Cirrhosis and End-Stage Liver Disease

  • James M. Tatum
  • Eric J. Ley


An experienced surgeon always approaches cirrhosis or end-stage liver disease with some trepidation. In the chapter that follows, we review the management of system and specific scenarios encountered while caring for critically ill patients with severe liver disease before and after surgery. The chapter provides a typical intensive care unit system-based approach with more detailed discussions of the management of specific clinical challenges as relevant.


Liver failure Transplantation Hepatitis Cirrhosis Encephalopathy 


  1. 1.
    Child CG, Turcott JGT. Surgery and portal hypertension. In: Child CG, editor. Liver and portal hypertension. Philadelphia: Saunders; 1964.Google Scholar
  2. 2.
    Befeler AS, Palmer DE, Hoffman M, Longo W, Solomon H, Di Biscegli AM. The safety of intra-abdominal surgery in patients with cirrhosis: model for end-stage liver disease score is superior to Child-Turcotte-Pugh classification in predicting outcome. Arch Surg. 2005;140:650–4.CrossRefGoogle Scholar
  3. 3.
    Inaba K, Barmparas G, Resnick S, Browder T, Chan LS, Lam L, et al. The model for end-stage liver disease score. Arch Surg. 2011;146:1074.CrossRefGoogle Scholar
  4. 4.
    Reverter E, Tandon P, Augustin S, Turon F, Casu S, Bastiampillai R, et al. A MELD-based model to determine risk of mortality among patients with acute variceal bleeding. Gastroenterology. 2014;146:412.CrossRefGoogle Scholar
  5. 5.
    Northup PG, Wanamaker RC, Lee VD, Adams RB, Berg CL. Model for end-stage liver disease (MELD) predicts nontransplant surgical mortality in patients with cirrhosis. Ann Surg. 2005;242:244.CrossRefGoogle Scholar
  6. 6.
    Annamalai A, Harada MY, Chen M, Tran T, Ko A, Ley E, et al. Predictors of mortality in the critically ill cirrhotic patient: is the model for end-stage liver disease enough? J Am Coll Surg. 2016;16:1636–42.Google Scholar
  7. 7.
    Dalal A, Lang JD. Anesthesthetic considerations for patients with liver disease. In: Abdeldayem H, editor. Hepatic surgery. Ruheja: InTech; 2013.Google Scholar
  8. 8.
    Guo G, XZ W, LJ S, Yang CQ. Clinical features of ischemic hepatitis caused by shock with four different types: a retrospective study of 328 cases. Int J Clin Exp Med. 2016;8:16670–5.Google Scholar
  9. 9.
    Fouad YM, Yehia R. Hepato-cardiac disorders. World J Hepatol. 2014;27:41–54.CrossRefGoogle Scholar
  10. 10.
    Poelzl G, Auer J. Cardiohepatic syndrome. Curr Heart Fail Rep. 2014;12:68.CrossRefGoogle Scholar
  11. 11.
    Tatum JM, Quinn AM, Genyk YS, Sher LS, Matsuoka LK, Hackman A, et al. Cardiac surgery at the time of simultaneous liver-kidney transplantation. J Curr Surg. 2016;6:37–40. CrossRefGoogle Scholar
  12. 12.
    Bolognesi M. Splanchnic vasodilation and hyperdynamic circulatory syndrome in cirrhosis. World J Gastroenterol. 2014;20:2555.CrossRefGoogle Scholar
  13. 13.
    Ge PS, Runyon BA. Treatment of patients with cirrhosis. N Engl J Med. 2016;375:767.CrossRefGoogle Scholar
  14. 14.
    Chen A, Massoni J, Jung D, Crippin J. Indwelling tunneled catheter for the management of hepatic hydrothorax. A pilot study. Ann Thorac Surg. 2016;13:435–8.Google Scholar
  15. 15.
    Mirrakhimov AE, Ayach T, Gray A. Indwelling tunneled pleural catheter for the management of hepatic hydrothorax: a word of caution. Ann Thorac Surg. 2016;13:1432.Google Scholar
  16. 16.
    Jung Y. Surgical treatment of hepatic hydrothorax: a “four-step approach”. Ann Thorac Surg. 2016;101:1195–7.CrossRefGoogle Scholar
  17. 17.
