Advertisement

The ICU Management of Alcoholic Liver Disease

  • Jessica L. Mellinger
  • Robert J. FontanaEmail author
Chapter
  • 3 Downloads

Abstract

Alcoholic liver disease (ALD) can present with a spectrum of clinical findings ranging from asymptomatic hepatic steatosis to life-threatening alcoholic hepatitis with jaundice or decompensated cirrhosis with ascites and protein-calorie malnutrition. Patients with alcoholic hepatitis (AH) have jaundice, coagulopathy, and a 30–60% 6-month mortality despite abstinence and supportive care. Recent data from a large multicenter study demonstrated that corticosteroids and pentoxyfilline have minimal survival benefit in AH. Therefore, many experts recommend a short course of corticosteroids only in selected AH patients whose total bilirubin levels improve within 1 week of starting treatment. ICU care for patients with ALD requires initial management of alcohol withdrawal syndromes (AWS) as well as addressing infections, bleeding, and renal failure. Management of AWS includes protocolized administration of benzodiazepines based on clinical status in a monitored setting along with correction of metabolic disturbances and supplementation of micronutrient deficiencies. Patients with severe AWS may require anti-psychotics or even propofol with intubation for severe withdrawal symptoms and cardiopulmonary instability. Treatment of upper GI bleeding in patients with ALD includes establishment of large bore IV access and early administration of IV antibiotics, proton pump inhibitors, and octreotide to further reduce bleeding. Targets for blood product replacement include a hemoglobin of 8 g/dL, an INR < 1.5 and platelets of >50 K to minimize the risk of ongoing bleeding. Following adequate gastric lavage, urgent therapeutic endoscopy is recommended to identify and treat the source of bleeding. Patients with refractory variceal bleeding may require balloon tamponade to achieve hemostasis and emergent TIPS for portal decompression. Many ICU patients with complications of ALD may develop acute kidney injury due to volume depletion, ATN, or hepatorenal syndrome. Initiation of hemodialysis in patients with ALD is frought with complications, and patients with HRS have particularly poor survival. In conclusion, management of the ICU patient with ALD requires coordinated care delivered by the intensivist in conjunction with the GI specialist and mental health provider to achieve optimal short- and long-term outcomes.

Keywords

Cirrhosis Alcohol withdrawal Delirium tremens MELD score Variceal bleeding Alcoholic hepatitis 

Abbreviations

AH

Alcoholic hepatitis

AKI

Acute kidney injury

ALD

Alcoholic liver disease

ATN

Acute tubular necrosis

AUD

Alcohol use disorder

AWS

Alcohol withdrawal syndrome

CIWA-Ar

Clinical Institute Withdrawal Assessment for Alcohol, Revised

CNS

Central nervous system

DT

Delirium tremens

DSM-V

Diagnostic and Statistical Manual of Mental Disorders, 5th Edition

DBP

Diastolic blood pressure

HRS

Hepatorenal syndrome

ICU

Intensive care unit

INR

International normalized ratio

MAP

Mean arterial pressure

NSAID

Non-steroidal anti-inflammatory drugs

SBP

Spontaneous bacterial peritonitis

TIPS

Transjugular intrahepatic portosystemic shunt

Notes

Acknowledgment

Grant Support: Support for Dr. Fontana provided in part by the National Institutes of Diabetes, Digestive, and Kidney Diseases (DK U-01-58369) as a member of the Acute Liver Failure Study Group. Support for Dr. Mellinger provided by an NIH NIAAA K23 Career Development Award (K23 AA026333–01).

