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Hu Y, Zhou M, Liu D, Gong J. Risk Factors for Glue Extrusion Bleeding After Endoscopic Injection of Cyanoacrylate Glue for Gastric Varices: A Retrospective Study of 269 Patients. Dig Dis Sci 2025:10.1007/s10620-025-08999-9. [PMID: 40164951 DOI: 10.1007/s10620-025-08999-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2024] [Accepted: 03/16/2025] [Indexed: 04/02/2025]
Abstract
BACKGROUND Glue extrusion bleeding is a major complication of endoscopic cyanoacrylate glue injection for the treatment of gastric varices. However, its risk factors remain unclear. AIMS This retrospective study aimed to evaluate the risk factors for bleeding associated with glue extrusion. METHODS This study analyzed the medical data of cirrhotic patients who underwent endoscopic obliteration for gastric varices using cyanoacrylate glue between January 2016 and December 2022. The data within 1 year after therapy were carried out with logistic regression. A nomogram model was constructed based on the factors. RESULTS 269 patients were enrolled. Risk factors associated with glue extrusion bleeding included the volume of the glue (≥ 4 mL)(OR 1.289, 95% CI 1.051-1.580; P = 0.015), massive ascites (OR 5.645, 95% CI 2.260-14.097; P = 0.000), active hemorrhage during endoscopy (OR 2.830, 95% CI 1.284-6.234; P = 0.010), and the use of β-blockers was a protective factor (OR 0.185, 95% CI 0.07-0.485; P = 0.001). The nomogram model had good prediction accuracy, with an area under the curve of 0.74 (95% CI 0.658-0.822; P < 0.001). CONCLUSION Massive ascites, active hemorrhage during endoscopy, glue volume ≥ 4 mL, and the use of β-blockers are associated with glue extrusion bleeding. At-risk patients may benefit from controlling the volume of the glue, undergoing endoscopic ultrasound and using β-blockers.
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Affiliation(s)
- Yihuan Hu
- Department of Gastroenterology, Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan Province, China
- Research Center of Digestive Diseases, Central South University, Changsha, 410011, Hunan Province, China
- Clinical Research Center of Digestive Diseases of Hunan Province, Changsha, 410011, Hunan Province, China
| | - Mei Zhou
- Department of Gastroenterology, Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan Province, China
- Research Center of Digestive Diseases, Central South University, Changsha, 410011, Hunan Province, China
- Clinical Research Center of Digestive Diseases of Hunan Province, Changsha, 410011, Hunan Province, China
| | - Deliang Liu
- Department of Gastroenterology, Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan Province, China
- Research Center of Digestive Diseases, Central South University, Changsha, 410011, Hunan Province, China
- Clinical Research Center of Digestive Diseases of Hunan Province, Changsha, 410011, Hunan Province, China
| | - Jian Gong
- Department of Gastroenterology, Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan Province, China.
- Research Center of Digestive Diseases, Central South University, Changsha, 410011, Hunan Province, China.
- Clinical Research Center of Digestive Diseases of Hunan Province, Changsha, 410011, Hunan Province, China.
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Nguyen NN, Nguyen BT, Nguyen TDT, Tran TTT, Mai TNH, Le HNT, Dang HN, Nguyen VBN, Ngo NYT, Vo CT. A novel risk-predicted nomogram for acute kidney injury progression in decompensated cirrhosis: a double-center study in Vietnam. Int Urol Nephrol 2025:10.1007/s11255-025-04398-1. [PMID: 39955461 DOI: 10.1007/s11255-025-04398-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2024] [Accepted: 01/26/2025] [Indexed: 02/17/2025]
Abstract
OBJECTIVES Acute kidney injury (AKI) is commonly encountered in patients hospitalized for decompensated cirrhosis and is associated with prolonged hospital stays, increased treatment burden, and even mortality. The present study aimed to determine the prevalence of and develop a predictive nomogram for AKI in patients with decompensated cirrhosis. METHODS This cross-sectional, double-center study involved 544 patients hospitalized with decompensated cirrhosis. Acute kidney injury was diagnosed using American Gastroenterological Association's guidelines with one more criterion: an increase in serum creatinine ≥ 0.3 mg/dL within 48 h or an increase in serum creatinine ≥ 50% compared to baseline serum creatinine or when the urine output is reduced below 0.5 mL/kg/h for > 6 h. We used the Bayesian model averaging method find the optimal model for predicting AKI. A predictive nomogram was also developed to enable risk prediction. RESULTS The overall AKI prevalence was 26.7% (95% Confidence interval [CI] 25.7-27.7). The optimal model for predicting AKI included diuretic therapy (odds ratio [OR]: 5.55; 95%CI 3.31-9.33), infection (OR: 2.06; 95%CI 1.31-3.22), ascites (OR: 3.20; 95%CT: 1.67-6.13), Child-Pugh group C (OR: 2.91; 95%CI 1.84-4.62), serum potassium (OR per 1 mmol/L increase: 1.62; 95%CI 1.25-2.1) and serum chloride (OR per 1 mmol/L decrease: 1.03; 95%CI 1.01-1.06). The area under the receiver operating characteristic curve was 0.8, with a 95%CI ranging from 0.75 to 0.84. CONCLUSIONS Acute kidney injury was relatively common among patients hospitalized for decompensated cirrhosis. A novel nomogram-including diuretic therapy, infection, ascites, Child-Pugh group C, serum potassium and, serum chloride, was helpful for the selective screening of AKI in patients with decompensated cirrhosis.
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Affiliation(s)
- Nghia N Nguyen
- Can Tho University of Medicine and Pharmacy, 179 Nguyen Van Cu Street, An Khanh Ward, Ninh Kieu District, Can Tho City, 902510, Vietnam
| | - Bao T Nguyen
- Can Tho University of Medicine and Pharmacy, 179 Nguyen Van Cu Street, An Khanh Ward, Ninh Kieu District, Can Tho City, 902510, Vietnam.
| | - Thuy D T Nguyen
- Can Tho University of Medicine and Pharmacy, 179 Nguyen Van Cu Street, An Khanh Ward, Ninh Kieu District, Can Tho City, 902510, Vietnam
| | - Tam T T Tran
- Can Tho University of Medicine and Pharmacy, 179 Nguyen Van Cu Street, An Khanh Ward, Ninh Kieu District, Can Tho City, 902510, Vietnam
| | - Tan N H Mai
- Can Tho University of Medicine and Pharmacy, 179 Nguyen Van Cu Street, An Khanh Ward, Ninh Kieu District, Can Tho City, 902510, Vietnam
| | - Huyen N T Le
- Can Tho University of Medicine and Pharmacy, 179 Nguyen Van Cu Street, An Khanh Ward, Ninh Kieu District, Can Tho City, 902510, Vietnam
| | - Hoang N Dang
- Can Tho University of Medicine and Pharmacy, 179 Nguyen Van Cu Street, An Khanh Ward, Ninh Kieu District, Can Tho City, 902510, Vietnam
| | - Vy B N Nguyen
- Can Tho University of Medicine and Pharmacy, 179 Nguyen Van Cu Street, An Khanh Ward, Ninh Kieu District, Can Tho City, 902510, Vietnam
| | - Nhi Y T Ngo
- Hoan My Cuu Long Hospital, 20 Vo Nguyen Giap Street, Phu Thu Ward, Cai Rang District, Can Tho City, 902510, Vietnam
| | - Cuong T Vo
- Can Tho University of Medicine and Pharmacy Hospital, 179 Nguyen Van Cu Street, An Khanh Ward, Ninh Kieu District, Can Tho City, 902510, Vietnam
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Wang Y, Song SJ, Jiang Y, Lai JCT, Wong GLH, Wong VWS, Yip TCF. Role of noninvasive tests in the prognostication of metabolic dysfunction-associated steatotic liver disease. Clin Mol Hepatol 2025; 31:S51-S75. [PMID: 38934108 PMCID: PMC11925434 DOI: 10.3350/cmh.2024.0246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 06/20/2024] [Accepted: 06/26/2024] [Indexed: 06/28/2024] Open
Abstract
In managing metabolic dysfunction-associated steatotic liver disease, which affects over 30% of the general population, effective noninvasive biomarkers for assessing disease severity, monitoring disease progression, predicting the development of liver-related complications, and assessing treatment response are crucial. The advantage of simple fibrosis scores lies in their widespread accessibility through routinely performed blood tests and extensive validation in different clinical settings. They have shown reasonable accuracy in diagnosing advanced fibrosis and good performance in excluding the majority of patients with a low risk of liver-related complications. Among patients with elevated serum fibrosis scores, a more specific fibrosis and imaging biomarker has proved useful to accurately identify patients at risk of liver-related complications. Among specific fibrosis blood biomarkers, enhanced liver fibrosis is the most widely utilized and has been approved in the United States as a prognostic biomarker. For imaging biomarkers, the availability of vibration-controlled transient elastography has been largely improved over the past years, enabling the use of liver stiffness measurement (LSM) for accurate assessment of significant and advanced fibrosis, and cirrhosis. Combining LSM with other routinely available blood tests enhances the ability to diagnose at-risk metabolic dysfunction-associated steatohepatitis and predict liver-related complications, some reaching an accuracy comparable to that of liver biopsy. Magnetic resonance imaging-based modalities provide the most accurate quantification of liver fibrosis, though the current utilization is limited to research settings. Expanding their future use in clinical practice depends on factors such as cost and facility availability.