    Bartoletti M, Giannella M, Caraceni P, Domenicali M, Ambretti S, Tedeschi S, et al. Epidemiology and outcomes of bloodstream infection in patients with cirrhosis. J Hepatol. 2014;61:51.CrossRefGoogle Scholar
  18. 18.
    O’Brien AJ, Fullerton JN, Massey KA, Auld G, Sewell G, James S, et al. Immunosuppression in acutely decompensated cirrhosis is mediated by prostaglandin E2. Nat Med. 2014;20:518.CrossRefGoogle Scholar
  19. 19.
    Hassan EA, El-Rehim ASA, Hassany SM, Ahmed AO, Elsherbiny NM, Mohammed MH. Fungal infection in patients with end-stage liver disease: low frequency or low index of suspicion. Int J Infect Dis. 2014;23:69.CrossRefGoogle Scholar
  20. 20.
    Møller S. Extrahepatic complications to cirrhosis and portal hypertension: haemodynamic and homeostatic aspects. World J Gastroenterol. 2014;20:15499.CrossRefGoogle Scholar
  21. 21.
    Cosarderelioglu C, Cosar AM, Gurakar M, Dagher NN, Gurakar A. Hepatopulmonary syndrome and liver transplantation: a recent review of the literature. J Clin Transl Hepatol. 2016;4:47–53.CrossRefGoogle Scholar
  22. 22.
    Levesque E, Saliba F, Ichaï P, Samuel D. Outcome of patients with cirrhosis requiring mechanical ventilation in ICU. J Hepatol. 2014;60:570.CrossRefGoogle Scholar
  23. 23.
    Lee KC, Chiang AA. THe outcome of terminal liver cirrhosis patients requiring mechanical ventilation. Med J Free China Ed. 1997;1997:88–94.Google Scholar
  24. 24.
    Goldfarb G, Nouel O, Poynard T, Reuff B. Efficiency of respiritory assistance in cirrhotic patients with liver failure. Intensive Care Med. 1983;9:271–3.CrossRefGoogle Scholar
  25. 25.
    Chihara Y. Use of noninvasive ventilation for pediatric patients after liver transplantation: a decrease in the need for reintubation. Liver Transpl. 18:1217–5.Google Scholar
  26. 26.
    Karcz M, Schwaiberger D, Lachmann B, Papadakos PJ. Acute respiratory failure complicating advanced liver disease. Semin Respir Crit Care Med. 2012;33:96–110.CrossRefGoogle Scholar
  27. 27.
    Plauth M, Cabré E, Riggio O, Assis-Camilo M, Pirlich M, Kondrup J, et al. ESPEN guidelines on enteral nutrition: liver disease. Clin Nutr. 2006;25:285.CrossRefGoogle Scholar
  28. 28.
    Galloway AC, Schwartz CF, Ribakove GH, Crooke GA, Gogoladze G, Ursomanno P, et al. A decade of minimally invasive mitral repair: long-term outcomes. Ann Thorac Surg. 2009;88:1180.CrossRefGoogle Scholar
  29. 29.
    Kalaitzakis E. Gastrointestinal dysfunction in liver cirrhosis. World J Gastroenterol. 2014;20:14686.CrossRefGoogle Scholar
  30. 30.
    Koretz RL, Avenell A, Lipman TO. Nutritional support for liver disease. Cochrane Database Syst Rev. 2012;(5):CD008344.Google Scholar
  31. 31.
    Benjamin J, Singla V, Arora I, Sood S, Joshi YK. Intestinal permeability and complications in liver cirrhosis: a prospective cohort study. Hepatol Res. 2012;43:200.CrossRefGoogle Scholar
  32. 32.
    Jakubczyk M, Różowicz A, Spychalska K, Nakonowska B, Kupczyk K, Kusza K. Analysis of occurrence of bacteraemia with pathogens from gastrointestinal tract in patients fed parenterally and enterally in the intensive care unit. Gastroenterol Rev. 2016;2:127.CrossRefGoogle Scholar
  33. 33.
    Kim JJ, Tsukamoto MM, Mathur AK, Ghomri YM, Hou LA, Sheibani S, et al. Delayed paracentesis is associated with increased in-hospital mortality in patients with spontaneous bacterial peritonitis. Am J Gastroenterol. 2014;109:1436.CrossRefGoogle Scholar
  34. 34.
    Runyon BA. Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis 2012. Hepatology. 2013;57:1651.CrossRefGoogle Scholar
  35. 35.
