Curbside Consultation of the Liver

Mitchell L. Shiffman, MD received his MD degree from the State University of New York, Upstate Medical Center in Syracuse, NY. He then completed internship and residency training in Internal Medicine at the Medical College of Virginia (now the Virginia Commonwealth University Medical Center) in Richmond, VA. He remained at this institution for fellowship training in Gastroenterology and Hepatology, which included two years of research training funded by a National Institutes of Health training grant. After completing his training, Dr. Shiffman joined the faculty of the Virginia Commonwealth University as an Assistant Professor of Medicine and has remained at this institution throughout his academic career. He is currently a Professor of Medicine, and has been the Chief of the Hepatology Section and Medical Director of the Liver Transplant Program at the VCU Medical Center for over a decade. Dr. Shiffman has authored or coauthored over 200 original articles, editorials, reviews, and/or book chapters. His clinical research has focused on improving our understanding and developing better treatments for viral hepatitis B and C. He is a member of the Board of Trustees of the American College of Gastroenterology, and has served on numerous NIH grant review committees and is a member of the Editorial Boards of Liver Transplantation and Liver International.

CONTENTS Dedication Acknowledgments About the Editor Contributing Authors Preface Section I: VIRAL HEPATITIS C Question 1: What Is the Likelihood That My Patient With Chronic Hepatitis C Will Develop Cirrhosis, Heaptocellular Carcinoma, and/or Hepatic Decompensation? Question 2: How Should a Patient Who Tests Positive for Chronic Hepatitis C but Has Persistently Normal Serum Liver Amino-Transaminases Be Evaluated? Question 3: Do All Patients With Chronic Hepatitis C Virus Require a Liver Biopsy? Question 4. How Often Should I Measure HCV RNA While Treating a Patient With Peginterferon and Ribavirin? Question 5: When A Patient Receiving Peginterferon and Ribavirin Therapy Develops Anemia Should I Prescribe Epoetin Alfa or Reduce the Dose of the Ribavirin? Question 6: Is There Anything I Can Do to Improve the Chance That an African American With Chronic Hepatitis C Will Respond to Peginterferon and Ribavirin? Question 7: Is It Safe to Treat Patients With Chronic Hepatitis C and Cirrhosis With Peginterferon and Ribavirin? Question 8: How Often Should I Follow a Patient Who Had Chronic Hepatitis C After He Achieved a Sustained Virologic Response? Section II: Viral Hepatitis B Question 9: Which Patients With Chronic Hepatitis B Require a Liver Biopsy? Question 10: How Do I Decide Which Medication to Utilize in a Patient With Hepatitis B Virus? Question 11: Can I Ever Stop Treatment in a Patient With Chronic Hepatitis B Receiving an Oral Antiviral Agent? Question 12: How Do I Know When a Patient Receiving an Oral Antiviral Agent Has Developed Resistence and What Do I When This Happens? Question 13: How Do I Treat a Patient Who Is Coinfected With Chronic Hepatitis B and C Viruses? Section III: LIVER DISEASE IN PATIENTS WITH HIV INFECTION Question 14: How Does Having HIV Affect the Likelihood That My Patient With Chronic HCV Will Develop Cirrhosis? Question 15: Which Patients With Chronic HCV and HIV Coinfection Should Be Treated With Peginterferon and Ribavirin? Question 16: Is There a Simple Way to Treat a Patient Who Is Coinfected With Hepatitis B Virus and HIV? Question 17: What Things Could Cause My Patient With HIV to Develop Jaundice? Question: 18 Should I Stop HIV Medications in a Patient Who Has Developed an Elevation In Serum Liver Transaminases? Section IV: GENETIC DISORDERS THAT CAUSE CHRONIC LIVER DISEASE Question 19: What Is the Best Screening Test for Genetic Hemochromatosis? Question 20: How Frequently Should I Have a Patient With Genetic Hemochromatosis Undergo Phlebotomy? Question 21: What Is the Best Screening Test for Wilson's Disease? Question 22: What Should I Tell My Patient Who Is a Carrier for Alpha-1-Antitrypsin Deficiency? Question 23: Do All Patients With Autoimmune Hepatitis