Patients with Liver Cirrhosis as Frequent Attenders of Emergency Departments

A Comprehensive Evaluation of Emergency Department Utilization by Patients With Cirrhosis

INTRODUCTION

Emergency department (ED)-based care is required for cirrhosis management, yet the burden of cirrhosis-related ED healthcare utilization is understudied. We aimed to describe ED utilization within a statewide health system and compare the outcomes of high ED use (HEDU) vs non-HEDU in individuals with cirrhosis.

METHODS

We retrospectively reviewed charts of adults with cirrhosis who presented to any of 16 EDs within the Indiana University Health system in 2021. Patient characteristics, features of the initial ED visit, subsequent 90-day healthcare use, and 360-day outcomes were collected. Multivariable logistic regression models were used to identify predictors HEDU status which was defined as ≥2 ED visits within 90 days after the index ED visit.

RESULTS

There were 2,124 eligible patients (mean age 61.3 years, 53% male, and 91% White). Major etiologies of cirrhosis were alcohol (38%), metabolic dysfunction-associated steatohepatitis (27%), and viral hepatitis (21%). Cirrhosis was newly diagnosed in the ED visit for 18.4%. Most common reasons for ED visits were abdominal pain (21%), shortness of breath (19%), and ascites/volume overload (16%). Of the initial ED visits, 20% (n = 424) were potentially avoidable. The overall 90-day mortality was 16%. Within 90 days, there were 366 HEDU (20%). Notable variables independently associated with HEDU were model for end-stage liver disease-sodium (adjusted odds ratio [aOR] 1.044, 95% confidence interval [CI] 1.005-1.085), prior ED encounter (aOR 1.520, 95% CI 1.136-2.034), and avoidable initial ED visit (aOR 1.938, 95% CI 1.014-3.703).

DISCUSSION

Abdominal pain, shortness of breath, and ascites/fluid overload are the common presenting reasons for ED visits for patients with cirrhosis. Patients with cirrhosis presenting to the ED experience a 90-day mortality rate of 16%, and among those who initially visited the ED, 20% were HEDU. We identified several variables independently associated with HEDU. Our observations pave the way for developing interventions to optimize the care of patients with cirrhosis presenting to the ED and to lower repeated ED visits.

Characterization of patients with acutely decompensated cirrhosis who received care in different highly complex emergency services of Medellín, Colombia

INTRODUCTION

Cirrhosis is one of the ten leading causes of death in the Western hemisphere and entails a significant cost of health care.

OBJECTIVE

To describe the sociodemographic, clinical, and laboratory characteristics of patients older than 18 years who received care for acute decompensation of cirrhosis in the emergency services of three highly complex centers in Medellín, Colombia.

MATERIALS AND METHODS

This was an observational retrospective cohort study from clinical records. The results were analyzed by frequency measures and represented in tables and graphics.

RESULTS

In total, 576 clinical records met the inclusion criteria; 287 were included for analysis, and 58.9% were men, with an average age of 64 (± 13.5) years. The most frequent causes of cirrhosis were alcohol intake (47.7%), cryptogenic or unspecified etiology (29.6%), and non-alcoholic fatty liver disease (9.1%). The main reasons for visiting the emergency department were the presence of edema and/or ascites (34.1%), suspicion of gastrointestinal bleeding (26.5%), abdominal pain (14.3%) and altered mental status (13.9%). The most frequent clinical manifestations of an acute decompensation of cirrhosis were ascites (45.6%), variceal hemorrhage (25.4%), hepatic encephalopathy (23.0%), and spontaneous bacterial peritonitis (5.2%). During their treatment, 56.1% of the patients received intravenous antibiotics; 24.0%, human albumin; 24.0%, vasoactive support, and 27.5%, blood products; 21.3% required management in an intensive or intermediate care unit, registering 53 deceased patients for a mortality of 18.5%.

CONCLUSION

Patients who consult the emergency services due to acute decompensation of cirrhosis demand a high amount of health resources, frequently present associated complications, and a high percentage requires management in critical care units and shows a high in-hospital mortality rate.

