to management of cirrhosis in older patients compared with younger patients. These include increased sensitivity to salt restriction, protein restriction, and fluid overload, which may not be appreciated by gastroenterologists who have not been given specific training in geriatric hepatic disease.166 Management of variceal bleeding can be particularly problematic, because the high incidence of ischemia renders use of β antagonists and vasopressin more dangerous. Recognition of encephalopathy is difficult in patients with underlying dementia, and spontaneous bacterial peritonitis is underdiagnosed in geriatric patients due to the lack of usual systemic responses to intraperitoneal infection (fever, elevated white blood cell count, guarding). Current transplant guidelines often use age as a cutoff, rather than function or cognition. Although transplantation is not contraindicated in patients older than 60 years, it is rarely performed, despite evidence that survival of patients up to 72 years of age with a transplant is comparable to that of younger individuals.166 Variceal bleeding in the elderly patient Variceal hemorrhage is the most serious complication of portal hypertension and accounts for approximately one third of cirrhosis-related deaths. Between 50% and 60% of patients with cirrhosis develop gastroesophageal varices, and 30% will experience bleeding within 2 years of diagnosis. Current techniques stress early obliteration of varices using banding or sclerotherapy; however, there are little data to guide endoscopic treatment in the elderly.167 Use of vasopressin in older patients can be dangerous due to the possibility of precipitating myocardial ischemia or arrhythmias in patients with preexisting heart disease.168 Nonalcoholic steatohepatitis and use of statins As the population ages and becomes more obese, gastroenterologists will observe a significant increase in the number of geriatric patients referred for complications of obesity and diabetes. These include motility disorders such as gastroparesis and constipation due to autonomic neuropathy as well as liver dysfunction due to nonalcoholic steatohepatitis (NASH). More than 35% of the population aged 65 years or older are obese. Diabetes currently affects 12% of the US population, and more than 70% of affected individuals fall into the geriatric age range. It has been estimated that a further 6% of individuals in the United States have “borderline” diabetes or diabetes that has not been diagnosed because elevated glucose levels occur intermittently or have not caused significant symptoms. The latter may be particularly problematic, because there is evidence that NASH may progress to fibrosis and cirrhosis in a larger percentage of patients than previously believed. The other issue that is becoming a major problem is the difficulty of using lipid-lowering drugs, such as statins, in patients with clear indications for treatment (diabetes and known coronary artery disease) who also have NASH. Often these patients are diagnosed with NASH as a result of elevated liver enzyme levels found in screening blood tests performed before initiating treatment with the drug. Guidelines for treatment of these patients are not clear due to a lack of data on the long-term effects of lipid-lowering drugs on liver function in elderly patients with NASH. The problem is potentially enormous because approximately 20% of the population has hypercholesterolemia, defined as a total serum cholesterol level >240