Management of patients with hepatobiliary disorders

Dr. Guadalupe Garcia-Tsao reviewed the evidence supporting treatment recommendation for patients with variceal hemorrhage at the 2013 AGA Spring Postgraduate Course. Early resuscitation (transfusion with hemoglobin in 7-9-g/L range, antibiotic prophylaxis, and vasoactive drugs) remains the cornerstone in the management of patients with variceal hemorrhage. Patients should undergo an upper endoscopy within 12 hours of presentation; those confirmed to have bled from esophageal varices should then undergo endoscopic variceal ligation, whereas those with bleeding gastric varices can be considered for early transjugular intrahepatic portosystemic shunt (TIPS). Early TIPS (ideally done within 24 hours) should also be considered for patients at high risk for rebleeding. These include patients with Child class C cirrhosis or those with Child class B but with active bleeding during endoscopy.

Dr. Bruce Runyon provided an overview of management of patients with ascites. The first-line strategies in the treatment of ascites include complete cessation of alcohol consumption, sodium restriction (2-g/d salt diet), diuretics, and consideration for liver transplantation. Second-line treatments include discontinuation of beta blockers, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers; consideration to add midodrine, especially in the profoundly hypotensive patients; serial therapeutic paracenteses; and TIPS. TIPS can be considered in patients with refractory ascites who are younger than 65 year old, those with a caregiver at home, Child-Pugh score less than 12, MELD score less than 18, no evidence of alcoholic hepatitis, no severe spontaneous hepatic encephalopathy, and an ejection fraction greater than 60%.

Dr. Alan Barkun provided evidence-based recommendations to guide imaging and treatment decisions in patients with biliary obstruction. High-quality abdominal ultrasound remains the most cost-effective initial test in patients with biliary obstruction. Choice of subsequent imaging is based on the likelihood of benign versus malignant obstruction.

In patients with symptomatic cholelithiasis, presence of common bile duct (CBD) stones on ultrasound, ascending cholangitis, or bilirubin greater than 4 mg/dL should prompt preoperative endoscopic retrograde cholangiopancreaticography (ERCP). Preoperative ERCP is also warranted in patients who have a dilated CBD in the presence of a mildly elevated bilirubin level (1.8-4 mg/dL). Patients who do not meet these criteria but who are still suspected to have CBD stones (gallstone pancreatitis, abnormal liver tests other than bilirubin) should undergo a preoperative magnetic resonance cholangiopancreaticograph (MRCP), endoscopic ultrasound (EUS), or intraoperative cholangiogram to rule out CBD stones. Remaining patients are at low risk for CBD stones and can be managed with laparoscopic cholecystectomy alone. In patients suspected to have malignant biliary obstruction, the next imaging modality should be selected based on the level of biliary obstruction. If the lesion is suspected to involve the upper or middle third of CBD, then the best test is an MRCP or a helical CT cholangiography (although an EUS may be used for lesions in the mid third). Either an ERCP or EUS can be used for lesions involving lower third of CBD. A PET CT in a locally advanced lesion may help rule out distant metastasis. In patients with advanced disease, palliative treatment may include an EUS (with fine-needle aspiration) and an ERCP with stenting or percutaneous transhepatic cholangiograpy.

Dr. William Brugge discussed the management of intraductal papillary mucinous neoplasms (IPMNs). IPMN is a common yet slowly progressive neoplasm. Resection should be considered only in the presence of high-risk stigmata: obstructive jaundice, enhancing solid component in the cyst, or with pancreatic duct dilation grater than 10 mm. Other worrisome features that need evaluation with EUS/FNA include cysts greater than 3cm, main duct 5-9 mm, and suspicion for a mural nodule. Surgery is recommended if EUS/FNA confirms main duct involvement, presence of a mural nodule, or if the cytology is positive for malignancy. Patients who do not have any of these alarm signs can be monitored. However, the type and frequency of follow-up imaging depends on the size of the largest cyst: Cysts greater than 3 cm need MRI alternating with EUS every 3 months; 2-3-cm cysts require EUS every 3-6 months; 1-2-cm cysts require annual CT or MRI. Patients with small cysts (less than 1 cm) can be imaged every 2-3 years with a CT or an MRI.

Dr. Bruce Bacon discussed the current and future treatment options for patients with hepatitis C virus infection. With the advent of direct-acting antiviral agents, hepatitis C treatment will become shorter, safer, and more effective in the near term. Given this changing landscape, the most important decision that patients and clinicians face today is whether to treat now or wait for new treatment. Although each decision has to be tailored to a given patient’s clinical condition and wishes, patients with mild fibrosis (F0-F2), those with prior nonresponse to pegylated interferon–based treatment, and patients with cirrhosis (particularly those with portal hypertension) may benefit from waiting for these new treatments.

Dr. Kanwal is associate professor of medicine at Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, Houston.

