Midtown Morning Report: What are the differences between primary biliary cholangitis and primary sclerosing cholangitis?

The Bottom Line:  “PBC, formerly known as primary biliary cirrhosis, is a chronic inflammatory autoimmune cholestatic liver disease characterized by the destruction of small intrahepatic bile ducts, leading to fibrosis and eventually cirrhosis and its complications.”
“PSC is a chronic cholestatic liver disease in which inflammation and fibrosis lead to multifocal biliary strictures and progression to end-stage liver disease. Intra- and extrahepatic bile ducts are primarily affected. The close association with inflammatory bowel diseases (IBDs) is a hallmark of the condition, affecting about two-thirds of the patients.” (Sarcognato)

Sarcognato

EUH Morning Report: What are the causes of decompensated liver failure?

The Bottom Line: “The occurrence of more than one causative factor in a single patient can lead to more rapid progression to cirrhosis. Aetiology might also influence the comorbidities associated with cirrhosis.”
“Cirrhosis develops after a long period of inflammation that results in replacement of the healthy liver parenchyma with fibrotic tissue and regenerative nodules, leading to portal hypertension. The disease evolves from an asymptomatic phase (compensated cirrhosis) to a symptomatic phase (decompensated cirrhosis), the complications of which often result in hospitalisation, impaired quality of life, and high mortality.” (Gines)

EUH Morning Report: What is the pathophysiology of Hepatic Hydrothorax?

The Bottom Line: “Pathophysiology of hepatic hydrothorax is mainly related to the direct passage of fluid from the peritoneal cavity through diaphragmatic defects.  The most supported mechanism of HH formation is the direct passage of fluid from the peritoneal to the pleural cavity through diaphragmatic defects. The presence of these defects was confirmed by various modalities including direct visualization during surgery, color doppler ultrasonography, MRI, SPECT-CT, scintigraphy, and dye infusion in the peritoneal cavity. These defects were classified as blebs, fenestrations, and large defects.” (Chaaban)

Chaaban

EUH Morning Report: What is the role of ammonia levels in the diagnosis and assessment of hepatic encephalopathy?

The Bottom Line: “The attraction of the ammonia theory to explain hepatic encephalopathy continues to lead physicians to check and follow blood ammonia levels in patients with chronic liver disease and suspected HE. However, ammonia measurement, as in the clinical vignette, should be replaced by a thorough clinical evaluation to rule out other causes for altered mental status. Serial exams of the patient should guide management, not ammonia levels.” (Ninan)

Ninan

EUH Morning Report: What is the benefit of early paracentesis for cirrhotic patients with ascites?

The Bottom Line:” Early paracentesis is associated with reduced inpatient mortality, SBP-related mortality, and 30-day readmission. Given its impact on outcomes, early paracentesis should be a new quality metric. Further education and interventions are needed to improve both adherence and outcomes.” (Rosenblatt)

Rosenblatt

Midtown Morning Report: Is there a role for correcting INR (international normalized ratio) in bleeding cirrohosis patients?

The Bottom Line: “Despite the commonly accepted dogma that an elevated INR in a cirrhotic patient corresponds with an increased hemorrhagic risk during the performance of invasive procedures, the literature does not support this belief.” (Harrison)

• “Hemostasis in cirrhotic patients is a dynamic balance.”
• “In the majority of clinical scenarios, patients with cirrhosis and impaired protein synthesis achieve hemostasis despite elevated INR values and may be more prone to thrombotic or thromboembolic events.”
• “The best application of INR to a patient with liver disease is to monitor the degree of impairment of synthetic function or to predict mortality.” (Harrison)

Midtown Morning Report: What is the risk of secondary bacterial peritonitis from peritoneal dialysis?

The Bottom Line: “Secondary bacterial peritonitis is not  common and typically arises secondary to a perforated viscus or inflammation/abscess of an intra-abdominal organ. Presentation is less than 5% of cirrhotic patients with intra-abdominal infection. Patients with indwelling abdominal devices such as catheters for dialysis should be considered at risk“ (Kuftinec)

EUH Morning Report: What are best practices for albumin infusions for paracentesis?

The Bottom Line: To avoid hemodynamic changes associated with large-volume paracentesis (Volume >5 L), infuse albumin 6-8 g/L ascitic fluid removed. (DynaMed)

“Although there are no studies on the modalities of albumin administration, it seems advisable to infuse HA relatively slowly to avoid possible cardiac overload due to the existence of a latent cirrhotic cardiomyopathy, starting during the presumed final part of the paracentesis or at the end of paracentesis when the volume of ascites removed is known and the paracentesis-induced increase in cardiac output begins to return to baseline.” (AISF-SIMTI, p. 13)

EUH Morning Report: What are the management strategies for decompensated cirrhosis?

The Bottom Line: “[T]he overall management of decompensated cirrhosis can be addressed using two approaches. The first approach is the suppression of the etiological factor(s) that has caused liver inflammation and cirrhosis development, whereas the second approach is based on targeting key factors of pathogenesis of cirrhosis decompensation and progression.” (EASL, 2018, pgs. 407-408)

NEJM Journal Watch: Early Paracentesis for Cirrhotic Patients with Ascites: A Missed Opportunity

John P. Haydek, MD and Daniel D. Dressler, MD, MSc, SFHM, FACP reviewing: Rosenblatt R, Tafesh Z, Shen N, et al. Early Paracentesis in High-Risk Hospitalized Patients: Time for a New Quality Indicator. Am J Gastroenterol. 2019 Dec;114(12): 1863-1869.

Paracentesis within 1 day of hospital admission is associated with lower inpatient mortality and fewer readmissions.