Require Immune Suppressive Medications? Question 24: My Patient With and Autoimmune Hepatitis Cannot Take Corticosteroids. Are There Any Other Medications I Could Use? Question 25: Do I Need to Perform a Liver Biopsy in All Patients With Autoimmune Hepatitis Prior To Initiating Steroids? Section V: FATTY LIVER DISEASE Question 26: Which Patients With Fatty Liver Disease on Ultrasound Require a Liver Biopsy? Question 27: An Obese Patient With Hypercholesterolemia Was Recently Started on a Statin and Is Now Found to Have Elevated Serum Liver Transaminases. Do I Need to Stop This Medication? Question 28: What Is the Best Medication to Utilize In a Patient With Fatty Liver Disease and Type 2 Diabetes Mellitus? Question 29: My Patient With Chronic Hepatitis C Also Has Evidence of Nonalcoholic Steatohepatitis (NASH) on His Liver Biopsy. What Can I Do to Increase His Chance of Responding to Peginterferon and Ribavirin Treatment? Question 30: Can A Patient of Normal Body Weight, a Normal Serum Cholesterol Level, and No History of Diabetes Have Fatty Liver Disease? Section VI: CHOLESTATIC LIVER DISEASES Question 31: When Should I Initiate Treatment With Ursodeoxycholic Acid and What Dose Should I Utilize In My Patient With Primary Biliary Cirrhosis? Question 32: What Type of Testing Does My Patient With Primary Biliary Cirrhosis Require? Question 33: Is Ursodeoxycholic Acid Effective for the Treatment of Primary Sclerosing Cholangitis? Question 34: Should I Be Screening My Patient With Primary Sclerosing Cholangitis for Cholangiocarcinoma? Question 35: Should All Patients With Suspected Sclerosing Cholangitis Undergo an ERCP to Confirm This Diagnosis? Question 36: My Patient With Ulcerative Colitis Recently Underwent a Total Colectomy for Severe Dysplasia. Does This Reduce The Risk That He Will Get Primary Sclerosing Cholangitis? Section VII: CIRRHOSIS Question 37: Which Asymptomatic Patients With Cirrhosis Should Undergo an Upper Endoscopy To Determine If They Have Esophageal Varices? Question 38: I Just Banded Actively Bleeding Varicies in a Patient With Known Cirrhosis. The Patient Is Now Hemodynamically Stable. Is There Anything Else I Should Recommend? Question 39: Which Patients With Chronic Liver Disease Should I Screen For Hepatocellular Carcinoma? Question 40: Should I Vaccinate My Patients With Cirrhosis for Viral Hepatitis A and B? Question 41: A Healthy Patient Not Known to Have Chronic Liver Disease, With Normal Liver Chemistries and Liver Function Was Found to Have a 4-Centimeter Liver Mass on Ultrasound. Should I Biopsy This? Question 42: I Was Asked to See a Patient With Tense Ascites. How Much Ascites Is Safe to Remove at Any One Time? Question 43: I Have Been Increasing the Dose of Diuretics in My Patient With Ascites Over Several Weeks. He Still Has Ascites but Has Now Developed an Elevation in Serum Creatinine to 2.0 Mg/dl. What Should I Do? Question 44: My Patient With Cryptogenic Cirrhosis Was Recently Hospitalized With Spontaneous Bacterial Peritonitis. How Long Should She Be Treated With Antibiotics? Question 45: My Patient With Cirrhosis Has an Elevated Serum Ammonia but No Symptoms of Hepatic Encephalopathy. How Much Lactulose Should I Recommend? Question 46: My Patient With Hepatic Encephalopathy Continues to Be Mildly Confused Despite Taking Lactulose Twice Daily And Having Multiple Episodes Of Diarrhea Daily. Should I Increase The Dose Further? Section VIII: LIVER TRANSPLANTATION Question 47: My Patient With Cirrhosis Suffers From Severe Fatigue but Has Normal Liver Function and Has Never Had a Major Complication of Cirrhosis. Should I Refer This Patient For a Liver Transplant? Question 48: What Should I Recommend for My Patient With Cirrhosis Who Was Recently Found To Have A New 2-Centimeter Liver Mass By Ultrasound Screening? Question 49: I Have Been Asked to See a Patient Who Had a Liver Transplant 5 Years Ago In Another State. He Has Not Been Seen by His Liver Transplant Center In 2 Years. His Serum Creatinine Is 2.5 mg/dl but His Liver Enzymes and Liver Function Tests are Normal. He Does Not Want to Go Back To His Transplant Center. What Should I Do? Index