Generic placeholder image

Reviews on Recent Clinical Trials

Editor-in-Chief

ISSN (Print): 1574-8871
ISSN (Online): 1876-1038

Review Article

Liver Cirrhosis Complications Management at the Emergency Department

Author(s): Emidio Scarpellini, Carmelo Luigiano, Gianluca Svegliati-Baroni, Dan Dumitrascu, Tiziana Larussa, Valeria Santori, Francesco Luzza and Ludovico Abenavoli*

Volume 15, Issue 4, 2020

Page: [331 - 338] Pages: 8

DOI: 10.2174/1574887115666200603160816

Price: $65

Abstract

Background and Aims: Liver cirrhosis (LC) of any origin has always been a source of several emergencies for physicians working at the Emergency Department (ER). LC patients can present with several complications that are sometimes difficult to recognize and treat.

Thus, we reviewed the literature evidence for the diagnosis and management of several LC related emergencies.

Methods: We conducted a search on the main medical databases for papers, reviews, metanalyses, case series, and RCTs using the following keywords and their associations: liver cirrhosis, variceal hemorrhage, ascites, hepatic encephalopathy, spontaneous bacterial peritonitis, hepato-renal syndrome, emergency.

Results: Main LC emergencies are upper gastrointestinal hemorrhage, decompensated ascites and spontaneous bacterial peritonitis, hepatic encephalopathy, hepato-renal syndrome. Their management is partly medical and interventional. Very often, the final cure of some complications, such as hepato-renal syndrome, is represented by liver transplantation.

Conclusion: Although LC prevalence is going to fall in the following years, due to HBV and HCV optimized treatments, its complications represent a significant admission percentage at the ER and challenge for physicians’ skills.

Keywords: Liver cirrhosis, variceal hemorrhage, ascites, spontaneous bacterial peritonitis, hepato-renal syndrome, emergency.

