By Stacey Butterfield
The hepatitis C epidemic may have crested thanks to recent pharmacological advances, but the flood of cirrhosis is still rising in the U.S., attendees at the Hospital Medicine precourse at Internal Medicine Meeting 2022 were warned on Wednesday morning.
“Remember, a lot of people with hepatitis C infection don't know it and they've had it for a long time. So many of them present with decompensation of chronic liver disease as their initial manifestation,” said William Sanchez, MD, a specialist in transplant hepatology at Mayo Clinic in Rochester, Minn., during a lecture on cirrhosis.
Along with the wave of liver damage from hepatitis C, there’s an even bigger one of nonalcoholic steatohepatitis. “It's a manifestation of obesity and metabolic syndrome, and there's no end in sight for that,” he said. “Not all patients who have fatty liver disease become cirrhotic, but a small percentage of a very big number translates to a big number of disease visits.”
Dr. Sanchez cited a 2017 analysis of the National Health and Nutrition Examination Survey that found 23.8% of U.S. adults with nonalcoholic fatty liver disease had stage 2 or worse fibrosis.
Further complicating caring for the complications of liver disease is the advancing age of the affected patients. “The patients who have developed cirrhosis and its complications tend to be skewing older, with more comorbidity. So therefore, fewer of them will be candidates for transplantation,” he said.
And then there’s one more big challenge. “A lot of these patients are underserved and many of them have not seen a [liver] specialist, let alone a subspecialist like myself,” said Dr. Sanchez.
The result is going to be a lot of cirrhosis care by internists, both inside and outside of the hospital, and to assist with that, he reviewed a few key points.
“There's often some confusion in terms of terminology and language in reversibility of hepatitis and jaundice and liver failure and cirrhosis. I get all kinds of consultations [reflecting this],” Dr. Sanchez said.
As an analogy to explain the progression of liver disease, he compared it to that from acute bronchitis to oxygen-dependent emphysema. Like bronchitis, acute hepatitis causes signs and symptoms, including fatigue, malaise, and pain. “That's not organ failure. That’s a symptom of liver injury,” he said.
Some causes of liver injury, like untreated hepatitis C, are chronic, leading to persistent injury, but they can still be reversible for a while, equivalent to lung damage in someone who quits smoking.
“Over time that chronic injury, if repeated, begins to develop fibrosis and becomes irreversible,” said Dr. Sanchez, noting that this condition is still a step before organ failure. “Decompensated cirrhosis with ascites and variceal hemorrhage is an organ-failure state.”
Esophageal varices are a common reason for cirrhosis patients to present to the hospital, occurring in half of those with the disease, and at even higher rates in those with more severe cases, Dr. Sanchez said. They’re also dangerous. “Mortality from hemorrhage remains high even when bleeding is controlled,” he added.
Thus, it’s important to suspect that any gastrointestinal bleed in a patient with liver disease may be a bleeding varix. “If it’s a peptic ulcer and you treat it like a varix, nothing bad will happen to the patient. If it’s a varix and you treat it like a peptic ulcer, the patient will likely not survive,” said Dr. Sanchez.
The severity of the condition will often be apparent, he noted. “Patients who develop variceal hemorrhage present dramatically. It's massive bleeding. … If they're not unstable now, wait and they will become so.”
Treatment is largely supportive, with IV fluid and transfusions. “It seems very fundamental, but the most important thing for patients who are bleeding is to not let them bleed to death,” he said. “There's two specific medical therapies that are important.”
IV octreotide should be started ASAP if a variceal bleed is even suspected. “It's very easy, it's 50/50: 50 microgram bolus with a 50 microgram per hour infusion,” he said. “It’s easy to turn off” if the diagnosis turns out to be wrong, he noted.
Patients with variceal hemorrhage also need antibiotics. “These patients do die of sepsis,” he said. “The most common form of sepsis in patients with cirrhosis and bleeding is spontaneous bacterial peritonitis.”
Recognizing spontaneous bacterial peritonitis (SBP) can be tricky, Dr. Sanchez warned. “The really important takeaway is that symptoms are unreliable and inconsistent,” he said. “Every time there's an ED note that says a patient does not have a fever and cannot have SBP, a hepatologist sheds a tear.”
Both fever and abdominal pain are specific, but not sensitive, for SBP. “Often what people will present with is their numbers. … Renal function is worse than it was last week. My bili[rubin] was worse than it was last week,” Dr. Sanchez said. “Unless you know what their bilirubin was last week, that doesn't tell you anything.”
Encephalopathy is probably the most common symptom, he added. But accurate diagnosis requires a [spinal] tap and subsequent cell count and culture. “This is not a diagnosis that you want to wait around to make. ‘We should have someone tap that patient tomorrow’—that's probably not a great idea,” he said.
Once SBP is diagnosed, it should be treated with IV antibiotics and IV albumin to prevent worsening renal function, followed by long-term oral ciprofloxacin prophylaxis. Recurrences are common, occurring in 70% of patients, and the long-term outlook is grim, Dr. Sanchez said. “Their one-year survival in SBP is less than 50%.”
The poor outcomes of patients with SBP, and ascites generally, can make a transjugular intrahepatic portosystemic shunt (TIPS) seem like an appealing treatment. “People get very excited about TIPS and patients are often pushed towards TIPS because it's high-tech, and it's interventional,” he said.
TIPS does decrease the need for paracentesis but has not been shown to improve survival or quality of life. “This surprises people who think, ‘Well, going in once a week in person for paracentesis is terrible. TIPS is going to be better,’” he said. The tradeoff that explains the lack of benefit is higher risk of encephalitis after TIPS.
Additional issues include that TIPS is not appropriate for patients with portal hypertension and it doesn’t work well in older patients, in Dr. Sanchez’s clinical experience. It can also interfere with later surgery. “By the time you're thinking about TIPS, you probably should have been thinking about whether it's suitable to do a transplant referral,” he said.
Also, always remember to check that patients are adhering to the very first line of ascites treatment, which is dietary sodium restriction. “It's a hard thing for patients but it's the most important,” he said. “Many, many more patients need a dietitian than need TIPS.” ■