Notfallmedizinisch relevante Komplikationen der Leberzirrhose

Aufgrund der zunehmenden Inzidenz der Leberzirrhose [1] in den letzten Jahren stellt die dekompensierte Leberzirrhose einen häufigen Grund für eine Vorstellung in einer Notaufnahme dar. Wegen des breiten Spektrums an möglichen Akutkomplikationen, die frühzeitig erkannt und adäquat anbehandelt werden müssen, ist ein strukturiertes Vorgehen für eine erfolgreiche Therapie essenziell.

Kernaussagen

• Die Leberzirrhose ist eine chronische Lebererkrankung mit steigender Prävalenz, die durch die vielfältige Ausprägung ihrer Komplikationen eine Herausforderung in der Notfallversorgung darstellen kann.

• Ein gutes Verständnis der Pathophysiologie hilft, die relevanten Akutkomplikationen als solche zu erkennen.

• Aufgabe der Notfallmedizin ist es, die richtigen diagnostischen Schritte zu gehen und die Akutbehandlung einzuleiten.

• Über die unmittelbare Akutbehandlung hinaus ist die Anbahnung einer strukturierten Betreuung erforderlich, um wiederholte und prognostisch relevante Komplikationen zu vermeiden.

• Zudem ist die besondere Situation von betroffenen Patienten zu berücksichtigen, die durch sozioökonomische Faktoren wie auch ein dem Krankheitsbild der Leberzirrhose anhaftendes Stigma häufig einen erschwerten Zugang zu unserem Gesundheitssystem haben.

Schlüsselwörter

Hepatopathie - Lebererkrankungen - Blutung - Peritonitis - akut-auf-chronisches Leberversagen - portale Hypertension

