Cirrhosis/Ascites/Hepatic encephalopathy

Patient could be drinking too much Alcohol or might have had Hepatitis B or C for a long time or might have had none of these

Presents to ER with altered mental status, or fluid overload.


Routine Labs, EKG, CXR, UA

US of abdomen

NH3 Level, Tylenol level

IV Lasix



Aspiration precautions


Hepatitis Panel: Hepatitis A antibody, Hepatitis B Surface antigen, Hepatitis B Surface antibody, Hepatitis B Core Antibody, Hepatitis C antibody

Lactulose 15-45mg PO / Enema for elevated NH3 (explain to the patients that Lactulose is important after discharge in preventing Encephalopathy as some patients might stop taking it when they feel good so they can avoid going to bathroom frequently)

Continue diuretics like Lasix and Spironolactone

IR consult for Paracentesis

Order: LDH, Protein, Glucose, Gram Stain, C/S, Cell Count and Diff, Cytology, Albumin

Paracentesis for Ascitis–>IR consult

May need IV Albumin for large volume paracentesis

Vitamin K for high INR

Alcoholics: Thiamine 100mg, Folic acid 1mg, Multivitamin one tab daily


EGD for varices/Portal HTN evaluation–>Propranolol PO if present

Out patient evaluation for transplant at a Tertiary care center-patient needs to be sober for 6months

Other tests for Elevated LFT:
ANA IgG antibody

Anti-dsDNA antibodies

Serum Copper

Mitochondrial Antibody

Smooth Muslce Antibody

Serum Ceruloplasmin

Serum Alpha-1 Antitrypsin

Alpha Fetoprotein Tumor Marker

Earn CME from UpToDate: Cirrhosis in adults: Overview of complications, general management, and prognosis