Top 10 Clinical Tips for New Gastroenterology and Hepatology Fellows

Although you will continue to build your knowledge base throughout fellowship, we wanted to help kick off your journey with our 'top 10 clinical tips'.

1. Patients may not always require transfusion of FFP for an elevated INR. Consider TEG based transfusions for active bleeding.
2. Hepatic encephalopathy is a clinical diagnosis. There is no need to trend ammonia.
3. Anticoagulation is not necessarily contraindicated in cirrhosis, particularly in patients that are well compensated. Risks and benefits should be discussed with the patient prior to initiation.
4. Nutritional interventions and physical therapy should be prioritized in patients with cirrhosis. Patients with liver disease are often already malnourished and nutritional deficiencies will only worsen when they are acutely ill.  It is just as important to ensure those with alcohol use disorder are referred to chemical dependency treatment at the time of discharge.
5. Normal liver chemistries  are not the full story in patients with non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH). Use clinical prediction models to  risk stratify patients with NASH and NAFLD
6. After variceal hemorrhage, if there is no clear indication (i.e GERD, esophagitis, peptic ulcer disease) consider stopping PPI therapy or only continuing therapy for 10 days. If varices were banded, PPI’s can reduce the size of post banding ulcers, but should not be used as a long-term treatment option. If non-selective beta blockers are started for esophageal varices, ensure heart rate is appropriate and titrate to resting heart rate.
7. Always think about the possibility of TIPS for patients with cirrhosis, particularly in those with difficult to manage ascites, hepatic hydrothorax or recurrent or uncontrollable variceal bleeding.
8. Infection is a leading cause of mortality in patients with cirrhosis particularly with episodes of GI bleeding.  You should have a low threshold to start empiric antibiotics.
9. Steroids can be considered for treatment of alcoholic hepatitis. Calculate Maddrey’s Discriminant function first and make sure to implement the Lille score at 7 days to stop steroids (Lille score ≥0.45 -> stop steroids). Beware of giving steroids in those with active GI bleeding, renal failure, active infection or acute pancreatitis.
10. All patients with cirrhosis admitted to the hospital should undergo paracentesis (preferably early), as this is associated with improved outcomes and decreased mortality.