    Nasr G, Hassan A, Ahmed S, Serwah A. Predictors of large volume paracentesis induced circulatory dysfunction in patients with massive hepatic ascites. J Cardiovasc Dis Res. 2010;1:136.CrossRefGoogle Scholar
  36. 36.
    Kathpalia P, Bhatia A, Robertazzi S, Ahn J, Cohen SM, Sontag S, et al. Indwelling peritoneal catheters in patients with cirrhosis and refractory ascites. Intern Med J. 2015;45:1026.CrossRefGoogle Scholar
  37. 37.
    Belghiti J, Durand F. Abdominal wall hernia in the setting of cirrhosis. Semin Liver Dis. 1997;17:219–26.CrossRefGoogle Scholar
  38. 38.
    Carbonell AM, Wolfe LG, DeMaria EJ. Poor outcomes in cirrhosis-associated hernia repair: a nationwide cohort study of 32,033 patients. Hernia. 2005;9:353.CrossRefGoogle Scholar
  39. 39.
    Coelho JC, Claus CM, Campos AC, Costa MA, Blum C. Umbilical hernia in patients with liver cirrhosis: a surgical challenge. World J Gastrointest Surg. 2016;8:476.CrossRefGoogle Scholar
  40. 40.
    Curro G. Percutaneous gall bladder aspiration as an alternative to laparoscopic cholecystectomy in Child-Pugh C cirrhotic patients with acute cholecystitis. Gut. 2006;55:898.CrossRefGoogle Scholar
  41. 41.
    Delis S, Bakoyiannis A, Madariaga J, Bramis J, Tassopoulos N, Dervenis C. Laparoscopic cholecystectomy in cirrhotic patients: the value of MELD score and Child–Pugh classification in predicting outcome. Surg Endosc. 2009;24:407.CrossRefGoogle Scholar
  42. 42.
    Hall J, Singh G, Hood D, Mateo R, Weaver F, Selby R, et al. Management of an abdominal aortic aneurysm in a patient with end-stage liver disease. Am J Transplant. 2004;4:666.CrossRefGoogle Scholar
  43. 43.
    Sabbagh C, Chatelain D, Nguyen-Khac E, Rebibo L, Joly J-P, Regimbeau J-M. Management of colorectal cancer in patients with cirrhosis: a retrospective, case-matched study of short- and long-term outcomes. Dig Liver Dis. 2016;48:429.CrossRefGoogle Scholar
  44. 44.
    D'Amico G. Upper digestive bleeding in cirrhosis. Post-therapeutic outcome and prognostic indicators. Hepatology. 2003;38:599.CrossRefGoogle Scholar
  45. 45.
    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.CrossRefGoogle Scholar
  46. 46.
    de Franchis R. Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol. 2010;53:762.CrossRefGoogle Scholar
  47. 47.
    O’Leary JG, Reddy KR, Wong F, Kamath PS, Patton HM, Biggins SW, et al. Long-term use of antibiotics and proton pump inhibitors predict development of infections in patients with cirrhosis. Clin Gastroenterol Hepatol. 2015;13:753.CrossRefGoogle Scholar
  48. 48.
    McCarty TR, Njei B. Self-expanding metal stents for acute refractory esophageal variceal bleeding: a systematic review and meta-analysis. Dig Endosc. 2016;28:539.CrossRefGoogle Scholar
  49. 49.
    Ginès P, Schrier RW. Renal failure in cirrhosis. N Engl J Med. 2009;361:1279.CrossRefGoogle Scholar
  50. 50.
    Restuccia T, Ortega R, Guevara M, Ginès P, Alessandria C, Ozdogan O, et al. Effects of treatment of hepatorenal syndrome before transplantation on posttransplantation outcome. A case-control study. J Hepatol. 2004;40:140.CrossRefGoogle Scholar
  51. 51.
    Schepke M, Appenrodt B, Heller J, Zielinski J, Sauerbruch T. Prognostic factors for patients with cirrhosis and kidney dysfunction in the era of MELD: results of a prospective study. Liver Int. 2006;26:834.CrossRefGoogle Scholar
  52. 52.
    Alessandria C, Ozdogan O, Guevara M, Restuccia T, Jiménez W, Arroyo V, et al. MELD score and clinical type predict prognosis in hepatorenal syndrome: relevance to liver transplantation. Hepatology. 2005;41:1282.CrossRefGoogle Scholar
  53. 53.