Dr. Guadalupe Garcia-Tsao reviewed the evidence supporting treatment recommendation for patients with variceal hemorrhage at the 2013 AGA Spring Postgraduate Course. Early resuscitation (transfusion with hemoglobin in 7-9-g/L range, antibiotic prophylaxis, and vasoactive drugs) remains the cornerstone in the management of patients with variceal hemorrhage. Patients should undergo an upper endoscopy within 12 hours of presentation; those confirmed to have bled from esophageal varices should then undergo endoscopic variceal ligation, whereas those with bleeding gastric varices can be considered for early transjugular intrahepatic portosystemic shunt (TIPS). Early TIPS (ideally done within 24 hours) should also be considered for patients at high risk for rebleeding. These include patients with Child class C cirrhosis or those with Child class B but with active bleeding during endoscopy.

Dr. Bruce Runyon provided an overview of management of patients with ascites. The first-line strategies in the treatment of ascites include complete cessation of alcohol consumption, sodium restriction (2-g/d salt diet), diuretics, and consideration for liver transplantation. Second-line treatments include discontinuation of beta blockers, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers; consideration to add midodrine, especially in the profoundly hypotensive patients; serial therapeutic paracenteses; and TIPS. TIPS can be considered in patients with refractory ascites who are younger than 65 year old, those with a caregiver at home, Child-Pugh score less than 12, MELD score less than 18, no evidence of alcoholic hepatitis, no severe spontaneous hepatic encephalopathy, and an ejection fraction greater than 60%.

Dr. Alan Barkun provided evidence-based recommendations to guide imaging and treatment decisions in patients with biliary obstruction. High-quality abdominal ultrasound remains the most cost-effective initial test in patients with biliary obstruction. Choice of subsequent imaging is based on the likelihood of benign versus malignant obstruction.

In patients with symptomatic cholelithiasis, presence of common bile duct (CBD) stones on ultrasound, ascending cholangitis, or bilirubin greater than 4 mg/dL should prompt preoperative endoscopic retrograde cholangiopancreaticography (ERCP). Preoperative ERCP is also warranted in patients who have a dilated CBD in the presence of a mildly elevated bilirubin level (1.8-4 mg/dL). Patients who do not meet these criteria but who are still suspected to have CBD stones (gallstone pancreatitis, abnormal liver tests other than bilirubin) should undergo a preoperative magnetic resonance cholangiopancreaticograph (MRCP), endoscopic ultrasound (EUS), or intraoperative cholangiogram to rule out CBD stones. Remaining patients are at low risk for CBD stones and can be managed with laparoscopic cholecystectomy alone. In patients suspected to have malignant biliary obstruction, the next imaging modality should be selected based on the level of biliary obstruction. If the lesion is suspected to involve the upper or middle third of CBD, then the best test is an MRCP or a helical CT cholangiography (although an EUS may be used for lesions in the mid third). Either an ERCP or EUS can be used for lesions involving lower third of CBD. A PET CT in a locally advanced lesion may help rule out distant metastasis. In patients with advanced disease, palliative treatment may include an EUS (with fine-needle aspiration) and an ERCP with stenting or percutaneous transhepatic cholangiograpy.

Dr. William Brugge discussed the management of intraductal papillary mucinous neoplasms (IPMNs). IPMN is a common yet slowly progressive neoplasm. Resection should be considered only in the presence of high-risk stigmata: obstructive jaundice, enhancing solid component in the cyst, or with pancreatic duct dilation grater than 10 mm. Other worrisome features that need evaluation with EUS/FNA include cysts greater than 3cm, main duct 5-9 mm, and suspicion for a mural nodule. Surgery is recommended if EUS/FNA confirms main duct involvement, presence of a mural nodule, or if the cytology is positive for malignancy. Patients who do not have any of these alarm signs can be monitored. However, the type and frequency of follow-up imaging depends on the size of the largest cyst: Cysts greater than 3 cm need MRI alternating with EUS every 3 months; 2-3-cm cysts require EUS every 3-6 months; 1-2-cm cysts require annual CT or MRI. Patients with small cysts (less than 1 cm) can be imaged every 2-3 years with a CT or an MRI.

Dr. Bruce Bacon discussed the current and future treatment options for patients with hepatitis C virus infection. With the advent of direct-acting antiviral agents, hepatitis C treatment will become shorter, safer, and more effective in the near term. Given this changing landscape, the most important decision that patients and clinicians face today is whether to treat now or wait for new treatment. Although each decision has to be tailored to a given patient’s clinical condition and wishes, patients with mild fibrosis (F0-F2), those with prior nonresponse to pegylated interferon–based treatment, and patients with cirrhosis (particularly those with portal hypertension) may benefit from waiting for these new treatments.

Dr. Kanwal is associate professor of medicine at Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, Houston.

