Outcomes of Gastrointestinal Bleeding in Patients with Alcoholic Liver Disease

Abstract

Introduction: Acute on chronic liver failure (ACLF) in alcoholic liver disease (ALD) can be due to superimposed alcoholic hepatitis (AH) or other non-AH causes. Gastrointestinal (GI) bleeding leads to significant decompensation in patients with underlying ALD and contributes to the high in-hospital mortality (IHM) in patients with ACLF. We aimed to evaluate GI bleeding outcomes in patients with ALD and to determine whether IHM was different among AH and non-AH patients. Methods: Medical charts of patients discharged with a diagnosis of alcoholic cirrhosis, AC, were reviewed to select patients with characterized AC (alcohol use of >40 g/d in women and >60 g/d in men for >5 yrs., exclusion of other liver diseases, not diagnosed with AH) and meeting ACLF criteria. Similarly, patients discharged with AH were reviewed for characterizing diagnosis of AH (criteria as for AC, active alcohol use until 3 weeks prior, and serum bilirubin >5 mg/dL). Patients who were admitted with GI bleeding or developed GI bleeding during hospitalization were included in this study. Chi-square and t-tests were used for comparing categorical and continuous variables respectively. Logistic regression model was built to determine predictors of IHM. Results: Of 216 patients with ACLF, 47 (22%) presented with or developed GI bleeding (15 with AH and 32 with non-AH). Non-AH patients compared to those with AH differed on presentation with hematemesis (69% vs 40%, p < 0.0001), infection rate (22% vs 80%, p=0.002), median serum bilirubin (6 vs 19 mg/dL, p < 0.0001), median INR (2.1 vs 6.6, p < 0.0001), and length of hospitalization (8.7 vs 18.0 days, p=0.049). 12 (80%) of the AH patients and 27 (84%) non-AH patients underwent EGD with esophageal varices (5 in AH and 14 in non-AH) being the most common endoscopic finding. IHM was similar comparing non-AH and AH patients (41% vs 47%). On logistic regression analysis, age, sex, hemoglobin at admission, infection, receipt of EGD, and MELD score were not found to be predictors of IHM. Conclusion: GI bleeding occurs in about a quarter of patients with decompensated ALD and ACLF, with a higher prevalence in non-AH patients, compared to those with AH. Characteristics of GI bleeding differ comparing non-AH with AH causes for decompensation of ALD. Although IHM is similar, AH patients consume more hospital resources with longer hospital stay.