Graphical Abstract
[1]
Murray CJ, Atkinson C, Bhalla K, et al. U.S. Burden of Disease Collaborators. The state of US health, 1990-2010: Burden of diseases, injuries, and risk factors. JAMA 2013; 310(6): 591-608.
[http://dx.doi.org/10.1001/jama.2013.13805] [PMID: 23842577]
[2]
Tsochatzis EA, Bosch J, Burroughs AK. Liver cirrhosis. Lancet 2014; 383(9930): 1749-61.
[http://dx.doi.org/10.1016/S0140-6736(14)60121-5] [PMID: 24480518]
[3]
Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W. Practice guidelines committee of the american association for the study of liver diseases; practice parameters committee of the american college of gastroenterology. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology 2007; 46(3): 922-38.
[http://dx.doi.org/10.1002/hep.21907] [PMID: 17879356]
[4]
Nusrat S, Khan MS, Fazili J, Madhoun MF. Cirrhosis and its complications: Evidence based treatment. World J Gastroenterol 2014; 20(18): 5442-60.
[http://dx.doi.org/10.3748/wjg.v20.i18.5442] [PMID: 24833875]
[5]
Garcia-Tsao G. Current management of the complications of cirrhosis and portal hypertension: Variceal hemorrhage, ascites, and spontaneous bacterial peritonitis. Dig Dis 2016; 34(4): 382-6.
[http://dx.doi.org/10.1159/000444551] [PMID: 27170392]
[6]
Agrawal K, Kumar P, Markert R, Agrawal S. Risk Factors for 30-day readmissions of individuals with decompensated cirrhosis. South Med J 2015; 108(11): 682-7.
[http://dx.doi.org/10.14423/SMJ.0000000000000371] [PMID: 26539950]
[7]
Bajaj JS, O’Leary JG, Reddy KR, et al. NACSELD. Second infections independently increase mortality in hospitalized patients with cirrhosis: The North American consortium for the study of end-stage liver disease (NACSELD) experience. Hepatology 2012; 56(6): 2328-35.
[http://dx.doi.org/10.1002/hep.25947] [PMID: 22806618]
[9]
D’Amico G, Garcia-Tsao G, Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: A systematic review of 118 studies. J Hepatol 2006; 44(1): 217-31.
[http://dx.doi.org/10.1016/j.jhep.2005.10.013] [PMID: 16298014]
[10]
Nishikawa H, Osaki Y. Liver cirrhosis: Evaluation, nutritional Status, and prognosis. Mediators Inflamm 2015; 2015872152
[http://dx.doi.org/10.1155/2015/872152] [PMID: 26494949]
[11]
Fukui H, Saito H, Ueno Y, et al. Evidence-based clinical practice guidelines for liver cirrhosis 2015. J Gastroenterol 2016; 51(7): 629-50.
[http://dx.doi.org/10.1007/s00535-016-1216-y] [PMID: 27246107]
[12]
Weingart SD. EMCrit Podcast 5 – intubating the critical GI bleeder. EMCrit blog. Published on 21 June 2009. Available from: http://emcrit.org/podcasts/intubating-gi-bleeds/ Accessed date: 18 June 2017
[13]
Weingart SD. Preoxygenation, reoxygenation, and delayed sequence intubation in the emergency department. J Emerg Med 2011; 40(6): 661-7.
[http://dx.doi.org/10.1016/j.jemermed.2010.02.014] [PMID: 20378297]
[14]
Leung FW. The venerable nasogastric tube. Gastrointest Endosc 2004; 59(2): 255-60.
[http://dx.doi.org/10.1016/S0016-5107(03)02691-9] [PMID: 14745400]
[15]
Barkun AN, Bardou M, Kuipers EJ, et al. International Consensus Upper Gastrointestinal Bleeding Conference Group. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med 2010; 152(2): 101-13.
[http://dx.doi.org/10.7326/0003-4819-152-2-201001190-00009] [PMID: 20083829]
[16]
Kei J, Mebust DP. Comparing the effectiveness of a novel suction set-up using an adult endotracheal tube connected to a meconium aspirator vs. a traditional yankauer suction instrument. J Emerg Med 2017; 52(4): 433-7.
[http://dx.doi.org/10.1016/j.jemermed.2016.09.006] [PMID: 27751699]
[17]
Lyon RM, Perkins ZB, Chatterjee D, Lockey DJ, Russell MQ. Kent, Surrey & Sussex Air Ambulance Trust. Significant modification of traditional rapid sequence induction improves safety and effectiveness of pre-hospital trauma anaesthesia. Crit Care 2015; 19: 134.
[http://dx.doi.org/10.1186/s13054-015-0872-2] [PMID: 25879683]
[18]
Long B, Koyfman A. The emergency medicine evaluation and management of the patient with cirrhosis. Am J Emerg Med 2018; 36(4): 689-98.
[http://dx.doi.org/10.1016/j.ajem.2017.12.047] [PMID: 29290508]
[19]
Merli M, Nicolini G, Angeloni S, et al. Incidence and natural history of small esophageal varices in cirrhotic patients. J Hepatol 2003; 38(3): 266-72.
[http://dx.doi.org/10.1016/S0168-8278(02)00420-8] [PMID: 12586291]
[20]
Northup PG, Caldwell SH. Coagulation in liver disease: A guide for the clinician. Clin Gastroenterol Hepatol 2013; 11(9): 1064-74.
