Editorials - November 1, 2001 - American Family Physician

Editorials

Preventive Strategies for Chronic Liver Disease

ADRIAN M. DI BISCEGLIE, M.D.
Saint Louis University School of Medicine
St. Louis, Missouri

Chronic liver disease is a major cause of death in the United States and around the world. We have come to understand that alcohol is not the only cause of cirrhosis. In fact, chronic hepatitis C virus infection is the leading cause of cirrhosis in this country. A substantial portion of the U.S. population has nonalcoholic steatohepatitis, a condition associated with diabetes, obesity and insulin resistance.¹ In a two-part article published in American Family Physician, Riley and Bhatti^2,3 provide guidance for family physicians who are caring for patients with liver disease.

See article
on page 1555.

Gastroenterologists and hepatologists are often involved in making the diagnosis of chronic liver disease and arranging for specific therapy. However, family physicians are usually responsible for the day-to-day care of patients with chronic liver disease. They are often called on to treat these patients for conditions unrelated to the liver disease and to counsel them on measures that may maximize quality of life and prevent further disease progression.

Riley and Bhatti^2,3 provide valuable guidance to family physicians. Much of their advice is evidence-based, while some is empiric, based on circumstantial evidence and reasonable assumptions. They emphasize that patients with chronic liver disease must abstain from alcohol use, even if their liver disease is not associated with alcohol. There is clear evidence that consuming even a few drinks a day exacerbates the progression of hepatic fibrosis in patients with chronic hepatitis C virus infection.⁴ Patients with chronic liver disease should also be vaccinated against hepatitis A and B if they are not immune or already infected with these viral agents.⁵

The use of drugs, minerals, herbs and vitamins is much more problematic. Many patients insist on taking herbal supplements or remedies. Most of these remedies are benign, although it is not clear that they offer any real benefit.⁶ Patients must be informed that some herbal medicines can cause liver disease, and Riley and Bhatti² list various potential hepatotoxins.

Many prescription medicines are also potentially hepatotoxic, but evidence that their use in patients with chronic liver disease increases the risk of toxicity or the need for increased monitoring is lacking. Similarly, we cannot make recommendations regarding iron use. Iron overload may lead to liver disease and, in patients with chronic hepatitis C virus infection, iron depletion by phlebotomy results in transient improvement of liver injury.⁷ Beyond these observations, however, we currently have no evidence to recommend that patients with chronic liver disease restrict iron intake.

Riley and Bhatti's recommendations for patients with advanced liver disease are firmly grounded.³ All patients with cirrhosis should undergo endoscopy to determine if they have varices; noncardioselective beta blockers have been clearly proved to decrease the risk of bleeding from esophageal varices.⁸ Patients with cirrhosis should also be screened for hepatocellular carcinoma on a regular basis and should avoid excessive salt in their diet.

In patients with chronic liver disease, nonsteroidal anti-inflammatory drugs should be used with caution, if at all, because these drugs may worsen sodium retention or precipitate renal failure. Patients who have had spontaneous bacterial peritonitis are at great risk for further infections and should receive prophylactic antibiotics.⁹ Riley and Bhatti³ also provide sound recommendations on referral for liver transplantation.

When patients with chronic liver disease ask what they can do to improve their condition, family physicians now have some useful suggestions that may make all the difference.

REFERENCES

Falck-Ytter Y, Younossi ZM, Marchesini G, McCullough AJ. Clinical features and natural history of nonalcoholic steatosis syndromes. Semin Liver Dis 2001;21:17-26.

Riley TR III, Bhatti AM. Preventive strategies in chronic liver disease: Part I. Alcohol, vaccines, toxic medications and other supplements, diet and exercise. Am Fam Physician 2001;64:1555-60.

Riley TR III, Bhatti AM. Preventive strategies in chronic liver disease: Part II. Cirrhosis. Am Fam Physician 2001 (In press).

Poynard T, Bedossa P, Opolon P. Natural history of liver fibrosis progression in patients with chronic hepatitis C. The OBSVIRC, METAVIR, CLINIVIR, and DOSVIRC groups. Lancet 1997;349:825-32.

National Institutes of Health Consensus Development Conference Panel statement: management of hepatitis C. Hepatology 1997;26(3 suppl 1):S2-10.

Strader DB, Zimmerman HJ. Complementary and alternative medicine in hepatitis C. In: Liang JT, Hoofnagle JH, eds. Hepatitis C. San Diego: Academic Press, 2000:45368.

