Transcript Cirrhosis

Inpatient Management of the
Cirrhotic Patient
Things You Will Learn
Background Information:
-What is cirrhosis
- What is compensated versus decompensated cirrhosis
Admission Evaluation:
- If patient has ascites
- If the patient has SBP
- If patient has acute kidney injury
- If patient has hepatic encephalopathy
- If patient has gastrointestinal bleeding
- Pain management
Preoperative Evaluation:
- Risk Factors for morbidity/mortality
- “Status” of the Liver
- Type of Surgery
- Contraindications to Surgery
Hepatocentric View
“In the beginning, there was nothing………
Then God created the liver and gave it
internal viscera and appendages to provide
sustenance and mobility.”
A bit about me…
Things You Will Learn
Background Information:
-What is cirrhosis
- What is compensated versus decompensated cirrhosis
Admission Evaluation:
- If patient has ascites
- If the patient has SBP
- If patient has acute kidney injury
- If patient has hepatic encephalopathy
- If patient has gastrointestinal bleeding
- Pain management
Preoperative Evaluation:
- Risk Factors for morbidity/mortality
- “Status” of the Liver
- Type of Surgery
- Contraindications to Surgery
What is Cirrhosis?

The end stage of any chronic liver disease
 HCV and EtOH are main causes in USA
 Results in two major syndromes
– Portal hypertension
– Hepatic insufficiency

Associated with hyperdynamic circulatory state
due to
– Peripheral vasodilation
– Splanchnic vasodilation
Manifestations of Decompensation
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Jaundice: hepatic insufficiency
GEV: portal HTN and hyperdynamic circulation
Ascites: sinusoidal HTN and sodium retention due
to vasodilation and neurohumoral systems
HRS: peripheral dilation->renal vasoconstriction
HE: shunting through portosystemic collaterals,
brain edema, and hepatic insufficiency
“Status of the Liver”
1964 – Child and Turcotte publish a system to
predict mortality related to portocaval shunt
surgery in cirrhosis*
 1973 – Pugh modified C-T scoring system to
predict mortality related to esophageal surgery for
bleeding varices (replaced ‘nutritional status”
with PT)**
 Child’s score = C-P score = CTP score

*Child, CG, Turcotte, JG. Surgery and portal hypertension. In: The Liver and Portal Hypertension, Child, CG (Ed),
Saunders, Philadelphia 1964. p.50.
**Pugh RNH, Murray-Lyon IM, Dawson JL, Pietroni MC and Williams R. Transection of the esophagus for bleeding
esophageal varices. Brit. J. Surg. 60: 646-654, 1973
Child’s Classification
Points*
Presentation:
1
2
3
Albumin (g/dl)
> 3.5
2.8 - 3.5
< 2.8
Prothrombin
time (INR)
< 1.7
1.7 - 2.3
> 2.3
Bilirubin (mg/dl)
<2
2-3
>3
Ascites
Absent
Mild/Moderate
Severe
(diuretic responsive) (diuretic refractory)
Encephalopathy
None
Gr. I – II
Gr. III – IV
(precipitated)
(chronic)
*Class A = 5-6 points, B = 7-9 points, C = 10-15 points
Interpreting Child’s Score

These grades correlate with one- and two-year
patient survival:
– Class A - 100 and 85 %
– Class B - 80 and 60 %
– Class C - 45 and 35 %

Child’s class A are compensated
– Median survival ~9-12 years
– Management goals:



Treat underlying liver disease
Prevention/early diagnosis of complications
Child’s class B&C are decompensated
Things You Will Learn
Background Information:
-What is cirrhosis
- What is compensated versus decompensated cirrhosis
Admission Evaluation:
- If patient has ascites
- If the patient has SBP
- If patient has renal insufficiency
- If patient has portosystemic encephalopathy
- If patient has gastrointestinal bleeding
- Pain management
Preoperative Evaluation:
- Risk Factors for morbidity/mortality
- “Status” of the Liver
- Type of Surgery
- Contraindications to Surgery
If The Patient Has Ascites

Development of ascites in cirrhosis is common (60%
over 10yrs); once ascites develops mortality can
reach 50% over the next 2yrs.
 Ascites formation is very common in postoperative
setting in patients with cirrhosis/portal HTN due to
liberal use of saline IVF (this can often be the initial
presentation of cirrhosis - - missed pre-op!)
If The Patient Has Ascites

