1) Alcohol-related liver disease (ARLD) places a significant burden on healthcare systems. Patients with ARLD often have multiple hospital admissions before death from liver failure or complications.
2) Early identification of alcohol misuse and intervention can help reduce further liver damage if patients change their drinking behavior. However, screening and treatment of ARLD remains suboptimal in many hospitals.
3) Prognosis in ARLD depends on severity of liver disease and presence of complications. Scores like MELD and CLIF-SOFA can help predict outcomes but assessment of social factors is also important.
Alcoholic liver disease is a result of over-consuming alcohol that damages the liver, leading to a buildup of fats, inflammation, and scarring. It can be fatal.
Alcoholic liver disease (ALD) encompasses a spectrum of injury, ranging from simple steatosis to frank cirrhosis and is the oldest form of liver injury known to mankind. The pathophysiology of ALD is quite complex: encompassing factors related to genetics, gender, ethnicity, consumption patterns and co-morbid conditions. The diagnosis of ALD is based on a combination of features, including history of ‘significant’ alcohol intake, clinical evidence of liver disease, and supporting laboratory abnormalities such as Alanine aminotransferase (ALAT), Aspartate aminotransferase (ASAT), Hepatic imaging, Full blood count and liver biopsy. Treatment and management of alcoholic liver disease are abstinence from alcohol, Liver Transplantation and Therapy for Alcoholic Hepatitis which includes Nutrition Therapy, and Steroids.
Alcoholic liver disease is a result of over-consuming alcohol that damages the liver, leading to a buildup of fats, inflammation, and scarring. It can be fatal.
Alcoholic liver disease (ALD) encompasses a spectrum of injury, ranging from simple steatosis to frank cirrhosis and is the oldest form of liver injury known to mankind. The pathophysiology of ALD is quite complex: encompassing factors related to genetics, gender, ethnicity, consumption patterns and co-morbid conditions. The diagnosis of ALD is based on a combination of features, including history of ‘significant’ alcohol intake, clinical evidence of liver disease, and supporting laboratory abnormalities such as Alanine aminotransferase (ALAT), Aspartate aminotransferase (ASAT), Hepatic imaging, Full blood count and liver biopsy. Treatment and management of alcoholic liver disease are abstinence from alcohol, Liver Transplantation and Therapy for Alcoholic Hepatitis which includes Nutrition Therapy, and Steroids.
this presentation consists of information about alcoholic liver disease like introduction, risk factors, treatments, and many other things.
so stay tuned
Alcoholic liver disease a brief insight- by Rxvichu! :)RxVichuZ
Hello my friends and peer readers.............................
With utmost humility and bliss, I present to you my 25th POWERPOINT PRESENTATION...published in GOOGLE SLIDESHARE..............................:) :)
Thanks to all readers and critics worldwide...for ur constant support................:)
Presenting infront of you all....my ppt on ALCOHOLIC LIVER DISEASE................
It contains precise information on the disease involved under ALD...Mainly CIRRHOSIS and STEATOSIS has been stressed upon.
Do go through the slides, and keep sharing your reviews and ideas....for better enhancement of my future works in the same......................
Keep reading well........
Always remember, that its more worthwhile to WORK SMART, than to WORK HARD!
Thank you!
Vishnu.R.Nair,
5th year pharm.D,
National College of Pharmacy,
Kerala University of Health Sciences(KUHS), Kerala, India.
:) :)
David Anderson gives an entertaining and informative talk about Acute Liver Failure at BCC4. He covers thinking about diagnosis, management and prognosis of acute liver failure. The podcast for this presentation is found at www.intensivecarenetwork.com
Dr Sachin Gupta an intensivist at Peninsula Health presents on the difficulties we currently face in predicting bleeding and how this might change in the future.
this presentation consists of information about alcoholic liver disease like introduction, risk factors, treatments, and many other things.
so stay tuned
Alcoholic liver disease a brief insight- by Rxvichu! :)RxVichuZ
Hello my friends and peer readers.............................
With utmost humility and bliss, I present to you my 25th POWERPOINT PRESENTATION...published in GOOGLE SLIDESHARE..............................:) :)
Thanks to all readers and critics worldwide...for ur constant support................:)
Presenting infront of you all....my ppt on ALCOHOLIC LIVER DISEASE................
