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Frailty in patients with cirrhosis is associated with increased morbidity and mortality. In this study, we aimed to determine the prevalence of frailty and its impact on mortality and hospitalization in patients with cirrhosis. An elaborate search was undertaken in the databases "PubMed, Scopus, Web of Science, and Cochrane, and preprint servers", and an assessment of all published articles till 17 February 2023 was done. Studies that provided data on prevalence, mortality and hospitalization among frail patients with cirrhosis were included. The study characteristics and data on the prevalence, mortality, and hospitalization were extracted from included studies. The primary outcome was to estimate the pooled prevalence of frailty and determine its impact on mortality and hospitalization in patients with cirrhosis. Overall, 12 studies were included. Data on prevalence of frailty and mortality were available in 11 studies, while seven studies reported data on hospitalization. The analysis conducted among 6126 patients with cirrhosis revealed pooled prevalence of frailty to be 32% (95% confidence interval [CI], 24–41). A total of 540 events of death revealed a pooled mortality rate of 29% (95% CI, 19–41). Six-month and twelve-month pooled estimates of mortality were found to be 24% (95% CI, 17–33) and 33% (95% CI, 23–45), respectively. The pooled hospitalization rate among the seven studies was 43% (95% CI, 21–68). The prevalence of frailty in patients with cirrhosis is high, leading to poor outcomes. Frailty assessment should become an integral part of cirrhosis evaluation. PROSPERO 2022 CRD42022377507. [Display omitted] [ABSTRACT FROM AUTHOR]

This study delved into cirrhosis-related infections to unveil their epidemiology, risk factors, and implications for antimicrobial decisions. We analyzed acutely decompensated cirrhosis patients (n = 971) from North India between 2013–2023 at a tertiary center. Microbiological and clinical features based on infection sites (EASL criteria) and patient outcomes were assessed. Median age was 45 years; 87% were males with 47% having alcoholic hepatitis. Of these, 675 (69.5%) had infections; 305 (45%) were culture-confirmed. Notably, 71% of confirmed cases were multi-drug resistant organisms (MDRO)-related, chiefly carbapenem-resistant (48%). MDRO prevalence was highest in pulmonary (80.5%) and skin-soft-tissue infections (76.5%). Site-specific distribution and antimicrobials were suggested. Predictive models identified prior hospitalization [OR:2.23 (CI:1.58–3.14)], norfloxacin prophylaxis [OR:2.26 (CI:1.44–3.55)], prior broad-spectrum antibiotic exposure [OR:1.61 (CI:1.12–2.30)], presence of systemic inflammatory response-SIRS [OR:1.75 (CI: 1.23–2.47)], procalcitonin [OR:4.64 (CI:3.36–6.40)], and HE grade [OR:1.41 (CI:1.04–1.90)], with an area under curve; AUC of 0.891 for infection prediction. For MDRO infection prediction, second infection [OR: 7.19 (CI: 4.11–12.56)], norfloxacin prophylaxis [OR: 2.76 (CI: 1.84–4.13)], CLIF-C OF [OR: 1.10 (CI: 1.01–1.20)], prior broad-spectrum antibiotic exposure [OR: 1.66 (CI: 1.07–2.55)], rifaximin [OR: 040 (0.22–0.74)] multisite [OR: 3.67 (CI: 1.07–12.56)], and polymicrobial infection [OR: 4.55 (CI: 1.45–14.17)] yielded an AUC of 0.779 and 93% specificity. Norfloxacin prophylaxis, multisite infection, mechanical ventilation, prior broad-spectrum antibiotic exposure, and infection as acute precipitant predicted carbapenem-resistant infection (AUC: 0.821). Infections (culture-proven or probable), MDROs, carbapenem/pan-drug resistance, and second infections independently linked with mortality (P < 0.001), adjusted for age, leucocytosis, and organ failures. A model incorporating age [HR:1.02 (CI: 1.01–1.03), infection [HR:1.52 (CI: 1.05–2.20)], prior hospitalization [HR:5.33 (CI: 3.75–7.57)], norfloxacin [HR:1.29 (CI: 1.01–1.65)], multisite infection [HR:1.47 (CI:1.06–2.04)], and chronic liver failure consortium-organ failure score; CLIF-C OF [HR:1.17 (CI: 1.11–1.23)] predicted mortality with C-statistics of 0.782 (P < 0.05). High MDRO burden, especially carbapenem-resistant, necessitates urgent control measures in cirrhosis. Site-specific epidemiology and risk models can guide empirical antimicrobial choices in cirrhosis management. [Display omitted] [ABSTRACT FROM AUTHOR]

Spider angiomas are dilated vascular channels in the skin. They have a central arteriole with surrounding vascular channels resembling legs of a spider, hence the name. They are frequently associated with liver cirrhosis, thyrotoxicosis, and pregnancy. We present the case of a 49-year-old gentleman who was referred to our liver clinic with complaints of jaundice and ascites of one-month duration. The patient was a chronic alcohol consumer, consuming country-made liquor, 80–100 grams/day for past 8–10 years. He was diagnosed with Acute on chronic liver failure with a model for end-stage liver disease score of 38. During his hospital stay, he developed active spurting from a spider angioma on his lower lip (video 1), which was initially tackled with hand compressions, which stopped bleeding for a few minutes, restarting again after the compressions were lifted. It was then decided to inject 0.1 mL cyanoacrylate glue injection using a 21-gauge needle, immediately stopping active spurt (video 2), (Figure 1). A small ulcer formed at the injection site, which healed in few days, and the patient was discharged to home. Spider angiomas are characteristic cutaneous manifestation of liver cirrhosis with a specificity of 95%. 1 The prevalence of spider angiomas in cirrhosis is reported to be around 30–40%. Li Hongyu et al. in their study on 198 individuals reported the prevalence to be 47%. 2 They can be graded from grade 1+ (readily recognizable containing a body, legs, and surrounding erythema) to grade 4+ (visible pulsations with a hand lens and raised central punctum with many obvious "spider legs" radiating from it). 3 Underlying pathogenesis in cirrhosis is multifactorial including decrease levels of testosterone and high levels of estradiol, 4 hyperdynamic circulation, high levels of substance-P, and vascular endothelial growth factor leading to angiogenesis and vasodilation. 5,6 Spider angiomas can be single or multiple and are usually seen in the territory of superior vena cava—the face (nose, lips, forehead), upper chest, and arms. 2 These lesions have been associated with bleeding esophageal varices and hepatopulmonary syndrome. Bleeding from spider angiomas is unusual. Rarely, fine-needle electrocautery, potassium-titanyl-phosphate (KTP) laser, or electro desiccation has been used to clear spider angiomas for cosmetic concerns. Treatment includes hand or ice compressions and treating the underlying cause. Use of cyanoacrylate glue for bleeding spider angioma has not been reported in the literature. We think this can be a handy bedside tool to combat an active spurt of bleeding when conventional methods have failed, as in our case; however, further studies are warranted. [Display omitted] [ABSTRACT FROM AUTHOR]