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Affiliation(s)
- Yue Wang
- Medical Data Analytic Center, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
- State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - Sherlot Juan Song
- Medical Data Analytic Center, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
- State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - Yichong Jiang
- Medical Data Analytic Center, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
- State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - Jimmy Che-To Lai
- Medical Data Analytic Center, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
- State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - Grace Lai-Hung Wong
- Medical Data Analytic Center, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
- State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - Vincent Wai-Sun Wong
- Medical Data Analytic Center, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
- State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - Terry Cheuk-Fung Yip
- Medical Data Analytic Center, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
- State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
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Drolz A. [Bleeding in liver diseases]. Med Klin Intensivmed Notfmed 2024; 119:458-464. [PMID: 39138654 DOI: 10.1007/s00063-024-01167-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Accepted: 07/08/2024] [Indexed: 08/15/2024]
Abstract
Bleeding events are feared complications in patients with advanced liver diseases and are associated with morbidity and mortality. In this context, gastrointestinal bleeding, particularly upper gastrointestinal bleeding, has a special clinical importance. In addition to endoscopic measures for hemostasis, reducing portal pressure in particular is a key component of treatment. Although the standard coagulation parameters are often altered in patients with liver diseases, optimizing coagulation plays a secondary role. Typically, a bundle of measures are employed in patients with portal hypertensive bleeding, which nowadays in most cases can halt the bleeding and stabilize the situation. The measures include endoscopy, antibiotic treatment, vasopressor treatment and, if necessary, shunt placement (transjugular intrahepatic portosystemic shunt).
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Affiliation(s)
- Andreas Drolz
- I. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland.
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Hu Y, Zhou M, Liu D, Gong J. Risk Factors for Rebleeding After Endoscopic Injection of Cyanoacrylate Glue for Gastric Varices: A Systematic Review and Meta-Analysis. Dig Dis Sci 2024; 69:2890-2903. [PMID: 38864930 DOI: 10.1007/s10620-024-08482-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 05/06/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND Rebleeding is a significant complication of endoscopic injection of cyanoacrylate in gastric varices in cirrhotic patients. AIM This systematic review and meta-analysis aimed to evaluate the efficiency of endoscopic cyanoacrylate injection and summarized the risk factors for rebleeding. METHODS Databases were searched for articles published between January 2012 and December 2022. Studies evaluating the efficiency of endoscopic injection of cyanoacrylate glue for gastric varices and the risk factors for rebleeding were included. RESULTS The final analysis included data from 24 studies. The hemostatic rates ranged from 65 to 100%. The pooled rate of gastric varices recurrence was 34% [95% CI 21-46, I2 = 61.4%], early rebleeding rate was 16% [95% CI 11-20, I2 = 37.4%], late rebleeding rate was 39% [95% CI 36-42, I2 = 90.9%], mild and moderate adverse events rate were 28% [95% CI 24-31, I2 = 91.6%], 3% [95% CI - 2 to 8, I2 = 15.3%], rebleeding-related mortality rate was 6% [95% CI 2-10, I2 = 0%], all-cause mortality rate was 17% [95% CI 12-22, I2 = 63.6%]. Independent risk factors for gastric variceal rebleeding included portal venous thrombosis, ascites, cyanoacrylate volume, fever/systemic inflammatory response syndrome, red Wale sign, previous history of variceal bleeding, active bleeding and paragastric veins. The use of proton pump inhibitors could be a protective factor. CONCLUSIONS Endoscopic cyanoacrylate glue injection is an effective and safe treatment for gastric varices. Cirrhotic patients with the above risk factors may benefit from treatment aimed at reducing portal hypertension, antibiotic prophylaxis, and anticoagulation if they meet the indications.
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Affiliation(s)
- Yihuan Hu
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
- Research Center of Digestive Diseases, Central South University, Changsha, 410011, Hunan, China
- Clinical Research Center of Digestive Diseases of Hunan Province, Changsha, 410011, Hunan, China
| | - Mei Zhou
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
- Research Center of Digestive Diseases, Central South University, Changsha, 410011, Hunan, China
- Clinical Research Center of Digestive Diseases of Hunan Province, Changsha, 410011, Hunan, China
| | - Deliang Liu
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
- Research Center of Digestive Diseases, Central South University, Changsha, 410011, Hunan, China
- Clinical Research Center of Digestive Diseases of Hunan Province, Changsha, 410011, Hunan, China
| | - Jian Gong
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China.
- Research Center of Digestive Diseases, Central South University, Changsha, 410011, Hunan, China.
- Clinical Research Center of Digestive Diseases of Hunan Province, Changsha, 410011, Hunan, China.
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Zhang YH, Hu B. Future directions of noninvasive prediction of esophageal variceal bleeding: No worry about the present computed tomography inefficiency. World J Gastrointest Endosc 2024; 16:108-111. [PMID: 38577650 PMCID: PMC10989247 DOI: 10.4253/wjge.v16.i3.108] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 01/16/2024] [Accepted: 02/06/2024] [Indexed: 03/14/2024] Open
Abstract
In this editorial, we comment on the minireview by Martino A, published in the recent issue of World Journal of Gastrointestinal Endoscopy 2023; 15 (12): 681-689. We focused mainly on the possibility of replacing the hepatic venous pressure gradient (HVPG) and endoscopy with noninvasive methods for predicting esophageal variceal bleeding. The risk factors for bleeding were the size of the varices, the red sign and the Child-Pugh score. The intrinsic core factor that drove these changes was the HVPG. Therefore, the present studies investigating noninvasive methods, including computed tomography, magnetic resonance imaging, elastography, and laboratory tests, are working on correlating imaging or serum marker data with intravenous pressure and clinical outcomes, such as bleeding. A single parameter is usually not enough to construct an efficient model. Therefore, multiple factors were used in most of the studies to construct predictive models. Encouraging results have been obtained, in which bleeding prediction was partly reached. However, these methods are not satisfactory enough to replace invasive methods, due to the many drawbacks of different studies. There is still plenty of room for future improvement. Prediction of the precise timing of bleeding using various models, and extracting the texture of variceal walls using high-definition imaging modalities to predict the red sign are interesting directions to lay investment on.
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Affiliation(s)
- Yu-Hang Zhang
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Bing Hu
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
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Nall S, Arshad H, Contractor B, Sunina F, Raja F, Chaudhari SS, Batool S, Amin A. Predictors of Acute Kidney Injury in Patients Hospitalized With Liver Cirrhosis: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e52386. [PMID: 38361702 PMCID: PMC10868655 DOI: 10.7759/cureus.52386] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2024] [Indexed: 01/27/2024] Open
Abstract
Acute kidney injury (AKI) frequently occurs in hospitalized individuals with liver cirrhosis and represents a significant risk factor for early in-hospital mortality, holding crucial clinical and prognostic importance. The objective of this meta-analysis was to assess the risk factors associated with AKI in hospitalized individuals with cirrhosis. This systematic review and meta-analysis was conducted in concordance with guidelines provided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. Two independent researchers systematically searched major databases, including MEDLINE/PubMed, Web of Science, and EMBASE, from January 2015 until December 2023. A total of 14 studies were included in this meta-analysis, of which six were prospective, and the remaining were retrospective. Of the 9,659 cirrhosis patients in the 14 included studies, 3,968 had developed AKI with a pooled incidence of 41% (95% confidence interval = 34-47%). Our findings showed that a high Model for End-Stage Liver Disease (MELD) score, infection, high Child-Pugh-Turcotte stage score, high serum creatinine, high serum bilirubin, and low serum albumin were significantly associated with high incidence of AKI in liver cirrhosis patients. The results emphasize the importance of vigilant monitoring in cirrhosis patients to detect any indications of AKI, followed by meticulous and attentive management.
