Early paracentesis in decompensated cirrhosis
As I write this piece, the newspaper front pages are in overdrive over the spread of Coronovirus from central China. There has been talk of military evacuations of Brits in high incidence regions. The medical registrar WhatsApp group at my hospital is replete with protocols to follow should we encounter a suspected carrier.
Understandably there are some voices muttered from the side lines that perhaps some of this is a touch overblown; policy based on panic rather than actual risk. Time will tell…
Yet it is a common trait of human nature to base our risk assessments on a variety of subjective experiences rather than objective actuarial analyses, often shaped by multiple subconscious influences ‘nudging’ us in a particular direction. Classically, the immediate and novel will be disproportionately weighted over the distant and old. Therefore a new, contagious virus from a far off land suddenly seems terrifying, whereas the threat of, say, mass antimicrobial resistance and what this means for our antibiotic prescribing seems a bit dry and a problem for another day.
This latter issue also falls foul of another bias in our risk assessments: the individual trumping the statistic. When it comes to our use of antibiotics, we would always err on the side of treating, fearing a missed infection in the individual before us over a larger, more distant problem of resistance from which we remain somewhat disconnected.
In a roundabout way this brings me to our use of antibiotics in patients with liver disease. Patients with decompensated cirrhosis are at significantly increased risk of severe sepsis, and rightly we tend to be very concerned about infection and set a low threshold for antibiotic treatment. But while I spend a lot of time worrying about the deteriorating patient in front of me, I also fear the extent to which as a specialty we are contributing to the very real problem of antibiotic resistance through our use of antibiotics.
A basic but vital means of rationalising our prescribing is timely and appropriate sampling for culture, and therefore I recommend reading the QIP published by Jesudian and colleagues in the current issue of Frontline Gastroenterology. They aimed to increase the rates of early diagnostic paracentesis (‘Ascitic tap’) ie within 12 hours, of patients admitted acutely with decompensated cirrhosis. The rationale for the project was some evidence in past studies showing this improves survival, and indeed this practice is recommended in the BASL Cirrhosis bundle. However, I would say that survival benefit of early sampling is difficult to robustly demonstrate (in the referenced study, survival benefit was lost after adjustment for confounders), and that this is really a secondary issue. Because of the threat of resistant bacteria, we should be making every effort to take blood and ascetic cultures before initiating broad spectrum antibiotics, increasing the chance of subsequent narrowing down once sensitivities are obtained.
The intervention in the study was very straightforward: posters in A&E, some training sessions and kits available in the department to perform the tap (in my view they provided more than enough- a green needle and 10ml syringe is enough!). Targeting A&E makes sense, as there is generally an ultrasound machine readily available to assist the procedure, and then ensures all the appropriate investigations are sent before the patient is lost on a medical ward.
Through these interventions they increased the proportion of patients having an ascitic tap at all (71% vs 91%) and having an early tap (48% vs 81%). The study was too small to comment robustly on outcomes related to this, but any simple intervention that helps to focus our antibiotic treatment in this patient group has to be applauded.
So do have a look at the study, as it may provide some simple pointers as to how practice could be improved in your department. Coronovirus may be forgotten this time next year, but multi-resistant organisms are here to stay. Small but simple measures like this could have a big impact.
Liver histology for the generalist
The complexity of modern medicine can at times appear overwhelming as the range of diagnostic investigations and personalised interventions exponentially increases. Therefore I have always been rather drawn to the weekly histopathology meeting in the departments I work in; somehow this very basic interaction with a tissue sample and ‘seeing’ a disease process directly feels like we are coming back to basics, to lessons learned in medical school, to medicine in its purest and simplest form.
So it was with great pleasure I saw this review on medical liver biopsy also in the current issue of Frontline. Providing a clear overview from normal histological features through to the main indications and pathological features of liver disease- as well as excellent figures in the paper, there are further images in the supplementary material- this paper will refresh anyone involved in managing liver disease on when to order this test and how to interpret the result. Furthermore, for those of us attending histopathology MDTs, the images will help us understand more clearly the features highlighted by the pathologists as the cases are presented.
As the indications for this test evolve with the development of non-invasive markers, and which is not without its risks (the authors quote a 0.4% risk of bleeding and 0.11% mortality risk), it is important to clearly understand what we hope to achieve with liver histology, when it should be considered and, importantly, what information the pathologist needs to give us a clinically meaningful report. All of this is covered in this excellent review, and I therefore commend you to have a read. Enjoy the secret pleasure of going back to basics!