Table 3.

Management of Manifestations of End-Stage Liver Disease and Coexisting Conditions of Primary Sclerosing Cholangitis.

Condition	Manifestation	Test	Treatment
Cirrhosis	Esophageal or gastric varices or hepatocellular cancer	Screening for esophageal or gastric varices with esophagogastroduodenoscopy every 2–3 yr; screening for hepatocellular cancer with abdominal ultrasonographic examination yearly with or without measurement of alpha-fetoprotein	Patients with no varices: observe, repeat esophagogastroduodenoscopy; patients with small varices: treat with nadolol (at a dose of 40 mg orally at bedtime); patients with large varices: ligation; patients with hepatocellular cancer: assess for ablation, resection, or transplantation
New elevation in level of bilirubin, CA 19-9, or both, or clinical cholangitis	Dominant stricture (benign or malignant)	MRCP, ERCP, or both	Patients with benign dominant stricture: endoscopic dilation; patients with malignant dominant stricture: assess for transplantation or palliative biliary stenting
Gallbladder disease	Polyp or polyps, or mass	Abdominal ultrasonography	Patients with polyps or mass: cholecystectomy; consider use of chemotherapy if cancer extends beyond gallbladder wall
Inflammatory bowel disease	Colon cancer	Colonoscopy and surveillance biopsies; yearly screening, even after liver transplantation	Patients with colon cancer: colectomy; consider use of chemotherapy according to stage guidelines for colon cancer
Metabolic bone disease	Osteopenia or osteoporosis	Bone-mineral-density testing; screening every 2–3 yr	Patients with osteopenia: calcium, 1.0–1.5 g/day and vitamin D, 1000 IU/day; patients with osteoporosis: bisphosphonate plus calcium, 1.0–1.5 g/day and vitamin D, 1000 IU/day