Article Figures & Data
Figures
- Figure 1
Risk factors for development of liver cirrhosis.
aNewer studies have suggested possible benefit of statins in patients with cirrhosis.
bOpioids have been shown to be associated with increased readmission rates in patients with cirrhosis.
Based on information in references 3–6.
Tables
Laboratory test Function Rationale Complete blood cell count Patients with liver disease are more prone to bleeding due to decrease production of liver clotting factors May manifest as anemia Often decreased platelet levels Alanine aminotransferase (ALT)/aspartate aminotransferase (AST) ALT is an enzyme found in the liver ALT increased during liver injury AST is an enzyme found in the liver, heart, muscle, and kidneys AST increased in the presence of liver injury Elevated AST is less specific than ALT for liver injury Albumin Albumin is a protein made by the liver Often decreased in chronic liver disease Alkaline phosphatase Alkaline phosphatase is an enzyme often produced by bile ducts, also produced by bone May be normal or elevated in liver disease Total bilirubin Bilirubin, a breakdown product of heme, is conjugated by the liver to allow for removal from the body May be increased in liver disease Damage to the liver may result in inability to process bilirubin Gamma-glutamyl transferase An enzyme found primarily in the liver May be elevated in liver disease Can be used in elevated alkaline phosphatase to determine if origin is hepatic or bone Prothrombin time (PT)/international normalized ratio (INR) Measure amount and function of clotting factors Because clotting factors are produced by the liver, PT and INR may be prolonged in patients with liver disease Diagnostic test Disease process Hepatitis B surface antigen, immunoglobulin M anti-hepatitis B core antigen Acute hepatitis B Hepatitis B surface antigen, positive viremia on highly sensitive hepatitis B virus DNA assay Chronic hepatitis B Anti-hepatitis C virus, hepatitis C virus RNA (confirmatory) Hepatitis C Antismooth muscle antibody, antinuclear antibody Autoimmune hepatitis Antiliver kidney microsomal antibody, antisoluble liver antigen antibody (both less common) Autoimmune hepatitis Iron level, serum ferritin, transferrin saturation Hemochromatosis Ceruloplasmin Wilson disease Alpha-1 antitrypsin phenotype Alpha-1 antitrypsin deficiency Lipid panel, hemoglobin A1c, hepatic ultrasonography Nonalcoholic fatty liver disease, nonalcoholic steatohepatitis Aspartate aminotransferase > alanine aminotransferase, elevated gamma-glutamyl transferase, elevated mean corpuscular volume Alcoholic liver disease Antimitochondrial antibody Primary biliary cholangitis Based on information in references 4 and 6.
Scorea Bilirubin INR Albumin Ascites Encephalopathy A < 2 mg/dL < 1.7 > 3.5 g/dL Absent Absent B 2–3 mg/dL 1.7–2.2 2.8–3.5 g/dL Mild Mild C > 3 mg/dL > 2.2 < 2.8 g/dL Severe Severe ↵a Class A = < 6 points; class B = 7 to 9 points; class C = > 10 points.
INR = international normalized ratio
From information in references 10 and 11.
Complication Screening recommendations Esophageal varices Initial screening may be performed by platelet count and transient elastography
All patients with high-risk varices should be offered esophagogastroduodenoscopy
For those with medium to large varices, endoscopic variceal band ligation is appropriate for prevention of bleeding9Hepatocellular carcinoma All patients with cirrhosis should undergo routine ultrasonography every 6 months to screen for hepatocellular carcinoma9,16 Hepatic encephalopathy Clinical diagnosis based on exclusion of other causes of brain dysfunction18
Ammonia levels should not be used to diagnose or stage patients with hepatic encephalopathy17,18Antimicrobials: azithromycin, cefoperazone, ceftazidime, ceftriaxone, chloramphenicol, erythromycin, griseofulvin, ketoconazole, metronidazole, nalidixic acid, nitrofuantoin (chronic use), piperacillin, roxithromycin, telithromycin, tetracycline Avoid or use with caution any medications that undergo first-pass metabolism or detoxification in the liver29 Acetaminophen Should not exceed 2 g per day or 500 mg per dose5,30 Nonsteroidal anti-inflammatory drugs Contraindicated in patients with advanced cirrhosis due to risk of further hepatotoxicity and higher risks of renal failure5 Antihypertensives Monitor patients for evidence of hypotension or ascites; discontinue as necessary5 Metformin Recent studies have shown metformin may be beneficial in treatment of steatohepatitis and may protect against hepatocellular carcinoma5,29
Continue metformin in patients with diabetes5,29Statins May be safely used and possibly beneficial to prevent decompensation, despite common practice to hold or deprescribe5,29,31 Vitamin A Restrict to < 5,000 IU daily5 Opioids and benzodiazepines Should be avoided5,32 Proton pump inhibitors Avoid due to the potential risk of potentiating spontaneous bacterial peritonitis5,29
In this issue
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- Article
- ABSTRACT
- DIAGNOSIS
- DIAGNOSTIC TESTING
- SCORING SYSTEMS FOR THE DEGREE OF LIVER INJURY
- ESOPHAGEAL VARICES: SCREENING AND PREVENTION
- HEPATOCELLULAR CARCINOMA
- SCREEN FOR HEPATOTOXIC MEDICATIONS
- OFFICE EVALUATION OF HEPATIC ENCEPHALOPATHY
- IMMUNIZATION AND EXPOSURE REDUCTION
- LIFESTYLE MODIFICATIONS
- TAKE-HOME MESSAGES
- DISCLOSURES
- Acknowledgments
- REFERENCES
- Figures & Data
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