Publication History

Article published online:
25 June 2024

• Literatur

• 1 Ginès P, Krag A, Abraldes JG. et al. Liver cirrhosis. Lancet 2021; 398: 1359-1376 DOI: 10.1016/S0140-6736(21)01374-X. (PMID: 34543610)
• 2 D’Amico G, Morabito A, D’Amico M. et al. Clinical states of cirrhosis and competing risks. J Hepatol 2018; 68: 563-576 DOI: 10.1016/j.jhep.2017.10.020. (PMID: 29111320)
• 3 Moreau R, Jalan R, Gines P. et al. Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis. Gastroenterology 2013; 144: 1426-1437 DOI: 10.1053/j.gastro.2013.02.042. (PMID: 23474284)
• 4 de Franchis R, Bosch J, Garcia-Tsao G. et al. Baveno VII – Renewing consensus in portal hypertension. J Hepatol 2022; 76: 959-974 DOI: 10.1016/j.jhep.2021.12.022. (PMID: 35120736)
• 5 European Association for the Study of the Liver. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol 2018; 69: 406-460 DOI: 10.1016/j.jhep.2018.03.024. (PMID: 29653741)
• 6 Kovalak M, Lake J, Mattek N. et al. Endoscopic screening for varices in cirrhotic patients: data from a national endoscopic database. Gastrointest Endosc 2007; 65: 82-88 DOI: 10.1016/j.gie.2006.08.023. (PMID: 17185084)
• 7 Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten e. V. (DGVS). S2k-Leitlinie Gastrointestinale Blutung. AWMF-Register Nr. 021–28. Version 1.0. 31.05.2017 Accessed May 06, 2024 at: https://register.awmf.org/de/leitlinien/detail/021–028
• 8 Huaringa-Marcelo J, Huaman MR, Brañez-Condorena A. et al. Vasoactive agents for the management of acute variceal bleeding: a systematic review and meta-analysis. J Gastrointestin Liver Dis 2021; 30: 110-121 DOI: 10.15403/jgld-3191. (PMID: 33723542)
• 9 Lisman T, Hernandez-Gea V, Magnusson M. et al. The concept of rebalanced hemostasis in patients with liver disease: communication from the ISTH SSC working group on hemostatic management of patients with liver disease. J Thromb Haemost 2021; 19: 1116-1122 DOI: 10.1111/jth.15239. (PMID: 33792172)
• 10 Tripodi A, Salerno F, Chantarangkul V. et al. Evidence of normal thrombin generation in cirrhosis despite abnormal conventional coagulation tests. Hepatology 2005; 41: 553-558 DOI: 10.1002/hep.20569. (PMID: 15726661)
• 11 O’Leary JG, Greenberg CS, Patton HM. et al. AGA clinical practice update: coagulation in cirrhosis. Gastroenterology 2019; 157: 34-43.e1 DOI: 10.1053/j.gastro.2019.03.070.
• 12 Lee YY, Tee H-P, Mahadeva S. Role of prophylactic antibiotics in cirrhotic patients with variceal bleeding. World J Gastroenterol 2014; 20: 1790-1796 DOI: 10.3748/wjg.v20.i7.1790. (PMID: 24587656)
• 13 Tsai CF, Chen MH, Wang YP. et al. Proton pump inhibitors increase risk for hepatic encephalopathy in patients with cirrhosis in a population study. Gastroenterology 2017; 152: 134-141 DOI: 10.1053/j.gastro.2016.09.007. (PMID: 27639806)
• 14 Gralnek IM, Camus Duboc M, Garcia-Pagan JC. et al. Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2022; 54: 1094-1120 DOI: 10.1055/a-1939-4887. (PMID: 36174643)
• 15 Mangas-Sanjuan C, Martínez-Moreno B, Bozhychko M. et al. Over-the-scope clip for acute esophageal variceal bleeding. Dig Endosc 2019; 31: 712-716 DOI: 10.1111/den.13493. (PMID: 31330068)
• 16 Bettinger D, Thimme R, Schultheiß M. Implantation of transjugular intrahepatic portosystemic shunt (TIPS): indication and patient selection. Curr Opin Gastroenterol 2022; 38: 221-229 DOI: 10.1097/MOG.0000000000000831. (PMID: 35471813)
• 17 Azoulay D, Castaing D, Majno P. et al. Salvage transjugular intrahepatic portosystemic shunt for uncontrolled variceal bleeding in patients with decompensated cirrhosis. J Hepatol 2001; 35: 590-597 DOI: 10.1016/s0168-8278(01)00185-4. (PMID: 11690704)
