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Scoring Systems for Alcoholic Hepatitis
( Patrick S. Kamath ) 대한간학회 2016 춘·추계 학술대회 (KASL) Vol.2016 No.1
Alcoholic hepatitis is associated with a high risk of short-term mortality, between 30-50% at 3 months. Alcoholic hepatitis hasbeen associated with multi-organ failure when superimposed on chronic liver disease, a condition more recently termed, “acuteon chronic liver failure”. Management of the patient with alcoholic hepatitis requires intensive care in those with multiple organfailure; specific treatments aimed at reversing the hepatic injury; and interventions towards alcohol rehabilitation. Corticosteroidsimprove survival at 28 days, though the magnitude of benefit may not be as large as previously believed. Among those patientswho respond to steroids, complete abstinence from alcohol is associated with improved survival at one year. No medical therapyalone is associated with improved survival beyond 6 months, and liver transplantation remains the best option for patients withliver failure who are rehabilitated from alcohol abuse. There is a subset of patients in whom all interventions, either medicalor psychosocial, are futile.In patients with alcoholic hepatitis, the risk for mortality is related to severity of liver disease, the attending complications ofinfection and multiple-organ failure, inflammatory response, histology, risk for continued alcohol abuse, and perhaps geneticpolymorphisms. Identifying whether the course of implemented therapy is having the intended effect is also critical so that thetherapy and its inherent toxicities can be obviated if a benefit is unlikely to be conferred. Such is the example with corticosteroidtherapy whereby initial studies showed that a lack of improvement in bilirubin after one week of therapy indicated futility. Thereis, therefore, the need for accurate risk scores to stratify patients for mortality at both baseline state and at interval times afterinitiation of therapy.Mathurin and colleagues combined static scores (MDF, MELD and ABIC) with a dynamic score (Lille) to determine which combinationhad the best prognostic value. They concluded that the MELD + Lille combination was significantly better than the MDF+ Lille, or ABIC + Lille score in predicting patient survival.
( Patrick S. Kamath ) 대한간학회 2016 춘·추계 학술대회 (KASL) Vol.2016 No.1
There are approximately one million adult patients with congenital heart disease (CHD) in the United States and the numberis increasing. Hepatic complications are common and may occur secondary to persistent chronic passive venous congestion ordecreased cardiac output due to the underlying cardiac disease, or as a result of palliative cardiac surgical procedures performedin infancy or childhood; transfusion or drug related hepatitis may also occur. The unique physiology of Fontan circulation is particularlyprone to development of hepatic complications and is in part related to the duration of the Fontan procedure. Liver biochemicaltest abnormalities may be related to cardiac failure, due to intrinsic liver disease, secondary to palliative interventions,or drug-related. Ascites, hemorrhage from gastro-esophageal varices, portal vein thrombosis, and rarely, hepatocellular carcinomamay also occur. Abnormalities such as hypervascular nodules are often seen; in the presence of cirrhosis surveillance forhepatocellular carcinoma is necessary. Judicious perioperative support is required when cardiac surgery is performed in patientswith advanced hepatic disease. Traditional models for liver disease staging may not fully capture the severity of disease in patientswith CHD. The effectiveness or safety of isolated liver transplantation in patients with significant CHD is limited in adults; combinedheart-liver transplantation may be required in those with decompensated liver disease or hepatocellular carcinoma, butexperience is limited in the presence of significant CHD. The long term sequelae of many reparative cardiac surgical proceduresare not yet fully realized, and understanding the unique and diverse hepatic associations and the role for early cardiac transplantationin this population is critical. As this population continues to grow and age, consideration should be given to developconsensus guidelines for a multidisciplinary approach to optimize management of this vulnerable population.