VIBES: a systematic approach to the management of cirrhosis
Volume ...

VIBES: a systematic approach to the management of cirrhosis

Volume (ascites, edema, hepatic hydrothorax, hepatorenal syndrome):

 • Current diuretics (spironolactone/lasix 5:2 ratio) & response; dietary Na+ restriction (<2 g/d), fluid restriction 1.5L (if Na<125)

 • Prior history of LVPs, thoras for hepatic hydrothorax, consideration of TIPS if refractory

Infection (SBP):

 • Prior history of SBP, whether has indication for 1° or 2° ppx

 • Current treatment (if diagnostic paracentesis reveals PMNs >250) or ppx (CTX if active GIB; otherwise cipro or Bactrim)

Bleeding (esophageal/gastric varices, portal hypertensive gastropathy, coagulopathy):

 • Prior history/source of bleeding, therapies (e.g. banding, sclerotherapy, TIPS), current prophylaxis (e.g. βB)

 • Current bleed: severity, IV access, H/H trends, medical therapy (PPI/octreotide), results/plan for EGD, SBP ppx as above

Encephalopathy (portosystemic encephalopathy):

 • Prior history of encephalopathy, precipitant, and treatment

 • Current severity, trend, precipitant, goal #BM on lactulose/rifaximin (eg: goal 4 BM/day or titrate to improvement in mental status)

Screening/Surgery (transplant):

 • Vaccinations: HAV, HBV, Influenza, Pneumovax, Prevnar (and up-to-date on all other vaccines), should see Transplant ID

 • Maintenance: alcohol abstinence, avoid NSAIDs

 • Malignancy: HCC screening with q6m RUQUS + AFP

 • Transplant status: listed or not listed, MELD score, Milan criteria if HCC, classically requires ~6 months sobriety

#VIBES #mnemonic #management #cirrhosis #Hepatology
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