Complications
Hepatic encephalopathy is a common and serious complication of severe liver damage from alcohol use. Causation is thought to be multi-factorial, resulting in brain exposure to ammonia that has bypassed the liver through portosystemic shunting. It can be diagnosed by the confusion assessment method (CAM), a brief questionnaire that assesses, among other things, attention, memory, organisation, and sleep and wakefulness. Confusion Assessment Method instrument (CAM) Opens in new window [ Cognitive Impairment Screening with 6 Questions Opens in new window ] The earliest stage is 'minimal hepatic encephalopathy', which impairs fitness to drive and can be diagnosed with the computerised inhibitory control test.[157]
Early symptoms include forgetfulness, difficulty in concentrating, and rapid changes in mental state, including agitation or confusion. Bad fruity-smelling breath and tremor may be associated clinical findings. Late-stage presentation of encephalopathy is stupor and eventually coma. Lactulose and rifaximin are used to prevent and to treat this condition in susceptible patients with ARLD.
Liver fibrosis in cirrhosis causes increased resistance to blood flow through the portal vein (portal hypertension). This produces secondary complications such as variceal bleeding, ascites, splenomegaly, and secondary thrombocytopenia. Progression of portal hypertension is not reversible without liver transplantation or prolonged alcohol abstinence.
GI bleeding occurs secondary to the development of gastro-oesophageal varices, haemorrhoids, and portal hypertensive gastropathy or enteropathy, along with the presence of coagulopathy from reduced synthetic function of the liver and the presence of thrombocytopenia secondary to splenomegaly. Patients with cirrhosis and GI bleeding should receive antibiotic prophylaxis to reduce mortality, infections, re-bleeding, and length of hospital stay.[158]
Patients with advanced liver disease should be screened for oesophageal varices and treated with prophylactic non-selective beta-blockers such as propranolol, nadolol, or carvedilol if they have oesophageal varices of 5 mm or more. Prophylactic endoscopic banding can be utilised if oesophageal varices are 5 mm or more and the patient is intolerant to beta-blockers or not deemed suitable for beta-blocker therapy. If oesophageal varices are not found, or if they are <5 mm, then surveillance at 1- to 2-year intervals is indicated until a therapeutic decision is reached.[159]
Restrictive blood transfusion (only when Hb ≤7 g/dL [≤70 g/L] with target of 7-9 g/dL [70-90 g/L]) is preferred over liberal blood transfusion (when Hb is ≤9 g/dL [≤90 g/L] with target of 9-11 g/dL [90-110 g/L]) because liberal blood transfusion increases portal hypertension, while restrictive transfusion decreases re-bleeding rate in all patients with cirrhosis, and decreases mortality in patients with Child-Pugh A and B cirrhosis.[160]
Coagulopathy occurs from reduced synthetic function of coagulation factors in the liver due to cirrhosis.
Renal impairment is a secondary complication from portal hypertension and high renin-angiotensin system activity.
Non-steroidal anti-inflammatory drugs (NSAIDs) may increase the risk for kidney failure.
Hepatorenal syndrome occurs if the kidneys significantly reduce their own blood flow distribution in response to the altered blood flow in the liver, which decreases mean arterial pressure because of extreme vasodilation. Hepatorenal syndrome is a life-threatening complication. It presents as acute kidney failure in the absence of other kidney diseases and is associated with high mortality.
Medical management options also include albumin with terlipressin, norepinephrine (noradrenaline), or midodrine plus octreotide.[161] Surgical procedures such as transjugular intrahepatic portosystemic shunt can be used to bridge until liver transplantation.
Cirrhosis greatly increases the risk for hepatocellular carcinoma (HCC). Serial ultrasound studies of the abdomen are used to screen at-risk patients for HCC. Treatment options such as radiofrequency ablation, transarterial chemo-embolisation (TACE), transarterial microsphere embolisation, immunotherapy, and liver transplantation can be used to treat liver cancer.
Bacterial infections are extremely common in advanced cirrhosis and may increase the risk for bleeding. Patients have higher risk of bacterial infections in ascites fluid and in the urinary, respiratory, and gastrointestinal tracts, from repeated hospital admissions.
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