Podcast 528:  Decompensated Liver Failure 

<p><strong>Contributor: Michael Hunt, MD</strong></p> <p><strong>Educational Pearls:</strong></p> <ul> <li style="font-weight: 400;"><span style= "font-weight: 400;">Cirrhosis is the end stage of chronic structural damage to the liver. This is most commonly due to  alcohol but other causes viral hepatitis and hepatotoxic drugs</span></li> <li style="font-weight: 400;"><span style= "font-weight: 400;">Cirrhotic patients are very prone to GI bleeding and infections, partially due to the role the liver plays in producing immune and clotting factors</span></li> <li style="font-weight: 400;"><span style="font-weight: 400;">These patients can easily become “sick”. Use the shock index (heart rate / systolic blood pressure) as a rapid assessment of hemodynamic status. >0.7 is worrisome, >1 should prompt resuscitation. </span></li> <li style="font-weight: 400;"><span style= "font-weight: 400;">Because cirrhotic patients are immunocompromised, do not rely on the presence of fever and peritonitis to diagnose spontaneous bacterial peritonitis (SBP), and have a low threshold to perform a diagnostic paracentesis</span></li> <li style="font-weight: 400;"><span style= "font-weight: 400;">Polymorphonuclear (PMN)</span> <span style= "font-weight: 400;">count > 250 in the ascitic fluid suggests SBP</span></li> <li style="font-weight: 400;"><span style="font-weight: 400;">With GI bleeding in cirrhotics, antibiotics have a mortality benefit, while PPIs and octreotide have limited benefit</span></li> </ul> <p><strong>References</strong></p> <p><span style="font-weight: 400; font-size: 10pt;">Chinnock B, Hendey GW, Minnigan H, Butler J, Afarian H. Clinical impression and ascites appearance do not rule out bacterial peritonitis. J Emerg Med. 2013 May;44(5):903-9. doi: 10.1016/j.jemermed.2012.07.086. Epub 2013 Mar 7.</span></p> <p><span style="font-weight: 400; font-size: 10pt;">Pericleous M, Sarnowski A, Moore A, Fijten R, Zaman M. The clinical management of abdominal ascites, spontaneous bacterial peritonitis and hepatorenal syndrome: