The Patient With Cirrhosis: Don't Miss This
From Medscape Gastroenterology > GI Common Concerns -- Computer Consult
The Patient With Cirrhosis: Don't Miss This
David A. Johnson, MD
Authors and Disclosures
Cirrhosis Care: Omissions in Practice
Hello. I am Dr. David Johnson, Professor of Medicine and Chief of Gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia. Welcome back to another session of GI Common Concerns -- Computer Consult.
Today, I would like to discuss cirrhosis and some of the errors in clinical practice that I see frequently. Whether you are a primary care physician, a gastroenterologist, or a nurse practitioner, pay attention to this because a number of things are not being done according to the official guideline recommendations.
Let's talk about the patient with cirrhosis. You might be following such patients with a gastroenterologist. If you are a gastroenterologist, please pay particular attention because several things are frequently missed in the care of the patient with cirrhosis.
First, all patients with cirrhosis, irrespective of the genesis of cirrhosis, should be vaccinated (if they are not either infected or already protected) for hepatitis A and B. Regardless of the cause of the patient's cirrhosis (for example, complex and decompensated liver disease), these patients need to be vaccinated for hepatitis A and B. It should be standard. You should be checking to see whether they have been vaccinated and making sure this is documented in the chart.
Patients with cirrhosis should be counseled about what they eat. Why do I say that? We know that these patients are at significant risk for infection. We will talk about that in a second when we talk about bacterial peritonitis, but a very unique infection that has been evident in the cirrhotic patient is vibrio vulnificus. This organism is frequently harbored in shellfish, particularly oysters. We see vibrio vulnificus infections in patients who have ingested raw oysters.
Patients with cirrhosis should be absolutely counseled that they should not eat raw seafood, particularly the filter feeders like oysters and clams. Coming from the Tidewater, Virginia, area where people live on oysters, and oyster festivals and events are routine, it is very difficult for me to counsel patients about this and have them accept it, but it is important because there can be life-threatening implications. Talk to your patients about vibrio vulnificus, make sure you document in the chart that you had this conversation, and reiterate and revisit this with them when they come back. Recognize that eating raw filter feeders, in particular oysters, is not allowed in patients with cirrhosis
The next thing I want to talk about is patients with gastrointestinal bleeding. No matter what type of gut bleed it is, patients with cirrhosis and ascites and gastrointestinal bleeding should be placed on prophylactic antibiotics. If they are able to take an oral antibiotic, norfloxacin is a reasonable option (400 mg twice a day). Ceftriaxone 1 g intravenously daily for 7 days is the other option. Six trials have looked at these regimens and shown a preventive benefit -- you can reduce the likelihood of bacterial peritonitis developing during the hospital stay when the patient is admitted not for bacterial peritonitis but because of gastrointestinal bleeding. The disruption of the gut integrity obviously allows gut bacteria to be transmitted through the bowel wall to the ascitic fluid. If these patients have ascites, they need prophylaxis antibiotics so don't forget that when they come in because of a diverticular bleed.
Let's talk a little bit about screening, because this is an area that is misunderstood. We screen patients for varices and for hepatocellular carcinoma -- complications of cirrhosis, irrespective of cause. The standard for screening for hepatocellular carcinoma used to be checking alpha-fetoprotein level every 6 months and doing an ultrasound every 12 months.
The new American Association for the Study of Liver Disease (AASLD) standards update the surveillance recommendations. Alpha-fetoprotein is no longer recommended. Instead, an ultrasound every 6 months is now recommended. Alpha-fetoprotein has a fairly poor sensitivity for hepatocellular carcinoma. Sensitivities may be as low as 40%-60%, with a specificity of approximately 80%. You may say, "If the alpha-fetoprotein is high, it is more predictive." However, the positive predictive value does not change very much from a level of 20 ng/mL, which is not that high (the sensitivity or the positive predictive value may be in the range of 30%-40%) to 400 ng/mL (which would be an alarm value) at which the positive predictive value is still only around 60%.
Efforts have been made to look at other markers such as glycosylated alpha-fetoprotein. You might see this on some of your laboratory test options. This test is no longer recommended. Alpha-fetoprotein may be falling by the wayside as far as the sensitivity and specificity data, and it leads to higher costs
The current recommendation is to obtain an ultrasound every 6 months and follow these patients closely. If a lesion is evident, the patient needs to be referred to a gastroenterologist, and depending on the size of that lesion, the patient should either have repeat ultrasound in 3 months (if the lesion is under 1 cm) or further diagnostic testing with MRI and imaging to assess the vascular pattern in the lesions. All lesions do not require biopsies. You can actually make a diagnosis of hepatocellular carcinoma on the basis of noninvasive testing with radiologic means.
The other necessary screening is for varices. Patients with cirrhosis should be screened for varices. The annual incidence of development of varices is about 8%. Varices are evident in up to 50% of patients with cirrhosis but not in all, and the recommendation is that all patients should be screened for varices. This new recommendation may be different from what you are currently doing.
If you find varices, in the past, ablation was recommended if they were larger than 5 mm in size. Performing ablation was recommended for moderate or large varices with banding, which is quite easy for us to do now. Not doing banding is recommended in the absence of a primary bleed. The recommendation is to start the patient on a nonselective beta-blocker (nadolol or propranolol).
The recommendation is to screen patients who have cirrhosis every 2 to 3 years in the absence of identified varices. If you find small varices, repeat this in 1-2 years. For larger varices, begin the patient on beta-blockers. You don't need to necessarily do surveillance on these patients unless there is evidence of bleeding. Recommendations for varices have changed a lot. Do not slip bands on these patients. Start them on nonselective beta-blockers.
Assessing the mental status of patients with cirrhosis is something you should routinely be doing in your practice. It is very easy to make a diagnosis of hepatic encephalopathy. For patients who are totally delirious or are confabulating and disoriented, it isn't rocket science to figure that out, and those patients should obviously be followed closely by a gastroenterologist.
A newly recognized diagnosis is "minimal hepatic encephalopathy." These patients come in and are fairly cogent and alert, but one thing we are recognizing is that these patients have impaired psychomotor function. We are seeing impairment in the driving capabilities of these patients.
I now routinely ask my patients with cirrhosis or chronic liver disease about moving violations, traffic violations, and accidents. These are often increased not only in patients with overt hepatic encephalopathy but also in patients with minimal hepatic encephalopathy. I ask about day and night sleep reversal, which is associated with very subtle stage 1 encephalopathy. Patients may find that they are up at night and sleep during the day. Ask about their driving habits and talk to their family members. Do they get lost, are they frequently losing sense of direction when they are driving, have they had motor vehicle accidents or traffic violations? These may be very subtle indicators of that patient drifting into hepatic encephalopathy, and their driving privileges should be very strongly curtailed, if not totally taken away. This is something that needs to be monitored and this may be a patient that you want to put on some type of therapy. Again, this patient should be referred to a gastroenterologist.
Making a Difference in Cirrhosis
I will leave you with these points that are not routinely attended to in the clinical practice of gastroenterology, primary care, internal medicine, and family practice. These are things that you should be more educated about, whether you are a gastroenterologist or other clinician, you should be looking for these things to help your patients with cirrhosis.
If you have any questions, consult the AASLD. Use the guidelines, refer to them, and hopefully make a difference in your patients with chronic liver disease. I am Dr. David Johnson. Thanks for listening.
American Association for the Study of Liver Diseases