Up-to-date & evidence-based resources for managing Cirrhosis

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Meet the team

Meet the team of experts that contributed to cirrhosiscare.ca

Cirrhosis

• Making a Diagnosis
• Work up the etiology
• Disease Severity
• Etiology management specific to cirrhosis
• Screen for Complications

Making a Diagnosis

1. Top tips
2.  Algorithms
   • Making a diagnosis of Cirrhosis
3. Additional info
   • Physical exam findings
   • Ultrasound findings
   • Quality considerations for Transient Elastography
   • Transient Elastography cut-offs
   • Liver biopsy findings
4. Tutorials
5. Patient Materials
6. Links and Calculators
7. Downloadable content
8. Video Links
9. References
10. Give us feedback

Work up the etiology

1. Top tips
2. Cirrhosis Etiologies
   • Most common
   • Less common causes
3. Etiology Considerations
   • R-Factor for liver injury calculator
4. Initial Lab investigations
5. Tutorials
6. Patient Materials
7. Links
8. References
9. Give us feedback

Disease Severity

1. Top tips
2.  Algorithms
   • Assessing Liver Disease Severity
   • Assessing Surgical Risk
3. Additional info
   • D’Amico’s prognostic sub-stages
   • More info on the Child Pugh score and the MELD Na score including prognostic limitations
4. Tutorials
5. Patient Materials
6. Calculators
7. Downloadable content
8. References
9. Give us feedback

Etiology management specific to cirrhosis

1. Top Tips
2. Hepatitis C
3. Non alcoholic fatty liver disease (NAFLD)
4. Hemochromatosis
5. Hepatitis B
6. Autoimmune hepatitis
7. Primary biliary cholangitis
8. Primary sclerosing cholangitis
9. Tutorials
10. Patient Materials
11. Other content
12. Calculators
13. References
14. Give us feedback

Screen for Complications

1. Top tips
2.  Algorithms
   • Compensated cirrhosis – Screening for liver related complications
   • Decompensated cirrhosis – Screening for liver related complications
3. Tutorials
4. Patient Materials
5. Downloadable content
6. References
7. Give us feedback

Treatment

• Ascites
• Alcoholic hepatitis
• Alcohol Use Disorder
• Hepatic Hydrothorax
• Renal Dysfunction
• Hyponatremia

Ascites

1. Top tips
2. Connect Care Order panels
3. Connect Care General Cirrhosis Admission and Discharge Order Sets
4. Algorithms
   • Ascites – Initial Work-up
   • Ascites – General management
   • Ascites – Specific management
5. Additional info
   • Serum-ascites albumin gradient
6. Tutorials
7. Patient Materials
8. Downloadable content
9. Video Links
10. References
11. Give us feedback

Alcoholic hepatitis

1. Top tips
2. Connect Care Order panels
3. Connect Care General Cirrhosis Admission and Discharge Order Sets
4. Algorithms
   • Alcohol associated hepatitis Diagnosis and Severity grading
   • Alcohol associated hepatitis General Management
   • Alcohol associated hepatitis Specific Management
5. Tutorials
6. Patient Materials
7. Calculators
8. Downloadable content
9. References
10. Give us feedback

Alcohol Use Disorder

1. Top tips
2. Connect Care Order panels
3. Connect Care General Cirrhosis Admission and Discharge Order Sets
4. Algorithms
   • Alcohol Use Disorder Diagnosis and Treatment
5. Additional info
   • Brief interventions
   • DSM-5 Alcohol Use Disorder
   • Information about AUD relapse prevention medications
6. Tutorials
7. Patient Materials
8. Calculators
9. Downloadable content
10. References
11. Give us feedback

Hepatic Hydrothorax

1. Top tips
2. Connect Care Order panels
3. Connect Care General Cirrhosis Admission and Discharge Order sets
4. Algorithms
   • Hydrothorax Initial Work-up
   • Hydrothorax General management
   • Hydrothorax Specific management
5. Tutorials
6. Patient Materials
7. Calculators
8. Video Links
9. References
10. Give us feedback

Renal Dysfunction

1. Top tips
2. Connect Care Order panels
3. Connect Care General Cirrhosis Admission and Discharge Order sets
4. Algorithms
   • Diagnosing and treating Acute Kidney Injury (AKI)
5. Additional info
   • Criteria for HRS-AKI
   • New nomenclature for additional HRS-NAKI subtypes
6. Pharmacological therapy for HRS
7. When to consider consulting Nephrology
8. Tutorials
9. Patient Materials
10. Calculators
11. Downloadable content
12. References
13. Give us feedback