Clues:
– Exam: palpable left/small right lobe,
splenomegaly, caput medusa
– Labs:
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Platelets < 175,000
Hepatic insufficiency: albumin <3.8, INR >1.3
– Imaging: nodular liver, splenomegaly
If The Patient Has Ascites

Diagnostic paracentesis:
– No coagulopathy cutoff, need for “reversal”, etc
– Cell count and differential, albumin, and total protein
– If first presentation, concern over infection, or atypical
presentation
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Glucose
Bedside culture
Flow cytometry
Simultaneous blood cultures (more later)
LDH
Triglycerides
– Don’t forget serum albumin to determine SAAG
If The Patient Has Ascites
-
-
Make the diagnosis (i.e. recognize it, then analyze the
fluid - - diagnostic paracentesis)
Turn off the NS IV infusion! Think about carrier
solutions for each of the patient’s IV infusions
Sodium restriction: 2gm/day (88mEq)
Oral diuretics: spironolactone alone or
spironolactone/furosemide (100/40 ratio)
Goal: 300-500 ml/d (no edema) vs. 1000 ml/d (w/ edema)
Tense ascites: perform a large volume paracentesis (don’t
forget the albumin - - 6-8 gm per liter ascites removed)
High risk patients with ascites should be placed on SBP
prophylaxis (TP<1 and advanced liver failure)
If The Patient Has Ascites
-
Do NOT use furosemide alone
- Sodium not taken up in LoH absorbed in DCT/CT due
to hyperaldosteronism
-
Do NOT use IV diuretics
No evidence that other diuretics (metolazone,
thiazides, torsemide) offer advantage of
spironolactone +/- furosemide
Things You Will Learn
Background Information:
-What is cirrhosis
- What is compensated versus decompensated cirrhosis
Admission Evaluation:
- If patient has ascites
- If the patient has SBP
- If patient has acute kidney injury
- If patient has hepatic encephalopathy
- If patient has gastrointestinal bleeding
- Pain management
Preoperative Evaluation:
- Risk Factors for morbidity/mortality
- “Status” of the Liver
- Type of Surgery
- Contraindications to Surgery
If The Patient Has SBP
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Most common infection in cirrhosis
Occurs in 10-20% of hospitalized patients with cirrhosis
and ascites
Mortality 10-20% (was 80% when first described)
Early diagnosis is KEY to management and reduction of
complications
Diagnostic paracentesis in any patient with cirrhosis and
ascites:
- Upon hospital admission
- Who develops S/Sx compatible with SBP (abd pain, F/C)
- With worsening renal or liver function
If The Patient Has SBP
-
Diagnosis established:
- Ascites PMN cell count >250
- Ensure bedside cultures collected
- Simultaneous BCx should also be drawn (>50% SBP
also have bacteremia)
- Traumatic tap if >10,000 RBC
-
Subtract 1 PMN for every 250 RBC
If The Patient Has SBP
-
Do not wait on culture results to start Abx
- Cefotaxime most studied (2g q12hr)
- 3rd generation cephalosporine (ceftriaxone 1-2g q12hr)
- “Quinolone” ok if community-acquired, uncomplicated
- Extended spectrum Abx (carbapenems, piperacillin/tazobactam)
if nosocomial SBP
Can change to PO in 48hrs if improving
- 5 day course of Tx minimum, 8 days preferred, thus 7
days reasonable
- Repeat paracentesis/broaden coverage if not improving in
48hrs (expect at least 25% PMN decrease)
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If The Patient Has SBP
-
Albumin to prevent renal dysfunction (10% vs.
3%) and 3 month mortality (41% vs. 22%)
- 1.5g/kg on day #1 within 6 hours of Dx
- 1.0g/kg on day #3 (reasonable to tailor to renal fx)
-
What NOT to do:
- Avoid aminoglycosides
- No large volume paracentesis
- Avoid diuretics (stop them if Pt is taking them)
Cuban Rock Iguana
Cuban Rock Iguana
Cuban Rock Iguana
Things You Will Learn
Background Information:
-What is cirrhosis
- What is compensated versus decompensated cirrhosis
Admission Evaluation:
- If patient has ascites
- If the patient has SBP
- If patient has acute kidney injury
- If patient has hepatic encephalopathy
- If patient has gastrointestinal bleeding
- Pain management
Preoperative Evaluation:
- Risk Factors for morbidity/mortality
- “Status” of the Liver
- Type of Surgery
- Contraindications to Surgery
If The Patient Acute Kidney
Injury (AKI)

AKI occurs in ~19% hospitalized patients with cirrhosis
– Pre-renal ~68% of these
– Intra-renal next most common (ATN vs. GN)
– Post-renal <1%
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Hepatorenal syndrome (HRS) is a form of pre-renal
failure: systemic/splanchnic vasodilation and reduced
EAV->renal vasoconstriction
HRS ~33% of pre-renal AKI (1/5 of cirrhotics hospitalized
with AKI)
Development of HRS-1 median survival ~2wks
Dec. Effective Arterial Pressure
(inc. CO/CI, dec. SVR, splanchnic vasodilation)
Endotoxemia
Nitric Oxide
Carotid/Renal Baroreceptors Sense Dec. Perfusion
Activation of Endogenous Vasoconstrictors
Dec. renal PG’s
synthesis and effect
Non-Osmotic
R.A.A.S
S.N.S
AgII
Dec. PGE2
Aldo
Na+/H2O
Retention
Loss of local
renal vasodilators
ADH
V2 Receptor
Inc. Renal
Vascular Tone
H2O
Retention
Abnml Renal
Hemodynamics
If The Patient Has AKI

Definition of HRS shifting target
– Consensus conferences: Cr double to >2.5
– Suggested that Tx initiated earlier, with only
1.5-fold increase in Cr from baseline

Key to success is the early recognition and
Tx of this condition
If The Patient Has AKI
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D/C medications that decrease blood
volume
– Diuretics
– Lactulose
– Vasodilators

Expand intravascular volume
– Albumin 1g/kg up to max 100g
– NS if over-diuresis is suspected
If The Patient Has AKI

Search for and Tx AKI precipitants
– Infection
– Fluid loss
– Blood loss

If no improvement or continued worsening
– Renal U/S to R/O post-renal AKI
– Urinary sediment to R/O intrinsic AKI
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Proteinuria/hematuria suggests GN
Granular/epithelial casts suggests ATN
– Historical clues such as sepsis, hypovolemia, recent
nephrotoxins, contrast dye help sort out ATN vs. HRS
If The Patient Has AKI

OLT is only definitive Tx that provides long-term
survival
 Arteriolar vasoconstrictors bridge to OLT
– Terlipressin most studied but not available in USA
– Midodrine plus octreotide most common in USA
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Midodrine: start 5-7.5mg PO TID and increase to 12.5-15mg
TID
Octreotide 100mcg SQ TID and increase to 200mcg SQ TID
(continues infusion or used as sole therapy->no benefit)
– Should be coupled with albumin infusions
Things You Will Learn
Background Information:
-What is cirrhosis
- What is compensated versus decompensated cirrhosis
Admission Evaluation:
- If patient has ascites
- If the patient has SBP
- If patient has acute kidney injury
- If patient has hepatic encephalopathy
- If patient has gastrointestinal bleeding
- Pain management
Preoperative Evaluation:
- Risk Factors for morbidity/mortality
- “Status” of the Liver
- Type of Surgery
- Contraindications to Surgery
If The Patient Has Hepatic
Encephalopathy (HE)

