of the complica- ACT QUICKLY FOR SUSPECTED VARICEAL BLEEDING AND tions of cirrhosis can be challenging. To aid gastroenterologists DONT FORGET SECONDARY PROPHYLAXIS TO PREVENT caring for this booming population, we propose the following RECURRENT BLEEDING “Dos and Don’ts” for management of cirrhosis in the inpatient Patients with cirrhosis and upper gastrointestinal hemorrhage and outpatient settings (Table 1). should undergo upper endoscopy within 12 h of presentation (Fig. 2). Prior to endoscopy, all patients should receive vasoactive agents and antibiotics. As patients with cirrhosis and gastrointes- ALL PATIENTS WITH ASCITES ADMITTED TO THE tinal bleeding are at high risk for bacterial infections (not limited HOSPITAL SHOULD HAVE A DIAGNOSTIC PARACENTESIS, to SBP), antibiotics should be provided even if patients do not REGARDLESS OF COAGULOPATHY have ascites [5]. Spontaneous bacterial peritonitis (SBP) is ofen asymptomatic and Patients who had a variceal bleed are at high risk for recurrent early treatment is associated with improved outcomes. Accord- bleeding. Secondary prophylaxis includes starting non-selective ingly, patients with ascites who undergo a diagnostic paracentesis beta-blockers (NSBB) on discharge and scheduling follow-up on admission have reduced in-hospital mortality. Tere is no evi- endoscopy to eradicate varices. Increasing data show that NSBB dence that patients with elevated International Normalized Ratios also improves all-cause mortality [6]. Early Transjugular Intra- or thrombocytopenia beneft from periprocedural prophylactic hepatic Portosystemic Shunt placement should be considered blood product transfusions [2]. in appropriate candidates (CTP B with endoscopically active bleeding despite medical therapy or CTP C with a score <14), even if they do not re-bleed afer initial endoscopic therapy TREAT SBP AGGRESSIVELY IN THE HOSPITAL AND START (Table 2) [4]. SECONDARY PROPHYLAXIS ON DISCHARGE Following a diagnosis of SBP, patients should promptly receive antibiotics (Fig. 1). SBP is associated with the development of INCORPORATE HEALTH MAINTENANCE INTO EACH hepatorenal syndrome, thus 25% albumin solution should be VISIT, even if it is outside the scope of “typicAL infused to maintain intravascular volume to protect the kidneys GAstroenterology” cARE [3]. Diuretics should be held until the infection has resolved. Vaccination status including infuenza and pneumococcal vac- Empiric antibiotic therapy fails in up to 25% of cases; a repeat cines should be assessed at each visit. Vaccination against hepa- diagnostic paracentesis should be considered if there is no clinical titis A and B are recommended in cirrhosis, but only one in three improvement afer 48 h. Long-term antibiotic prophylaxis should patients with cirrhosis complete this vaccination series [7]. Gas- be initiated on discharge. Of note, data from randomized trials troenterology clinics should have the capacity to provide on-site of patients without SBP suggest beneft from quinolone-based vaccination. primary prophylaxis, specifcally those with Child-Turcotte Pugh Cardiovascular disease is prevalent in patients with cirrho- (CTP) scores ≥9 and bilirubin ≥3 or impaired renal function sis, but owing to concerns of hepatotoxicity many providers are 1Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA. 2Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA. 3Veterans Affairs Hospital, Ann Arbor, MI, USA. Correspondence: A.S.L. (email: [email protected]) © 2018 The American College of Gastroenterology The American Journal of GASTROENTEROLOGY 2 THE RED SECTION hesitant to prescribe statins. Statins are safe in patients with Furthermore, there is mounting evidence that statin use is asso- compensated cirrhosis, and current guidelines do not even ciated with decreased risk of decompensation and mortality [8]. recommend assessing liver enzymes afer initiating statins [7]. Gastroenterologists should educate patients and other medical providers that statins should be prescribed when indicated in IT patients with chronic liver disease. H Table 1 “Dos and Don’ts” In the hospital C Do Don’t A PROACTIVELY DISCUSS SAFE PAIN MANAGEMENT IN Patient presents Perform a diagnostic Delay the procedure for CIRRHOSIS with ascites paracentesis on admis- coagulopathy or transfuse sion blood products prior to Over the counter and prescription analgesic use is common in cir- procedure rhosis. Acetaminophen is