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Affiliation(s)
- Scott Nall
- Medicine, Central Michigan University School of Medicine, Saginaw, USA
| | | | - Bianca Contractor
- Internal Medicine, Smt. Nathiba Hargovandas Lakhmichand (NHL) Municipal Medical College, Ahmedabad, IND
| | - Fnu Sunina
- Medicine, Jinnah Postgraduate Medical Centre, Karachi, PAK
| | - Fnu Raja
- Pathology, MetroHealth Medical Center, Cleveland, USA
| | - Sandipkumar S Chaudhari
- Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, USA
- Family Medicine, University of North Dakota School of Medicine and Health Sciences, Fargo, USA
| | - Saima Batool
- Internal Medicine, Hameed Latif Hospital, Lahore, PAK
| | - Adil Amin
- Cardiology, Pakistan Navy Ship (PNS) Shifa, Karachi, PAK
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Pfisterer N, Schwarz M, Jachs M, Putre F, Ritt L, Mandorfer M, Madl C, Trauner M, Reiberger T. Endoscopic band ligation is safe despite low platelet count and high INR. Hepatol Int 2023; 17:1205-1214. [PMID: 37024710 PMCID: PMC10522720 DOI: 10.1007/s12072-023-10515-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 03/07/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND Prophylactic endoscopic band ligation (EBL) is used to prevent variceal bleeding in patients with liver cirrhosis. The association of thrombocytopenia, high INR (international normalized ratio) and liver dysfunction with the risk of procedure-related bleeding (PRB) remains debated and recommendations are controversial. METHODS We analyzed real-life data of cirrhotic patients undergoing elective EBL at two large Viennese centers between Q1/2000-Q1/2018. PRB was defined as bleeding occurring within 30 days after EBL. RESULTS We included 617 patients undergoing a total of 1178 prophylactic EBL procedures (median 2 per patient). Sixteen (2.6%) of 617 patients experienced PRB after a median of 12.5 (IQR 17.3) days with no difference in characteristics and laboratory values between the two groups. The proportion of patients with platelets (PLT) < 50 G/L or INR ≥ 1.5 was similar in patients with vs. without PRB. A higher MELD showed a non-significant association with EBL-related bleeding risk (odds ratio, OR 1.07; 95% confidence interval 95% CI 1.00-1.16, p = 0.058). While serum bilirubin was a significant predictor for PRB (OR: 1.10; 95% CI 1.03-1.18), the presence of large varices (OR 0.85 vs. small varices; 95% CI 0.20-3.84), INR (OR 0.50; 95% CI 0.10-3.14), PLT (OR 1.00; 95% CI 1.00-1.01) and the use of non-selective betablockers (OR 1.20; CI 95% 0.38-3.76) were not associated with PRB. CONCLUSION EBL is safe and procedure-related bleedings are rare (2.6%) including in patients with thrombocytopenia < 50 G/L or high INR ≥ 1.5. Only high MELD, and especially high bilirubin seem to be linked to an increased risk of EBL-related bleeding.
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Affiliation(s)
- Nikolaus Pfisterer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
- 4. Medizinische Abteilung für Gastroenterologie und Hepatologie, Klinik Landstrasse, Vienna, Austria
| | - Michael Schwarz
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
- 4. Medizinische Abteilung für Gastroenterologie und Hepatologie, Klinik Ottakring, Vienna, Austria
| | - Mathias Jachs
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Florian Putre
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Lukas Ritt
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Christian Madl
- 4. Medizinische Abteilung für Gastroenterologie und Hepatologie, Klinik Landstrasse, Vienna, Austria
- Private Medical School, Sigmund Freud University, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria.
- Christian-Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria.
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Ryou M, DeWitt JM, Das KK, Shami VM. AGA Clinical Practice Update on Interventional EUS for Vascular Investigation and Therapy: Commentary. Clin Gastroenterol Hepatol 2023; 21:1699-1705.e2. [PMID: 37162434 DOI: 10.1016/j.cgh.2023.03.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 03/17/2023] [Accepted: 03/20/2023] [Indexed: 05/11/2023]
Abstract
DESCRIPTION The purpose of this AGA Institute Clinical Practice Update is to review the available evidence supporting and examine opportunities for future research in endoscopic ultrasound-guided vascular investigation and therapies. METHODS This Clinical Practice Update was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Clinical Gastroenterology and Hepatology. This expert commentary incorporates important as well as recently published studies in this field, and it reflects the experiences of the authors who are advanced endoscopists with expertise in endoscopic ultrasound-guided vascular investigation and therapy.
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Affiliation(s)
- Marvin Ryou
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts.
| | - John M DeWitt
- Department of Gastroenterology and Hepatology, Indiana University Health, Indianapolis, Indiana
| | - Koushik K Das
- Division of Gastroenterology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Vanessa M Shami
- Division of Gastroenterology and Hepatology, University of Virginia Medical Center, Charlottesville, Virginia
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Radlinski MJ, Strand DS, Shami VM. Evolution of interventional endoscopic ultrasound. Gastroenterol Rep (Oxf) 2023; 11:goad038. [PMID: 37398926 PMCID: PMC10313421 DOI: 10.1093/gastro/goad038] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 05/19/2023] [Accepted: 06/01/2023] [Indexed: 07/04/2023] Open
Abstract
Endoscopic ultrasound (EUS) has become an indispensable modality for the assessment of the gastrointestinal tract and adjacent structures since its origin in the 1980s. Following the development of the linear echoendoscope, EUS has evolved from a purely diagnostic modality to a sophisticated tool for intervention, with numerous luminal, pancreaticobiliary, and hepatic applications. Broadly, these applications may be subdivided into three categories: transluminal drainage or access procedures, injection therapy, and EUS-guided liver interventions. Transluminal drainage or access procedures include management of pancreatic fluid collection, EUS-guided biliary drainage, EUS-guided bile duct drainage, EUS-guided pancreatic duct drainage, and enteral anastomosis formation. Injection therapies include therapeutic EUS-guided injections for management of malignancies accessible by EUS. EUS-guided liver applications include EUS-guided liver biopsy, EUS-guided portal pressure gradient measurement, and EUS-guided vascular therapies. In this review, we discuss the origins of each of these EUS applications, evolution of techniques leading to the current status, and future directions of EUS-guided interventional therapy.
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Affiliation(s)
- Mark J Radlinski
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
| | - Daniel S Strand
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
| | - Vanessa M Shami
- Corresponding author. Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, VA 22908, USA. Tel: +1-434-989-4381;
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Measurement of skeletal muscle volume is useful for predicting prognosis in patients with liver cirrhosis. Eur J Gastroenterol Hepatol 2022; 34:1151-1157. [PMID: 36170684 DOI: 10.1097/meg.0000000000002435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Hepatic venous pressure gradient (HVPG) and the model for end-stage liver disease (MELD) score were previously reported as prognostic factors for outcome in patients with liver cirrhosis (LC), and recently, the presence of sarcopenia was reported to be an indicator of worse prognosis in these patients. AIM This retrospective study aimed to clarify the importance of sarcopenia as a prognostic factor in patients with LC. MATERIAL AND METHODS The MELD-Na score, HVPG, and skeletal muscle index (SMI) were measured in 202 patients between January 2013 and August 2020. We performed linear regression analysis between HVPG and SMI and calculated suitable cutoff values of HVPG for predicting presarcopenia and of HVPG, ΔSMI (i.e. the decrease in SMI per year, for predicting survival). Overall survival rates with the HVPG and ΔSMI cutoff values were compared by Kaplan-Meier estimates and log-rank tests. Prognostic factors for survival were analyzed by Cox regression univariate and multivariate analyses. RESULTS In total, 71% (143/202) of patients presented with presarcopenia. Linear regression showed a significantly negative correlation between HVPG and SMI. Survival was significantly worse in the group with presarcopenia than in the group without. Survival was worse also in the group with an HVPG value ≥ 15 and ΔSMI ≥ -2.4. Cox regression multivariate analyses showed that MELD-Na score, HVPG, HVPG ≥ 15, ΔSMI, and ΔSMI ≥ -2.4 were independent prognostic factors. CONCLUSION Skeletal muscle volume, especially ΔSMI, has a prognostic value equivalent to that of the MELD-Na score and HVPG.
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12
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Chotalia M, Topiwala U, Iqbal A, Parekh D, Isaac JL, Perera MTPR, Arshad MA. Incidence of Gastrointestinal Bleeding After Transesophageal Echocardiography Use in Orthotopic Liver Transplantation. Transpl Int 2022; 35:10753. [PMID: 36338536 PMCID: PMC9632341 DOI: 10.3389/ti.2022.10753] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 09/29/2022] [Indexed: 12/05/2022]
Abstract
The risk of upper gastrointestinal bleeding (UGIB) after transesophageal echocardiography (TEE) in patients with high grade esophageal varices (EV) that are undergoing Orthotopic Liver transplantation (OLT) is poorly understood. This was a retrospective single-centre cohort study in all patients that underwent OLT at Queen Elizabeth Hospital Birmingham between September 2016 and September 2018. The primary outcome was to determine the incidence of UGIB in patients that have undergone OLT with EV that received TEE. 401 patients were included in the study, of which 320 (80%) received TEE. The incidence of post-operative UGIB in patients that received TEE was 1.6% (5/320) in the entire cohort: 2.7% (4/149) in patients with no evidence of EV and 0.6% (1/171) in patients with EV. UGIB occurred in 1 patient with grade 2 EV and did not occur in patients with grade 1 or 3 EV. The incidence of UGIB in patients that received TEE was not statistically different to patients that did not: 1.6% (5/320) vs. 3.7% (3/81) p = 0.218. In conclusion, in patients that underwent OLT, intra-operative TEE use was associated with low rates of UGIB, even in cohorts with high grade EV. This suggests that TEE is a relatively safe method of haemodynamic monitoring in patients undergoing OLT.
