Clinical Commander

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gi.cirrhosis.core.v1

Cirrhosis (chronic, compensated + decompensated)

hepatologychronicacuteadultoutpatientinpatienttransition
Start encounter →Print handoutPRODUCTION

Manifest is full and current (AASLD 2024 + AASLD 2023 ACLF + Baveno VII + AASLD MASLD + AASLD HCC + ACG ALD + BMJ BP) with 6 phenotypes (compensated, decompensated, ACLF, alcohol, MASH, viral) and complete medication/dosing tables. Problem-package at src/lib/tier3/problem-package/packages/cirrhosis/ has full atoms; a sibling decompensation-focused package at gi.cirrhosis_decompensation.inpatient/ provides the `_design-brief.md` cited above. Workups acute_cholangitis-like wiring uses hepatic_encephalopathy + sbp_workup + hepatorenal_syndrome (all in clinical-tools-registry). Calculators MELD-Na + MELD 3.0 wired; Maddrey, FIB-4, APRI also in manifest. Gaps for PRODUCTION: evidence.pmids array empty (manifest cites guideline labels but no numeric PMIDs); no engine-specific test_files; regimen_axes empty (carvedilol, propranolol, spironolactone, furosemide, lactulose, rifaximin, albumin, terlipressin, octreotide, ceftriaxone, prednisolone all in manifest.medications without RxCUI verification).

Entry points (7)

  • symptom
    Jaundice / scleral icterus
    jaundice
  • symptom
    New or worsening ascites
    ascites
  • symptom
    Variceal bleed — hematemesis / melena
    hematemesis_melena
  • symptom
    Hepatic encephalopathy / confusion / asterixis
    hepatic_encephalopathy
  • lab_abnormality
    Thrombocytopenia + abnormal LFTs / synthetic dysfunction
    thrombocytopenia_with_lft_abn
  • imaging
    Cirrhotic morphology on US/CT/MRI
    cirrhotic_liver_us
  • problem_list
    Existing cirrhosis on problem list (visit / readmission)
    cirrhosis

Required inputs (19)

  • agerequired
    demographic • used at CONTEXT
    Transplant eligibility, frailty, MELD-Na age component
  • sbprequired
    vital • used at CONTEXT
    Hypotension precipitates HRS-AKI; variceal bleed shock
  • hrrequired
    vital • used at CONTEXT
    Hyperdynamic circulation; SBP / sepsis screen
  • total_bilirubinrequired
    lab • used at INITIAL_WORKUP
    MELD/MELD-Na/MELD3/Child-Pugh component (AASLD 2023 Biggins)
  • inrrequired
    lab • used at INITIAL_WORKUP
    MELD/MELD-Na/MELD3/Child-Pugh component (AASLD 2023 Biggins)
  • creatininerequired
    lab • used at INITIAL_WORKUP
    MELD/MELD-Na/MELD3 component; HRS-AKI workup (AASLD 2023)
  • sodiumrequired
    lab • used at INITIAL_WORKUP
    MELD-Na/MELD3 component; hyponatremia <125 = red flag (AASLD 2023 Biggins)
  • albuminrequired
    lab • used at INITIAL_WORKUP
    Child-Pugh + MELD3 component; nutritional status (AASLD 2023)
  • plateletsrequired
    lab • used at INITIAL_WORKUP
    Portal hypertension surrogate; FIB-4 (Baveno VII 2022)
  • ast_altrequired
    lab • used at INITIAL_WORKUP
    AST:ALT ratio (alcoholic >2:1); FIB-4 / APRI (AASLD 2023)
  • afp
    lab • used at MONITORING
    HCC surveillance (AASLD 2023 HCC)
  • ammonia
    lab • used at BRANCHING_WORKUP
    HE workup (note: not required for HE diagnosis per AASLD 2023)
  • liver_us_dopplerrequired
    imaging • used at INITIAL_WORKUP
    HCC surveillance, portal vein patency, ascites (AASLD 2023 HCC)
  • egd_variceal_screen
    imaging • used at INITIAL_WORKUP
    Variceal screening for portal hypertension (Baveno VII 2022 de Franchis)
  • alcohol_userequired
    history • used at CONTEXT
    Etiology + abstinence is highest-yield intervention (ACG 2023 ALD)
  • viral_hepatitisrequired
    history • used at CONTEXT
    HCV cure (DAA), HBV suppression (AASLD 2024)
  • mash_metabolicrequired
    history • used at CONTEXT
    MASH etiology — leading cause; weight, T2DM, lipids, BP control (AASLD 2023 MASLD)
  • decompensation_historyrequired
    history • used at CONTEXT
    Compensated vs decompensated phenotype (EASL 2018)
  • current_medsrequired
    medication • used at CONTEXT
    Avoid NSAIDs / nephrotoxins; check beta-blocker / lactulose / rifaximin / diuretics (AASLD 2023)

