Impact Of Cirrhosis Research Articles

Impact of cirrhosis on surgical outcome after pancreaticoduodenectomy

To elucidate surgical outcomes of pancreaticoduodenectomy (PD) in patients with liver cirrhosis. We studied retrospectively all patients who underwent PD in our centre between January 2002 and December 2011. Group A comprised patients with cirrhotic livers, and Group B comprised patients with non-cirrhotic livers. The cirrhotic patients had Child-Pugh classes A and B (patient's score less than 8). Preoperative demographic data, intra-operative data and postoperative details were collected. The primary outcome measure was hospital mortality rate. Secondary outcomes analysed included duration of the operation, postoperative hospital stay, postoperative morbidity and survival rate. Only 67/442 patients (15.2%) had cirrhotic livers. Intraoperative blood loss and blood transfusion were significantly higher in group A (P = 0.0001). The mean surgical time in group A was significantly longer than that in group B (P = 0.0001). Wound complications (P = 0.02), internal haemorrhage (P = 0.05), pancreatic fistula (P = 0.02) and hospital mortality (P = 0.0001) were significantly higher in the cirrhotic patients. Postoperative stay was significantly longer in group A (P = 0.03). The median survival was 19 mo in group A and 24 mo in group B. Portal hypertension (PHT) was present in 16/67 cases of cirrhosis (23.9%). The intraoperative blood loss and blood transfusion were significantly higher in patients with PHT (P = 0.001). Postoperative morbidity (0.07) and hospital mortality (P = 0.007) were higher in cirrhotic patients with PHT. Patients with periampullary tumours and well-compensated chronic liver disease should be routinely considered for PD at high volume centres with available expertise to manage liver cirrhosis. PD is associated with an increased risk of postoperative morbidity in patients with liver cirrhosis; therefore, it is only recommended in patients with Child A cirrhosis without portal hypertension.

Clinical outcomes of oncologic gastrointestinal resections in patients with cirrhosis

Cirrhosis is a risk factor for postoperative morbidity and mortality after general surgical procedures. However, the impact of cirrhosis on outcomes of surgical resection for gastrointestinal (GI) malignancies has not been described. The authors' objective was to characterize early postoperative and transitional outcomes in cirrhotic patients undergoing GI cancer surgery. Query of the National Inpatient Sample Database (2005-2008) identified 106,729 patients who underwent resection for GI malignancy; 1479 (1.4%) had cirrhosis. The association of cirrhosis with postoperative outcomes was examined. The primary outcome measure was in-hospital mortality. Secondary outcomes included length-of-stay (LOS) and discharge to long-term care facility (LTCF). Cirrhotic patients had higher risk of in-hospital mortality (8.9% vs 2.8%, P < .001), longer LOS (11.5 ± 0.26 vs 10.0 ± 0.03 days, P < .001), and higher rate of discharge to LTCF (19.0% vs 15.7%, P < .001). Mortality was highest in patients with moderate to severe liver dysfunction (21.5% vs 6.5%, P < .001). On multivariate analysis, cirrhosis was an independent predictor of in-hospital mortality (odds ratio [OR], 3.0; 95% confidence interval [CI] 2.5-3.7) and nonhome discharge (OR, 1.7; 95% CI, 1.4-2.0). In cirrhotic patients, moderate to severe liver dysfunction was the only independent predictor of in-hospital mortality (OR, 4.03; 95% CI, 2.7-5.9), but did not predict discharge disposition. Resection of GI malignancy in cirrhotics is associated with poor early postoperative and transitional outcomes, with severity of liver disease being the primary determinant of postoperative mortality. These data suggest that GI cancer operations can be performed safely in well-selected cirrhotic patients with mild liver dysfunction.

