Burden of decompensated cirrhosis and ascites on hospital services in a tertiary care facility: time for change?

BACKGROUND: Ascites, the most frequent complication of cirrhosis, is associated with poor prognosis and reduced quality of life. Recurrent hospital admissions are common and often unplanned, resulting in increased use of hospital services. AIMS: To examine use of hospital services by patients with cirrhosis and ascites requiring paracentesis, and to investigate factors associated with early unplanned readmission. METHODS: A retrospective review of the medical chart and clinical databases was performed for patients who underwent paracentesis between October 2011 and October 2012. Clinical parameters at index admission were compared between patients with and without early unplanned hospital readmissions. RESULTS: The 41 patients requiring paracentesis had 127 hospital admissions, 1164 occupied bed days and 733 medical imaging services. Most admissions (80.3%) were for management of ascites, of which 41.2% were unplanned. Of those eligible, 69.7% were readmitted and 42.4% had an early unplanned readmission. Twelve patients died and nine developed spontaneous bacterial peritonitis. Of those eligible for readmission, more patients died (P = 0.008) and/or developed spontaneous bacterial peritonitis (P = 0.027) if they had an early unplanned readmission during the study period. Markers of liver disease, as well as haemoglobin (P = 0.029), haematocrit (P = 0.024) and previous heavy alcohol use (P = 0.021) at index admission, were associated with early unplanned readmission. CONCLUSION: Patients with cirrhosis and ascites comprise a small population who account for substantial use of hospital services. Markers of disease severity may identify patients at increased risk of early readmission. Alternative models of care should be considered to reduce unplanned hospital admissions, healthcare costs and pressure on emergency services.

Assessment of alcohol histories obtained from patients with liver disease: opportunities to improve early intervention.

BACKGROUND: Alcohol is an important primary and comorbid cause of liver injury in patients referred for investigation and management of liver disease. Early assessment and documentation of alcohol consumption is therefore essential, and recommended in both general practice and hospital settings. AIMS: To determine the extent and accuracy of documentation of alcohol consumption in patients referred for evaluation of liver disease. METHODS: Patients were interviewed using a structured questionnaire. The medical records of all patients interviewed were reviewed to obtain information from the referral letter and the hepatology consultations. RESULTS: Eighty-three patients were surveyed. Only 14 referrals had an informative alcohol history, despite 27 patients admitting risky alcohol consumption at the initial hepatology consultation. Ninety per cent of initial consultations had an informative alcohol history documented, whereas only 56% of patients attending a follow-up appointment had informative documentation. Assessment of alcohol consumption was comparable between the hepatology consultation and the structured questionnaire, but four subjects had substantially different alcohol histories. Alcohol Use Disorders Identification Test identified all patients reporting harmful alcohol consumption on the questionnaire. CONCLUSIONS: Hazardous alcohol use is prevalent in subjects attending hepatology clinics, but informative alcohol histories, which are crucial to patient management, are rarely documented in referrals. Screening tools improve documentation and accuracy of alcohol histories, and their use by general practitioners and hospital clinicians would improve detection rates of hazardous drinking and allow earlier intervention. Systematic use of screening tools in hepatology clinics will provide opportunities for education and reinforce recommendations to reduce hazardous or harmful alcohol consumption.

Prolonged confusion following convulsions due to generalized nonconvulsive status epilepticus.

Among patients with a prolonged confusional state after convulsive seizure, we diagnosed 8 cases as generalized nonconvulsive status epilepticus. Six had a history of seizures, and 2 had new onset. The convulsive seizures were generalized in 6 and focal in two. The postictal confusion lasted up to 36 hours in the most prolonged case, and a delayed response to anticonvulsant medications occurred in all cases. The clinical symptoms ranged from mild confusion to coma. Psychiatric manifestations or automatisms were rare. The presumed etiology was due to diverse causes, but a withdrawal state was the most common. EEG demonstrated continuous or nearly continuous generalized ictal discharges of variable morphology. These cases call attention to the fact that some prolonged confusional states following convulsive seizures are in fact due to persistent seizure activity that can be diagnosed by EEG.