• 18 Maimone S, Saffioti F, Filomia R. et al. Predictors of re-bleeding and mortality among patients with refractory variceal bleeding undergoing salvage transjugular intrahepatic portosystemic shunt (TIPS). Dig Dis Sci 2019; 64: 1335-1345 DOI: 10.1007/s10620-018-5412-x. (PMID: 30560334)
• 19 Nicoară-Farcău O, Han G, Rudler M. et al. Pre-emptive TIPS in high-risk acute variceal bleeding. An updated and revised individual patient data meta-analysis. Hepatology 2023; 79: 624-635 DOI: 10.1097/HEP.0000000000000613. (PMID: 37782566)
• 20 Trebicka J, Gu W, Ibáñez-Samaniego L. et al. Rebleeding and mortality risk are increased by ACLF but reduced by pre-emptive TIPS. J Hepatol 2020; 73: 1082-1091 DOI: 10.1016/j.jhep.2020.04.024. (PMID: 32339602)
• 21 Hernández-Gea V, Procopet B, Giráldez Á. et al. Preemptive-TIPS improves outcome in high-risk variceal bleeding: an observational study. Hepatology 2019; 69: 282-293 DOI: 10.1002/hep.30182. (PMID: 30014519)
• 22 Lv Y, Yang Z, Liu L. et al. Early TIPS with covered stents versus standard treatment for acute variceal bleeding in patients with advanced cirrhosis: a randomised controlled trial. Lancet Gastroenterol Hepatol 2019; 4: 587-598 DOI: 10.1016/S2468-1253(19)30090-1. (PMID: 31153882)
• 23 García-Pagán JC, Caca K, Bureau C. et al. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med 2010; 362: 2370-2379 DOI: 10.1056/NEJMoa0910102. (PMID: 20573925)
• 24 Ferenci P, Lockwood A, Mullen K. et al. Hepatic encephalopathy--definition, nomenclature, diagnosis, and quantification: final report of the working party at the 11th World Congresses of Gastroenterology, Vienna, 1998. Hepatology 2002; 35: 716-721 DOI: 10.1053/jhep.2002.31250. (PMID: 11870389)
• 25 Labenz C, Wörns MA, Schattenberg JM. et al. Epidemiology of hepatic encephalopathy in german hospitals – the EpHE study. Z Gastroenterol 2017; 55: 741-747 DOI: 10.1055/s-0043-114671. (PMID: 28701025)
• 26 Poordad FF. Review article: the burden of hepatic encephalopathy. Aliment Pharmacol Ther 2007; 25 (Suppl. 1) 3-9 DOI: 10.1111/j.1746-6342.2006.03215.x. (PMID: 17295846)
• 27 Vilstrup H, Amodio P, Bajaj J. et al. Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver. Hepatology 2014; 60: 715-735 DOI: 10.1002/hep.27210. (PMID: 25042402)
• 28 Festi D, Vestito A, Mazzella G. et al. Management of hepatic encephalopathy: focus on antibiotic therapy. Digestion 2006; 73 (Suppl. 1) 94-101 DOI: 10.1159/000089784. (PMID: 16498257)
• 29 Piano S, Brocca A, Mareso S. et al. Infections complicating cirrhosis. Liver Int 2018; 38 (Suppl. 1) 126-133 DOI: 10.1111/liv.13645. (PMID: 29427501)
• 30 Rimola A, García-Tsao G, Navasa M. et al. Diagnosis, treatment and prophylaxis of spontaneous bacterial peritonitis: a consensus document. International Ascites Club. J Hepatol 2000; 32: 142-153 DOI: 10.1016/s0168-8278(00)80201-9. (PMID: 10673079)
• 31 Fernández J, Navasa M, Gómez J. et al. Bacterial infections in cirrhosis: epidemiological changes with invasive procedures and norfloxacin prophylaxis. Hepatology 2002; 35: 140-148 DOI: 10.1053/jhep.2002.30082. (PMID: 11786970)
• 32 Long B, Koyfman A. The emergency medicine evaluation and management of the patient with cirrhosis. Am J Emerg Med 2018; 36: 689-698 DOI: 10.1016/j.ajem.2017.12.047. (PMID: 29290508)
• 33 Ginés P, Quintero E, Arroyo V. et al. Compensated cirrhosis: natural history and prognostic factors. Hepatology 1987; 7: 122-128 DOI: 10.1002/hep.1840070124. (PMID: 3804191)
• 34 D’Amico G, Garcia-Tsao G, Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies. J Hepatol 2006; 44: 217-231 DOI: 10.1016/j.jhep.2005.10.013. (PMID: 16298014)
