VA AM Report 8.23-Decompensated Cirrhosis

Huat brought the heat this morning with a great case of decompensated cirrhosis. Here are some key pearls:

http://www.aasld.org/sites/default/files/guideline_documents/AlcoholicLiverDisease1-2010.pdf

For future reference, comprehensive overview and practice guidelines. We talked about the spectrum of alcoholic liver disease, from acute alcoholic hepatitis to more chronic cirrhosis.

What makes cirrhosis “decompensated?”

-new or worsening ascites
-encephalopathy
-variceal bleed
-hepatorenal syndrome
-hepatopulmonary syndrome
-SBP
-HCC

Basically anyone who develops a complication of cirrhosis. Plenty of helpful metrics to guide prognosis and treatment, usually in the inpatient setting we use the MELD score (Model for End-Stage Liver Disease), which initially was used to predict outcomes after TIPS (Trans-jugular Intrahepatic Portosystemic Shunt), is now used to help triage patients for liver transplant. You can find a good calculator here: http://www.mayoclinic.org/medical-professionals/model-end-stage-liver-disease/meld-score-90-day-mortality-rate-alcoholic-hepatitis

Other liver pearls right quick:

-First line treatment for new ascites is sodium restriction <2g daily, then move to diuretics, fluid restrict only if first two are ineffective
-Remember, recommended treatment for confirmed or suspected SBP is antibiotic treatment with good gram negative coverage (ceftriaxone for instance) AND albumin, 1g/kg body weight.
-Matt Schwede dropped some LTU pearls: the top 3 causes of decompensated cirrhosis are infection, and infection, and oh right infection. Get the tap and treat, SBP untreated has a mortality rate in excess of 80%.
-Once a patient w/ cirrhosis has developed SBP, overall 2-year mortality rate may be as high as 70-80%, consider referral to transplant once a patient has developed SBP

SBP prophylaxis indications

Patients with cirrhosis and gastrointestinal bleeding. Antibiotic prophylaxis in this setting has been shown to decrease mortality in randomized trials [17].

Patients who have had one or more episodes of SBP. In such patients, recurrence rates of SBP within one year have been reported to be close to 70 percent [34].

Patients with cirrhosis and ascites if the ascitic fluid protein is <1.5 g/dL (15 g/L) along with either impaired renal function or liver failure. Impaired renal function is defined as a creatinine ≥1.2 mg/dL (106 micromol/L), a blood urea nitrogen level ≥25 mg/dL (8.9 mmol/L), or a serum sodium ≤130 mEq/L (130 mmol/L]). Liver failure is defined as a Child-Pugh score ≥9 and a bilirubin ≥3 mg/dL (51 micromol/L). (from uptodate)

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