Gastroenterology Hepatology

Liver transplantation: pretransplant management - systemic inflammatory response syndrome (SIRS)

How can I be sure that the patient has systemic inflammatory response syndrome?

Patients with new onset decompensation of chronic liver failure secondary to cirrhosis of many causes (alcohol, viral hepatitis, autoimmune disease, metabolic disorders – e.g., metabolic syndrome or hemochromatosis) often have clinical features of systemic inflammatory response syndrome (SIRS). The challenge for the managing care provider is to determine whether the clinical phenomena are accounted for by the hemodynamic effects of cirrhosis and portal hypertension, additional sources of inflammatory stimuli (e.g., medications, alcohol or infection), or other events likely to alter hemodynamics, such as variceal hemorrhage.

A tabular or chart listing of features and signs and symptoms

The clinical features of SIRS are the following:

  • – Peripheral leukocytosis

  • – Tachycardia

  • – Systemic hypotension

How can I confirm the diagnosis?

Patients with cirrhosis who present with SIRS should undergo the following evaluation:

  • – Rule out infection: blood cultures, urine cultures, diagnostic paracentesis if ascites is present, and chest radiography. In selected cases, aspiration of cerebrospinal fluid (lumbar puncture) is appropriate.

  • – Rule out overt or covert GI bleeding: monitor hemoglobin; esophagogastroduodenoscopy; colonoscopy.

  • – Rule out confounding medications or toxins: take history of recent use of alcohol and medications, including OTC medications, herbs, and supplements; check blood and urine toxicology screen. Consider alcoholic hepatitis in the correct setting.

What other diseases, conditions, or complications should I look for in patients with systemic inflammatory response syndrome?

Associated diseases, conditions, or complications include:

  • – Pneumonia

  • – Urinary tract infection

  • – Spontaneous bacterial peritonitis

  • – Acute variceal hemorrhage

  • – Acute alcoholic hepatitis

What is the right therapy for the patient with systemic inflammatory response syndrome?

Therapy for the patient with SIRS involves the following procedures:

  • – Resuscitate appropriately.

  • – Support blood pressure.

  • – In patients with an identified infection, treat with antibiotics.

  • – Treat alcoholic hepatitis with corticosteroids and/or pentoxifylline in selected cases.

  • – Patients with diagnosed spontaneous bacterial peritonitis benefit from intravenous infusions of albumin, in addition to antibiotics.

What is the most effective initial therapy?

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Listing of usual initial therapeutic options, including guidelines for use, along with expected result of therapy.

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A listing of a subset of second-line therapies, including guidelines for choosing and using these salvage therapies

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Listing of these, including any guidelines for monitoring side effects.

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How should I monitor the patient with disease SIRS?

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What's the evidence?

Lucey, MR, Maturin, P, Morgan, TR. "Alcoholic hepatitis". N Engl J Med. vol. 360. 2009. pp. 2758-69.

"European Association for the Study of the Liver. EASL clinical practice guidelines on management of ascites, spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis". J Hepatol. vol. 53. 2010. pp. 397-417.

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