[http://dx.doi.org/10.1016/j.cgh.2013.02.026] [PMID: 23506859]
[21]
Clevenger B, Mallett SV. Transfusion and coagulation management in liver transplantation. World J Gastroenterol 2014; 20(20): 6146-58.
[http://dx.doi.org/10.3748/wjg.v20.i20.6146] [PMID: 24876736]
[22]
Weeder PD, Porte RJ, Lisman T. Hemostasis in liver disease: implications of new concepts for perioperative management. Transfus Med Rev 2014; 28(3): 107-13.
[http://dx.doi.org/10.1016/j.tmrv.2014.03.002] [PMID: 24721432]
[23]
Tripodi A, Mannucci PM. The coagulopathy of chronic liver disease. N Engl J Med 2011; 365(2): 147-56.
[http://dx.doi.org/10.1056/NEJMra1011170] [PMID: 21751907]
[24]
Ewe K. Bleeding after liver biopsy does not correlate with indices of peripheral coagulation. Dig Dis Sci 1981; 26(5): 388-93.
[http://dx.doi.org/10.1007/BF01313579] [PMID: 7249879]
[25]
Caldwell SH. Management of coagulopathy in liver disease. Gastroenterol Hepatol (N Y) 2014; 10(5): 330-2.
[PMID: 24987319]
[26]
Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med 2013; 368(1): 11-21.
[http://dx.doi.org/10.1056/NEJMoa1211801] [PMID: 23281973]
[27]
Noval-Padillo JA, León-Justel A, Mellado-Miras P, et al. Introduction of fibrinogen in the treatment of hemostatic disorders during orthotopic liver transplantation: Implications in the use of allogenic blood. Transplant Proc 2010; 42(8): 2973-4.
[http://dx.doi.org/10.1016/j.transproceed.2010.08.011] [PMID: 20970586]
[28]
Bennett C, Klingenberg SL, Langholz E, Gluud LL. Tranexamic acid for upper gastrointestinal bleeding. Cochrane Database Syst Rev 2014; (11): CD006640
[PMID: 25414987]
[29]
Hou MC, Lin HC, Liu TT, et al. Antibiotic prophylaxis after endoscopic therapy prevents rebleeding in acute variceal hemorrhage: A randomized trial. Hepatology 2004; 39(3): 746-53.
[http://dx.doi.org/10.1002/hep.20126] [PMID: 14999693]
[30]
Luigiano C, Iabichino G, Judica A, Virgilio C, Peta V, Abenavoli L. Role of endoscopy in management of gastrointestinal complications of portal hypertension. World J Gastrointest Endosc 2015; 7(1): 1-12.
[http://dx.doi.org/10.4253/wjge.v7.i1.1] [PMID: 25610530]
[31]
Wells M, Chande N, Adams P, et al. Meta-analysis: Vasoactive medications for the management of acute variceal bleeds. Aliment Pharmacol Ther 2012; 35(11): 1267-78.
[http://dx.doi.org/10.1111/j.1365-2036.2012.05088.x] [PMID: 22486630]
[32]
Chojkier M, Conn HO. Esophageal tamponade in the treatment of bleeding varices. A decadel progress report. Dig Dis Sci 1980; 25(4): 267-72.
[http://dx.doi.org/10.1007/BF01308516] [PMID: 6967005]
[33]
Monescillo A, Martínez-Lagares F, Ruiz-del-Arbol L, et al. Influence of portal hypertension and its early decompression by TIPS placement on the outcome of variceal bleeding. Hepatology 2004; 40(4): 793-801.
[http://dx.doi.org/10.1002/hep.20386] [PMID: 15382120]
[34]
Kuiper JJ, de Man RA, van Buuren HR. Review article: Management of ascites and associated complications in patients with cirrhosis. Aliment Pharmacol Ther 2007; 26(Suppl. 2): 183-93.
[http://dx.doi.org/10.1111/j.1365-2036.2007.03482.x] [PMID: 18081661]
[35]
Ginés P, Arroyo V, Quintero E, et al. Comparison of paracentesis and diuretics in the treatment of cirrhotics with tense ascites. Results of a randomized study. Gastroenterology 1987; 93(2): 234-41.
[http://dx.doi.org/10.1016/0016-5085(87)91007-9] [PMID: 3297907]
[36]
Bernardi M, Caraceni P, Navickis RJ, Wilkes MM. Albumin infusion in patients undergoing large-volume paracentesis: A meta-analysis of randomized trials. Hepatology 2012; 55(4): 1172-81.
[http://dx.doi.org/10.1002/hep.24786] [PMID: 22095893]
[37]
Garcia-Tsao G. Spontaneous bacterial peritonitis: A historical perspective. J Hepatol 2004; 41(4): 522-7.
[http://dx.doi.org/10.1016/j.jhep.2004.09.001] [PMID: 15464231]
[38]
Kim JJ, Tsukamoto MM, Mathur AK, et al. Delayed paracentesis is associated with increased in-hospital mortality in patients with spontaneous bacterial peritonitis. Am J Gastroenterol 2014; 109(9): 1436-42.
[http://dx.doi.org/10.1038/ajg.2014.212] [PMID: 25091061]
[39]
Hoefs JC, Canawati HN, Sapico FL, Hopkins RR, Weiner J, Montgomerie JZ. Spontaneous bacterial peritonitis. Hepatology 1982; 2(4): 399-407.
[http://dx.doi.org/10.1002/hep.1840020402] [PMID: 7095741]
[40]
Runyon BA, Hoefs JC. Culture-negative neutrocytic ascites: A variant of spontaneous bacterial peritonitis. Hepatology 1984; 4(6): 1209-11.