Hyponatremia

1. Top tips
2. Connect Care General Cirrhosis Admission and Discharge Order Sets
3. Algorithms
   • Hyponatremia in Cirrhosis
4. Tutorials
5. Patient Materials
6. Video Links
7. References
8. Give us feedback

• Varices
• Hepatic Encephalopathy
• Hepatocellular Carcinoma
• Portal Vein Thrombosis
• SBP
• ICU Management
• Liver Transplantation

Varices

1. Top tips
2. Connect Care Order panels
3. Connect Care General Cirrhosis Admission and Discharge Order Sets
4. Algorithms
   • Variceal Surveillance and Management: Compensated Cirrhosis
   • Variceal Surveillance and Management: Decompensated Cirrhosis
   • Acute Variceal Hemorrhage
5. Additional info
   • Choosing between beta-blockers versus endoscopic variceal ligation
   • Practical tips on the use of NSBBs
   • A Practical Approach to Rectal Varices
6. Patient Materials
7. Calculators
8. Downloadable content
9. Video Links
10. References
11. Give us feedback

Hepatic Encephalopathy

1. Top tips
2. Connect Care Order panels
3. Connect Care General Cirrhosis Admission and Discharge Order Sets
4. Algorithms
   • Overt Hepatic Encephalopathy: Diagnosis and Immediate Management
   • Overt Hepatic Encephalopathy: Additional Management
5. Additional info
   • Subjective tool for grading: Modified West Haven Criteria
   • Objective tool for grading: CHESS
   • Alternate Objective tool for grading: Glasgow Coma Scale
   • Medications to use with caution 
6. Tutorials
7. Patient Materials
8. Downloadable content
9. References
10. Give us feedback

Hepatocellular Carcinoma

1. Top tips
2. Connect Care General Cirrhosis Admission and Discharge Order Sets
3. Surveillance
4. Algorithms
   • Diagnosis
   • Li-RADS: Categorize each observation detected
   • The Alberta HCC Algorithm: Staging and Treatment
5. Additional info
   • Child-Pugh Classification
   • ECOG Performance Status
   • Surgical Resection
   • Ablation
   • Liver transplantation
   • TACE
   • TARE
   • Chemotherapy
   • SBRT
   • Palliative care considerations
6. Tutorials
7. Patient Materials
8. Calculators
9. Downloadable content
10. References
11. Give us feedback

Portal Vein Thrombosis

1. Top tips
2. Connect Care General Cirrhosis Admission and Discharge Order Sets
3. Algorithms
   • Portal Vein Thrombosis in Cirrhosis
4. Tutorials
5. Patient Materials
6. Downloadable content
7. References
8. Give us feedback

SBP

1. Top tips
2. Connect Care Order Panels
3. Algorithms
   • SBP Diagnosis and Management: General Management
   • SBP Specific Management
4. Tutorials
5. Patient Materials
6. Downloadable content
7. Video Links
8. References
9. Give us feedback

ICU Management

1. Top tips
2. Connect Care General Cirrhosis Admission and Discharge Order Sets
3. Hypotension/shock
4. Respiratory failure
5. Neurological Dysfunction
6. Renal Dysfunction
7. Hemostatic Disorders
8. Variceal Bleeding
9. Sepsis
10. Additional info
    • Acute-on-chronic liver failure (ACLF) prognostication
11. Tutorials
12. Patient Materials
13. Downloadable content
14. References
15. Give us feedback

Liver Transplantation

1. Top tips
2. Connect Care General Cirrhosis Admission and Discharge Order Sets
3. Indications for liver transplantation
4. Contraindications for liver transplantation
5. Tutorials
6. Patient Materials
7. Calculators
8. References
9. Give us feedback

Symptom Management

• Anxiety
• Anorexia
• Breathlessness
• Constipation
• Delirium/agitation (excluding HE)
• Depression
• Fatigue

Anxiety

1. Top tips
2. Assess for anxiety
3. Consider potential causes
4. Mild anxiety: consider non-pharmacological therapies
5. Moderate to severe anxiety: consider pharmacological and non-pharmacological therapies
6. Reassess using validated tools
7. References
8. Give us feedback