    Lloyd-Donald P, Vasudevan A, Angus P, Gow P, Mårtensson J, Glassford N, et al. Coagulation in acutely ill patients with severe chronic liver disease: insights from thromboelastography. J Crit Care. 2017;38:215.CrossRefGoogle Scholar
  54. 54.
    Tripodi A, Anstee QM, Sogaard KK, Primignani M, Valla DC. Hypercoagulability in cirrhosis: causes and consequences. J Thromb Haemost. 2011;9:1713.CrossRefGoogle Scholar
  55. 55.
    Rodríguez-Castro KI. Spontaneous bleeding or thrombosis in cirrhosis: what should be feared the most? World J Hepatol. 2015;7:1818.CrossRefGoogle Scholar
  56. 56.
    Raja K, Jacob M, Asthana S. Portal vein thrombosis in cirrhosis. J Clin Exp Hepatol. 2014;4:320.CrossRefGoogle Scholar
  57. 57.
    Aggarwal A. Deep vein thrombosis and pulmonary embolism in cirrhotic patients: systematic review. World J Gastroenterol. 2014;20:5737.CrossRefGoogle Scholar
  58. 58.
    Harding DJ, Perera MT, Frederick C, Olliff S, Tripathi D. Portal vein thrombosis in cirrhosis: controversies and latest developments. World J Gastroenterol. 2015;21:6769–84.CrossRefGoogle Scholar
  59. 59.
    Shatzel J, Dulai PS, Harbin D, Cheung H, Reid TN, Kim J, et al. Safety and efficacy of pharmacological thromboprophylaxis for hospitalized patients with cirrhosis: a single-center retrospective cohort study. J Thromb Haemost. 2015;13:1245.CrossRefGoogle Scholar
  60. 60.
    Intagliata NM, Henry ZH, Shah N, Lisman T, Caldwell SH, Northup PG. Prophylactic anticoagulation for venous thromboembolism in hospitalized cirrhosis patients is not associated with high rates of gastrointestinal bleeding. Liver Int. 2013;34:26.CrossRefGoogle Scholar
  61. 61.
    Georgiou C, Inaba K, Teixeira PGR, Hadjizacharia P, Chan LS, Brown C, et al. Cirrhosis and trauma are a lethal combination. World J Surg. 2009;33:1087.CrossRefGoogle Scholar
  62. 62.
    Tapper EB, Halbert B, Mellinger J. Rates of and reasons for hospital readmissions in patients with cirrhosis: a multistate population-based cohort study. Clin Gastroenterol Hepatol. 2016;14:1181.CrossRefGoogle Scholar
  63. 63.
    Volk ML, Tocco RS, Bazick J, Rakoski MO, Lok AS. Hospital readmissions among patients with decompensated cirrhosis. Am J Gastroenterol. 2011;107:247.CrossRefGoogle Scholar
  64. 64.
    Tapper EB, Finkelstein D, Mittleman MA, Piatkowski G, Chang M, Lai M. A quality improvement initiative reduces 30-day rate of readmission for patients with cirrhosis. Clin Gastroenterol Hepatol. 2016;14:753.CrossRefGoogle Scholar
  65. 65.
    Tatum JM, Barmparas G, Ko A, Dhillon N, Smith E, Margulies DR, Ley EJ. Analysis of survival after initiation of continuous renal replacement therapy in a surgical intensive care unit. JAMA Surg. 2017. [Epub ahead of print] PubMed PMID: 28636702
  66. 66.
    Pugh RN, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg. 1973;60:646–9.CrossRefGoogle Scholar
  67. 67.
    Kamath PS, Wiesner RH, Malinchoc M, Kremers W, Therneau TM, Kosberg CL, et al. A model to predict survival in patients with end-stage liver disease. Hepatology. 2001;33(2):464–70.CrossRefGoogle Scholar
  68. 68.
    Biggins SW, Kim WR, Terrault NA, Saab S, Balan V, Schiano T, et al. Evidence-based incorporation of serum sodium concentration into MELD. Gastroenterology. 2006;130(6):1652–60.CrossRefGoogle Scholar
  69. 69.
    United Network for Organ Sharing (UNOS). Calculators. Accessed 11 July 2017. Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of SurgeryCedars-Sinai Medical CenterLos AngelesUSA

Personalised recommendations