HE (or portosystemic encephalopathy: PSE) is a
clinical spectrum of reversible abnormalities in
neuropsychiatric function of patients with advanced
liver disease
 Continuum of neuropsychiatric alteration:
– Episodic (acute): either precipitated or spontaneous
– Recurrent : 2 or more acute episodes per year
– Persistent (chronic): persistent deficits negatively affect
social/occupational function
– Minimal (subclinical): only found with careful testing
If The Patient Has HE
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Precipitating Factors:
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Infection
Recent TIPS placement
Non-compliance
HCC
HV/PV thrombosis
Hypovolemia
GI bleeding
Hypokalemia
Metabolic alkalosis (diarrhea)
Hypoxia
Sedatives
Hypoglycemia
Asterixis
If The Patient Has HE
Grade
Mental Status
Neuro. Findings
0
No alterations
No alterations
1
Trivial lack of awareness,
euphoria or anxiety, short
attention span
Tremor, uncoordinated, poor
handwriting, early asterixis
2
Lethargy, disorientation,
personality changes,
inappropriate behavior
Asterixis, slurred speech, ataxia,
hypoactive reflexes
3
Somnolence to semi stupor,
confusion, response to noxious
stimuli
Hyperactive reflexes, Babinski,
clonus
4
Coma, no response to noxious
stimuli
Dilated pupils, coma, decerebrate
posturing (transient)
If The Patient Has HE
Psycodynamic or “Trail test”
If The Patient Has HE
Therapy:
1) Fix/Remove the precipitating factors
2) Lactulose: 30-50ml q2h initially, then TID (goal 3-5
soft BM/d); can use 300ml retention enemas also
3) Antibiotics: rifaximin 200-600mg TID
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4)
5)
6)
No evidence that combo with lactulose is better
Use in patients who can’t tolerate or don’t respond to lactulose
Flumazenil: 0.4-2.0 mg IV (lasts 2-4 hrs only)
Don’t restrict protein (1.0 -1.2 g/kg/day)
If recent TIPS may need reduction/occlusion
Hutia a.k.a “Banana Rat”
“Banana Rat: The Other White
Meat”
Things You Will Learn
Background Information:
-What is cirrhosis
- What is compensated versus decompensated cirrhosis
Admission Evaluation:
- If patient has ascites
- If the patient has SBP
- If patient has acute kidney injury
- If patient has hepatic encephalopathy
- If patient has gastrointestinal bleeding
- Pain management
Preoperative Evaluation:
- Risk Factors for morbidity/mortality
- “Status” of the Liver
- Type of Surgery
- Contraindications to Surgery
Acute Gastrointestinal Bleeding

Liver involved in all 3 systems (coagulation,
fibrinolysis and protein C dep. pathway)
 Nearly all proteins involved in hemostasis are produced
in the liver (exceptions: Factor VIII, vWF,
thrombomodulin)
 Impaired production and clearance effect fibrinolytic
system (dec. clearance t-PA, PAI-1)
 Clinical importance of PLT dysfxn in cirrhosis unclear;
thrombocytopenia is due to splenic sequestration
Acute Gastrointestinal Bleeding

Overall have impaired thrombin generation and less
stable fibrin structure with increased fibrinolysis
(“defective hemostatic plug”)
 Hemostatic disturbances in cirrhosis are similar to
those described for DIC
Acute Variceal Hemorrhage
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Acute variceal hemorrhage mortality 15-20%
Acute Variceal Hemorrhage
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Volume expansion: colloids over crystalloids
– SBP 90-100mm Hg
– HR<100 bpm

Transfusion of blood products to maintain
– Hgb ~8g/dl (higher increases re-bleeding/mortality)
– Platelets ~50,000
– INR to 1.3

Consider prophylactic intubation if massive
bleeding and decreased LOC
Acute Variceal Hemorrhage

Initiate somatostatin analog (octreotide) as soon
as diagnosis suspected
– 50 mcg IV bolus followed by 50 mcg/hr infusion
– Continued for 5 days

Antibiotic prophylaxis for 3-7 days with cipro
vs. ceftriaxone (ascites, PSE, bilirubin >3,
malnutrition)
 Endoscopic evaluation within 12 hours
Acute Variceal Hemorrhage
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Sengstaken Blakemore tube: 2 balloons
Linton tube: large gastric balloon
Control hemorrhage in >80%
Mortality is 20% due to complications
– Aspiration
– Migration
– Perforation
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Re-bleeding after deflation almost universal
Only used in patients in whom shunt planned within 24
hours
 Intubation strongly recommended
Things You Will Learn
Background Information:
-What is cirrhosis
- What is compensated versus decompensated cirrhosis
Admission Evaluation:
- If patient has ascites
- If the patient has SBP
- If patient has acute kidney injury
- If patient has hepatic encephalopathy
- If patient has gastrointestinal bleeding
- Pain management
Preoperative Evaluation:
- Risk Factors for morbidity/mortality
- “Status” of the Liver
- Type of Surgery
- Contraindications to Surgery
Pain Management