It contains precise information on the disease involved under ALD...Mainly CIRRHOSIS and STEATOSIS has been stressed upon.
Do go through the slides, and keep sharing your reviews and ideas....for better enhancement of my future works in the same......................
Keep reading well........
Always remember, that its more worthwhile to WORK SMART, than to WORK HARD!
Thank you!
Vishnu.R.Nair,
5th year pharm.D,
National College of Pharmacy,
Kerala University of Health Sciences(KUHS), Kerala, India.
:) :)
David Anderson gives an entertaining and informative talk about Acute Liver Failure at BCC4. He covers thinking about diagnosis, management and prognosis of acute liver failure. The podcast for this presentation is found at www.intensivecarenetwork.com
Dr Sachin Gupta an intensivist at Peninsula Health presents on the difficulties we currently face in predicting bleeding and how this might change in the future.
Clive Woolfe, Irishman and RPA Intensivist, speaks at Bedside Critical Care Conference. In this podcast, he gives an overview of the prognostication and management of chronic liver disease. See www.intensivecarenetwork.com for the podcast.
Claire Cattigan is an Intensivist and Deputy Director of ICU at The University Hospital Geelong. She is interested in the management of paediatric patients in mixed ICUs and gives a fascinating talk on the challenges and rewards of introducing paediatric patient care into a general, adult intensive care unit.
This presentation includes basic important facts about cirrhosis in clinical point of view.This might helpful in clinical management of patient suspecting cirrhosis.
BCC4: Sarah Wesley- To Thin or Not To Thin (The heart and anticoagulation)SMACC Conference
To thin or not to thin? That is a great question which Wesley helps answer with her talk on the heart and anticoagulation. This podcast was recorded at BCC4. Full posts can be found at intensivecarenetwork.com
Medical considerations in dental treatment of patients with liver disease. Main types of liver disease, clinical manifestations, lab tests, treatment considerations.
A limited presentation about a) age related renal functional changes b) management of CKD, including advance care planning and transplantation referral c) management of potentially risky drugs in the elderly with CKD (NOACs)
Geriatric Nephrology (changes in renal physiology, Chronic Kidney Disease, Advanced Care Planning for the elderly patients with CKD, pharmacotherapy of common medical problems in the older individual with chronic kidney disease)
This is a lecture note for 5th semester MBBS students. Lecture notes on hepatology, liver disease, alcoholic liver disease, alcohol-related liver disease, alcoholic hepatitis, portal hypertension, ascites. Introduction to ascites and management of ascites.
Mr. AMF 62 years presented with central chest pain on exertion for last 4 monthsHypertension(BP-220/120 mmHg) for last 4 years, taking 4 anti hypertensives.Diabetes for last 5 years (HbA1c-9.3%).Smoking for 8 years.Dyslipedemic for 3 years. H/o 5 times hospital admissions due to heart failure in last 3 years.ECG-Anterior wall ischemiaEF-58%During careful clinical exam- renal bruit on left side.Coronary angiogram done and revealed DVD. Renal angiogram showed significant left renal artery stenosis. Coronary angioplasty and left renal artery angioplasty done.
Mr AMF now have no chest pain on exertion after 3 months of coronary angioplasty.
Now BP is controlled (130/85 mm Hg), taking B blockers and ARB due to intolerance of ACE inhibitors.
No hospital admission during this period.
Diabetes and serum lipids are controlled.
Controverse in terapia cu statine in hepatopatiile cronice difuzeALEXANDRU ANDRITOIU
sunt prezentate rezultate din studii si cazuri clinice particulare, exemplificand-se dislipidemia din diverse afectiuni hepatice difuze si rolul terapiei cu statine, intre riscuri si beneficii la acesti pacienti
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
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Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdf
Hazeldine on Alcoholic Liver Disease
1. ALCOHOL IN THE ICU:
A HEPATOLOGISTS VIEW OF ALCOHOL-
RELATED LIVER DISEASE (ARLD)
Dr Simon Hazeldine
Gastroenterologist and Hepatologist
Fiona Stanley Hospital
December 2015
3. The burden of alcohol
• 3.8% global mortality
• 4.6% disability-adjusted life-years (DALYS) lost due to
premature death.
