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?

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College Answer

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.

Discussion

Severe hepatic encephalopathy in ICU seems to actually have a slightly better outcome than other sorts of organ system failures.

  • The mortality at 1 year is about 54% according to one small study.
  • Those patients who require nothing other than mechanical ventilation (i.e. ones who got intubated for low GCS and airway protection) tend to have better outcomes.
  • The ones which have ascites, varices (which bleed) as well as sepsis - their 1-year mortalty tends to be as high as 60%.
  • In spite of these grim numbers, the admission of cirrhosis patients to ICU is no longer viewed as a completely futile exercise, because there has been a gradual expansion of the treatment options available to them, and because their outcomes have improved with time.

Several things can be added, with regard to prognostication in chronic liver disease patients admitted to ICU:

  • Childs-Pugh at admission is associated with survival at 12 months (Warren et al, 2015). Specifically:
    • Class A = 100% survival at 12 months
    • Class B = 50% survival at 12 months
    • Class C = 25% survival at 12 months
  • The MELD score gives a 3- month  mortality prediction in patients awaiting a liver transplant:
    • 40 or more — 71.3% mortality
    • 30–39 — 52.6% mortality
    • 20–29 — 19.6% mortality
    • 10–19 — 6.0% mortality
    • <9 — 1.9% mortality
  • In ICU, the liver scores have little influence because many other organ systems play are role in death or survival. Well-rounded models (SOFA, APACHE) are better at predicting ICU outcomes than liver-specific scoring systems (Levesque et al, 2012)

References

References

Fichet, Jérôme, et al. "Prognosis and 1-year mortality of intensive care unit patients with severe hepatic encephalopathy." Journal of critical care 24.3 (2009): 364-370.

 

García-Martínez, Rita, Macarena Simón-Talero, and Juan Córdoba. "Prognostic assessment in patients with hepatic encephalopathy." Disease markers 31.3 (2011): 171-179.

 

Wendon, Julia, et al. "Critical care and cirrhosis: outcome and benefit." Current opinion in critical care 17.5 (2011): 533-537.

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Wendon, Julia, et al. "Critical care and cirrhosis: outcome and benefit." Current opinion in critical care 17.5 (2011): 533-537.

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Peng, Ying, Xingshun Qi, and Xiaozhong Guo. "Child–Pugh Versus MELD Score for the Assessment of Prognosis in Liver Cirrhosis: A Systematic Review and Meta-Analysis of Observational Studies." Medicine 95.8 (2016).