Di Bisceglie AM, Bonkovsky HL, Chopra S, Flamm S, Reddy SK, Grace N, et al. Iron reduction as an adjuvant to interferon therapy in patients with chronic hepatitis C who have previously not responded to interferon: a multicenter, prospective, randomized, controlled trial. Hepatology 2000;32:135-8.

Burroughs AK, Patch D. Primary prevention of bleeding from esophageal varices. N Engl J Med 1999;340:1033-5.

Rolachon A, Cordier L, Bacq Y, Nousbaum JB, Franza A, Paris JC, et al. Ciprofloxacin and long-term prevention of spontaneous bacterial peritonitis: results of a prospective controlled trial. Hepatology 1995;22(4 pt 1):1171-4.

Adrian M. Di Bisceglie, M.D., is professor of internal medicine and chief of hepatology at Saint Louis University School of Medicine, St. Louis. He is also medical director for the American Liver Foundation, New York, N.Y.

Address correspondence to Adrian M. Di Bisceglie, M.D., Division of Gastroenterology and Hepatology, Saint Louis University Hospital, 3635 Vista Ave., St. Louis, MO 63110 (e-mail: dibiscam@slu.edu).

Hypodermoclysis in the Treatment of Dehydration

SUDEEP GILL, M.D.
University of Toronto
Toronto, Ontario

MONIDIPA DASGUPTA, M.D., F.R.C.P.C.
University of Western Western Ontario
London, Ontario

PAULA ROCHON, M.D., M.P.H., F.R.C.P.C.
University of Toronto
Toronto, Ontario

Hypodermoclysis, the subcutaneous infusion of fluids, has been practiced for almost a century. Despite its successful use, hypodermoclysis remains an underrecognized and underused method of rehydration. In this issue of American Family Physician, Shvartzman and Sasson¹ provide a practical overview of this useful rehydration technique.

See article
on page 1575.

Hypodermoclysis fell out of favor during the 1950s after several case reports detailed complications related to its use.² Many of these complications, however, were the result of inappropriately high infusion rates or the use of hypertonic solutions that caused excessive fluid shifts and cardiovascular compromise.² During the 1980s, hypodermoclysis made a comeback after several articles described its potential benefits when properly administered. In 1996, Rochon and colleagues conducted a systematic review of the literature on this topic.²

Hypodermoclysis is frequently part of palliative care.^1,3 The treatment of dehydration in this setting is controversial. Some experts argue that terminally ill patients should not receive invasive rehydration therapy for a variety of clinical and ethical reasons; others counter that maintaining hydration using hypodermoclysis can prevent the occurrence of agitated delirium. One advantage of hypodermoclysis in the palliative care setting is that it can be used to administer certain analgesics (e.g., morphine and hydromorphone) to patients who are no longer able to take these drugs orally. In some cases, palliative care patients who are intolerant of oral narcotics prefer the subcutaneous administration of narcotics.⁴ Studies^5,6 comparing intravenous with subcutaneous administration of narcotics have demonstrated similar pain control with both methods.

Hypodermoclysis has been proved valuable in treating dehydration in older adults in long-term care institutions. Older adults often get acute intercurrent illnesses in which fluid replacement is an important component of treatment. If administering intravenous therapy for rehydration is not possible in a long-term care setting, which is nearly always the case, patients are transferred to an acute-care hospital for intravenous rehydration. Such a transfer can be a traumatic experience for a frail older patient. Hypodermoclysis performed in long-term care settings can be a convenient and cost-effective alternative to hospitalization.

As described in detail by Shvartzman and Sasson,¹ subcutaneous fluid infusion requires much of the same equipment used in intravenous therapy. The needle of a small-gauge catheter can be inserted into tissue at various sites including the thighs, abdominal wall, back, thorax and arms. Fluids are efficiently absorbed into the vasculature. The infusion volume at a single site should be limited to approximately 1.5 L during a 24-hour period. The infusion rate should be maintained above 20 mL per hour to prevent clogging of the line and below 75 mL per hour to prevent localized swelling.

It is important to discuss the composition of the fluids used in hypodermoclysis. Isotonic or electrolyte-containing hypotonic solutions should be used. The use of hypertonic or electrolyte-free solutions and rapid infusion rates can precipitate cardiovascular collapse, as was reported in the 1950s. Whether or not hyaluronidase should be added to subcutaneous fluids is debated, as Shvartzman and Sasson¹ discuss. Hyaluronidase is an enzyme that, theoretically, facilitates diffusion of fluids in the interstitium. Although radioisotope studies have shown that hyaluronidase may increase the rate of absorption of subcutaneous fluid,⁷ this finding does not translate into clinical benefits.² Furthermore, hyaluronidase can produce allergic reactions.