Anorexia

1. Top tips
2. Consider potential contributing causes
3. Consider non-pharmacological therapies
4. Pharmacological therapy 
5. Special considerations at End of Life (last few days to weeks)
6. References
7. Give us feedback

Breathlessness

1. Top tips
2. Assess for breathlessness with validated tools
3. Consider non-pharmacological therapies
4. When to consider pharmacological therapy
5. Special considerations at End of Life
6. References
7. Give us feedback

Constipation

1. Top tips
2. Consider potential contributing causes
3. Consider non-pharmacological therapies
4. Pharmacological therapies
5. Opioid Induced Constipation
6. Special considerations at End of Life
7. References
8. Give us feedback

Delirium/agitation (excluding HE)

1. Top tips
2. Assess for anxiety with validated tools
3. Consider potential contributing causes
4. Consider non-pharmacological therapies along with PRN pharmacological therapies
5. PRN pharmacological therapies
6. Refractory symptoms
7. Special considerations at End of Life
8. References
9. Give us feedback

Depression

1. Top tips
2. Additional assessment tools for depression
3. Consider potential contributing causes
4. Mild depression: consider non-pharmacological therapy 
5. Moderate to severe depression: consider pharmacological and non-pharmacological therapies
6. Reassess using validated tools 
7. References
8. Give us feedback

Fatigue

1. Top tips
2. Assess for additional modifiable contributing factors
3. Consider non-pharmacological therapies
4. When to consider pharmacological therapies
5. Special considerations at End-of-Life
6. References
7. Give us feedback 

• Muscle cramps
• Nausea & Vomiting
• Pain
• Pruritus
• Sleep Disturbance

Muscle cramps

1. Top tips
2. Assess and address any other potential treatable causes
3. Consider non-pharmacological management
4. When to consider pharmacological management
5. Special considerations at End of Life
6. References
7. Give us feedback

Nausea & Vomiting

1. Top tips
2. Consider potential contributing causes
3. Consider non-pharmacological therapies
4. When to consider pharmacological therapies if nausea persists
5. End of Life considerations
6. References
7. Give us feedback

Pain

1. Top tips
2. Consider differential diagnosis
3. Apply assessment tools specific to pain
4. Consider non-pharmacological therapies
5. When to consider pharmacological therapies
6. Special considerations at End of Life
7. References
8. Give us feedback

Pruritus

1. Top tips
2. Assess and treat possible contributing factors
3. Consider non-pharmacological treatment
4. When to consider topical pharmacological treatment
5. When to consider systemic therapy
6. References
7. Give us feedback

Sleep Disturbance

1. Top tips
2. Assess for sleep disturbance with validated tools
3. Consider potential contributing causes
4. Consider non-pharmacological treatment
5. When to consider pharmacological treatment 
6. Special considerations for End-of-Life
7. References
8. Give us feedback

Tools

• Calculators
• Order sets

Calculators

1. Calculator selector
2. Total Tumor Volume
3. Child Pugh Calculator
4. AST to Platelet Ratio Index(APRI) calculator
5. FIB4
6. R-factor Liver Injury calculator
7. AUDIT-C
8. Light’s Criteria
9. FeNa Calculator
10. ALBI
11. Confusion Assessment Method(CAM)
12. Maddrey Discriminant Function
13. PHQ-9
14. Epworth Sleepiness Scale
15. Itch score
16. Pruritis Numerical Rating Scale
17. ESAS-r Pain Scale
18. GAD-7
19. PEG3 Pain, Enjoyment and General Activity scale
20. HADS
21. Sleep Timing and Sleep Quality Screening Questionnaire
22. DAST-10

Order sets

• Cirrhosis Adult Admission Orders
• Cirrhosis Adult Discharge Orders
• Liver disease work up 
• Ascites Hepatic Hydrothorax, Edema in Cirrhosis Order Panel
• Inpatient Cirrhosis Paracentesis Order Panel
• Outpatient Cirrhosis Paracentesis Order Panel
• Alcohol Associated Hepatitis Order Panel
• Alcohol Use Disorder in Cirrhosis Order Panel
• Inpatient Thoracentesis Order Panel
• Outpatient Thoracentesis Order Panel
• Renal Dysfunction Order Panel
• Hepatorenal Syndrome (HRS) Order Panel
• Variceal Bleed Order Panel
• Hepatic Encephalopathy Order Panel
• SB-Peritonitis-Pleuritis Order Panel