Tawny trauma: Cirrhosis affects patient response to trauma

The word cirrhosis stands for a chronic inflammation of connective tissue, especially of the liver. Coined in 1827 by French physician Rene Theophile Hyacinthe Laennec, the orange-yellow appearance of the diseased liver led to the combination of the Greek kirrhos (red-yellow, yellow-brown, tawny in color) and osis (a disease or condition).*

Liver disease affects one out of every 10 people in the U.S. It is likely that number is an underestimation of the true incidence, as many cases of liver disease go undiagnosed. Cirrhosis is a late stage of scarring from fibrosis. Cirrhosis has several known causes, including chronic alcohol abuse; Hepatitis B, C, and D; nonalcoholic fatty liver disease; hemochromatosis; cystic fibrosis; Wilson’s disease; genetic disorders; primary biliary cirrhosis; infection; and medications (isoniazid or methotrexate).

Symptoms of cirrhosis often include jaundice, fatigue, easy bleeding or bruising, loss of appetite, nausea, weight loss, pruritus, edema, ascites, gynecomastia, palmar erythema, and confusion (hepatic encephalopathy). As the disease progresses, it may lead to portal hypertension, bleeding from enlarged veins (esophageal and gastric varices), splenomegaly, malnutrition, bone loss, and increased risk of hepatocellular cancer.

Effects of trauma on cirrhotic patients

Cirrhotic patients in various stages of progression may have tenuous physiology. A traumatic injury requiring operative intervention during a later stage of the disease may be enough to tip the balance and set off a downward spiral of hepatic decompensation, leading to liver failure or hepatorenal syndrome, followed by other organ failures.

The Child-Turcotte score (created by Charles G. Child III, MD, FACS, and Jeremiah G. Turcotte, MD, FACS) was originally designed to predict the operative mortality after portocaval shunt surgery. R.N.H Pugh, MD, later modified this score and although it is not prospectively validated, it has stood the test of time. This scoring system is used widely to assess the severity of cirrhosis and predict perioperative morbidity and mortality for elective and emergency surgery. Child-Turcotte-Pugh encompasses three scores, ranging from the least (A) to most severe (C). Patients with cirrhosis undergoing an abdominal operation that are Child-Turcotte-Pugh class A, B, or C are associated with a mortality of 10 percent, 30–31 percent, and 76–82 percent, respectively.

To examine the occurrence of injuries in patients with cirrhosis, the National Trauma Data Bank® (NTDB®) research admission year 2017 medical records were searched using the International Classification of Diseases, Tenth Revision Clinical Modification codes. Specifically searched were records containing the comorbid conditions field DG_01.

Those records containing a field value of 25 (cirrhosis) were used. A total of 9,747 records were found, 8,669 of which contained a discharge status, including 4,846 patients discharged to home, 1,234 to acute care/rehab, 1,780 to skilled nursing facilities; 809 died (see Figure 1). Of these patients, 67 percent were male, on average 57.6 years of age, had an average hospital length of stay of 7.7 days, an intensive care unit length of stay of 6.2 days, an average injury severity score of 10.4, and were on the ventilator for an average of 6.9 days.

Figure 1. Hospital discharge status

Figure 1. Hospital discharge status

The top three mechanisms of injury accounting for more than 90 percent of all cases were fall (64.1 percent), motor vehicle related (18.6 percent), and struck by/against (7.8 percent). See Figure 2 for more information on cirrhosis-related mechanisms of injury. Of those patients tested for alcohol, almost 44 percent (2,091 out of 4,765) tested positive.

Figure 2. Mechanism of injury

Figure 2. Mechanism of injury

Patients diagnosed with cirrhosis can take some steps to reduce further liver damage, including eating a healthy diet, getting regular exercise, limiting dietary sodium and alcohol, and discussing the medications and any vitamins they are taking with their physician. Save tawny for describing a lion’s coat or the color you get when you mix too many paints together—not to describe one’s liver.

Throughout the year, we highlight these data through brief reports that are published monthly in the Bulletin. The NTDB Annual Report can be found on the American College of Surgeons website as a PDF file. In addition, information is available on our website about how to obtain NTDB data for more detailed study. If you are interested in submitting your trauma center’s data, contact Melanie L. Neal, Manager, NTDB, at mneal@facs.org.

Acknowledgment

Statistical support for this column was provided by Ryan Murphy, Data Analyst, NTDB.


*Online Etymology Dictionary. Cirrhosis definition. Available at: www.etymonline.com/word/cirrhosis. Accessed June 30, 2019.

American Liver Foundation. Cirrhosis: What you need to know to prevent liver damage. Available at: https://liverfoundation.org/wp-content/uploads/2018/04/ALF-Cirrhosis-Fact-Sheet.pdf. Accessed June 30, 2019.

Hanje AJ, Patel T. Preoperative evaluation of patients with liver disease. Nat Clin Pract Gastroenterol Hepatol. 2007;4(5):266-267.

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