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Affiliation(s)
- Minesh Chotalia
- Department of Anaesthetics and Critical Care, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
- Birmingham Acute Care Research Group, University of Birmingham, Birmingham, United Kingdom
| | - Upasana Topiwala
- Department of Anaesthetics and Critical Care, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Asim Iqbal
- Department of Anaesthetics and Critical Care, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
- Department of Anesthesiology and Perioperative Care, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Dhruv Parekh
- Department of Anaesthetics and Critical Care, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
- Birmingham Acute Care Research Group, University of Birmingham, Birmingham, United Kingdom
| | - John L. Isaac
- Department of Anaesthetics and Critical Care, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - M. Thamara P. R. Perera
- Department of Liver Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- Department of Liver Surgery, Birmingham Children’s Hospital NHS Foundation Trust, Birmingham, United Kingdom
| | - Mohammed A. Arshad
- Department of Anaesthetics and Critical Care, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
- *Correspondence: Mohammed A. Arshad,
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Roberts LN, Lisman T, Stanworth S, Hernandez-Gea V, Magnusson M, Tripodi A, Thachil J. Periprocedural management of abnormal coagulation parameters and thrombocytopenia in patients with cirrhosis: Guidance from the SSC of the ISTH. J Thromb Haemost 2022; 20:39-47. [PMID: 34661370 DOI: 10.1111/jth.15562] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 10/05/2021] [Accepted: 10/11/2021] [Indexed: 12/12/2022]
Abstract
Prolonged prothrombin time and thrombocytopenia are common in patients with cirrhosis. These parameters do not reflect the overall hemostatic rebalance or bleeding risk in the periprocedural setting; however, attempts to correct these parameters remain frequent. We review the literature on periprocedural bleeding risk, bleeding risk factors, and the risk and benefits of hemostatic interventions in patients with cirrhosis. We provide guidance recommendations on evaluating bleeding risk in this patient group and management of hemostatic abnormalities in the periprocedural setting.
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Affiliation(s)
- Lara N Roberts
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital, London, UK
| | - Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Simon Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
- Department of Haematology, Oxford University Hospitals, NHS Foundation Trust, Oxford, UK
- Radcliffe Department of Medicine, University of Oxford and NIHR Oxford Biomedical Research Centre (Haematology), Oxford, UK
| | - Virginia Hernandez-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, IDIBAPS, Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), University of Barcelona, Barcelona, Spain
| | - Maria Magnusson
- Department of Pediatrics, Clinical Chemistry and Blood Coagulation Research, MMK, CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Department of Haematology, Karolinska University Hospital, Stockholm, Sweden
| | - Armando Tripodi
- IRCCS Ca' Granda Maggiore Hospital Foundation, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milano, Italy
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
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14
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Kobayashi K, Uldry E, Kokudo T, Cristaudi A, Kawaguchi Y, Shirata C, Yamaguchi T, Dormond O, Duran R, Hasegawa K, Demartines N, Halkic N. Correlation Between Portal Pressure and Indocyanine Green Retention Rate is Unaffected by the Cause of Cirrhosis: A Prospective Study. World J Surg 2021; 45:2546-2555. [PMID: 33891139 PMCID: PMC8236033 DOI: 10.1007/s00268-021-06111-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2021] [Indexed: 12/22/2022]
Abstract
Background Accurate estimation of the hepatic functional reserve before liver resection is important to avoid post-hepatectomy liver failure (PHLF). The aim of the present study was to evaluate the association of indocyanine green retention test with portal pressure by the cause of cirrhosis (non-viral vs. viral) and assessed postoperative outcomes including incidence of PHLF in patients with viral and non-viral cirrhosis. Methods The cohort includes 50 consecutive patients with liver cirrhosis scheduled for liver resection for primary liver tumors at the Lausanne University Hospital between 2009 and 2018. Results There were 31 patients with non-viral liver cirrhosis (Non-virus group) and 19 with viral liver cirrhosis (virus group). The indocyanine green retention rate at 15 min (ICG-R15) (p = 0.276), Hepatic Venous Portal Gradient (HVPG; p = 0.301), and postoperative outcomes did not differ between the non-virus group and viral group. ICG-R15 and HVPG showed a significant linear correlation in all patients (Spearman’s rank correlation coefficient, ρ = 0.599, p < 0.001), the non-virus group (ρ = 0.555, p = 0.026), and the virus group (ρ = 0.534, p = 0.007). A receiver operating characteristic curve analysis showed that ICG-R15 was a predictor for presence of portal hypertension (PH; HVPG ≥ 12 mmHg) (area under the curve [AUC] = 0.780). The cut-off value of ICG-R15 for predicting the presence of PH was 16.0% with 72.3% of sensitivity and 79.0% of specificity. Conclusions The ICG-R15 level was associated with portal pressure in both patients with non-virus cirrhosis and patients with virus cirrhosis and predicts the incidence of PH with relatively good discriminatory ability. Clinical trial number https://clinicalTrials.gov(ID:NCT00827723) Local ethics committee number CER-VD 251.08
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Affiliation(s)
- Kosuke Kobayashi
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland. .,Hepato-Pancreatico-Biliary Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Emilie Uldry
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Takashi Kokudo
- Hepato-Pancreatico-Biliary Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Alessandra Cristaudi
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Yoshikuni Kawaguchi
- Hepato-Pancreatico-Biliary Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Chikara Shirata
- Hepato-Pancreatico-Biliary Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takamune Yamaguchi
- Hepato-Pancreatico-Biliary Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Olivier Dormond
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Rafael Duran
- Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Kiyoshi Hasegawa
- Hepato-Pancreatico-Biliary Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
| | - Nermin Halkic
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
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15
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Drolz A, Schramm C, Seiz O, Groth S, Vettorazzi E, Horvatits T, Wehmeyer MH, Schramm C, Goeser T, Roesch T, Lohse AW, Kluwe J. Risk factors associated with bleeding after prophylactic endoscopic variceal ligation in cirrhosis. Endoscopy 2021; 53:226-234. [PMID: 32894867 DOI: 10.1055/a-1214-5355] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Prophylactic endoscopic variceal band ligation (EVL) is frequently performed in patients with liver cirrhosis. The aim of our study was to identify factors associated with early upper gastrointestinal bleeding (UGIB) in cirrhosis patients after prophylactic EVL. METHODS 787 nonemergency EVLs performed in 444 patients in two German University medical centers were analyzed retrospectively. RESULTS Within 30 days after EVL, 38 UGIBs were observed (4.8 % of all procedures). Bilirubin levels (hazard ratio [HR] 1.5, 95 % confidence interval [CI] 1.2-2.0 for a 2-fold increase) and presence of varices grade III/IV according to Paquet (HR 2.6, 95 %CI 1.3-5.0 compared with absence or smaller sized varices) were independently associated with UGIB following EVL. International normalized ratio (INR) was associated with bleeding events in the univariate analysis but did not reach statistical significance after adjustment for bilirubin and presence of varices grade III/IV (HR 1.2, 95 %CI 0.9-1.6 for an increase by 0.25). There was no statistically significant association between platelet count or fibrinogen levels and UGIB. Substitution of coagulation products did not affect incidence of bleeding after EVL, which also applied to patients with "coagulopathy" (INR > 1.5 and/or platelet count < 50 × 109/L). No association between proton pump inhibitor therapy and post-EVL UGIB was observed. CONCLUSIONS EVL is a safe procedure and immediate bleeding complications are rare. Serum bilirubin levels and size of varices, rather than coagulation indices, are associated with UGIB after EVL. Our data do not support the preventive substitution of blood or coagulation products.
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Affiliation(s)
- Andreas Drolz
- Department of Internal Medicine I, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Christoph Schramm
- Department of Gastroenterology and Hepatology, University Hospital Cologne, Cologne, Germany
| | - Oliver Seiz
- Department of Internal Medicine I, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Stefan Groth
- Department of Interdisciplinary Endoscopy, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Eik Vettorazzi
- Department of Medical Biometry and Epidemiology, University Medical Center, Hamburg, Germany
| | - Thomas Horvatits
- Department of Internal Medicine I, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Malte H Wehmeyer
- Department of Internal Medicine I, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Christoph Schramm
- Department of Internal Medicine I, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Tobias Goeser
- Department of Gastroenterology and Hepatology, University Hospital Cologne, Cologne, Germany
| | - Thomas Roesch
- Department of Interdisciplinary Endoscopy, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Ansgar W Lohse
- Department of Internal Medicine I, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Johannes Kluwe
- Department of Internal Medicine I, University Medical Center Hamburg Eppendorf, Hamburg, Germany
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Feder S, Wiest R, Weiss TS, Aslanidis C, Schacherer D, Krautbauer S, Liebisch G, Buechler C. Proprotein convertase subtilisin/kexin type 9 (PCSK9) levels are not associated with severity of liver disease and are inversely related to cholesterol in a cohort of thirty eight patients with liver cirrhosis. Lipids Health Dis 2021; 20:6. [PMID: 33461570 PMCID: PMC7814535 DOI: 10.1186/s12944-021-01431-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 01/07/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Proprotein convertase subtilisin/kexin type 9 (PCSK9) is of particular importance in cholesterol metabolism with high levels contributing to hypercholesterolemia. Cholesterol and sphingolipids are low in patients with liver cirrhosis. Purpose of this study was to find associations of plasma PCSK9 with circulating cholesterol and sphingolipid species and measures of liver disease severity in patients with liver cirrhosis. METHODS PCSK9 protein levels were determined by ELISA in systemic vein (SVP), hepatic vein (HVP) and portal vein plasma of patients with mostly alcoholic liver cirrhosis. PCSK9 and LDL-receptor protein expression were analysed in cirrhotic and non-cirrhotic liver tissues. RESULTS Serum PCSK9 was reduced in patients with liver cirrhosis in comparison to non-cirrhotic patients. In liver cirrhosis, plasma PCSK9 was not correlated with Child-Pugh score, Model for End-Stage Liver Disease score, bilirubin or aminotransferases. A negative association of SVP PCSK9 with albumin existed. PCSK9 protein in the liver did not change with fibrosis stage and was even positively correlated with LDL-receptor protein levels. Ascites volume and variceal size were not related to PCSK9 levels. Along the same line, transjugular intrahepatic shunt to lower portal pressure did not affect PCSK9 concentrations in the three blood compartments. Serum cholesterol, sphingomyelin and ceramide levels did not correlate with PCSK9. Stratifying patients by high versus low PCSK9 levels using the median as cut-off, several cholesteryl ester species were even low in the subgroup with high PCSK9 levels. A few sphingomyelin species were also reduced in the patients with PCSK9 levels above the median. PCSK9 is highly expressed in the liver but systemic, portal and hepatic vein levels were similar. PCSK9 was not correlated with the inflammatory proteins C-reactive protein, IL-6, galectin-3, resistin or pentraxin 3. Of note, HVP PCSK9 was positively associated with HVP chemerin and negatively with HVP adiponectin levels. CONCLUSIONS In the cohort of patients with liver cirrhosis mostly secondary to alcohol consumption high PCSK9 was associated with low levels of certain cholesteryl ester and sphingomyelin species. Positive correlations of PCSK9 and LDL-receptor protein in the liver of patients with chronic liver injury are consistent with these findings.
