1. ETOH, Chronic Viral Hepatitis, Hemocromatosis, APAP, Toxins, Wilson's disease, Cryptogenic, PBC, drugs. For complete list see text books.

S & S:

  1. Malaise, lethargy, ascites, pruritis, N/V, anorexia, jaundice, gynecomastia, spider angioma, asterexis ("flapping"), testicular atrophy
  2. Major symptoms of complications: a) AMS 2ry to Hepatic encephalopathy ; b) UGI 2ry to esophageal or gastric varices; c) Fever 2ry to SBP; d) Renal failure 2ry to hepatorenal syndrome; e) Electrolyte imbalance ( Na)


  1. Lab abnormalities such as  anemia,  plt, bilirubin, Alk. Phos, Na/K, PT/PTT,  ammonia.


ER personnel deal generally  with complications.

  1. Hepatic Encephalopathy:
      1. Neomycin 1- 2 g PO q6hr.
      2. Lactulose  30 ml tid. Titrate to 3-5 BM/day
      3. Flumazenil, the benzodiazepine antagonist is given by some to diagnose / treat the HE. The idea behind this approach is supported by finding high levels of GABA in plasma.
  2. Bleeding  Esophageal Varices:
      1. IVF, O2, PRBC, Vit. K
      2. NG tube. Controversies about NG tube exist since this may cause further  traumatic bleed
      3. Consider Vasopressin 20 U in 200 ml NS IV @ 0.3 U/min but can be titrated to 0.9 U/min to control the bleed
      4.  STAT GI consult for Sengstaken-Blakemore tube or for schlerotherapy.
  3. SBP - see in ID section .
  4. Therapeutic ascites - fluid to be withdrawn as much as possible. Diuretics are used as well.
  5. Hepatorenal Syndrome - may occur in absence of any precipitating event or be precipitated by infection, bleed, diuretics. Pt develops oliguria and low urine Na (> urine osmolality, < urine Na).