Subcutaneous therapy has several potential advantages over intravenous therapy. Subcutaneous administration of fluids is easier to set up, less invasive and often better tolerated. In patients who might try to pull the catheter out, hypodermoclysis can be administered at sites that the patient cannot easily reach. Relative to intravenous therapy, hypodermoclysis is generally associated with lesser use of restraints and is less restrictive to patients' mobility. Furthermore, subcutaneous fluids can be administered in long-term care settings, thus potentially preventing the necessity for patient transfers to hospitals, which may lead to substantial cost savings.

The limitations of subcutaneous fluid therapy must also be recognized. It is not appropriate in the management of severe dehydration because the volume and rate of rehydration is limited. Complications are similar to those associated with intravenous therapy but occur less often. Sterile precautions are required to avoid infections at infusion sites. Catheters should be replaced at least every 72 hours or sooner if signs of infection develop. The catheter should be covered with a transparent adhesive film to keep it in place and allow monitoring of the site for localized reactions.

A recent prospective, observational study⁸ has confirmed many of the benefits of subcutaneous fluid infusion. This study of 55 patients shows that hypodermoclysis is safe and effective in providing maintenance fluids and rehydration therapy in frail elderly subjects with mild to moderate dehydration. Overall, hypodermoclysis is associated with significantly fewer adverse effects compared with intravenous therapy.⁸

Hypodermoclysis is underused as a technique for treating dehydration in terminally ill patients and institutionalized older adults. Subcutaneous fluid infusion is easily administered and has several important advantages over hospitalization for intravenous therapy in these patient populations. After a century of changing fortunes, interest in hypodermoclysis is again mounting.^1,2,9

REFERENCES

Sasson M, Shvartzman P. Hypodermoclysis--a useful technique for the family physician. Am Fam Physician 2001;64:1575-8.

Rochon PA, Gill SS, Litner J, Fischbach M, Goodison AJ,Gordon M. A systematic review of the evidence for hypodermoclysis to treat dehydration in older people. J Gerontol A Biol Sci Med Sci 1997;52: M169-76.

Steiner N, Bruera E. Methods of hydration in palliative care patients. J Palliat Care 1988;14:6-13.

Moulin DE, Johnson NG, Murray-Parsons N, Geoghegan MF, Goodwin VA, Chester MA. Subcutaneous narcotic infusions for cancer pain. CMAJ 1992;146:891-7.

Moulin DE, Kreeft JH, Murray-Parsons N, Bouquillon AI. Comparison of continuous subcutaneous and intravenous hydromorphone infusions for management of cancer pain. Lancet 1991;337: 465-8.

Nelson KA, Glare PA, Walsh D, Groh ES. A prospective, within-patient, crossover study of continuous intravenous and subcutaneous morphine for chronic cancer pain. J Pain Symptom Manage 1997;13:262-7.

Lipschitz S, Campbell AJ, Roberts MS, Wanwimolruk S, McQueen EG, McQueen M, et al. Subcutaneous fluid administration in elderly subjects. J Am Geriatr Soc 1991;39:6-9.

Dasgupta M, Binns MA, Rochon PA. Subcutaneous fluid infusion in a long-term care setting. J Am Geriatr Soc 2000;48:795-9.

Frisoli Jr A, de Paula AP, Feldman D, Nasri F. Subcutaneous hydration by hypodermoclysis. Drugs Aging 2000;16:313-9.

Sudeep Gill, M.D., is a geriatric medicine resident at the University of Toronto, Toronto, Ontario.

Monidipa Dasgupta, M.D., F.R.C.P.C., is a geriatric medicine resident at the University of Western Ontario, London, Ontario.

Paula A. Rochon, M.D., M.P.H., F.R.C.P.C., is a geriatrician and researcher at the Kunin-Lunenfeld Applied Research Unit, Baycrest Centre for Geriatric Care, the Institute for Clinical Evaluative Sciences, and the University of Toronto, all in Toronto, Ontario.

Address correspondence to Paula A. Rochon, M.D., M.P.H., Baycrest Centre for Geriatric Care, 3560 Bathurst St., North York, Ontario Canada M6A 2E1.

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