A cirrhotic patient in an internal medicine ward
Authors:
Karel Dvořák 2; Přemysl Falt 3; Pavla Paterová; Štěpán Šembera 1; Michal Šenkyřík 5; Jiří Cyrany 1
Authors‘ workplace:
II. interní gastroenterologická klinika, Lékařská fakulta Univerzity Karlovy a Fakultní nemocnice Hradec Králové
1; Oddělení gastroenterologie a hepatologie, Krajská nemocnice Liberec, a. s.
2; II. interní klinika – gastroenterologická a geriatrická, Lékařská fakulta Univerzity Palackého a Fakultní nemocnice Olomouc
3; Ústav klinické mikrobiologie, Lékařská fakulta Univerzity Karlovy a Fakultní nemocnice Hradec Králové
4; Interní gastroenterologická klinika, Lékařská fakulta Masarykovy univerzity a Fakultní nemocnice Brno
5
Published in:
Vnitř Lék 2022; 68(1): 19-25
Category:
Main Topic
Overview
Liver cirrhosis represents a common condition with substantial mortality. Manifestation and progression of ascites, hepatic encephalopathy or gastrointestinal bleeding are among main reasons for hospital admission. Infections represent another specific area in cirrhotic patients. Timely and correct diagnosis and therapy of these conditions are the mainstay of optimal outcome. Manifestation of complications of liver cirrhosis significantly deteriorates prognosis of the patient. Ascites in portal hypertension develops as a result of sodium and consequently water retention. Therapy comprises of restriction of sodium intake, diuretic therapy with combination of spironolactone and furosemide, alternatively large-volume paracentesis. Hepatic encephalopathy comprises a spectrum of neuropsychiatric abnormalities from subtle changes to overt desorientation and asterixis to hepatic coma. Treatment includes correcting of predisposing conditions, administering of non-absorbable disaccharides or rifaximin. The most common cause of bleeding in a cirrhotic patient is oesophageal bleeding. Therapy is complex including hemodynamic stabilisation, antibiotic prophylaxis, vasoactive and endoscopic treatment. Infections are common causes of decompensation and occurrence of complications of advanced chronic liver disease. Their unfavourable outcome is a result of a complex immune disorder in cirrhotic patients. Specific type of infection in cirrhosis is spontaneous bacterial peritonitis, which has to be always excluded with diagnostic paracentesis. The mainstay of successful therapy of infections is timely and vigorous broad spectrum antibiotic therapy which can significantly improve otherwise unfavourable outcome of these patients.
Keywords:
Cirrhosis – Ascites – bleeding – infection – encephalopathy
Sources
1. Tsochatzis E A, J Bosch, and A K Burroughs. Liver cirrhosis. Lancet, 2014;383(9930):1749- 1761.
2. de Franchis R, and V F Baveno. Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol, 2010;53(4):762-768.
3. European Association for the Study of the Liver. Electronic address, e.e.e. and L. European Association for the Study of the, EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol, 2018;69(2):406-460.
4. Rose C F et al. Hepatic encephalopathy: Novel insights into classification, pathophysiology and therapy. J Hepatol,2020;73(6):1526-1547.
5. Cordoba J et al. Characteristics, risk factors, and mortality of cirrhotic patients hospitalized for hepatic encephalopathy with and without acute‑on‑ chronic liver failure (ACLF). J Hepatol,2014;60(2):275-281.
6. Ge P S, B A Runyon. Treatment of Patients with Cirrhosis. N Engl J Med,2016;375(21): 2104-2105.
7. Gluud L L, H Vilstrup and M Y Morgan. Non‑absorbable disaccharides versus placebo/ no intervention and lactulose versus lactitol for the prevention and treatment of hepatic encephalopathy in people with cirrhosis. Cochrane Database Syst Rev,2016;(5):CD003044.
8. Cannon M D, P Martin and A F Carrion. Bacterial Infection in Patients with Cirrhosis: Don’t Get Bugged to Death. Dig Dis Sci,2020;65(1):31-37.
9. Mattos A A et al. Spontaneous bacterial peritonitis and extraperitoneal infections in patients with cirrhosis. Ann Hepatol,2020;19(5):451-457.
10. Státní ústav pro kontrolu léčiv. Fluorochinolonová antibiotika – omezení používání potvrzeno. Státní ústav pro kontrolu léčiv [online]. Copyright © 2018 [cit. 09. 12. 2021]. Dostupné z: https://www.sukl.cz/fluorochinolonova‑antibiotika‑omezeni‑pouzivani‑potvrzeno
11. European medicines agency. Disabling and potentially permanent side effects lead to suspension or restrictions of quinolone and fluoroquinolon antibiotics. European medicines agency [online]. Copyright © 2019 [cit. 09. 12. 2021]. Dostupné z: https://www.ema.europa. eu/en/documents/referral/quinolone‑fluoroquinolone‑article- 31-referral‑disabling‑potentially‑permanent‑side‑effects‑lead_ en.pdf
12. Bonkat G. EAU guidelines on urological infections. European association of urology [online]. Copyright © 2021 [cit. 09. 12. 2021]. Dostupné z: https://uroweb.org/guideline/ urological‑infections/
13. de Franchis R, Baveno VIF: Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol 2015;63(3):743-752.
14. Karstensen JG, Ebigbo A, Bhat P et al. Endoscopic treatment of variceal upper gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Cascade Guideline. Endosc Int Open 2020;8(7):E990-E997.
15. Fejfar T, Vaňásek T, Brůha R et al. Léčba krvácení v důsledku portální hypertenze při jaterní cirhóze - aktualizace doporučených postupů ČHS ČLS JEP. Gastroenterol Hepatol 2017,71(2):105-116.
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Diabetology Endocrinology Internal medicineArticle was published in
Internal Medicine
2022 Issue 1
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