Short-acting analgesics (and sedatives) are
always preferred in cirrhotics
 Opiods are metabolized via hepatic
glucuronidation (and oxidation); thus clearance
is impaired (potential for toxic metab. accum.)
 NSAIDs impair renal fxn in cirrhosis, as well as
decreasing natriuresis (effect on ascites therapy)
 NSAIDs increase risk for variceal bleeding (in
addition to standard risk for GI toxicity/PUD)
Pain Management
Recommendations:
1) Do not use NSAIDs (even COX-2’s) !!
2) Fentanyl is the opiod of choice in cirrhosis (long
acting methadone is safe as well)
3) If using morphine, oxycodone or demerol decrease
the dose by 50% and increase dosing interval 2-fold
4) Acetaminophen is the analgesic of choice !
(maximum dose 2 gm/day); but use caution in
cirrhotics who are actively drinking EtOH
5) Don’t forget about analgesic combinations containing
acetaminophen
Things You Will Learn
Background Information:
-What is cirrhosis
- What is compensated versus decompensated cirrhosis
Admission Evaluation:
- If patient has ascites
- If the patient has SBP
- If patient has acute kidney injury
- If patient has hepatic encephalopathy
- If patient has gastrointestinal bleeding
- Pain management
Preoperative Evaluation:
- Risk Factors for morbidity/mortality
- “Status” of the Liver
- Type of Surgery
- Contraindications to Surgery
Preoperative Evaluation:
Risk Factors for M&M in Cirrhotics
Characteristics of the Patient:
- Child’s classification (C>B>A)
- Presence of ascites or encephalopathy
- Presence of jaundice, hypoalbuminemia and/or prolonged PT
(>2.5-3 sec above normal, not correctable w/ Vit. K)
- Presence of portal hypertension
- On-going infection (i.e. SBP, cellulitis)
- Anemia, hypoxemia or malnutrion
Type of Surgery:
- Emergent
- Abdominal (esp. gastrectomy, colectomy, chole)
- Any cardiac surgery
- Hepatic resection
Perioperative Mortality and CPT
1984 – periop. mortality (non-shunt, abd.
surgery); Child’s A = 10%, B = 31%, C = 76%
 1997 – periop. mortality (non-shunt, abd.
surgery); Child’s A = 10%, B = 30%, C = 82%
 2003 – periop. mortality (non-shunt, abd.
surgery); Child’s A = 7.1%, B = 23%, C = 84%
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MELD For Pre-operative Risk Stratification

Retrospective 1980-2004, N=773 (675 MELD<15), ave. age 61
 Primary Endpoint: MELD as a predictor of peri-op mortality in
non-transplant surgery
 Secondary Endpoint: Does the type of surgery matter?
 ’93-’04 vs. ’80-’92 showed a trend toward better outcomes, but
NS overall
 “Other” vs. “Foregut” (hepatobiliary, pancreatic,UGI) surgery
trended to better overall outcomes
 Multivariate Analysis: Age (in increments of 10yr) increased
risk 1.5x (30d) and MELD (increments of 5pts) increased
mortality risk 2.2x (1.9-2.5) at 30days
MELD FOR PRE-OP RISK STRATIFICATION
MELD
<10
11-15
16-20
21-25
7 Day
Mortality
0.8%
6%
8%
15%
30 Day
Mortality
4%
15%
32%
58%
*MELD >25 had >60% mortality at 30d and >80 mortality at 90d
Model for End-Stage Liver Disease (MELD)
Website: www.mayoclinic.org/gi-rst/mayomodel6.html
Types of Surgery
Hepatic resection:
- operative mortality ‘92-’98 = 3-16% (approaching 0% in “centers
of excellence” ’99-’03)
Partial colectomy (open): (typically for diverticulitis)
- periop. mortality for Child’s A = 12.8%, Child’s C = 53%
Laparoscopic Surgery: (’05) – chole,spleen,colon,hernia,RY
- 0% mortality, 16% morbidity; 39/50 pts. Child’s A
Open cholecystectomy (for obstructive jaundice):
- mortality down from 25-28% (’82) to 8% (’97)
Cardiothoracic surgery: (‘04)
- morbidity: Child’s A = 60%, B = 72%, C = 100%
- mortality: Child’s A = 0%, B = 50%, C = 100%
Contraindications to Elective Surgery
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Acute viral hepatitis (especially icteric hepatitis)
Acute alcoholic hepatitis
Fulminant hepatic failure (unless OLT)
Child’s class C cirrhosis/ ? MELD > 20-25
Severe coagulopathy (PT > 3 sec out after Vit. K,
platelet count < 50k) - - relative contraindication
Severe extrahepatic complications:
- Hypoxemia (PaO2 < 50) (consider HPS)
- Cardiomyopathy/CHF
- Acute renal failure (consider HRS)
Summary Algorithm
Navy…it’s more than just a
job…
QUESTIONS ?