Dying with end stage liver disease with cirrhosis: insights from SUPPORT. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment

OBJECTIVES

To understand patterns of care and end-of-life preferences for patients dying with end stage liver disease with cirrhosis (ESLDC).

METHODS

Data were collected during the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT), a prospective cohort study of seriously ill hospitalized adults at five teaching hospitals in the United States, and included all patients enrolled in SUPPORT with ESLDC.

RESULTS

Of 575 patients with ESLDC, 166 died during index hospitalization, and 168 died in the following year. The majority were male (65%) and white (80%); the median age was 52 years. Most rated their quality of life as poor or fair, and multiple comorbidities were common. Most spent their last few days completely disabled. Families often reported loss of most income and the need to leave work or other activities in order to care for patients. Pain was at least moderately severe most of the time in one-third of patients. End-of-life preferences were not associated with survival. Most patients (66.8%) preferred CPR, but DNR orders and orders against ventilator use increased near death.

CONCLUSIONS

Patients with liver disease were young, likely to be male, and often had low incomes. The high burden of pain was comparable to that reported for patients with lung and colon cancer. Persons dying with liver disease may benefit from increased attention to relief of symptoms, improved home care, and advanced care planning.

Cancer and women

Women have special physiologic considerations that may increase their risk of being diagnosed with certain cancers; however, the most important aspect to remember is that women are diagnosed with and die from many of the same malignancies as men. Health care providers need to be vigilant in evaluating women because one of the best ways to increase the chance of survival is early detection.

Case report: a rare case of chylous ascites from Mycobacterium avium intracellulare in a patient with AIDS: review of the literature

Chylous ascites is a rare complication of acquired immunodeficiency syndrome (AIDS). Although it is most commonly associated with lymphoma, it has been reported in patients with Kaposi's sarcoma. There has been only one case reported of chyloperitoneum occurring in a pediatric patient as a result of Mycobacterium avium intracellulare (MAI). We report the first case of an adult patient with chylous ascites resulting as a complication of MAI. Chylous ascites (chyloperitoneum) is a rare complication of acquired immunodeficiency syndrome (AIDS). Only two cases of chylous ascites associated with AIDS have been reported in the literature (1, 2). In one case, chylous ascites was attributed to extensive abnormal Kaposi's sarcoma (1). In the second case, a 2-year-old child with Mycobacterium avium intracellulare (MAI) developed chylous ascites. (2) We report the first adult case of AIDS which has been complicated by a MAI infection causing mesenteric lymphadenopathy and chylous ascites.

Chronic pancreatitis: a complication of systemic lupus erythematosus

Systemic lupus erythematosus (SLE), an autoimmune disease with multisystem involvement, has been reported to be associated with a number of gastrointestinal complications. Acute pancreatitis is an unusual manifestation of this disorder. This report presents two cases of patients with SLE who developed chronic pancreatitis with no other identifiable etiology.

Marked hyperlipasemia in diabetic ketoacidosis. A report of three cases

We report three patients with diabetic ketoacidosis (DKA) who presented with striking elevations of serum lipase levels and less striking elevations of amylase and trypsinogen. All three had nausea and vomiting, but none had objective evidence of abdominal pain, and computed tomography scans of the pancreas were unremarkable. These cases suggest the association of asymptomatic enzyme elevations with DKA. We review the literature on this subject.