Episode 902: Liver Failure and Cirrhosis

Emergency Medical Minute

Contributor: Travis Barlock MD

Educational Pearls:

How do you differentiate between compensated and decompensated cirrhosis?

Use the acronym VIBE to look for signs of being decompensated.

• V-Volume

• Cirrhosis can cause volume overload through a variety of mechanisms such as by increasing pressure in the portal vein system and the decreased production of albumin.

• Look for pulmonary edema (dyspnea, orthopnea, wheezing/crackles, coughing up frothy pink sputum, etc.) or a tense abdomen.

• I-Infection

• The ascitic fluid can become infected with bacteria, a complication called Spontaneous Bacterial Peritonitis (SBP).

• Look for abdominal pain, fever, hypotension, and tachycardia. Diagnosis is made with ascitic fluid cell analyses (polymorphonuclear neutrophils >250/mm3)

• B-Bleeding

• Another consequence of increased portal pressure is that blood backs up into smaller blood vessels, including those in the esophagus.

• Over time, this increased pressure can result in the development of dilated, fragile veins called esophageal varices, which are prone to bleeding.

• Look for hematemesis, melena, lightheadedness, and pale skin.

• E-Encephalopathy

• A failing liver also does not clear toxins which can affect the brain.

• Look for asterixis (flapping motion of the hands when you tell the patient to hold their hands up like they are going to stop a bus)

Other complications to look out for.

• Hepatorenal syndrome

• Hepatopulmonary syndrome

References

1. Engelmann, C., Clària, J., Szabo, G., Bosch, J., & Bernardi, M. (2021). Pathophysiology of decompensated cirrhosis: Portal hypertension, circulatory dysfunction, inflammation, metabolism and mitochondrial dysfunction. Journal of hepatology, 75 Suppl 1(Suppl 1), S49–S66. https://doi.org/10.1016/j.jhep.2021.01.002

2. Enomoto, H., Inoue, S., Matsuhisa, A., & Nishiguchi, S. (2014). Diagnosis of spontaneous bacterial peritonitis and an in situ hybridization approach to detect an "unidentified" pathogen. International journal of hepatology, 2014, 634617. https://doi.org/10.1155/2014/634617

3. Mansour, D., & McPherson, S. (2018). Management of decompensated cirrhosis. Clinical medicine (London, England), 18(Suppl 2), s60–s65. https://doi.org/10.7861/clinmedicine.18-2-s60

Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMS II