Hospitals are going to be awash in liver disease for many years to come, hepatologist William Sanchez, MD, told attendees at the Mayo Clinic Hospital Medicine course held in Scottsdale, Ariz., in October.
“There are lots of new drugs for hepatitis C, but that's not going to stop the big tidal wave of patients who already have hepatitis C and are becoming cirrhotic. Behind that…is an even bigger tidal wave of NASH [nonalcoholic steatohepatitis] due to the obesity epidemic. And no one even knows when that is going to crest,” said Dr. Sanchez, who is an assistant professor of medicine at the Mayo Clinic in Rochester, Minn.
Given the prevalence of liver disease, hospitalists need expertise in managing the most common causes and complications of it. Dr. Sanchez gave them a few tips.
Alcohol is a well-known cause of liver disease, of course, but patients who present with it will not always reveal an obvious history of alcoholism. “Remember that for women the threshold for alcohol-related liver injury is 1 drink per day or greater. For men, the threshold is higher—3 drinks,” said Dr. Sanchez.
The definition of a drink is also smaller than what many patients pour for themselves. “You have to be nonjudgmental but you have to quantify: ‘How long does it take you to get through a bottle? If you were out at a restaurant, would this be a single or a double?’” he said.
Another challenge of diagnosis is distinguishing the disease from infectious causes of illness. “The inflammatory state of alcoholic hepatitis looks like sepsis. You have to dig hard and look for the infection and make sure it's not there,” said Dr. Sanchez.
Patients may often have both alcohol-related disease and infection. “The main way that these patients exit the world is that they develop sepsis,” he said. Malnutrition is often an issue, too. “Patients with alcoholic hepatitis are very, very often malnourished, because they're drinking their calories….You need to give them nutrients,” said Dr. Sanchez. Corticosteroids and pentoxifylline are also commonly used treatments, he noted.
If patients don't succumb to infection or malnutrition, the good news is that their conditions will usually improve if they abstain from alcohol. Hospitalists should do what they can to help with that. “Patients who have alcoholic hepatitis have life-threatening disease from alcohol. If you don't get them connected to mental health care, you're doing them a disservice because they're going to relapse and they're going to die,” said Dr. Sanchez.
Whether their disease is due to alcohol or another cause, liver patients often visit the hospital due to varices. “Varices are common. Varices can happen anywhere, but the place we worry about the most is the esophagus, which is the most common place to get them,” said Dr. Sanchez.
About half of patients with cirrhosis will have varices, and patients with more advanced liver disease are even more likely to have them. “The important thing to remember is that once people bleed from varices, their mortality rate is very high,” he said.
Patients admitted with bleeding from their varices generally need intensive care, Dr. Sanchez advised. “All patients with variceal hemorrhage are unstable hemodynamically. If they're not, wait and they will be,” he said.
After patients with esophageal variceal hemorrhage are stabilized on supportive care, they are generally treated with endoscopic intervention, often band ligation. Gastric varices are more difficult to treat. “They account for probably about 10% to 15% of variceal hemorrhage, so less common. If patients have gastric varices, the odds that we have a good tool to use endoscopically are low,” said Dr. Sanchez.
Some experts use glue injections off-label to treat gastric varices (it's the standard of care in Europe), but the most common treatment is transjugular intrahepatic portosystemic shunt (TIPS). TIPS is a solution to the portal hypertension that cirrhosis causes. “It creates a low-pressure shunt between a branch of the portal vein and a branch of the hepatic vein,” explained Dr. Sanchez. “You're taking all this blood and basically rerouting it around the liver.”
The upside of TIPS is that it reduces the pressure that causes varices to form and bleed. The downside is encephalopathy. “The biggest problem with TIPS is that they give people a lot of encephalopathy because this blood is not being filtered by the liver. All those noxious chemicals, like ammonia, are going right into the circulation,” Dr. Sanchez said.
When the alternative is uncontrollable bleeding from varices, the procedure can be worthwhile. “At the end of the day, I think TIPS is for refractory bleeding,” he said.
The most frequent complication of liver disease is ascites. “In a given 5-year period, about a third of cirrhotics will develop ascites,” said Dr. Sanchez. “The median survival of a patient with ascites is 50% at 1 year. It's worse than most cancers.”
Patients may come to the hospital because their ascites is causing bothersome symptoms, including abdominal pain, anorexia, and shortness of breath. Those are enough reason to treat, but the real concern is spontaneous bacterial peritonitis (SBP).
“If any cirrhotic patient with ascites is in the hospital, odds are SBP is in your differential diagnosis,” said Dr. Sanchez. “Patients that have ascites and develop SBP have a 1 in 5 chance of not surviving that hospitalization, and the recurrence rate is about 70% in a year.”
In addition to being deadly, SBP is easy to miss. “The symptoms are nonspecific or absent. Often, [patients] get a little bit more encephalopathy or their creatinine bumps a little bit….The only way to make the diagnosis is you have to tap the patient,” he said. “You should never not do the paracentesis.” If the tap shows a polymorphonuclear cell count greater than 250/µL, that's SBP.
Paracentesis is also useful in treatment of ascites, whether or not the patient has SBP. “Large-volume paracentesis is needed for lots of patients. It's safe to do often if these patients are distressed about their fluid. If you're taking off lots of volume, more than 5 liters, you should give them albumin back, because it prevents renal dysfunction,” said Dr. Sanchez.
Patients with SBP should be given antibiotics aimed at enteric gram-negative rods, intravenous albumin, and long-term antibiotic therapy to prevent a recurrence. The long-term risk is another reason that “you have to tap the patient,” as Dr. Sanchez repeatedly reminded his audience.
“People say, ‘Why don't we just give them antibiotics?’ If we treat this with antibiotics, we don't know that they have it again in a year,” he said.
Ascites often comes back, too, but that's not necessarily a reason to refer patients for TIPS. “Trading ascites for encephalopathy—not a great deal,” said Dr. Sanchez. “I get lots of patients referred for TIPS who really need to spend an hour with a dietitian learning about sodium restriction….Patients with TIPS have better ascites control, but the quality of life is not any better.”
During hospitalization for ascites, sodium restriction, along with diuretic therapy (a combination of spironolactone and furosemide), is the standard treatment. And don't forget paracentesis, Dr. Sanchez concluded, joking that he has a simple list of indications for diagnostic paracentesis: “New ascites, needs to be tapped. Old ascites, also needs to be tapped.”