Impact of Cirrhosis and Liver Transplant on Maternal Health During Labor and Delivery

The impact of cirrhosis or prior liver transplant on maternal health during pregnancy has not been studied. We sought to characterize outcomes during labor and delivery among pregnant women with these 2 conditions. A population-based cohort study of women admitted for labor and delivery to US hospitals between 1998 and 2005 was conducted using the Nationwide Inpatient Sample database. We compared health outcomes between pregnant women with cirrhosis or liver transplant with those without known liver disease, adjusting for potential confounders. The rates of cesarean section were higher among pregnant women with cirrhosis (n = 187; adjusted odds ratio [aOR], 2.4; 95% confidence interval [CI], 1.7-3.4) and those with prior liver transplant (n = 86; aOR, 1.8; 95% CI, 1.0-3.2), compared with general obstetrical patients (n = 662,408), as were the rates of preterm labor, peripartum infection, and hypertension. The rates of death (aOR, 42.5; 95% CI, 8.5-214), venous thromboembolism (aOR, 12.3; 95% CI, 4.9-31.0), and protein-calorie malnutrition (aOR, 67.4; 95% CI, 7.5-603), as well as the rates of placental abruption and peripartum blood transfusion, were specifically higher in cirrhotic women. Women with clinically apparent decompensated cirrhosis had higher rates of cesarean delivery, preterm labor, placenta previa, and peripartum blood transfusion than women with compensated cirrhosis. Pregnant women with cirrhosis or prior liver transplant are at higher risk of developing numerous adverse health problems than pregnant women without these conditions. Further prospective studies are warranted to assess the benefit of aggressive preventative measures and involvement of multidisciplinary health care teams.

The Impact of Cirrhosis and Portal Hypertension on Mortality Following Colorectal Surgery: A Nationwide, Population-Based Study

Population-based data on outcomes associated with colorectal procedures in cirrhotic patients are sparse. We sought to assess the impact of liver cirrhosis and portal hypertension on mortality following colorectal surgery. We queried patients who underwent colorectal surgery in the United States in the Nationwide Inpatient Sample (1998-2005). In-hospital mortality was determined for patients with no cirrhosis, compensated cirrhotic patients, and cirrhotic patients with portal hypertension. Multivariate logistic regression analysis was used to adjust for sociodemographic and clinical covariates. Patients with cirrhosis and cirrhosis with portal hypertension had significantly higher in-hospital mortality than patients with no cirrhosis (14% and 29% vs. 5%, respectively, P < 0.0001). In-hospital mortality was also significantly higher for emergent and urgent colorectal procedures compared with elective procedures (9.2% vs. 1.8%, P < 0.0001). Among elective colorectal procedures, adjusted mortality was increased in cirrhotic patients (adjusted odds ratio, 3.91; 95% confidence interval, 3.12-4.90) and cirrhotic patients with portal hypertension (adjusted odds ratio, 11.3; 95% confidence interval, 8.46-15.1) compared with patients with no cirrhosis. For nonelective procedures, the adjusted odds ratio for mortality in cirrhotic patients was 2.40 (95% confidence interval, 2.07-2.79) and in cirrhotic patients with portal hypertension the adjusted odds ratio was 5.88 (95% confidence interval, 4.90-7.06). Postoperative complications were more likely in cirrhotic patients (adjusted odds ratio, 1.35; 95% confidence interval, 1.20-1.52) and cirrhotic patients with portal hypertension (adjusted odds ratio, 1.82; 95% confidence interval, 1.55-2.15) relative to patients with no cirrhosis. Patients with liver cirrhosis, in particular, those with portal hypertension, have increased in-hospital mortality and morbidity following colorectal surgery. Strategies are needed to optimize preoperative risk.