Factors predicting mortality in patients with alcoholic liver cirrhosis visiting the emergency department

Liver cirrhosis (LC) is a major cause of morbidity and mortality worldwide and is becoming a regional and healthcare burden. South Korea is one of the 10 countries with the highest age standardized prevalence of decompensated LC. Moreover, the proportion of patients with alcoholic LC is increasing and there has been no decrease in the incidence of decompensated alcoholic LC. Patients with decompensated LC frequently visit the emergency department (ED). Several studies focused on patients with LC who visited the ED, but the studies about alcoholic LC were limited. This study aimed to identify predicting factors for mortality in alcoholic LC patients visiting the ED. This was a retrospective study of alcoholic LC patients who visited an ED between November 2017 and June 2021. The baseline characteristics, complications of LC, model for end-stage liver disease (MELD) score, and laboratory values including lactate were assessed. The primary outcome was in-hospital mortality. In total, 433 patients with alcoholic LC were included for analysis and the in hospital mortality rate was 15.9% (n = 69). Univariate regression analyses identified that MELD score, lactate, platelet, international normalized ratio, bilirubin, creatinine, albumin, and C-reactive protein (CRP) predicted in-hospital mortality. Multivariate regression analysis showed that MELD score, lactate, albumin, and CRP were significantly associated with in-hospital mortality. MELD score, lactate, albumin, and CRP predicted the mortality in alcoholic LC patients visiting the ED.

Hemoperitoneum From Bleeding Intra-Abdominal Varices: A Rare, Life-Threatening Cause of Abdominal Pain in a Patient With Cirrhosis

We report the case of a 54-year-old male with alcoholic cirrhosis who presented several times to the emergency department (ED) with right upper quadrant abdominal pain. Ten days after his initial presentation, the patient represented with hypotension and anemia. An abdominal CT angiogram identified hemorrhage from an ectopic varix successfully treated with emergent glue embolization of mesenteric, omental, and periumbilical varices. Intraperitoneal bleeding from ectopic varices in cirrhosis patients is a rare, life-threatening condition. Consideration and recognition of ectopic variceal hemorrhage in patients with cirrhosis can facilitate prompt life-saving treatment in a population susceptible to significant morbidity and mortality.

Mutual antagonism between indoleamine 2,3-dioxygenase 1 and nuclear factor E2-related factor 2 regulates the maturation status of DCs in liver fibrosis

Liver fibrosis can develop into liver cirrhosis and hepatocellular carcinoma substantially without effective available treatment currently due to rarely characterized molecular pathogenesis. Indoleamine 2,3-dioxygenase 1(IDO1) can be detected on antigen-presenting cells (APCs) and modulates various immune responses. However, the role of IDO1 in the regulation of dendritic cells (DCs) during liver fibrosis is rarely reported. Here, we found that hepatic IDO1 was up-regulated during CCL4-induced liver fibrosis, which accompanied by a significant decrease in the frequencies of CD11c⁺CD80⁺, CD11c⁺CD86⁺, CD11c⁺CD40⁺ and CD11c⁺MHCII⁺ cells and a reduction in the subsequent T cell proliferation rate, whereas these changes were reversed significantly in IDO1^-/- mice. Overexpressing IDO1 by adeno-associated viral vector serotype 9 (AAV9) significantly inhibited the maturation status of DCs, worsened fibrosis. In vitro studies showed that significantly elevated CD80, CD86, CD40 and MHCII expression were observed in BMDCs derived from IDO1^-/- mice. Moreover, the maturation of BMDCs derived from WT mice were significantly increased after stimulated with IDO1 inhibitor (1-methyl- D -tryptophan). Nuclear factor E2-related factor 2 (Nrf2), a key regulator of the cellular adaptive response to oxidative insults and inflammation, exhibited a markedly decrease in the liver of WT fibrotic mice, nevertheless, knockout of IDO1 enhanced the protein level of Nrf2. Moreover, the expression of IDO1 and Nrf2 exhibited inverse colocalization pattern suggesting that ectopically expressed IDO1 down-regulated Nrf2. Additionally, up-regulation of IDO1 was also observed in the livers of Nrf2^-/- fibrotic mice. Taken together, these data uncovered mutual antagonism between IDO1 and Nrf2 on the maturation status of DCs during hepatic fibrosis.