• Australian alcohol consumption
8. Main points from NCEPOD
• 71% patients that died due to ArLD had an admission to
hospital within the 2 years prior to their death and 46%
within 3-months!
• Patients outcomes were considerably better if cared for by
a specialist.
• Simple things were missed.
• Lack of escalation to higher levels of care and referral to
specialists.
• Missed opportunities for the alcohol services to intervene.
9. NCEPOD recommendations
• ALL patients presenting to hospital should be screened for
alcohol misuse.
• ALL patients presenting to acute services with a hx of
harmful drinking should be referred to alcohol services
• EACH hospital should have a 7-day alcohol specialist
nurse service, psych liaison and brief interventions /
access to services within 24 hours.
• Integrated Alcohol Care Team
• ALL patients with decompensated liver disease should be
seen by a specialist within 72 hours.
• Close liaison between medical and critical care teams
10. FSH alcohol in the ICU audit
• Over a 3-month period those patients ‘at risk’ of alcohol
excess including: liver related illnesses, pancreatitis,
seizures, overdoses, GI bleed etc.
• 20% had an admission within the last 3 months and 41%
within the last 2 years.
• Only 80% patients had an alcohol history at all during the
entire admission.
• Of those patients that were documented to drink alcohol
to excess only 12% were referred to the alcohol services.
11. ICU perspective: What do you want to
know about a patient with ArLD?
• Name, age etc
• Stage of liver disease and complications
• Indication for admission to ICU
• Comorbidities
• Detailed alcohol history
• Likelihood of abstinence
• Prognosis
• Are they on the liver transplant list?
12. • Threshold can be as low
as 25g ethanol / day
• Binge drinking –
M ≥5 SD in 2 hours
F ≥4 SD in 2 hours
• Consuming 60g alcohol / day
13. An approach to ArLD
•Bleeding
•Renal impairment and electrolyte abnormalities
•Ascites
•Infection
•Nutrition and Neoplasm
•Encephalopathy
•Social issues
14. An approach to ArLD
•Bleeding
•Renal impairment and electrolyte abnormalities
•Ascites
•Infection
•Nutrition and Neoplasm
•Encephalopathy
•Social issues
15. Comorbidities
• Cardiomyopathy
• Mental illness and poly-drug use / addiction
• Pancreatic insufficiency
• Diabetes
• Malnutrition
• Ischaemic heart disease
• Malignancy
• Central and peripheral neuropathy
• Myopathy
16. Detailed alcohol history: why is this
important?
• Screening tools used are the AUDIT-C, CAGE or ASSIST screening
tool.
• Identify those at risk of
• Complications of liver disease
• Alcohol withdrawal
• Referral to the liver service
• Opportunity to intervene and change drinking behaviour through
referral to alcohol services
• Early identification and intervention in the setting of hazardous
drinking is successful and cost effective in reducing consumption in
primary care (1) and ED (2).
• Up to 65% of patients with early liver disease stopped drinking at
harmful levels simply as a result of being informed of the diagnosis (1)
1. Kaner et al. The Cochrane library. Apr 2007
2. Gornal J. Alcohol and Public health. Under the influence. BMJ 2014
17. A common first presentation - Alcoholic
hepatitis
• Clinical syndrome
• Recent onset of jaundice +/- decompensation in patients with
recent alcohol misuse +/- tender liver +/- systemic inflammatory
response syndrome
• Lab results
• AST & ALT 1-6 ULN, high Bil & INR, low Alb, moderate CRP (20-
40)
19. Alcoholic Hepatitis - Treatment
• Corticosteroids
• Meta-anaylsis in 2011 showed that in severe ASH, corticosteroids
improve survival when compared to placebo (28 day mortality 20%
vs 34%) (1). Can be used in patients with infection if controlled
beforehand.
• Pentoxifylline
• evidence is dwindling
• N-acetylcysteine –
• only improves 1m survival in combination with steroids. Rarely
used (2).