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Affiliation(s)
- Susanne Feder
- Department of Internal Medicine I, Regensburg University Hospital, D-93042, Regensburg, Germany
| | - Reiner Wiest
- Department of Visceral Surgery and Medicine, University Inselspital, Bern, Switzerland
| | - Thomas S Weiss
- Children's University Hospital (KUNO), Regensburg University Hospital, Regensburg, Germany
| | - Charalampos Aslanidis
- Institute of Clinical Chemistry and Laboratory Medicine, Regensburg University Hospital, Regensburg, Germany
| | - Doris Schacherer
- Department of Internal Medicine I, Regensburg University Hospital, D-93042, Regensburg, Germany
| | - Sabrina Krautbauer
- Institute of Clinical Chemistry and Laboratory Medicine, Regensburg University Hospital, Regensburg, Germany
| | - Gerhard Liebisch
- Institute of Clinical Chemistry and Laboratory Medicine, Regensburg University Hospital, Regensburg, Germany
| | - Christa Buechler
- Department of Internal Medicine I, Regensburg University Hospital, D-93042, Regensburg, Germany.
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Wang K, Wang S, Xiong M, Wang C, Wang H. Non-invasive Assessment of Hepatic Venous Pressure Gradient (HVPG) Based on MR Flow Imaging and Computational Fluid Dynamics. LECTURE NOTES IN COMPUTER SCIENCE 2021:33-42. [DOI: 10.1007/978-3-030-87234-2_4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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de Oliveira Souza E, D'Amico ÉA, Flores da Rocha TR, Marcondes Ferreira C, Medeiros Batista J, Carneiro D'Albuquerque LA, Carrilho FJ, Queiroz Farias A. Preservation of platelet function in patients with cirrhosis and thrombocytopenia undergoing esophageal variceal ligation. Hepatobiliary Pancreat Dis Int 2020; 19:555-560. [PMID: 31982344 DOI: 10.1016/j.hbpd.2019.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 12/27/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Thrombocytopenia is a possible risk factor for bleeding after band ligation of esophageal varices. However, elevated von Willebrand factor (VWF) in cirrhosis improves platelet function and could decrease this risk. Our objective was to assess platelet function in patients with cirrhosis undergoing esophageal variceal ligation (EVL). METHODS The assessment consisted of platelet count, antigen and activity of VWF and VWF-cleaving protease ADAMTS-13 activity, and a platelet adhesion and aggregation test simulating vascular flow in vivo (Impact-RⓇ) prior to EVL. RESULTS Totally 111 patients were divided into three groups according to platelet count: (1) < 50 × 109/L (n = 38, 34.2%); (2) 50 × 109/L to 100 × 109/L (n = 47, 42.3%); and (3) > 100 × 109/L (n = 26, 23.4%). No statistically significant difference was found in the aggregate size of platelets [group 1: 41.0 (31.8-67.3) µm2; group 2: 47.0 (33.8-71.3) µm2; and group 3: 47.0 (34.0-66.0) µm2; P = 0.60] and no significant correlation was found between aggregate size and platelet count (Spearman r = 0.07; P = 0.47). Surface coverage was 4.1% (2.8%-6.7%), 8.5% (4.0%-10.0%), and 9.0% (7.1%-12.0%) (P < 0.001) in groups 1, 2 and 3, respectively and correlated with platelet count (Spearman r = 0.39; P < 0.0001). There was no significant difference between groups in VWF or ADAMTS-13. Post-EVL bleeding occurred in six (5.4%) patients (n = 2 in group 1, n = 1 in group 2, and n = 3 in group 3; P = 0.32). Patients with bleeding had higher MELD scores [15.0 (11.3-20.3) versus 12.0 (10.0-15.0); P = 0.025], but no difference was demonstrated for platelet function parameters. CONCLUSION Platelet function is preserved even in the presence of thrombocytopenia, including in the patients with post-EVL bleeding.
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Affiliation(s)
- Evandro de Oliveira Souza
- Division of Gastroenterology and Hepatology, University of Sao Paulo School of Medicine, Av. Dr. Eneas Carvalho de Aguiar, 255, 9th floor, office 9159, Sao Paulo, SP 05403-000, Brazil.
| | - Élbio Antônio D'Amico
- Hemostasis Laboratory, Hematology Service, University of Sao Paulo School of Medicine, Av. Dr. Eneas Carvalho de Aguiar, 255, 2nd floor, Sao Paulo, SP 05403-000, Brazil
| | - Tânia Rúbia Flores da Rocha
- Hemostasis Laboratory, Hematology Service, University of Sao Paulo School of Medicine, Av. Dr. Eneas Carvalho de Aguiar, 255, 2nd floor, Sao Paulo, SP 05403-000, Brazil
| | - Caroline Marcondes Ferreira
- Division of Gastroenterology and Hepatology, University of Sao Paulo School of Medicine, Av. Dr. Eneas Carvalho de Aguiar, 255, 9th floor, office 9159, Sao Paulo, SP 05403-000, Brazil
| | - Juliana Medeiros Batista
- Division of Gastroenterology and Hepatology, University of Sao Paulo School of Medicine, Av. Dr. Eneas Carvalho de Aguiar, 255, 9th floor, office 9159, Sao Paulo, SP 05403-000, Brazil
| | - Luiz Augusto Carneiro D'Albuquerque
- Division of Gastroenterology and Hepatology, University of Sao Paulo School of Medicine, Av. Dr. Eneas Carvalho de Aguiar, 255, 9th floor, office 9159, Sao Paulo, SP 05403-000, Brazil
| | - Flair José Carrilho
- Division of Gastroenterology and Hepatology, University of Sao Paulo School of Medicine, Av. Dr. Eneas Carvalho de Aguiar, 255, 9th floor, office 9159, Sao Paulo, SP 05403-000, Brazil
| | - Alberto Queiroz Farias
- Division of Gastroenterology and Hepatology, University of Sao Paulo School of Medicine, Av. Dr. Eneas Carvalho de Aguiar, 255, 9th floor, office 9159, Sao Paulo, SP 05403-000, Brazil
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Clinical Decompensation and Outcomes in Patients With Compensated Cirrhosis and a Hepatic Venous Pressure Gradient ≥20 mm Hg. Am J Gastroenterol 2020; 115:1624-1633. [PMID: 32453061 DOI: 10.14309/ajg.0000000000000653] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Hepatic venous pressure gradient (HVPG) of ≥10 mm Hg predicts clinical decompensation (CD) in compensated cirrhosis. A proportion of cirrhotic patients at presentation have high HVPG (≥20 mm Hg) and are compensated. The natural history, spectrum of CD, and mortality in this group is largely unknown. METHODS Consecutive compensated cirrhotic patients with HVPG ≥6 mm Hg (n = 741) were followed up for 3-6 months for the development of any CD. Patients were classified based on the baseline HVPG (6 to <12 mm Hg [low HVPG, Gr.A, n = 163], 12 to <20 mm Hg [intermediate HVPG, Gr.B, n = 437] and ≥20 mm Hg [high HVPG, Gr.C, n = 141]). We analyzed the predictors of first CD, HVPG response to carvedilol, and mortality in these groups. RESULTS CD developed in 217 (29.3%) patients during a mean follow-up of 1.6 ± 0.4 years, and those who developed CD had higher baseline HVPG (17.02 ± 4.79 vs 14.28 ± 4.86; P < 0.001). First CD was seen earlier (1.3 ± 0.7 years vs 1.5 ± 0.6 years and 1.6 ± 0.5 years, P = 0.02) and more frequently (44.7% vs 11% and 31.1%, P < 0.01) in high HVPG groups compared with low and intermediate HVPG groups, with higher mortality rates. Patients in the high HVPG group compared with the low HVPG group more often had NASH-cirrhosis (35.5% vs 19.6%; P 0.001), higher liver stiffness values (45.06 ± 20.46 vs 20.09 ± 5.47 kPa, P < 0.001), and lower platelet counts (113.37 ± 72.57 vs 151.7 ± 87.30/cmm, P < 0.001). Patients with HVPG ≥12 mm Hg received carvedilol, and a repeat HVPG performed in a proportion after 9.3 ± 2.4 months showed response (≥20% reduction in HVPG or <12 mm Hg) in 31.6% patients (Gr. B, 44.9% > Gr. C, 22.2%, P < 0.05). Baseline HVPG (HVPG ≥12 to <20 mm Hg [Hazard ratio: 2.73] and HVPG ≥20 mm Hg [Hazard ratio: 4.48], P < 0.001) independently predicted CD. DISCUSSION HVPG ≥20 mm Hg in patients with compensated cirrhosis independently predicts early and more frequent CD and poor outcomes. These patients should be labeled as "high-risk compensated cirrhosis," and early and effective interventions to reduce portal pressure should be initiated to improve long-term outcomes.
