1. Intern Report 07-20-2016

2. Patient Presentation  55yM no PMH presenting with worsening abdominal pain for 2-3 days. Describes pain as diffuse, non-radiation, not associated with food or BMs. Endorses subjective fevers for last 2 days. He has noticed increasing abdominal distention for past several months.  PMH: none, no regular care  Meds: none  Allergies: NKMA  SH: drinks 6-12 beers daily, sometimes more on the weekends. Denies tobacco, IVDU  FH: negative

3.  HR 84 RR 14 BP 115/65 O2 95%

4. Cirrhosis

5. Physical Exam Findings of Cirrhosis  Spider angiomas  Palma erythema  Gynecomastia  Testicular atrophy  Caput medusae  Ascites  Hepatomegaly  Splenomegaly

6. Spider angiomas

7. Palmar erythema

8. Caput medusae

9. Diagnosis  Labs  Liver function test  PT/INR to test for synthetic function  Acute hepatitis panel  Imaging  Abdominal US  Abdominal CT  Liver biopsy  Not necessary if clinical, laboratory and radiologic data is indicative of etiology

10. Steps in Cirrhosis  Identify etiology  Management of complications  Prophylactic treatment/studies  Transplant

11. Labs for Our Patient  CBC: 6.4>5.5<230  LFTs  AST: 105ALT: 55  Alk phos: 120 Tbili: 2.5  Protein: 5.0 Albumin: 3.2  Coags: INR 2.2  Acute hep panel: negative  RUQ US: fibrosis consistent with cirrhosis of the liver

12. Common Causes of Cirrhosis  Hepatitis C/B  Alcohol  NAFLD  Biliary obstruction/disease

13. Steps in Cirrhosis  Identify etiology  Management of complications  Prophylactic treatment/studies  Transplant

14. Complications of Cirrhosis  Ascites  Spontaneous bacterial peritonitis  Hepatic encephalopathy  Variceal hemorrhage  Hepatocellular carcinoma  Hepatorenal syndrome  Hepatopulmonary syndrome

15. What are you concerned for in our patient?

16. Ascites  Indications for paracentesis  New onset ascites (never been tapped)  Fever, abdominal pain, AMS, abnormal vitals  Lab abnormalities that may indicate infection (ie leukocytosis, lactate)  Therapeutic tap (five 25% albumin if >5L removed)  Order: cell count, protein, gram stain, culture, cytology  Serum-ascites albumin gradient (SAAG); if >1.1 c/w portal hypertension  Medical Management  Spironolactone 100mg + Lasix 40mg daily  Can titrated after 1 week, increase by 100mg and 40mg each time to max 400/160mg  Remember to watch electrolytes!!

17. Spontaneous Bacterial Peritonitis  Clinical manifestation  Fever, abdominal pain, AMS  Diagnosis with paracentesis  Absolute polymorphnuclear (PMN) leukocyte count >250cells/mm3  Treatment  Ceftriaxone 2gm IV q24h  Albumin 1.5gm/kg IV at presentation and 1gm/kg IV on day 3

18. Variceal hemorrhage  Clinical manifestations  Profound hematemesis  Diagnosis and Treatment  Octreotide  EGD: banding or balloon tamponade  Propranolol for prophylaxis

19. Hepatic Encephalopathy  Clinical manifestations  AMS, diurenal sleep pattern, asterixis, hyperactive deep tendon reflexes  Diagnosis  Clinical  Treatment  Lactulose, neomycin/rifaximin

20.  Vaccinations  Hepatitis A and B  Pneumococcal vaccine  Influenza vaccine  Studies  Screening EGD at time of diagnosis  Ultrasound every 6 months for HCC