65 Cases With Acute Alcoholic Liver Failure Patients Slow And Clinical Features, Prognosis Assessment And Treatment Based On Syndrome Differentiation Of Traditional Chinese Medicine

ObjectiveAlcoholic liver failure is the most severe clinical type of alcoholic liver disease. Acute-on-chronic alcoholic liver failure occurred in alcoholic hepatitis, alcohol ic cirrhosis which had a history of alcohol dependence is the most common. This disease has many complications and high mortality rate. The report on this aspect is still rare. Through the retrospective investigation of65cases of patients with acute-on-chronic alcoholic liver failure from Beijing Ditan Hospital, we tried to do a preliminary study about the clinical features, disease outcomes and their associated predictors. And this study will preliminary discussed the Traditional Chinese Medicine (TCM) syndrome differentiation of acute-on-chronic alcoholic liver failure.Methods:1、Retrieved cases admitted from January2002to January2012and diagnosed "alcoholic liver disease and severe hepatitis","alcoholic liver failure"。Based on acute-on-chronic alcoholic liver failure as defined by the filtered into and out of standard,65eligible cases were collected.2、Recorded patients general conditions, complications, the disease outcome and follow-up; Keep detailed records of laboratory results and other examination results; Recorded tongue and pulse, syndrome differentiation of patients which accepted TCM.3、 According to survey data, focus on analysis (1) The clinical features of acute-on-chronic alcoholic liver failure (2) The disease outcome and forecast (3) TCM symptoms characteristics and syndrome differentiation4、 Statistical methods:using SPSS19.0soft ware, applied descriptive statistics, independent sample t test, one-way ANOVA, chi-square test methods, etc. Bilateral P<0.05as the standard showing that difference was statistically significant.Result:1.clinical features:(1)Men more than women, men and women proportion was as high as64:1; Age between40-60incidence was the highest; Patients of drinking10to30years and average daily drink in80-400g accounted for over80%of the total number of patients.(2)93.8%(61/65) of the patients had seen doctors for liver disease before liver failure happened.70.5%of the patients (43/61) was diagnosed alcoholic liver cirrhosis when first visit. Ascites was the most common complication, accounting for72.3%, followed by upper gastrointestinal hemorrhage (26.2%) and hepatic encephalopathy (23.1%) before liver failure happened.(3)Infections, drinking too much recently, upper gastrointestinal bleeding was the most common cause of acute-on-chronic alcoholic liver fa ilure.(4)Common complications during hospitalization were ascites and hypoalbuminemia (100%), moderate and severe anemia (86.2%), electrolyte disorder (75.4%), hypersplenism (72.3%), hepatic encephalopathy (70.8%), upper gastrointestinal hemorrhage (56.9%), pulmonary infection (46.2%), hepatorenal syndrome (41.5%), multiple organ failure and alcohol withdrawl syndrome incidence was20%.(5)Patients with acute-on-chronic alcoholic liver failure have characteristics of alcoholic liver disease, such as AST> ALT and AST/ALT ratio>2cases accounted for about70%of the total, elevated GGT and the MCV, etc. The baseline TBIL was342.5±171umol/1, PTA was29.1±9.6%, direct bilirubin/total bilirubin levels was0.55±0.12.(6)30%of patients were found baseline serum creatininc increase, and85.7%of patients hypocalcemi a,70.8%hypona t rem ia,46.8%hypomagnesemia. Potassium abnormality rate was close to50%, mainly low potassium.(7)According to the results of36cases of patients with liver failure, baseline CD3, CD8, CD4were ruduced, and the CD4/CD8ratio was rised, show CD8decreased more obviously. Baseline complement C3, C4decreased. C3100%below normal, dropped more obviously.(8)Abdominal ultrasound results showed that86.2%patients had entered liver cirrhosis period, with typical cirrhosis manifestation or with blood flow changes in portal hypertension, splenomegaly, hydrothorax, ascites, etc; Endoscopy results from25patients showed about92%of the patients with esophageal varices,47.8%with gastric variccs; according to Chest X-ray or chest CT examination of63cases,33cases were found inflammation on one side or both.2, Disease outcomes30cases with acute acute-on-chronic alcoholic liver failure died in hospital. Mortality in hospital was46.2%. Multiple organ failure and hemorrhagic shock were the main cause of death, both were30%; Moreover, hepatic encephalopathy, hepatorenal syndrome each accounted for13.3%.21patients judged to be improved according to the assessment of therapeutic effects,3cases were died,5cases were lost,13cases were survived after they were discharged from the hospital (follow-up time from10months to6years).14cases of patients judged to be not improved when discharged,3cases were lost to fol low-up,10patients died after discharged, only1case of liver transplantation survival (follow-up time2years)Alcoholic liver failure cases show high mortality,4,8,12,24,48,96weeks cumulative mortality rates were27.7%,40%,41.5%,55.4%,61.5%,63.1%. Because there’re a total of8cases of the patients lost to follow-up, the mortality rate may be higher.3. Disease outcome prediction(1)Compare of the death group and not death group results showed that history of1iver cirrhosis of death group was longer than not death group. PT and INR were higher, and the levels of PTA, CHE, TCHO, blood Na were lower in death group. Two groups of patients have no significant differences in TBIL and DBIL levels;ALT, AST, LDH levels of the death group were higher, and ALB, GGT, TBA lower than the not death group, but no significant difference between the two groups;Using MELD, MELD-Na, MDF, CTP score four methods to measure the difference between death group and not death group, the results show that the scores by four methods at baseline were significantly different, P values were0.027,0.002,0.034,0.037, and the score of MELD-Na better than the other three. Dynamic scoring, at0,1,2,3,4,6weeks, MELD scores significantly greater in death group, there were significant differences between the two groups, and MELD-Na scores at0,3,4weeks had significant differences between the two groups, MDF scores at0,3,5weeks has significant differences, CTP scores at0,8weeks saw a significant difference. Four score methods are available to assess the prognosis of patients with alcoholic liver failure.