Decompensated Cirrhosis

# Decompensated Cirrhosis
Pt with known history of cirrhosis secondary to ***, with decompensation as evidenced by varices, ascites, and/or hepatic encephalopathy. Child Pugh Class: ***. MELD-Na: ***. Potential precipitants of decompensation: ***.

##Hepatic Encephalopathy
- Lactulose 25mL q2-3h until BM, then titrate to 3-4 BM/d. (Lactulose + Rifaximin 550 mg BID better than lactulose alone for HE reversal and all-cause mortality)

##Variceal bleeding
- Baseline EGD performed?
- Management: IV access, transfusions PRN, octreotide gtt, PPI, CTX x 5 days, and EGD; in refractory cases consider TIPS
- Secondary prophylaxis: Propranolol with goal HR 50-60s AND Serial EVL until obliteration & then re-assessment every 6-12 months

##Ascites/volume overload
- Management: 2g Na restriction, Start with 100mg/day spironolactone + 40mg/day furosemide (titrate every 3-5 days as tolerated, max doses: 400mg spironolactone, 160mg furosemide)
- Therapeutic Paracentesis PRN, If >4L ascites removed, then transfuse 6-8g albumin for every 1L ascites removed
- D/C Beta-Blocker as no longer beneficial once in decompensated state

##Spontaneous bacterial peritonitis (SBP)
Must rule out SBP in ALL inpatients with cirrhotic ascites
- Workup: Diagnostic Paracentesis with fluid sent for Cell count with Diff, Gram Stain, Culture, Glucose, Protein,
- Diagnosis: >250 PMNs, regardless of GS/Cx
- Treatment: Ceftriaxone x 5 days; 25% Albumin (1.5 g/kg day 1 & 1.0 g/kg day 3, max 100 g); d/c Beta-Blocker
- Prophylaxis: Cipro 500mg qday

##HCC Screening: AFP + US/CT/MRI every 6 months; last ***

##Transplant candidacy: ***

##Healthcare maintenance:
- Vaccinations: Pneumovax, Influenza, HAV, HBV
- Alcohol abstinence
- Avoid NSAIDs, limit APAP <2g/daily, avoid raw oysters/shellfish