• 1. Mathurin et al Gut 2011
• 2 E Nguyen-Khac et al. NEJM 20
20. Steroids Or Pentoxifylline for Alcoholic
Hepatitis (STOPAH) trial
• Group A : placebo / placebo Group B : placebo /
prednisolone Group C : pentoxifylline / placebo Group D
: pentoxifylline / prednisolone
• Primary end-point = death at day 28
• Secondary end-point = death or liver transplant at day 90
and 1 year
• Prednisolone 40mg od and or pentoxifylline 400mg tds for
1 month
Stopah trial. NEJM. 2015
21. STOPAH trial- Results
• Over 3 years, 5234 patients were screened and 1103
patients underwent randomisation.
• 1053 were available for the primary end-point.
• All patients were followed for 12 months or until death.
• The 4 groups were well matched in regards to their
baseline characteristics and lab results.
22. STOPAH - Results
Died % Lost to f/u % Withdrawn %
28 days 16 1 2
90 days 29 5 3
1 year 56 (died / liver
transplant)
8 4
27. STOPAH – Main points
• The use of steroids did not significantly reduce mortality at
28 days (although there was a trend) and made no
difference at 90 days and 1 year
• In secondary analysis – adjustments made for baseline
determinants of prognosis did reveal a significant
improvement in prognosis with steroids but only short
term (28 days).
• Pentoxifylline added no benefit
• Abstinence (self-reported) rates at 1 year were …………
28. STOPAH – Main points
• The use of steroids did not significantly reduce mortality at
28 days (although there was a trend) and made no
difference at 90 days and 1 year
• In secondary analysis – adjustments made for baseline
determinants of prognosis did reveal a significant
improvement in prognosis with steroids but only short
term (28 days).
• Pentoxifylline added no benefit
• Abstinence (self-reported) rates at 1 year were
37%!
30. Prognostic indicators of ArLD in the ICU
• MELD score: creatinine, bilirubin, INR
• Designed initially to improve organ allocation but is more widely
used.
• Studies have failed to demonstrate that other clinical
manifestations of liver decompensation, such as variceal
haemorrhage, HE, new onset ascites or SBP were independent
predictors of survival over and above the MELD score.
• Predicts 3 month mortality
Score Mortality
40 71.3%
30-39 52.6%
20-29 19.6%
10-19 6.0%
<9 1.9% Kamath PS et al. Hepatology. 2001
Kim WR. N Engl J Med. 2008
31. Prognostic indicators of ArLD in the ICU
• SOFA score: BP/Pressors, plts, bilirubin, GCS, creatinine,
PaO2/FiO2 ratio, mechanical ventilation
• Objective score to organ dysfunction over time, used in
clinical trials
• Not useful in deciding need for admission or predicting
outcome.
Moreno R. Intensive Care Med. 1999
32. Prognostic factors of ArLD
0
10
20
30
40
50
60
70
80
Alc r fatty
liver
disease
Alc r
hepatitis
(no
cirrhosis)
Alc r
cirrhosis
Alc r Hep
and
cirrhosis
% survival at 48 months
% survival at 48 months
• Alc. fatty liver disease – patients died of other causes not liver related
• Alc. r. hepatitis – ascites, ALT, gms of alcohol consumed, continued intake,
clinical disease severity.
• Alc. r. cirrhosis – INR, histology severity score. ?MELD
• Alc. r. hepatitis + cirrhosis – age, gms of alcohol consumed, AST:ALT ratio, histology,
clinical disease severity
Chedid A. Am J Gastro. 1991
33. Prognostic factors in ArLD – cirrhotic
patients
0
10
20
30
40
50
60
70
80
90
% survival at 1 year
% survival at 5 years
Jepsen P. Hepatology. 2010
35. Outcomes of decompensated liver
disease
• 165 consecutive patients were followed after there 1st
episode of decompensation alcohol related cirrhosis
(without HCC) and followed up until death.
• Median survival was 61 months.
Long-term Clinical Course of Decompensated Alcoholic
Cirrhosis: A Prospective Study of 165 Patients.
Alvarez, Marco et al. Journal of Clinical Gastroenterology.
45(10):906-911, 2011.