The Lost Years: The Impact of Cirrhosis on the History of Jazz

Jazz is considered to be one of America’s native art forms. However, the life of a jazz musician has been surrounded by substance abuse, and many of its greatest exponents died at a young age from the complications of cirrhosis and hepatocellular carcinoma. This is a changing scene, with improvements in working conditions for some jazz musicians and advances in prevention and treatment of viral hepatitis. However, the evolution of jazz has been affected by the premature deaths of many of America’s greatest musicians and innovators. The origins of American jazz can be traced back to New Orleans (USA), and its early pioneers assimilated musical influences from Africa, South America and the Caribbean. Although popular throughout the 1920s and 1930s, many jazz musicians were dealing with racial and financial difficulties throughout their careers. Jazz clubs were the performance platform and alcohol was a common addiction among jazz musicians (1,2). Cannabis, and later, intravenous heroin, became common drugs in the jazz community. The reasons for the high prevalence of substance abuse continue to this day. Jazz musicians often feel isolated from popular music culture (3) and are financially disadvantaged despite having formidable musical skills on their instruments. Some musicians turned to drugs in an attempt to stimulate creativity, whereas others used drugs to dampen the drudgery of smoky bars, the loneliness of being on the road and as a pathway to social camaraderie among their peers (3). A review of 40 eminent jazz musicians with regard to psychopathology showed a similar prevalence to other creative groups, with the exception of substance-related problems (4). The age at death of 80 great jazz musicians has suggested that the stressful lifestyle of jazz musicians may lead to a decreased life span (3). The end result of years of alcohol and drug abuse was a high prevalence of cirrhosis among jazz musicians, which led to premature death. It is likely that many of these cases would be related to both hepatitis B and C, and the chronic effects of alcoholism. Antiviral therapies and vaccinations became available only in the 1980s and health care may also have been unavailable to many jazz musicians. Hepatic encephalopathy, ascites, variceal bleeding, jaundice and hepatocellular carcinoma were all reported in jazz musicians. Charlie Parker demonstrated clinical features of cirrhosis, with ascites and variceal bleeding, and he spent time in a mental health hospital in Camarillo, California (USA). He died at 35 years of age in 1955. John Coltrane was a major innovator of avant-garde jazz in the 1960s and yet he passed away at 41 years of age in 1967 from hepatitis B and hepatocellular carcinoma. Hepatocellular carcinoma also claimed major saxophone stylists Stan Getz in 1990 and Steve Lacy in 2004. Variceal bleeding was the cause of death in Bill Evans, a lyrical pianist. He was one of the pianists on the classic recording ‘Kind of Blue’ by Miles Davis. On that same recording were John Coltrane and Wynton Kelly, who also died from the complications of cirrhosis. For some jazz musicians, the images of a smoke-filled bar became part of their classic sound (eg, Ben Webster, Coleman Hawkins, Lester Young, Billie Holiday, Dexter Gordon) but liver disease eventually caught up with all of them. The famous Four Brothers from the Woody Herman band (Stan Getz, Al Cohn, Serge Chaloff and Zoot Sims) all died from the complications of cirrhosis. Cirrhosis is not unique to jazz musicians, having been the cause of death in Ludwig van Beethoven (5) and many popular musicians such as Sammy Davis Jr. It is difficult to estimate the prevalence of cirrhosis in jazz musicians because the denominator is not known and many unheralded musicians have likely died without public attention. Hepatitis B vaccination could improve longevity, but alcoholism and hepatitis C remain major health issues among jazz musicians. The solution to these problems include better health education of musicians, but should also include a system to allow jazz musicians to escape the ravages of poverty. A safety net for artists exists in many European countries but this seems to be an unlikely solution in America. It is interesting to speculate where jazz may have gone if John Coltrane and Charlie Parker lived into their 80s rather than succumb to the ravages of liver disease in their 30s. If we assume an average life span of 75 years for an adult man, the jazz musicians depicted in Figure 1 have lost a combined 461 years of jazz productivity as a consequence of cirrhosis. Figure 1 The age at death from cirrhosis (including hepatocellular carcinoma) is shown versus the year of death. The musicians represented from left to right include: Bunny Berigan (BB), Dave Tough (DT), Charlie Parker (CP), Al Cohn (AC), Serge Chaloff (SC), Lester ...