References

  1. 1.
    Lucey MR, Mathurin P, Morgan TR. Alcoholic hepatitis. N Engl J Med. 2009;360:2758–69.CrossRefGoogle Scholar
  2. 2.
    Gowing LR, Ali RL, Allsop S, Marsden J, Turf EE. Global statistics on addictive behaviours: 2014 status report Addiction. 2015; 110: 904–919.Google Scholar
  3. 3.
    Mueller SW, Preslaski CR, Kiser TH, Fish DN, Lavelle JC, Malkoski SP, et al. A randomized, double-blind, placebo-controlled dose range study of dexmedetomidine as adjunctive therapy for alcohol withdrawal. Crit Care Med. 2014;42:1131–9.CrossRefGoogle Scholar
  4. 4.
    Walsham NE, Sherwood RA. Ethyl glucuronide. Ann Clin Biochem. 2012;49:110–7.CrossRefGoogle Scholar
  5. 5.
    Nguyen VL, Haber PS, Seth D. Applications and challenges for the use of phosphatidylethanol testing in liver disease patients. Alcohol Clin Exp Res. 2018;42(2):238–43.CrossRefGoogle Scholar
  6. 6.
    Dunn W, Jamil LH, Brown LS, Wiesner RH, Kim WR, Menon KVN, et al. MELD accurately predicts mortality in patients with alcoholic hepatitis. Hepatology. 2005;41:353–8.CrossRefGoogle Scholar
  7. 7.
    McPhail MJW, Shawcross DL, Abeles RD, Chang A, Patel V, Lee G, et al. Increased survival for patients with cirrhosis and organ failure in liver intensive care and validation of the chronic liver failure-sequential organ failure scoring system. Clin Gastroenterol Hepatol. 2014;13:1353–60.CrossRefGoogle Scholar
  8. 8.
    de Wit M, Jones DG, Sessler CN, Zilberberg MD, Weaver MF. Alcohol-use disorders in the critically ill patient. Chest. 2010;138:994–1003.CrossRefGoogle Scholar
  9. 9.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.CrossRefGoogle Scholar
  10. 10.
    Awissi D, Lebrun G, Fagnan M, Skrobik Y. Alcohol, nicotine, and iatrogenic withdrawals in the ICU. Crit Care Med. 2013;41:S57–68.CrossRefGoogle Scholar
  11. 11.
    DeCarolis DD, Rice KL, Ho L, Willenbring ML, Cassaro S. Symptom-driven lorazepam protocol for treatment of severe alcohol withdrawal delirium in the intensive care unit. Pharmacotherapy. 2007;27:510–8.CrossRefGoogle Scholar
  12. 12.
    Amato L, Minozzi S, Vecchi S, Davoli M. Benzodiazepines for alcohol withdrawal. Cochrane Database Syst Rev. 2010;(3):CD005063.Google Scholar
  13. 13.
    Awissi D, Lebrun G, Coursin DB, Riker RR, Skrobik Y. Alcohol withdrawal and delirium tremens in the critically ill: a systematic review and commentary. Intensive Care Med. 2012;39:16–30-30.CrossRefGoogle Scholar
  14. 14.
    Goodson CM, Clark BJ, Douglas IS. Predictors of severe alcohol withdrawal syndrome: a systematic review and meta-analysis. Alcohol Clin Exp Res. 2014;38:2664–77.CrossRefGoogle Scholar
  15. 15.
    Schuckit MA. Recognition and management of withdrawal delirium (delirium tremens). N Engl J Med. 2014;371:2109–13.CrossRefGoogle Scholar
  16. 16.
    Elisaf M, Merkouropoulos M, Tsianos EV, Siamopoulos KC. Acid-base and electrolyte abnormalities in alcoholic patients. Miner Electrolyte Metab. 1994;20:274–81.PubMedGoogle Scholar
  17. 17.
    Martin PR, Singleton CK, Hiller-Sturmhöfel S. The role of thiamine deficiency in alcoholic brain disease. Alcohol Res Health. 2004;27:134–42.Google Scholar
  18. 18.
    Singal AK, Charlton MR. Nutrition in alcoholic liver disease. Clin Liver Dis. 2012;16:805–26.CrossRefGoogle Scholar
  19. 19.
    Baltz JG, Argo CK, Al A. Mortality after percutaneous endoscopic gastrostomy in patients with cirrhosis: a case series. Gastrointest Endosc. 2010;72(5):1072–5.CrossRefGoogle Scholar
  20. 20.
    Villanueva C, Colomo A, Bosch A, Concepción M, Hernandez-Gea V, Aracil C, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013;368:11–21.CrossRefGoogle Scholar
  21. 21.
    Garcia-Tsao G, Sanyal AJ, Grace ND, Carey WD. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Am J Gastroenterol. 2007;102:2086–102.CrossRefGoogle Scholar
  22. 22.
