This is a brief outline of big things to look for in the hospitalized patient with cirrhosis.
Hepatic Encephalopathy
Diagnose: Asterixis? Confusion? Has HE historically?
What’s the cause? Infection, bleeding, HRS (poor renal clearance), worsening liver failure.
What to do? Lactulose, up to q2Hr to maximize clearance, titrate to mental status and stool frequency. Look for/treat underlying cause (pan culture including ascites tap, cxr, rectal, renal workup). Consider rifaximen.
Key Points: HE is dangerous in itself (aspiration, med non-adherence, falls, delirium), it is often a harbinger of badness (infection, bleed), but it's also fixable. It takes effort, and it's messy, but it's important for every patient.
Variceal bleeding
Diagnose: Recent melena/BRBPR? Rectal exam? (Not occult blood) Worse anemia? Known varices? Last EGD? On nonselective beta blocker? Known bleed?
What to do? If suspicious but not definite, do rectal exam, NPO, two large bore IV, type and screen, IV PPI BID, consent for blood, call GI to arrange EGD. If definitely bleeding, stat page GI, order blood, can use albumin while waiting, octreotide gtt and prophylactic ceftriaxone, low threshold to transfer to ICU.
What to worry about: Airway protection from blood and/or HE, hemorrhage requiring massive transfusion protocol. Decompensation can happen rapidly and without warning.
Key Points: The key to managing this condition is to be prepared with IV access, blood products/albumin, GI awareness, etc. Once a patient opens up, there is very little time.
Ascites
What to do? Main concern is ruling out SBP. If obviously distended, do diagnostic and therapeutic para, though likely need IR guided if you can’t get supervised. If ascites uncertain, get and ultrasound to confirm. Ideally diagnostic fluid prior to antibiotics, but don’t hold antibiotics for delayed paracentesis. Ceftriaxone 2gm daily. For large vol para, need to give albumin to counteract fluid shifts/avoid HRS. Long term treatment is diuretic vs TIPS vs serial para vs transplant.
Key Points: This rarely becomes an emergency except for overwhelming gram negative sepsis. However, ascites complicates everything, including: Respiratory restriction, urine obstruction, and pain which often necessitates opiates.
Hepatorenal Syndrome
Diagnose: Prerenal AKI in cirrhosis that doesn’t improve with albumin challenge.
What to do: Hold diuretics. Albumin challenge, if fails needs octreotide and midodrine. Workup and correct underlying drivers. Call renal and hope doesn’t need dialysis.
Key Points: This is rarely an emergency, but very high mortality. You need to differentiate HRS from prerenal AKI quickly and get the relevant treatment running and renal consulted.
Less Urgent Considerations:
Transplant Status?
Calculate MELD score, review chart and talk with patient. This is the ultimate and ideal fix for all of the above, but there are several barriers.
Heptaocellular Carcinoma
Status of last ruq u/s?