QS173. The Impact of Cirrhosis on Clinical Outcomes in Trauma Patients: An Analysis of The National Trauma Data Bank

QS173. The Impact of Cirrhosis on Clinical Outcomes in Trauma Patients: An Analysis of The National Trauma Data Bank

Impact of Cirrhosis on Outcomes in Trauma

Cirrhosis as an independent predictor of poor outcomes in trauma patients was identified in 1990. We hypothesized that the degree of preinjury hepatic dysfunction is, by itself, an independent predictor of mortality. The trauma registry at our Level I trauma center was queried for all ICD-9 codes for liver disease from 1999 to 2003, and patients were categorized as having Child-Turcotte-Pugh (CTP) class A, B, or C cirrhosis. Data analyzed included age, mechanism of injury, Abbreviated Injury Score (AIS), Injury Severity Score (ISS), Glasgow Coma Score (GCS), hospital length of stay, ventilator days, procedures performed, transfusion of blood products, admission lactate, base deficit, and mortality. Trauma Related Injury Severity Score (TRISS) methodology was used to calculate the probability of survival. Outcomes data were analyzed, and statistical comparison was performed using group t-test. Of the 50 patients meeting study criteria, 31 had alcohol-related cirrhosis, 18 had a history of hepatitis C, and 1 had cryptogenic cirrhosis. Twenty (40%) met CTP A classification, 16 (32%) met CTP B criteria, and 14 (28%) had CTP class C cirrhosis. One death occurred in the CTP A and B groups. Comparison between the five survivors and nine nonsurvivors from CTP class C showed no statistical significance in terms of age, ISS, TRISS, or GCS. The mortality rate for class C cirrhotic patients posttrauma continues to be higher than that predicted by TRISS, although patients with less severe hepatic dysfunction do not appear to have significantly lower than predicted survival. The degree of hepatic dysfunction remains an independent predictor of mortality and CTP C criteria must be considered when determining outcomes for patients posttrauma.

Impact of cirrhosis on the development of experimental hepatic metastases by B16F1 melanoma cells in C57BL/6 mice.

Metastases rarely occur in human livers with cirrhosis in clinical studies. We postulated that this phenomenon would also occur in experimental cirrhosis. Cirrhosis was established in C57BL/6 mice by carbon tetrachloride (CCl(4)) gastrogavage. B16F1 melanoma cells were injected into the mesenteric vein to induce hepatic metastases. Contrary to our postulate, there was greater than 4-fold increase in metastasis in animals with cirrhosis compared to controls. Intravital videomicroscopy showed that the hepatic sinusoids were narrower and more tumor cells were retained in the terminal portal vein (TPV) in cirrhotic livers. Immunohistochemistry demonstrated that the expression of vascular adhesion molecules was significantly increased in cirrhosis. Using confocal microscopy and the fluorescent nitric oxide (NO) probe 4,5-diaminofluorescein diacetate, a significantly lower level of NO release was detected in livers with cirrhosis both in basal conditions and after tumor cell arrest. Eight hours after mesenteric vein tumor cell injection, the percentage of apoptotic tumor cells in the sinusoids was 17% +/- 2% in livers with cirrhosis and 30% +/- 5% in normal livers. More mitotic and Ki-67 labeled tumor cells were seen in livers with cirrhosis. In conclusion, the changes in architecture and adhesion molecule expression in livers with cirrhosis may cause more tumor cells to arrest in the TPV. Lower levels of NO production may reduce apoptosis of B16F1 cells in livers with cirrhosis. As a result, these changes may promote the growth of metastasis in this cirrhotic model.

O.62 The impact of cirrhosis on nutritional intake and macronutrient preference

O.62 The impact of cirrhosis on nutritional intake and macronutrient preference

Impact of cirrhosis on the neuropsychological test performance of alcoholics.

Alcoholics and nonalcoholics with biopsy-proven cirrhosis were compared to each other and to a normal control group on a comprehensive battery of neuropsychological tests. No systematic differences were found between the two liver disease groups. These results indicate that a history of alcoholism does not substantially contribute to the manifest neuropsychological deficits beyond that due to a coexistent hepatic encephalopathy.