Dr. Guadalupe Garcia-Tsao reviewed the evidence supporting treatment recommendation for patients with variceal hemorrhage at the 2013 AGA Spring Postgraduate Course. Early resuscitation (transfusion with hemoglobin in 7-9-g/L range, antibiotic prophylaxis, and vasoactive drugs) remains the cornerstone in the management of patients with variceal hemorrhage. Patients should undergo an upper endoscopy within 12 hours of presentation; those confirmed to have bled from esophageal varices should then undergo endoscopic variceal ligation, whereas those with bleeding gastric varices can be considered for early transjugular intrahepatic portosystemic shunt (TIPS). Early TIPS (ideally done within 24 hours) should also be considered for patients at high risk for rebleeding. These include patients with Child class C cirrhosis or those with Child class B but with active bleeding during endoscopy.

Dr. Bruce Runyon provided an overview of management of patients with ascites. The first-line strategies in the treatment of ascites include complete cessation of alcohol consumption, sodium restriction (2-g/d salt diet), diuretics, and consideration for liver transplantation. Second-line treatments include discontinuation of beta blockers, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers; consideration to add midodrine, especially in the profoundly hypotensive patients; serial therapeutic paracenteses; and TIPS. TIPS can be considered in patients with refractory ascites who are younger than 65 year old, those with a caregiver at home, Child-Pugh score less than 12, MELD score less than 18, no evidence of alcoholic hepatitis, no severe spontaneous hepatic encephalopathy, and an ejection fraction greater than 60%.

Dr. Alan Barkun provided evidence-based recommendations to guide imaging and treatment decisions in patients with biliary obstruction. High-quality abdominal ultrasound remains the most cost-effective initial test in patients with biliary obstruction. Choice of subsequent imaging is based on the likelihood of benign versus malignant obstruction.

In patients with symptomatic cholelithiasis, presence of common bile duct (CBD) stones on ultrasound, ascending cholangitis, or bilirubin greater than 4 mg/dL should prompt preoperative endoscopic retrograde cholangiopancreaticography (ERCP). Preoperative ERCP is also warranted in patients who have a dilated CBD in the presence of a mildly elevated bilirubin level (1.8-4 mg/dL). Patients who do not meet these criteria but who are still suspected to have CBD stones (gallstone pancreatitis, abnormal liver tests other than bilirubin) should undergo a preoperative magnetic resonance cholangiopancreaticograph (MRCP), endoscopic ultrasound (EUS), or intraoperative cholangiogram to rule out CBD stones. Remaining patients are at low risk for CBD stones and can be managed with laparoscopic cholecystectomy alone. In patients suspected to have malignant biliary obstruction, the next imaging modality should be selected based on the level of biliary obstruction. If the lesion is suspected to involve the upper or middle third of CBD, then the best test is an MRCP or a helical CT cholangiography (although an EUS may be used for lesions in the mid third). Either an ERCP or EUS can be used for lesions involving lower third of CBD. A PET CT in a locally advanced lesion may help rule out distant metastasis. In patients with advanced disease, palliative treatment may include an EUS (with fine-needle aspiration) and an ERCP with stenting or percutaneous transhepatic cholangiograpy.

Dr. William Brugge discussed the management of intraductal papillary mucinous neoplasms (IPMNs). IPMN is a common yet slowly progressive neoplasm. Resection should be considered only in the presence of high-risk stigmata: obstructive jaundice, enhancing solid component in the cyst, or with pancreatic duct dilation grater than 10 mm. Other worrisome features that need evaluation with EUS/FNA include cysts greater than 3cm, main duct 5-9 mm, and suspicion for a mural nodule. Surgery is recommended if EUS/FNA confirms main duct involvement, presence of a mural nodule, or if the cytology is positive for malignancy. Patients who do not have any of these alarm signs can be monitored. However, the type and frequency of follow-up imaging depends on the size of the largest cyst: Cysts greater than 3 cm need MRI alternating with EUS every 3 months; 2-3-cm cysts require EUS every 3-6 months; 1-2-cm cysts require annual CT or MRI. Patients with small cysts (less than 1 cm) can be imaged every 2-3 years with a CT or an MRI.

Dr. Bruce Bacon discussed the current and future treatment options for patients with hepatitis C virus infection. With the advent of direct-acting antiviral agents, hepatitis C treatment will become shorter, safer, and more effective in the near term. Given this changing landscape, the most important decision that patients and clinicians face today is whether to treat now or wait for new treatment. Although each decision has to be tailored to a given patient’s clinical condition and wishes, patients with mild fibrosis (F0-F2), those with prior nonresponse to pegylated interferon–based treatment, and patients with cirrhosis (particularly those with portal hypertension) may benefit from waiting for these new treatments.

Dr. Kanwal is associate professor of medicine at Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, Houston.