• 35 Schrier RW, Arroyo V, Bernardi M. et al. Peripheral arterial vasodilation hypothesis: a proposal for the initiation of renal sodium and water retention in cirrhosis. Hepatology 1988; 8: 1151-1157 DOI: 10.1002/hep.1840080532. (PMID: 2971015)
• 36 Ripoll C, Groszmann R, Garcia-Tsao G. et al. Hepatic venous pressure gradient predicts clinical decompensation in patients with compensated cirrhosis. Gastroenterology 2007; 133: 481-488 DOI: 10.1053/j.gastro.2007.05.024. (PMID: 17681169)
• 37 Moore KP, Wong F, Gines P. et al. The management of ascites in cirrhosis: report on the consensus conference of the International Ascites Club. Hepatology 2003; 38: 258-266 DOI: 10.1053/jhep.2003.50315. (PMID: 12830009)
• 38 Arroyo V, Ginès P, Gerbes AL. et al. Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis. International Ascites Club. Hepatology 1996; 23: 164-176 DOI: 10.1002/hep.510230122. (PMID: 8550036)
• 39 Runyon BA, Montano AA, Akriviadis EA. et al. The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites. Ann Intern Med 1992; 117: 215-220 DOI: 10.7326/0003-4819-117-3-215. (PMID: 1616215)
• 40 Fernández-Esparrach G, Guevara M, Sort P. et al. Diuretic requirements after therapeutic paracentesis in non-azotemic patients with cirrhosis. A randomized double-blind trial of spironolactone versus placebo. J Hepatol 1997; 26: 614-620 DOI: 10.1016/s0168-8278(97)80427-8. (PMID: 9075669)
• 41 Lin CH, Shih FY, Ma MH. et al. Should bleeding tendency deter abdominal paracentesis?. Dig Liver Dis 2005; 37: 946-951 DOI: 10.1016/j.dld.2005.07.009. (PMID: 16185942)
• 42 Rondon-Berrios H, Velez JCQ. Hyponatremia in cirrhosis. Clin Liver Dis 2022; 26: 149-164 DOI: 10.1016/j.cld.2022.01.001. (PMID: 35487602)
• 43 Kim WR, Biggins SW, Kremers WK. et al. Hyponatremia and mortality among patients on the liver-transplant waiting list. N Engl J Med 2008; 359: 1018-1026 DOI: 10.1056/NEJMoa0801209. (PMID: 18768945)
• 44 Spasovski G, Vanholder R, Allolio B. et al. Clinical practice guideline on diagnosis and treatment of hyponatraemia. Nephrol Dial Transplant 2014; 29 (Suppl. 2) i1-i39 DOI: 10.1530/EJE-13-1020. (PMID: 24569125)
• 45 Ginès P, Schrier RW. Renal failure in cirrhosis. N. Engl. J Med 2009; 361: 1279-1290 DOI: 10.1056/NEJMra0809139. (PMID: 19776409)
• 46 Fasolato S, Angeli P, Dallagnese L. et al. Renal failure and bacterial infections in patients with cirrhosis: epidemiology and clinical features. Hepatology 2007; 45: 223-229 DOI: 10.1002/hep.21443. (PMID: 17187409)
• 47 Garcia-Tsao G, Parikh CR, Viola A. Acute kidney injury in cirrhosis. Hepatology 2008; 48: 2064-2077 DOI: 10.1002/hep.22605. (PMID: 19003880)
• 48 Nadim MK, Kellum JA, Forni L. et al. Acute kidney injury in patients with Cirrhosis: Acute disease quality Initiative (ADQI) and international Club of ascites (ICA) joint multidisciplinary consensus meeting. J Hepatol 2024; 71 DOI: 10.1016/j.jhep.2024.03.031.
• 49 Salerno F, Gerbes A, Ginès P. et al. Diagnosis, prevention and treatment of hepatorenal syndrome in cirrhosis. Gut 2007; 56: 1310-1318 DOI: 10.1136/gut.2006.107789. (PMID: 17389705)
• 50 Cavallin M, Piano S, Romano A. et al. Terlipressin given by continuous intravenous infusion versus intravenous boluses in the treatment of hepatorenal syndrome: a randomized controlled study. Hepatology 2016; 63: 983-992 DOI: 10.1002/hep.28396. (PMID: 26659927)
• 51 Gluud LL, Christensen K, Christensen E. et al. Terlipressin for hepatorenal syndrome. Cochrane Database Syst Rev 2012; (09) CD005162 DOI: 10.1002/14651858.CD005162.pub3. (PMID: 22972083)
• 52 European Medicines Agency (EMA). New recommendations for terlipressin-containing medicines in the treatment of hepatorenal syndrome. 30.09.2022 Accessed April 15, 2024 at: https://www.ema.europa.eu/en/news/new-recommendations-terlipressin-containing-medicines-treatment-hepatorenal-syndrome