    Sharma P, Singh S, Sharma BC, Kumar M, Garg H, Kumar A, et al. Propofol sedation during endoscopy in patients with cirrhosis, and utility of psychometric tests and critical flicker frequency in assessment of recovery from sedation. Endoscopy. 2011;43:400–5.CrossRefGoogle Scholar
  23. 23.
    Fagà E, De Cento M, Giordanino C, Barletti C, Bruno M, Carucci P, et al. Safety of propofol in cirrhotic patients undergoing colonoscopy and endoscopic retrograde cholangiography: results of a prospective controlled study. Eur J Gastroenterol Hepatol. 2011;24:70–6.CrossRefGoogle Scholar
  24. 24.
    Tsai H, Lin Y, Ko C, Lou H, Chen T, Tam K, et al. Propofol versus midazolam for upper gastrointestinal endoscopy in cirrhotic patients: a meta-analysis of randomized controlled trials. PLoS One. 2015;10:1–13.Google Scholar
  25. 25.
    Rudolph SJ, Landsverk BK, Freeman ML. Endotracheal intubation for airway protection during endoscopy for severe upper GI hemorrhage. Gastrointest Endosc. 2003;57:58–61.CrossRefGoogle Scholar
  26. 26.
    Herrera JL. Management of acute variceal bleeding. Clin Liver Dis. 2014;18(2):347–57.CrossRefGoogle Scholar
  27. 27.
    O’Shea RS, Dasarathy S, McCullough AJ. Alcoholic liver disease. Am J Gastroenterol. 2010;105:14–32.CrossRefGoogle Scholar
  28. 28.
    Thursz MR, Richardson P, Allison M, et al. Prednisolone or Pentoxifylline for alcoholic hepatitis. N Engl J Med. 2015;372:1619–28.CrossRefGoogle Scholar
  29. 29.
    Whitfield K, Rambaldi A, Wetterslev J, et al. Pentoxifylline for alcoholic hepatitis. Cochrane Database Syst Rev. 2009;(4):CD007339.Google Scholar
  30. 30.
    Parker R, Armstrong MJ, Corbett C, Rowe IA, Houlihan DD. Systematic review: pentoxifylline for the treatment of severe alcoholic hepatitis. Aliment Pharmacol Ther. 2013;37:845–54.CrossRefGoogle Scholar
  31. 31.
    Mathurin P, O’Grady J, Carithers RL, Phillips M, Louvet A, Mendenhall CL, et al. Corticosteroids improve short-term survival in patients with severe alcoholic hepatitis: meta-analysis of individual patient data. Gut. 2011;60:255–60.CrossRefGoogle Scholar
  32. 32.
    Louvet A, Naveau S, Abdelnour M, Ramond M, Diaz E, Fartoux L, et al. The Lille model: a new tool for therapeutic strategy in patients with severe alcoholic hepatitis treated with steroids. Hepatology. 2007;45:1348–54.CrossRefGoogle Scholar
  33. 33.
    Alvarez MA, Cabré E, Lorenzo-Zúñiga V, Montoliu S, Planas R, Gassull MA. Combining steroids with enteral nutrition: a better therapeutic strategy for severe alcoholic hepatitis? Results of a pilot study. Eur J Gastroenterol Hepatol. 2004;16:1375–80.CrossRefGoogle Scholar
  34. 34.
    Garcia-Tsao G, Parikh CR, Viola A. Acute kidney injury in cirrhosis. Hepatology. 2008;48:2064–77.CrossRefGoogle Scholar
  35. 35.
    Runyon BA. Management of adult patients with ascites due to cirrhosis: an update. Hepatology. 2009;49:2087–107.CrossRefGoogle Scholar
  36. 36.
    Angeli P, Volpin R, Gerunda G, Craighero R, Roner P, Merenda R, et al. Reversal of type 1 hepatorenal syndrome with the administration of midodrine and octreotide. Hepatology. 1999;29:1690–7.CrossRefGoogle Scholar
  37. 37.
    Esrailian E, Pantangco ER, Kyulo NL, Hu K, Runyon BA. Octreotide/midodrine therapy significantly improves renal function and 30-day survival in patients with type 1 hepatorenal syndrome. Dig Dis Sci. 2007;52:742–8.CrossRefGoogle Scholar
  38. 38.
    Cavallin M, Kamath PS, Merli M, Fasolato S, Toniutto P, Salerno F, et al. Terlipressin plus albumin versus midodrine and octreotide plus albumin in the treatment of hepatorenal syndrome: a randomized trial. Hepatology. 2015;62:567–74.CrossRefGoogle Scholar
  39. 39.
    Junior A, Farias AQ, d’Albequerque L, et al. Terlipressin versus norepinephrine in the treatment of hepatorenal syndrome: a systematic review and meta-analysis. PlosOne. 2014;9(9):e107466.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Division of Gastroenterology and Hepatology, Department of Internal MedicineUniversity of Michigan Medical CenterAnn ArborUSA

Personalised recommendations