43. Outcomes of patients with cirrhosis in the
ICU
• Admission to ICU is associated with improved survival
during the first 3 days of deterioration compared to ward
care (1).
1. Truog R et al. Crit Care Med 200
ICU mortality % Hospital
mortality %
Patients without
cirrhosis
Patients with
cirrhosis (2-4)
44. Outcomes of patients with cirrhosis in the
ICU
• Admission to ICU is associated with improved survival
during the first 3 days of deterioration compared to ward
care (1).
1. Truog R et al. Crit Care Med 200
ICU mortality % Hospital
mortality %
Patients without
cirrhosis
20
Patients with
cirrhosis (2-4)
45. Outcomes of patients with cirrhosis in the
ICU
• Admission to ICU is associated with improved survival
during the first 3 days of deterioration compared to ward
care (1).
1. Truog R et al. Crit Care Med 200
ICU mortality % Hospital
mortality %
Patients without
cirrhosis
20 30
Patients with
cirrhosis (2-4)
46. Outcomes of patients with cirrhosis in the
ICU
• Admission to ICU is associated with improved survival
during the first 3 days of deterioration compared to ward
care (1).
1. Truog R et al. Crit Care Med 200
ICU mortality % Hospital
mortality %
Patients without
cirrhosis
20 30
Patients with
cirrhosis
37
(2-4)
47. Outcomes of patients with cirrhosis in the
ICU
• Admission to ICU is associated with improved survival
during the first 3 days of deterioration compared to ward
care (1).
1. Truog R et al. Crit Care Med 2006.
2. Aggarwal A et al. Chest 2001.
3. Olson J et al Hepatology 2011.
4. Harrison et al. Crit Care. 2004.
ICU mortality % Hospital
mortality %
Patients without
cirrhosis
20 30
Patients with
cirrhosis
37 49
(2-4)
48. Outcomes of patients with cirrhosis in the
ICU
• Mortality is closely related to the number of organs
requiring support.
• MELD and SOFA are strongly associated to 28 day and 1
year mortality in a retrospective cohort study (1). This
study also showed that, as in other studies, improvement
in MELD and SOFA scores at 48 hrs after admission to
ICU predicts improved 28 day and 1 year mortality.
• MELD appears to be more accurate in predicting survival
confirming that liver dysfunction is the main factor in
predicting survival (1).
1. Boone M et al. J Critical Care. 2014
49. Fig. 2. Hospital mortality in the 246 patients with
cirrhosis admitted to the ICU and who required
mechanical ventilation according to the degree of Acute
on Chronic Liver Failure (ACLF) at admission as
defined by the CLIF-SOFA score.
Eric Levesque et al. J of Hepatol 2014
Fig. 3. Cumulative one-year survival of the 246
patients with liver cirrhosis admitted to the ICU and
who required mechanical ventilation.
Cirrhotic patients requiring ventilation
50. Outcomes of patients with cirrhosis in the
ICU
• In a study from Kings Hospital, London
• 660 cirrhotic patients admitted to ICU from 2000-2007
• Alcohol 47%, and variceal bleed 37% were the most
common causes for admission
• Invasive ventilation was required in 74% of cases,
vasopressors in 49% and 50% required RRT.
• 50% survived their ICU admission and 34% survived
hospital.
• Patients admitted with variceal bleeding and organ
dysfunction to ICU have a significantly better outcome
than other groups.
Shawcross D. J Hepatol 2012
51. Outcomes of patients with cirrhosis in the
ICU
• This study showed that patients with alcohol-related liver
disease do not have poorer outcomes or higher hospital
costs than those with cirrhosis from other etiologies (1).
• Just as Wildman and colleagues have shown for patients
with chronic obstructive pulmonary disease and asthma
admitted to ICU in the UK (2).
1. Shawcross D. J Hepatol 2012
2. Wildman M. BMJ. 2007
52. Outcomes of ‘alcoholics’ in the ICU
• Some studies show that alcohol dependence is
associated with increased rates of sepsis, organ failure
and hospital mortality amongst ICU patients (1).
• Christensen et al. studied 16,848 patients of whom 1229
(7.3%) were deemed to be alcoholic as determined by
ICD 10 codes, past discharge summaries and drug history
(2).
• They divided this group up into those with and without
complications of their alcoholism!
• Compared the 30 mortality of ‘non-alcoholics’ to
‘alcoholics’
Obrien JM. Crit Care Med 2007
Christensen S. Crit Care. 2012
53. Cumulative mortality curves (percent) for non-alcoholic and alcoholic ICU patients, Aarhus University Hospital Collaboration, 2001-2007.
30-d mortality
%
Adjusted
MRR
3-yr mortality
%
Adjusted
MMR
Non alcoholic
patients
19.7 1.0 40.9 1.0
Alc with
complications
33.6 1.64 64.5 1.67
Alc. Without
complications
15.9 1.04 36.2 1.16
Christensen S. Crit Care. 2012
54. The effects of abstinence
• The most important intervention is abstinence as it is an
important risk factor for disease progression (1).
• Outcomes improve with abstinence
• Histological improvement
• Decreased rates of progression to cirrhosis
• Reduction in portal pressure
• Decreased rates of variceal rebleeding
• Reduction in hospital admissions
• Improved survival
• Abstinence is more likely in those patients that receive
treatment for dependence or alcohol abuse both
pharmacological and psychosocial.
1. Chedid A. Am J Gastro. 1991
55. The effect of abstinence on mortality
Long-term Clinical Course of Decompensated Alcoholic
Cirrhosis: A Prospective Study of 165 Patients.
Alvarez, Marco et al. Journal of Clinical Gastroenterology.
45(10):906-911, 2011.
FIGURE 1 .
Actuarial probability of
survival in relation o abstinence.
56. Rates of abstinence relapse
• After an episode of severe alcoholic hepatitis
37% are abstinent at 1 year (1).
• After first diagnosis of decompensated liver
disease 60% remained abstinent at 10 years (2)
• Post liver transplantation reports vary from 10-
50% of “any use” (3,4). 10% of patients resume
heavy drinking after 1 year (5)
1. STOPAH Trial
2. Alverez. Journal Clinical Gastro. 2011
3. Mackie J et al. Liver transpl. 2001
4. Tome S. et al. J Hepatol. 2002
5. Tang et al Gut 1998
57. A common question from ICU
• Is this patient on the transplant list?
58. Liver Transplantation for ArLD
• Benefit is restricted to patients with advanced
decompensation (Child’s Pugh score 11-15)(1,2)
• 6-month ‘rule’
• Allow some patients to recover obviating the need
• Helps identify subset of patients likely to maintain abstinence after
liver transplant.
1. Poynard, T. et al. J Hepatol 1999
2. Vanlemmens C. et al. Ann Intern Med 2009
59. • Early liver transplantation
• Steroid non-responders
• First liver disease event
• Non response by Lille score ≥0.45 or worsening of liver
function by day 7.
• Patients selected on the basis of:
• absolute consensus of paramedical and medical staff
• no co-morbidities
• social integration
• supportive family members
• psychiatric evaluation and addictive profile
Mathurin NEJM 2011
60. Liver transplant for alcohol related
hepatitis
• By definition the patient is still consuming alcohol
• In the setting of Alc. Hep, if the patient has shown no
improvement by 3 months of medical management,
including abstinence the chance of spontaneous recovery
in patients with ASH and cirrhosis are poor.
• A study has shown an unequivicol improvement of
survival in patients who received early transplant.
Mathurin NEJM 2011
61. 0
25 %
50 %
75 %
100 %
0 50 100 150 180
74.7±9.8%
35±10.7%
p=0.005
Liver Transplantation for Severe Alcoholic Hepatitis
Transplanted
Non-transplanted
Days
Mathurin, NEJM 2011
Liver transplantation for severe alcohol-
related hepatitis
62. Alcohol in the ICU - Conclusion
• The stage of liver disease and likelihood of abstinence are
strong prognostic factors in predicting outcomes.
• Our main role, in patients with alcohol related liver
disease, is to give their liver the chance to recover by
treating the reversible problems and making sure they are
supported to maximise rates of long-term abstinence.
• Prevention is better than cure. Identification of patients
drinking hazardous amounts of alcohol will make the
biggest impact in the mortality figures.