(2) Liver failure stage has a significant effect on the disease outcome, nearly stage patients include6cases, no deaths,1case was lost after12weeks; Middle stage include33cases, the mortality and survival rate at4,12,24,48weeks were15.2%vs81.8%,24.2%vs60.6%,36.4%vs48.5%,39.4%vs42.4%, at96weeks, mortality was more than survival rate (48.5%vs33.3%); Late stage in elude26cases, mortalitywas higher than survival at4weeks (53.8%vs46.2%), this gap was widening with the prolongation time, mortality and survival rate was84.6%and11.5%at 96weeks(3)Patient age, drinking impact on disease outcomePatients with age>45compared with age≤45years old, the disease outcome at12,24,48,96weeks had significantdifference.Patients with age>45years old showed the increased risk of death after12weeks.Drinking duration>20years compared with the group of≤20years, disease outcome at48,96weeks had significant differences, patients of drinking duration>20years increased risk of death;According to patients with average daily consumption of> or≤200g compared, results show two groups of disease outcome no significant difference; According to whether stop drinking, the patients were divided into two groups, the results show disease outcome no significant difference;(4)Different grading method to measure the disease outcomeAccording to whether the baseline MELD score>18points (median) divided the patients into two groups, MELD score>18points, its mortality at4week was increased significantly than<18group(40.5%vs14.3%). According to whether the difference value of MELD score Week1and baseline≥2divided the patients into two groups, the mortality of group≥2was higher than group<2at4,8,12weeks, there were significant differences. Show patients with first week MELD score≥2more than the baseline significantly increased risk of death in the near future.Patients with baseline MELD score-Na>26and<26group compared, the risk of death at4,8,12,24,48,96weeks were significantly increased;With MDF baseline score<55and>55grouping, showed the disease outcome there was no significant difference between the two groups.4. TCM symptoms characteristics and syndrome differentiationAlcoholic liver failure belonged to the "acute and severe jaundice" category of traditional Chinesemedicine. It t ended to occur in patients with "Alcoholic Pi" and "Alcoholic Tympanites". We could see common complications such as "hepatic coma" and "bleeding", etc. Drinking too much, attack of external evil, improper diet and over tiredness were the common causes of acute and severe jaundice. The main cause of alcoholic liver failure is "Alcoholic Toxin". The nature of the disease was deficiency in origin and excess in superficiality. The spleen-stomach deficiency was the basis of disease attack, and damp-heat> blood heat and stasis was the important pathogenesis.Alcoholic liver failure patients mainly show red, dark red,purple tongue. Patients during recovery period may show red tongue few fluid. White thick, yellow thick, greasy tongue coatings were more common, and thin white, thin yellow, gray, black, less coatings were visible.Taut pulse, taut and slippery pulse more common, thready and rapid pulse vis ible.According to the clinical manifestations, the patients were divided into four types:damp-heat accumulation, toxic heat and blood stasis, spleen deficiency and dampness obstruction, qi and Yin deficiency, treatment:symptomatic treatment in acute condition.The patients were treated with clearing heat, eliminating dampness, cooling blood as the basic treatment. In the process of treatment, we should always be on protecting spleen and stomach, supports vital energy.ConclusionAcute-on-chronic alcoholic liver failure is the most severe type of alcoholic liver disease, and has high mortality rate. Clinical features included:men more than women, age40-60years old, drinking10to30years, average daily drink in80-400g more common. The common cause was infection, upper gastrointestinal bleeding, drinking too much recently. Common compl ications were in order:ascites, hypoalbuminemia, moderate and severe anemia, electrolyte disorder, hypersplenism, hepatic encephalopathy, upper gastrointestinal hemorrhage, pulmonary infection, hepatorenal syndrome, etc. Out of65patients,21cases improved when discharged from hospital (32.3%),14cases were not improved (21.5%),30cases died (46.2%). Alcoholic liver fai lure cases show high mortality,12,24,48,96weeks cumulative mortality rates were41.5%,55.4%,61.5%,63.1%. The group of pa t ient s died in hospital, PT and INR higher, the PTA, CHE, TCHO levels lower. Different stage of liver failure has a very obvious effect on disease outcome, risk of death the late stage>the middle stage>the early stage. Patients with age>45increased risk of death after12weeks, drinking duration>20years patients increased risk of death after48,96week. MELD score>18points, MILD-Na score>26points, week1MELD and baseline MELD score difference≥2points predictable increased risk of death. We can try to use Chinese traditional medicine for patients in relatively stable period, its curative effect evaluation needs further research.