A forty-two (42) year old man has been well, apart from a history of alcohol induced liver dysfunction and portal hypertension. He has abstained from alcohol for the past 8 months after being told that it would kill him. After a large haematemesis he presents drowsy, clinically shocked, with a blood pressure of 80 systolic, heart rate of 124 beats/minute, cold and clammy peripheries. He is also clinically jaundiced.
Variceal bleeding is diagnosed and it initially responds to therapy. 48 hours post admission he remains on invasive respiratory support, with weak withdrawal response to pain despite minimal sedation, a persistent coagulopathy, and is inotrope dependent. Serum bilirubin concentration is elevated (100 micromol/L [N 3-20]). He develops a further acute variceal bleed associated with hypotension.
At 6 days there has been no further haematemeses. However he has a Glasgow Coma Score (GCS) of 5, despite no sedation. His serum bilirubin concentration is now 350 micromol/L. Prothrombin time and serum creatinine concentration are twice normal. A CT of the head shows no focal abnormality.
(d) His wife tells you that he had been recently unjustly fired from work and for the week prior to his admission had started to drink heavily again. He had complained of headache for which he would frequently take paracetamol and had been eating poorly. She asks you what are his chances of survival. How do you respond?
Prognosis of hepatic encephalopathy and associated organ dysfunction depends on whether the process is acute or chronic, and whether there are any reversible factors. The very high bilirubin level (350 mcgmol/L), and the fact that this man has rebled from his varices make his prognosis worse, but not unsalvageable. Shunting procedures may decrease his likelihood of further bleeding but are likely to worsen the encephalopathy.
Severe hepatic encephalopathy in ICU seems to actually have a slightly better outcome than other sorts of organ system failures.
Several things can be added, with regard to prognostication in chronic liver disease patients admitted to ICU:
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