Vancouver IM LMR

Here are the slides for today’s presentation on cirrhosis

Key Takeaways:

• On consults, communicate whether cirrhosis is decompensated vs compensated, grade severity with Child Pugh C or MELD (MELD-Na), include the underlying etiology if known.
• Remember the key “sub issues” under cirrhosis management: Etiology, varices, ascites/SBP, hepatic encephalopathy, HCC, prevention, follow-up
• Commit to memory your approach to massive variceal bleeding
  • ABC MOVIE, large bore IVs, head of the bed 90 degrees (aspiration risk), stat labs, cross matching for 3+ units of blood and plan to give FFP as well, phone calls to ICU and GI immediately, panto/octreoxide/ceftriaxone
• Everyone with new ascites needs a diagnostic paracentesis (SAAG calculation, culture, cytology)
• Salt restriction indicated for ascites, fluid restriction only if concurrent hyponatremia

Updates in 2023!!! (Dec 5, 2023)

1. Carvedilol is the preferred beta-blocker for variceal bleed ppx
2. AASLD 2023: HCC screening by ultrasound and serum AFP q6months (sensitivity of US alone 53%, but US+AFP sensitivity 63%).
   • Recommendation not yet adopted by CASL (no new Canadian guidelines since 2018)
3. EGD no longer uniformly recommended for variceal screening in new diagnosis of compensated cirrhosis (risk stratification with liver stiffness by Fibroscan + PLT count -> carvedilol if high risk; scope only if intolerant/CI to beta-blocker)