• 53 Arroyo V, Moreau R, Jalan R. Acute-on-chronic liver failure. N Engl J Med 2020; 382: 2137-2145 DOI: 10.1056/NEJMra1914900. (PMID: 32459924)
• 54 Jalan R, Saliba F, Pavesi M. et al. Development and validation of a prognostic score to predict mortality in patients with acute-on-chronic liver failure. J Hepatol 2014; 61: 1038-1047 DOI: 10.1016/j.jhep.2014.06.012. (PMID: 24950482)
• 55 European Association for the Study of the Liver. EASL Clinical Practice Guidelines on acute-on-chronic liver failure. J Hepatol 2023; 79: 461-491 DOI: 10.1016/j.jhep.2023.04.021. (PMID: 37364789)
• 56 Nardelli S, Gioia S, Ridola L. et al. Proton pump inhibitors are associated with minimal and overt hepatic encephalopathy and increased mortality in patients with cirrhosis. Hepatology 2019; 70: 640-649 DOI: 10.1002/hep.30304. (PMID: 30289992)
• 57 Sturm L, Gahm C, Schultheiss M. et al. Proton pump inhibitor treatment is associated with acute-on-chronic liver failure in patients with advanced cirrhosis. Hepatol Commun 2023; 7: e00178 DOI: 10.1097/HC9.0000000000000178. (PMID: 37347229)
• 58 Sturm L, Bettinger D, Giesler M. et al. Treatment with proton pump inhibitors increases the risk for development of hepatic encephalopathy after implantation of transjugular intrahepatic portosystemic shunt (TIPS). United European Gastroenterol J 2018; 6: 1380-1390 DOI: 10.1177/2050640618795928. (PMID: 30386611)
• 59 Marot A, Trépo E, Doerig C. et al. Systematic review with meta-analysis: self-expanding metal stents in patients with cirrhosis and severe or refractory oesophageal variceal bleeding. Aliment Pharmacol Ther 2015; 42: 1250-1260 DOI: 10.1111/apt.13424. (PMID: 26472616)
• 60 Sauerbruch T, Mengel M, Dollinger M. et al. Prevention of rebleeding from esophageal varices in patients with cirrhosis receiving small-diameter stents versus hemodynamically controlled medical therapy. Gastroenterology 2015; 149: 660-668.e1 DOI: 10.1053/j.gastro.2015.05.011. (PMID: 25989386)
• 61 Rudler M, Hernández-Gea V, Procopet BD. et al. Hepatic encephalopathy is not a contraindication to pre-emptive TIPS in high-risk patients with cirrhosis with variceal bleeding. Gut 2023; 72: 749-758 DOI: 10.1136/gutjnl-2022-326975. (PMID: 36328772)
• 62 Riggio O, Ridola L, Pasquale C. Hepatic encephalopathy therapy: an overview. World J Gastrointest Pharmacol Ther 2010; 1: 54-63 DOI: 10.4292/wjgpt.v1.i2.54. (PMID: 21577297)
• 63 Piano S, Singh V, Caraceni P. et al. Epidemiology and effects of bacterial infections in patients with cirrhosis worldwide. Gastroenterology 2019; 156: 1368-1380.e10 DOI: 10.1053/j.gastro.2018.12.005. (PMID: 30552895)
• 64 Jalan R, Fernandez J, Wiest R. et al. Bacterial infections in cirrhosis: a position statement based on the EASL Special Conference 2013. J Hepatol 2014; 60: 1310-1324 DOI: 10.1016/j.jhep.2014.01.024. (PMID: 24530646)
• 65 Evans LT, Kim WR, Poterucha JJ. et al. Spontaneous bacterial peritonitis in asymptomatic outpatients with cirrhotic ascites. Hepatology 2003; 37: 897-901 DOI: 10.1053/jhep.2003.50119. (PMID: 12668984)
• 66 Navasa M, Follo A, Llovet JM. et al. Randomized, comparative study of oral ofloxacin versus intravenous cefotaxime in spontaneous bacterial peritonitis. Gastroenterology 1996; 111: 1011-1017 DOI: 10.1016/s0016-5085(96)70069-0. (PMID: 8831596)
• 67 Grant P, Ayuk J, Bouloux PM. et al. The diagnosis and management of inpatient hyponatraemia and SIADH. Eur J Clin Invest 2015; 45: 888-894 DOI: 10.1111/eci.12465. (PMID: 25995119)
• 68 Agency for Healthcare Research and Quality. Six domains of healthcare quality. 2022 Accessed April 15, 2024 at: https://www.ahrq.gov/talkingquality/measures/six-domains.html