12-phase flow (12)

  1. 1FRAME
    Confirm cirrhosis scope; distinguish compensated outpatient from decompensated/ACLF inpatient pathway (EASL 2018)
    inputs: decompensation_history
    advance: compensated vs decompensated assigned
  2. 2ENTRY
    Recognize jaundice, ascites, variceal bleed, HE, or known-cirrhosis follow-up trigger (AASLD 2023 Biggins)
    inputs: age
    advance: one entry trigger present
  3. 3CONTEXT
    Vitals, etiology screen (alcohol, viral, MASH), prior decompensations, NSAID/diuretic compliance, recent infection
    inputs: sbp, hr, alcohol_use, viral_hepatitis, mash_metabolic, current_meds
    advance: context captured
  4. 4RED_FLAGS
    Variceal bleed, HE grade 3-4, SBP, HRS-AKI, ACLF organ failure, severe hypoglycemia, hyponatremia <125 (AASLD 2023; EASL 2018)
    inputs: sbp, sodium, creatinine
    advance: red flag escalated to acute pathway or excluded
  5. 5INITIAL_WORKUP
    Full LFT panel, INR/PT, CBC w/ platelets, BMP (Cr/Na), albumin, viral hepatitis serologies, autoimmune panel if indicated, AFP, US with Doppler, EGD for variceal screen
    inputs: total_bilirubin, inr, creatinine, sodium, albumin, platelets, ast_alt, liver_us_doppler, egd_variceal_screen
    actions: panel.lft, panel.renal, panel.cbc
    advance: baseline labs + imaging returned
  6. 6BRANCHING_WORKUP
    Diagnostic paracentesis for any new ascites (SBP/SAAG); MRCP/MRI for HCC; ammonia/precipitant screen for HE; ACLF organ failure workup
    inputs: ammonia
    actions: sbp_workup, hepatic_encephalopathy, hepatorenal_syndrome
    advance: phenotype identified (compensated / decompensated / ACLF / alcohol / MASH / viral)
  7. 7DIFFERENTIAL
    Etiology — viral, alcoholic, MASH, autoimmune, PBC, PSC, hereditary (HH, Wilson, A1AT), drug-induced, Budd-Chiari, cardiac (AASLD 2023 Biggins)
    advance: etiology assigned
  8. 8RISK_STRATIFICATION
    MELD / MELD-Na / MELD 3.0 / Child-Pugh; Maddrey for AH; CLIF-C ACLF if ACLF
    inputs: total_bilirubin, inr, creatinine, sodium, albumin
    actions: calc.meld_na, calc.meld3, calc.fib4, calc.apri, calc.maddrey
    advance: severity scores documented
  9. 9TREATMENT
    Treat etiology (DAA / abstinence / HBV suppression / MASH lifestyle); Baveno VII variceal management; ascites diuretics + LVP+albumin; HE lactulose+rifaximin; SBP empiric ceftriaxone+albumin; HRS terlipressin+albumin; transplant referral MELD ≥15
    inputs: creatinine, sodium, platelets
    advance: etiology + complication-specific plan in motion
  10. 10DISPOSITION
    ICU for ACLF Grade 2-3 / variceal bleed / HE 4 / HRS-AKI; floor for stable decompensation; outpatient hepatology for compensated (EASL 2018; AASLD 2023)
    inputs: sbp
    advance: destination set
  11. 11MONITORING
    MELD-Na monthly during decompensation; LFT/INR/albumin q3-6mo compensated; HCC US+AFP q6mo; EGD q2-3yr; weight daily for ascites; daily Cr/Na on diuretics (AASLD 2023; Baveno VII 2022)
    inputs: total_bilirubin, creatinine, sodium, afp
    actions: panel.ascites
    advance: monitoring cadence set
  12. 12FOLLOWUP
    Hepatology q3mo decompensated / q6mo compensated; transplant eval at MELD ≥15; addiction services for AUD; vaccinations (HAV/HBV/flu/PNA/COVID); palliative care for advanced (AASLD 2023 Biggins)
    advance: follow-up scheduled