[http://dx.doi.org/10.1002/hep.1840040619] [PMID: 6500513]
[41]
Téllez-Ávila FI, Chávez-Tapia NC, Franco-Guzmán AM, Uribe M, Vargas-Vorackova F. Rapid diagnosis of spontaneous bacterial peritonitis using leukocyte esterase reagent strips in emergency department: uri-quick clini-10SG® vs. Multistix 10SG®. Ann Hepatol 2012; 11(5): 696-9.
[http://dx.doi.org/10.1016/S1665-2681(19)31445-0] [PMID: 22947532]
[42]
Chavez-Tapia NC, Soares-Weiser K, Brezis M, Leibovici L. Antibiotics for spontaneous bacterial peritonitis in cirrhotic patients. Cochrane Database Syst Rev 2009; (1): CD002232
[http://dx.doi.org/10.1002/14651858.CD002232.pub2] [PMID: 19160207]
[43]
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.
[http://dx.doi.org/10.1056/NEJM199908053410603] [PMID: 10432325]
[44]
Fernández J, Gustot T. Management of bacterial infections in cirrhosis. J Hepatol 2012; 56(Suppl. 1): S1-S12.
[http://dx.doi.org/10.1016/S0168-8278(12)60002-6] [PMID: 22300459]
[45]
Wong F, Bernardi M, Balk R, et al. International Ascites Club. Sepsis in cirrhosis: Report on the 7th meeting of the International Ascites Club. Gut 2005; 54(5): 718-25.
[http://dx.doi.org/10.1136/gut.2004.038679] [PMID: 15831923]
[46]
Tandon P, Garcia-Tsao G. Bacterial infections, sepsis, and multiorgan failure in cirrhosis. Semin Liver Dis 2008; 28(1): 26-42.
[http://dx.doi.org/10.1055/s-2008-1040319] [PMID: 18293275]
[47]
Poordad FF. Review article: The burden of hepatic encephalopathy. Aliment Pharmacol Ther 2007; 25(Suppl. 1): 3-9.
[http://dx.doi.org/10.1111/j.1746-6342.2006.03215.x] [PMID: 17295846]
[48]
Hadjihambi A, Arias N, Sheikh M, Jalan R. Hepatic encephalopathy: A critical current review. Hepatol Int 2018; 12(Suppl. 1): 135-47.
[http://dx.doi.org/10.1007/s12072-017-9812-3] [PMID: 28770516]
[49]
Weissenborn K. Hepatic Encephalopathy: Definition, clinical grading and diagnostic principles. Drugs 2019; 79(Suppl. 1): 5-9.
[http://dx.doi.org/10.1007/s40265-018-1018-z] [PMID: 30706420]
[50]
Vilstrup H, Amodio P, Bajaj J, et al. Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver. Hepatology 2014; 60(2): 715-35.
[http://dx.doi.org/10.1002/hep.27210] [PMID: 25042402]
[51]
Prasad S, Dhiman RK, Duseja A, Chawla YK, Sharma A, Agarwal R. Lactulose improves cognitive functions and health-related quality of life in patients with cirrhosis who have minimal hepatic encephalopathy. Hepatology 2007; 45(3): 549-59.
[http://dx.doi.org/10.1002/hep.21533] [PMID: 17326150]
[52]
Amodio P, Bemeur C, Butterworth R, et al. The nutritional management of hepatic encephalopathy in patients with cirrhosis: International Society for Hepatic Encephalopathy and Nitrogen Metabolism Consensus. Hepatology 2013; 58(1): 325-36.
[http://dx.doi.org/10.1002/hep.26370] [PMID: 23471642]
[53]
Hudson M, Schuchmann M. Long-term management of hepatic encephalopathy with lactulose and/or rifaximin: A review of the evidence. Eur J Gastroenterol Hepatol 2019; 31(4): 434-50.
[http://dx.doi.org/10.1097/MEG.0000000000001311] [PMID: 30444745]
[54]
Montoliu S, Ballesté B, Planas R, et al. Incidence and prognosis of different types of functional renal failure in cirrhotic patients with ascites. Clin Gastroenterol Hepatol 2010; 8(7): 616-22. [quiz: e80].
[http://dx.doi.org/10.1016/j.cgh.2010.03.029] [PMID: 20399905]
[55]
Ginès P, Guevara M, Arroyo V, Rodés J. Hepatorenal syndrome. Lancet 2003; 362(9398): 1819-27.
[http://dx.doi.org/10.1016/S0140-6736(03)14903-3] [PMID: 14654322]
[56]
Wong F. Recent advances in our understanding of hepatorenal syndrome. Nat Rev Gastroenterol Hepatol 2012; 9(7): 382-91.
[http://dx.doi.org/10.1038/nrgastro.2012.96] [PMID: 22614754]
[57]
Arroyo V, Guevara M, Ginès P. Hepatorenal syndrome in cirrhosis: pathogenesis and treatment. Gastroenterology 2002; 122(6): 1658-76.
[http://dx.doi.org/10.1053/gast.2002.33575] [PMID: 12016430]
[58]
Arroyo V, Ginès P, Gerbes AL, et al. Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis. International Ascites Club. Hepatology 1996; 23(1): 164-76.
[http://dx.doi.org/10.1002/hep.510230122] [PMID: 8550036]
[59]
Velez JC, Nietert PJ. Therapeutic response to vasoconstrictors in hepatorenal syndrome parallels increase in mean arterial pressure: a pooled analysis of clinical trials. Am J Kidney Dis 2011; 58(6): 928-38.
[http://dx.doi.org/10.1053/j.ajkd.2011.07.017] [PMID: 21962618]

Rights & Permissions Print Cite
© 2024 Bentham Science Publishers | Privacy Policy