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Pentraxin-3 is not related to disease severity in cirrhosis and hepatocellular carcinoma patients. Clin Exp Med 2020; 20:289-297. [PMID: 32078718 PMCID: PMC7181432 DOI: 10.1007/s10238-020-00617-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 02/15/2020] [Indexed: 12/19/2022]
Abstract
The acute-phase protein pentraxin-3 (PTX3) is a component of the innate immune system. Inflammation and tissue injury increased PTX3 in the injured liver, and accordingly, circulating PTX3 was induced in patients with chronic liver diseases. In the present study, PTX3 protein was determined in systemic, hepatic, and portal vein plasma of patients with liver cirrhosis to assess a possible association between hepatic PTX3 release and extent of liver injury. However, PTX3 levels were not related to disease severity. Of note, portal PTX3 levels were higher than concentrations in the hepatic vein. PTX3 in the hepatic and portal veins was negatively correlated with factor V, antithrombin 3, and prothrombin time. PTX3 did neither correlate with C-reactive protein nor galectin-3 or resistin, whereby the latter two proteins are associated with hepatic injury. PTX3 levels were not changed in cirrhosis patients with ascites or varices and did not correlate with the hepatic venous pressure gradient. Likewise, serum PTX3 was not correlated with histological steatosis, inflammation, or fibrosis stage in patients with hepatocellular carcinoma (HCC). Moreover, PTX3 was not associated with tumor node metastasis classification in HCC. Above all, PTX3 increased in hepatic, portal, and systemic blood immediately after transjugular intrahepatic portosystemic shunt (TIPS). Higher PTX3 in portal than hepatic vein plasma and further increase after TIPS suggests that the liver eliminates PTX3 from the circulation. In summary, PTX3 is not of diagnostic value in cirrhosis and HCC patients.
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Ede CJ, Ede R, Brand M. Selective versus non‐selective shunts for the prevention of variceal rebleeding. Cochrane Database Syst Rev 2019; 2019:CD013471. [PMCID: PMC6837277 DOI: 10.1002/14651858.cd013471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/09/2024]
Abstract
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the benefits and harms of any type of selective shunt versus any type of non‐selective shunt for the prevention of oesophagogastric variceal rebleeding in people with portal hypertension.
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Affiliation(s)
- Chikwendu J Ede
- University of the WitwatersrandDepartment of Surgery7 York RoadJohannesburgSouth Africa2193
| | - Roseline Ede
- University of the WitwatersrandDepartment of Dermatology7 York Road, ParktownJohannesburgSouth AfricaGauteng
| | - Martin Brand
- University of PretoriaDepartment of SurgeryPretoriaSouth Africa0001
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22
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Xiaoqing Z, Na L, Lili M, Jie C, Tiancheng L, Jian W, Shiyao C. Endoscopic Cyanoacrylate Injection with Lauromacrogol for Gastric Varices: Long-Term Outcomes and Predictors in a Retrospective Cohort Study. J Laparoendosc Adv Surg Tech A 2019; 29:1135-1143. [PMID: 31313965 DOI: 10.1089/lap.2019.0360] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Introduction: The first-line treatment for gastric variceal rebleeding in cirrhotic patients is endoscopic cyanoacrylate injection. We focused on the efficacy and prognosis of cyanoacrylate combined with Lauromacrogol® for gastric varices (GV) in a retrospective study of long-term follow-up. Materials and Methods: One hundred thirty patients with cirrhosis and GV from March 2011 to February 2013 were included. Sixty-eight patients underwent endoscopic cyanoacrylate injection with Lauromacrogol and 62 patients without Lauromacrogol. The median follow-up was 40.1 and 38.8 months, respectively. Results: The volumes of cyanoacrylate used for the GV eradication in the Lauromacrogol group were significantly lower than those in the Ethiodol® group (1.6 ± 0.8 versus 2.1 ± 1.2 mL, P = .029). No ectopic embolisms were observed during follow-up. The 1- and 3-year rebleeding-free rate did not differ between groups (83.7% and 59.2% versus 75.8% and 62.5%; P = .797). The same was observed for mortality (86.6% and 83.5% versus 85.5% and 83.7%; P = .955). New portal venous thrombosis (PVT) and progression of previous partial PVT were independently associated with rebleeding (hazard ratio [HR] 5.127, 95% confidence interval [CI], 2.430-10.817, P = .000) and death (HR 10.093, 95% CI, 3.988-25.548, P = .000). Conclusions: Endoscopic cyanoacrylate injection with Lauromacrogol might minimize the required dosage of cyanoacrylate, but it did not improve rebleeding rate or survival. Exacerbation of PVT was associated with rebleeding and death.
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Affiliation(s)
- Zeng Xiaoqing
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Li Na
- Department of Infectious Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ma Lili
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chen Jie
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Luo Tiancheng
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wang Jian
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chen Shiyao
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, China.,Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
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23
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Premkumar M, Rangegowda D, Kajal K, Khumuckham JS. Noninvasive estimation of intravascular volume status in cirrhosis by dynamic size and collapsibility indices of the inferior vena cava using bedside echocardiography. JGH OPEN 2019; 3:322-328. [PMID: 31406926 PMCID: PMC6684769 DOI: 10.1002/jgh3.12166] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 01/26/2019] [Accepted: 01/31/2019] [Indexed: 12/20/2022]
Abstract
Background and Aim Echocardiographic assessment of the inferior vena cava diameter (IVCD) and collapsibility index (IVCCI) is a noninvasive estimate of intravascular volume status (IVS) but requires validation for cirrhosis. We evaluated IVC dynamics in cirrhosis and correlated it with conventional tools such as central venous pressure (CVP), pulmonary capillary wedge pressure (PCWP), and right atrial pressure (RAP). Methods A total of 673 consecutive cirrhotic patients were screened by echocardiography, and 125 patients underwent right heart catheterization with recording of hepatic venous pressure gradient (HVPG), RAP, pulmonary artery (PA) pressure, and PCWP. CVP data were available for 80 (64%) patients, and finally, 76 patients (84% male, 50% ethanol related, mean age 52.1 years, 57.8% with ascites) with complete data were enrolled. Results The mean CVP measured was 12.8 ± 4.8 mmHg, and IVCCI was 29.5 ± 10.9%. The IVCD ranged from 0.97 to 2.26 cm and from 0.76 to 1.84 cm during expiration and inspiration, respectively, with a mean of 1.8 ± 0.9 cm. The mean IVCD correlated with RAP (r = 0.633, P = 0.043) but not with HVPG (r = 0.344, P = 0.755), PCWP (r = 0.562, P = 0.072), or PA pressure (r = 0.563, P = 0.588). A negative linear correlation was observed between the CVP and the IVCCI (r = −0.827, P = 0.023) in all patients and substratified for those with (r = −0.748, P = 0.039) and without ascites (r = −0.761, P = 0.047). A positive correlation was observed between CVP and IVCDmax (r = 0.671, P = 0.037) and IVCDmin (r = 0.612, P = 0.040). Conclusions IVCD and collapsibility index provides noninvasive IVS assessment, independent of HVPG or ascites, with the potential for calculating fluid requirements in cirrhosis.
