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Severity of liver failure determines mortality in patients with cirrhosis, variceal bleeding

While standard treatment effectively controlled variceal bleeding, mortality rates were high among patients with variceal bleeding and severe liver failure in a recent study.

In a prospective analysis, researchers evaluated 185 patients admitted to a medical facility with cirrhosis and variceal bleeding. Patients underwent endoscopy within 12 hours of admission, were treated for bleeding and received somatostatin for 72 hours and 7 days of antibiotics. Incidence of 5-day failure, defined as death, rebleeding or uncontrolled bleeding within 5 days of admission, was recorded.

Within the cohort, 78.3% had advanced liver disease (Child-Pugh class B or C), 28.1% had hepatocellular carcinoma (HCC) and 17.3% had portal vein thrombosis (PVT). Band ligation was performed in 171 patients, while five patients received Sengstaken-Blakemore tubes or transjugular intrahepatic portosystemic shunts because of uncontrolled bleeding.

Five-day failure occurred in 16.8% of patients, including 3.2% who experienced uncontrolled bleeding and 4.5% who experienced early rebleeding. Death because of 5-day failure occurred in 14.6% of participants, with common causes including bleeding (eight patients), hypoxic hepatitis (four patients) and liver failure (nine patients). More patients with Child-Pugh class C died (16 patients, 43.2%) than those with class B (10 patients, 9.2%) and A (one patient, 2.5%).

Multivariate analysis indicated that a white blood cell count greater than 10.3 x 109/L (OR=8.679, 2.646-28.468), Child-Pugh class C (OR=13.627, 4.257-43.623) and PVT (OR=2.942, 0.884-9.790) were independently predictive of 5-day failure (95% CI for all). Investigators also noted that patients with Child-Pugh class C who had PVT, advanced HCC, white blood cell counts greater than 10.3 x 109/L and/or creatinine levels greater than 3 mg/dL were more likely to experience 5-day failure (P=.04) and more likely to die after 6 weeks (P=.013) than patients with class C without these factors.

“The current standard of care is highly effective to control variceal bleeding, even in patients at high risk,” the researchers concluded. “The severity of liver failure is the main determinant of the acute outcome in bleeding patients. Further evaluation of alternative treatments to reduce early mortality despite bleeding control in patients with moderate to advanced liver impairment should be conducted.”