Abstract

The rates of liver disease in the UK are rising and hence more patients than ever are presenting to acute medical units with potentially life threatening sequelae. Early recognition and treatment of sepsis, kidney injury, bleeding and alcoholic hepatitis can significantly improve outcomes, but requires a comprehensive approach to assessment. This patient cohort often suffers from a perceived uniform poor prognosis, especially in alcohol related disease, but evidence for this is changing and reassessment of prognosis after 48 hours of organ support may be more accurate than that made ‘at the front door’. This article summarises the most important complications of decompensated cirrhosis, their early management, and presents a targeted system of care: ‘RING Liver’ – Renal failure, Infection, Nutrition, Gastrointestinal bleeding and transit, Liver dysfunction/transplantation. Factors favouring transfer to tertiary units are also explored.

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References

1. Thomson SJ, Westlake S, Rahman TM, et al. Chronic liver disease - an increasing problem: a study of hospital admission and mortality rates in England, 1979-2005, with particular reference to alcoholic liver disease. Alcohol Alcohol. 2008; 43(4): 416–22.
2. British Association for the Study of liver disease (BASL). A time to act: Improving health and outcomes in liver disease. The national plan for liver services (UK) 2009.
3. Jalan R, Gines P, Olson J, et al. Acute-on chronic liver failure. Journal of Hepatology. 2012 vol. 57 j 1336–1348.
4. Arroyo V, Guevara M, Gines P. Hepatorenal syndrome in cirrhosis: pathogenesis and treatment. Gastroenterology. 2002; 122(6): 1658–76.
5. Martin-Llahi M, Guevara M, Torre A, et al. Prognostic importance of the cause of renal failure in patients with cirrhosis. Gastroenterology. 2011; 140(2): 488–96 e4.
6. Salerno F, Gerbes A, Gine`s P, et al. Diagnosis, prevention and treatment of hepatorenal syndrome in cirrhosis. Gut. 2007; 56:1310–18.
7. Gluud LL, Christensen K, Christensen E, et al. Systematic review of randomized trials on vasoconstrictor drugs for hepatorenal syndrome. Hepatology. 2010; 51(2): 576–84.
8. Fede G, D’Amico G, Arvaniti V, et al. Renal failure and cirrhosis: a systematic review of mortality and prognosis. J Hepatol. 2012;56(4): 810–8.
9. Berry PA, Antoniades CG, Carey I, et al. Severity of the compensatory anti-inflammatory response determined by monocyte HLA-DR expression may assist in outcome prediction in cirrhosis Intensive. Care Med. 2011; 37(3): 453–60.
10. Sort P, Navasa M, Arroyo V, et al. Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N. Engl. J. Med. 1999; 341(6):403–9.
11. Singal AK, Charlton MR. Nutrition in alcoholic liver disease. Clin Liver Dis. 2012; 16(4): 805–26.
12. Austin MJ, Shawcross DL. Outcome of patients with cirrhosis admitted to intensive care. Curr Opin Crit Care. 2008; 14(2):202–7.
13. McCormick PA, Jenkins SA, McIntyre N, et al. Why portal hypertensive varices bleed and bleed: a hypothesis. Gut 1995; 36:100–3.
14. Goulis J, Armonis A, Patch D, et al. Bacterial infection is independently associated with failure to control bleeding in cirrhotic patients with gastrointestinal hemorrhage. Hepatology 1998; 27: 1207–12.
15. Bernard B, Grange JD, Khac EN, et al. Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding: a metaanalysis. Hepatology 1999; 29:1655–61.
16. Mathurin P, Mendenhall CL, Carithers RL Jr, et al. Corticosteroids improve short-term survival in patients with severe alcoholic hepatitis (AH): individual data analysis of the last three randomized placebo controlled double blind trials of corticosteroids in severe AH. J Hepatol 2002; 36(4): 480–7.
17. Forrest EH, Evans CD, Stewart S, et al. Analysis of factors predictive of mortality in alcoholic hepatitis and derivation and validation of the Glasgow alcoholic hepatitis score. Gut. 2005; 54(8): 1174–9.
18. Das V, Boelle PY, Galbois A, et al. Cirrhotic patients in the medical intensive care unit: early prognosis and long-term survival. Crit Care Med. 2010; 38(11): 2108–16.
19. Cholongitas E, Betrosian A, Senzolo M, et al. Prognostic models in cirrhotics admitted to intensive care units better predict outcome when assessed at 48 h after admission. J Gastroenterol Hepatol. 2008;23(8 Pt 1): 1223–7.
20. Mathurin P, Moreno C, Samuel D, et al. Early liver transplantation for severe alcoholic hepatitis. N Engl J Med. 2011 10; 365(19):1790–800.