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Affiliation(s)
- Madhumita Premkumar
- Department of Hepatology Institute of Liver and Biliary Sciences New Delhi India
| | - Devaraja Rangegowda
- Department of Hepatology Institute of Liver and Biliary Sciences New Delhi India
| | - Kamal Kajal
- Department of Anesthesia and Critical Care Medicine Institute of Liver and Biliary Sciences New Delhi India
| | - Jelen S Khumuckham
- Department of Cardiology Institute of Liver and Biliary Sciences New Delhi India
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24
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Clinical Aspects and Prognosis Evaluation of Cirrhotic Patients Hospitalized with Acute Kidney Injury. Can J Gastroenterol Hepatol 2019; 2019:6567850. [PMID: 30941330 PMCID: PMC6421012 DOI: 10.1155/2019/6567850] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 12/18/2018] [Accepted: 01/15/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Acute kidney injury occurs in approximately 20% of hospitalized cirrhotic patients. Mortality is estimated at 60% within a month and 65% within a year. AIMS To evaluate survival in 30 days and in 3 months of cirrhotic patients hospitalized with acute kidney injury, identifying factors associated with mortality. METHODS 52 patients with cirrhosis admitted to an academic tertiary center who presented acute kidney injury according to the International Club of Ascites criteria were evaluated. Clinical and laboratory data was collected at diagnosis between 2011 and 2015. RESULTS Average age was 54.6 (±10.7) years and 69.2% were male. The average MELD, MELD-Na, and Child-Pugh scores were 21.9 (±7.0), 24.5 (±6.7), and 10.1 (±2.2), respectively. Thirty patients (57.7%) were in acute kidney injury stage 1, 16 (30.8%) in stage 2, and six (11.6%) in stage 3. Mortality was 28.6% in 30 days and 44.9% in three months. In multivariate analysis, variables that were associated independently to mortality were lack of response to expansion treatment and Child-Pugh score. Mortality was 93.3% in three months among nonresponders compared to 28.6% among those who responded to volume expansion (p<0.0001). CONCLUSION Acute kidney injury in cirrhosis has dire prognosis, particularly in patients with advanced cirrhosis and in nonresponders to volume expansion.
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25
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Maruyama H, Kobayashi K, Kiyono S, Ogasawara S, Ooka Y, Suzuki E, Chiba T, Kato N, Komiyama Y, Takawa M, Nagamatsu H, Shiina S. Incidence and hemodynamic feature of risky esophageal varices with lower hepatic venous pressure gradient. Int J Med Sci 2019; 16:1614-1620. [PMID: 31839749 PMCID: PMC6909812 DOI: 10.7150/ijms.37040] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 10/14/2019] [Indexed: 12/14/2022] Open
Abstract
Background: To examine the incidence of cirrhosis patients with high-risk esophageal varices (EV) who show hepatic venous pressure gradient (HVPG) < 10 mmHg and to identify their hemodynamic features. Methods: This prospective study consisted of 110 cirrhosis patients with EV, all with the candidate for primary or secondary prophylaxis. Sixty-one patients had red sign, and 49 patients were bleeders. All patients underwent both Doppler ultrasound and HVPG measurement. Results: There were 18 patients (16.4%) with HVPG < 10 mmHg. The presence of venous-venous communication (VVC) was more frequent in patients with HVPG < 10 mmHg (10/18) than in those with HVPG ≥ 10 mmHg (19/92; p = 0.0021). The flow volume in the left gastric vein (LGV) and the incidence of red sign were higher in the former (251.9 ± 150.6 mL/min; 16/18) than in the latter (181 ± 100.5 mL/min, p = 0.02; 45/92; p = 0.0018). The patients with red sign had lower HVPG (13.3 ± 4.5) but advanced LGV hemodynamics (velocity 13.2 ± 3.8 cm/s; flow volume 217.5 ± 126.6 mL/min), whereas those without red sign had higher HVPG (16.2 ± 4.6, p = 0.001) but poorer LGV hemodynamics (10.9 ± 2.3, p = 0.002; 160.1 ± 83.1, p = 0.02). Conclusion: Patients with high-risk EV with HVPG < 10 mmHg showed 16.4% incidence. Although low HVPG may be underestimated by the presence of VVC, the increased LGV hemodynamics compensates for the severity of portal hypertension, which may contribute to the development of red sign.
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Affiliation(s)
- Hitoshi Maruyama
- Department of Gastroenterology, Juntendo University, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Kazufumi Kobayashi
- Department of Gastroenterology, Chiba University Graduate School of Medicine, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Soichiro Kiyono
- Department of Gastroenterology, Chiba University Graduate School of Medicine, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Sadahisa Ogasawara
- Department of Gastroenterology, Chiba University Graduate School of Medicine, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Yoshihiko Ooka
- Department of Gastroenterology, Chiba University Graduate School of Medicine, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Eiichiro Suzuki
- Department of Gastroenterology, Chiba University Graduate School of Medicine, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Tetsuhiro Chiba
- Department of Gastroenterology, Chiba University Graduate School of Medicine, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Naoya Kato
- Department of Gastroenterology, Chiba University Graduate School of Medicine, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Yasuyuki Komiyama
- Department of Gastroenterology, Juntendo University, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Masashi Takawa
- Department of Gastroenterology, Juntendo University, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Hiroaki Nagamatsu
- Department of Gastroenterology, Juntendo University, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Shuichiro Shiina
- Department of Gastroenterology, Juntendo University, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
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26
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Gastric Varices Bleed at Lower Portosystemic Pressure Gradients than Esophageal Varices. J Vasc Interv Radiol 2018; 29:636-641. [DOI: 10.1016/j.jvir.2017.10.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 10/12/2017] [Accepted: 10/12/2017] [Indexed: 02/07/2023] Open
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27
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Otani I, Oka S, Tanaka S, Tsuboi A, Kunihara S, Nagaoki Y, Aikata H, Chayama K. Clinical significance of small-bowel villous edema in patients with liver cirrhosis: A capsule endoscopy study. J Gastroenterol Hepatol 2018; 33:825-830. [PMID: 29023961 DOI: 10.1111/jgh.14016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 09/15/2017] [Accepted: 09/25/2017] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM The relationship between the presence of villous edema (VE) in portal hypertensive enteropathy and clinical factors remains unclear. The aim of this study was to reveal the clinical factors related to VE in patients with liver cirrhosis (LC), and investigate the clinical significance of VE. METHODS Between February 2009 and September 2016, 363 consecutive patients with LC underwent capsule endoscopy for diagnosing portal hypertensive enteropathy at Hiroshima University Hospital. We evaluated the relationship between the presence of VE and patients' clinical characteristics, findings of esophagogastroduodenoscopy and computed tomography, and survival time. RESULTS Villous edema was observed in 131 patients (36%), and severe lesions were found in 71 (20%). The presence of VE was significantly greater in patients with Child-Pugh classification B or C, esophageal varices, portal hypertensive gastropathy (PHG), ascites, portal vein thrombosis (PVT), and splenomegaly. In multivariate analysis, Child-Pugh class B or C, esophageal varices, PVT, and splenomegaly were significant predictive factors for the presence of VE. Severe VE was significantly greater in patients with Child-Pugh class B or C, serum albumin level ≤ 3.2 mg/dL, PHG, and PVT. In multivariate analysis, PHG, Child-Pugh class B or C, PVT, were significant predictive factors for severe VE. CONCLUSIONS Clinical factors related to portal hypertension were significantly correlated with VE. In particular PVT was correlated with the appearance and exacerbation of VE. Periodic capsule endoscopy in LC patients may lead to early detection of portal hypertension and PVT.
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Affiliation(s)
- Ichiro Otani
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Shiro Oka
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Shinji Tanaka
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
| | - Akiyoshi Tsuboi
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Sayoko Kunihara
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Yuko Nagaoki
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Hiroshi Aikata
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Kazuaki Chayama
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
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28
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Al Mahtab M, M Noor E Alam S, A Rahim M, A Alam M, A Khondaker F, L Moben A, Mohsena M, Mohammad Fazle Akbar S. Hepatic Venous Pressure Gradient Measurement in Bangladeshi Cirrhotic Patients: A Correlation with Child's Status, Variceal Size, and Bleeding. Euroasian J Hepatogastroenterol 2017; 7:142-145. [PMID: 29201796 PMCID: PMC5670257 DOI: 10.5005/jp-journals-10018-1235] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 08/30/2017] [Indexed: 12/29/2022] Open
Abstract
Background: Hepatic venous pressure gradient (HVPG) reflects the portal pressure in patients with cirrhotic portal hypertension. The aim of the study was to assess the relation of HVPG to variceal size, Child-Pugh status, and variceal bleeding. Materials and methods: A total of 96 patients with cirrhosis of liver were enrolled prospectively and each patient’s HVPG level was measured via the transfemoral route. Clinical and biochemical evaluation and upper gastrointestinal (GI) endoscopy were done in each subject. Severity of cirrhosis was assessed by Child’s status. Results: The mean HVPG was higher in patients with Child’s B and C (14.10 ± 7.56 and 13.64 ± 7.17 mm Hg respectively) compared with those of Child’s A (10.15 ± 5.63 mm Hg). The levels of HVPG differed significantly between Child’s classes A and B (p = 0.011) and Child’s A and C (p = 0.041). The mean HVPG was also higher in bleeders compared with nonbleeders with large varices (17.7 ± 5.5 vs 14.9 ± 4.7 mmHg respectively; p = 0.006). Conclusion: Hepatic venous pressure gradient seems to be important to assess the severity of liver cirrhosis. How to cite this article: Al Mahtab M, Noor E Alam SM, Rahim MA, Alam MA, Khondaker FA, Moben AL, Mohsena M, Akbar SMF. Hepatic Venous Pressure Gradient Measurement in Bangladeshi Cirrhotic Patients: A Correlation with Child’s Status, Variceal Size, and Bleeding. Euroasian J Hepato-Gastroenterol 2017;7(2):142-145.