safe in cirrhosis if doses are limited to Spontaneous Start antibiotics quickly Forget to prescribe 2000 mg daily and should be used for frst-line pain control. Non- bacterial and give albumin on day long-term antibiotics for steroidal anti-infammatory drugs should be avoided in patients peritonitis 1 and day 3 secondary prophylaxis with ascites due to the risk of renal injury. Many patients with Suspected Perform endoscopy and Forget secondary prophy- cirrhosis chronically use narcotics. Judicious narcotic use can be variceal bleeding start medical therapy laxis (NSBB and follow-up safe but may increase the risk of falls and hepatic encephalopa- HOW I APPRO (vasoactive agents and EGD(s)) antibiotics) quickly thy (HE) [9]. Non-pharmacologic modalities for pain including EGD esophagogastrodudodenoscopy, NSBB non-selective beta blocker physical therapy, counseling, and yoga or meditation should be considered. REFER EARLY TO DIETICIANS AND DONT RESTRICT PROTEIN Ascites present on SBP diagnosed Hospital discharge admission Te majority of patients with decompensated cirrhosis are in catabolic states and are malnourished, contributing to a host of adverse events including HE, falls, and disability [10]. Accord- Perform diagnostic Start IV antibiotics Prescribe long term ingly, protein intake should not be restricted. Cirrhosis patients paracentesis promptly antibiotics for secondary should take in 1.2–1.5 g/kg/day of protein and 30–40 kcal/kg/day Do not delay for Give 1.5 g prophylaxis of SBP elevated INR or albumin/kg body weight [11]. A nighttime snack should be recommended to help meet this thrombocytopenia on day 1 and 1.0 goal. Providing specifc dietary recommendations can be chal- g/kg on day 3 lenging given the need to balance sodium restriction for ascites Consider repeat diagnostic paracentesis (when present) and carbohydrate/calorie restriction for patients at 48 h with non-alcoholic steatohepatitis or diabetes (Fig. 3). Tus, early Fig. 1 Key points in diagnosis and management of spontaneous bacterial referral to a dietician is helpful. peritonitis (SBP). INR international normalized ratio, IV intravenous Suspected variceal bleed Upper endoscopy within 12 h with capacity for band ligation of varices IV antibiotics (1 g ceftriaxone daily or suitable alternative) Infusion of vasoactive agents such as octreotide or terlipressin Hospitalization for Continue antibiotics for 5–7 days (for all types of upper gastrointestinal confirmed bleeding) variceal bleed Continue vasoactive agents for 2–5 days (if patient dose not undergo TIPS) Secondary prophylaxis (if patient dose not undergo TIPS) Start NSBB on discharge Schedule repeat upper endoscopy in 2–4 weeks to eradicate varices Variceal bleed outpatient Uptitrate NSBB dose to resting heart rate of 55–60 beats per minute (for follow up propranolol or nadolol) NSBB can be used in the presence of ascites if the systolic blood pressure is > 90 mm Hg Repeat upper endoscopy as needed to fully eradicate varices Repeat upper endoscopy 3–6 months after varices fully eradicated Fig. 2 Acute and Subacute management of Variceal Bleeding. IV intravenous, NSBB non-selective beta blocker, TIPS transjugular intrahepatic portosys- temic shunt The American Journal of GASTROENTEROLOGY www.nature.com/ajg THE RED SECTION 3 Table 2 “Dos and Don’ts” in the clinic Do Don’t Health maintenance Assess vaccination status and general health maintenance is- Leave all health maintenance up to patients’ primary care sues (cardiovascular disease and smoking cessation) providers IT Pain management Discuss the safety of limited (2 g/day) acetaminophen use Prescribe NSAIDs H Nutrition Recognize malnutrition and refer to dieticians early Restrict protein C Quality of life Discuss common disabling symptoms in cirrhosis Wait for patients to bring these issues up A Alcohol use Screen for alcohol use disorders in all patients Forget to reassess over time Ascites management Instruct patients on self-management, salt restriction, weight Wait until ascites becomes unbearable necessitating recording, and red fags emergency room or hospital admissions Hepatocellular carcinoma Screen with ultrasound + serum AFP every 6 months Leave patients out of screening Liver transplant referral Refer early when a patient develops decompensated cirrhosis Wait until the patient is hospitalized in life-threatening condition Palliative
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