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Affiliation(s)
- Mamun Al Mahtab
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Shahbagh, Dhaka, Bangladesh
| | - Sheikh M Noor E Alam
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Shahbagh, Dhaka, Bangladesh
| | - Mohammad A Rahim
- Department of Hepatology Abdul Malek Ukil Medical College, Noakhali, Bangladesh
| | - Mohammad A Alam
- Department of Hepatology, Dhaka Medical College, Dhaka, Bangladesh
| | - Faiz A Khondaker
- Department of Hepatology, Shaheed Suhrawardi Medical College, Dhaka, Bangladesh
| | - Ahmed L Moben
- Department of Medicine, Kurmitola General Hospital, Dhaka, Bangladesh
| | - Masuda Mohsena
- Department of Community Medicine, Ibrahim Medical College, Dhaka, Bangladesh
| | - Sheikh Mohammad Fazle Akbar
- Department of Medical Sciences, Toshiba General Hospital, Tokyo, Japan.,Department of Medical Sciences, Miyakawa Memorial Research Foundation Tokyo, Japan
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Krautbauer S, Wiest R, Liebisch G, Buechler C. Associations of systemic sphingolipids with measures of hepatic function in liver cirrhosis are related to cholesterol. Prostaglandins Other Lipid Mediat 2017. [PMID: 28647317 DOI: 10.1016/j.prostaglandins.2017.06.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Lipoprotein particles are composed of various lipid classes including cholesterol and sphingolipids, and are low in serum of patients with liver cirrhosis. Hepatic decompensation is associated with a further decline of lipoproteins. Aim of the present work was to evaluate whether ceramide and sphingomyelin species are similarly changed in patients with liver cirrhosis and whether these variations are related to systemic cholesterol levels. In a cohort of 45 patients suffering from liver cirrhosis, cholesteryl ester species and subsequently total cholesterol were identified to be negatively associated with model of end stage liver disease (MELD) score. Indeed, the negative correlations of ceramide (Cer) and sphingomyelin (SM) species with MELD score, bilirubin and anti-thrombin 3 were non-significant after adjustment for cholesterol. Cer/SM ratios of species with identical acyl chains were not related to Child-Pugh or MELD score indicating that both lipids are comparably changed. Further, cholesterol levels and concentrations of all sphingolipids measured were similar in systemic, hepatic vein and portal vein blood. Cholesterol and distinct sphingolipids were similar before and 3 months after insertion of a transjugular intrahepatic portosystemic shunt while hexosylceramide 24:1 was significantly induced. It is concluded that analysis of distinct systemic sphingolipid species is not superior to measurement of cholesterol as non-invasive marker of hepatic injury in patients with liver cirrhosis.
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Affiliation(s)
- Sabrina Krautbauer
- Department of Internal Medicine I, Regensburg University Hospital, Regensburg, Germany; Institute for Clinical Chemistry and Laboratory Medicine, Regensburg University Hospital, Regensburg, Germany
| | - Reiner Wiest
- Department of Visceral Surgery and Medicine, University Inselspital, Bern, Switzerland
| | - Gerhard Liebisch
- Institute for Clinical Chemistry and Laboratory Medicine, Regensburg University Hospital, Regensburg, Germany
| | - Christa Buechler
- Department of Internal Medicine I, Regensburg University Hospital, Regensburg, Germany.
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30
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Maurice JB, Brodkin E, Arnold F, Navaratnam A, Paine H, Khawar S, Dhar A, Patch D, O'Beirne J, Mookerjee R, Pinzani M, Tsochatzis E, Westbrook RH. Validation of the Baveno VI criteria to identify low risk cirrhotic patients not requiring endoscopic surveillance for varices. J Hepatol 2016; 65:899-905. [PMID: 27388923 DOI: 10.1016/j.jhep.2016.06.021] [Citation(s) in RCA: 144] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 06/05/2016] [Accepted: 06/07/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS The Baveno VI guidelines propose that cirrhotic patients with a liver stiffness measurement (LSM) <20kPa and a platelet count >150,000/μl can avoid screening endoscopy as their combination is highly specific for excluding clinically significant varices. The aim of the study was to validate these criteria. METHODS Transient elastography data was collected from two institutions from 2006-2015. Inclusion criteria were a LSM ⩾10kPa and an upper gastrointestinal endoscopy within 12months, with a diagnosis of compensated chronic liver disease. Exclusion criteria were porto-mesenteric-splenic vein thrombosis and non-cirrhotic portal hypertension. Varices were graded as low risk (grade <2) or high risk (grade ⩾2). RESULTS The study included 310 patients (169 (55%) hepatitis C, and 275 (89%) Child-Pugh A). Varices were present in 23% cases, with 5% prevalence of high risk varices. Overall 102/310 (33%) met the Baveno VI criteria. Within this group 11% had varices and 2% had high risk varices, representing 2/15 (13%) of all high risk varices. The Baveno VI criteria gave a sensitivity 0.87, specificity 0.34, positive predictive value 0.06, negative predictive value 0.98, positive likelihood ratio 1.31 and negative likelihood ratio 0.39. The AUROC for LSM and platelet count combined was 0.746. CONCLUSIONS The Baveno VI criteria performed well correctly identifying 98% of patients who could safely avoid endoscopy. LAY SUMMARY This study examines the effectives of a recent set of guidelines published by the Baveno VI conference, which states that patients with chronic liver disease and a low liver stiffness (<20kPa) and high platelet count (>150) are at low risk of having varices and do not need a screening endoscopy. Varices are a complication of cirrhosis, confer a risk of serious bleeding, and can be diagnosed and treated by endoscopy. Our study reviewed the clinical records of patients who have had liver stiffness scans and endoscopy over a 9-year period at two hospitals. The results show that only about 2% of patients who meet the Baveno VI criteria will be miss-classified as not having varices.
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Affiliation(s)
- James B Maurice
- Department of Hepatology, Royal Free Hospital NHS Trust, United Kingdom; Department of Hepatology, Imperial College Healthcare NHS Trust, United Kingdom
| | - Edgar Brodkin
- Department of Hepatology, Royal Free Hospital NHS Trust, United Kingdom
| | - Frances Arnold
- Department of Hepatology, Royal Free Hospital NHS Trust, United Kingdom
| | | | - Heidi Paine
- Department of Hepatology, Imperial College Healthcare NHS Trust, United Kingdom
| | - Sabrina Khawar
- Department of Hepatology, Royal Free Hospital NHS Trust, United Kingdom
| | - Ameet Dhar
- Department of Hepatology, Imperial College Healthcare NHS Trust, United Kingdom
| | - David Patch
- Department of Hepatology, Royal Free Hospital NHS Trust, United Kingdom
| | - James O'Beirne
- Department of Hepatology, Royal Free Hospital NHS Trust, United Kingdom
| | - Raj Mookerjee
- Department of Hepatology, Royal Free Hospital NHS Trust, United Kingdom; Institute for Liver and Digestive Health, University College London, United Kingdom
| | - Massimo Pinzani
- Department of Hepatology, Royal Free Hospital NHS Trust, United Kingdom; Institute for Liver and Digestive Health, University College London, United Kingdom
| | - Emmanouil Tsochatzis
- Department of Hepatology, Royal Free Hospital NHS Trust, United Kingdom; Institute for Liver and Digestive Health, University College London, United Kingdom
| | - Rachel H Westbrook
- Department of Hepatology, Royal Free Hospital NHS Trust, United Kingdom.
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31
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Meier EM, Pohl R, Rein-Fischboeck L, Schacherer D, Eisinger K, Wiest R, Krautbauer S, Buechler C. Circulating lipocalin 2 is neither related to liver steatosis in patients with non-alcoholic fatty liver disease nor to residual liver function in cirrhosis. Cytokine 2016; 85:45-50. [DOI: 10.1016/j.cyto.2016.06.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 03/17/2016] [Accepted: 06/05/2016] [Indexed: 01/17/2023]
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32
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Systemic saturated lysophosphatidylcholine is associated with hepatic function in patients with liver cirrhosis. Prostaglandins Other Lipid Mediat 2016; 124:27-33. [DOI: 10.1016/j.prostaglandins.2016.06.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 06/01/2016] [Accepted: 06/01/2016] [Indexed: 12/11/2022]
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33
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Lee E, Kim YJ, Goo DE, Yang SB, Kim HJ, Jang JY, Jeong SW. Comparison of hepatic venous pressure gradient and endoscopic grading of esophageal varices. World J Gastroenterol 2016; 22:3212-3219. [PMID: 27003998 PMCID: PMC4789996 DOI: 10.3748/wjg.v22.i11.3212] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 11/27/2015] [Accepted: 12/30/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine the correlation between the hepatic venous pressure gradient and the endoscopic grade of esophageal varices.
METHODS: From September 2009 to March 2013, a total of 176 measurements of hepatic venous pressure gradient (HVPG) were done in 146 patients. Each transjugular HVPG was measured twice, first using an end whole catheter (EH-HVPG), and then using a balloon catheter (B-HVPG). The HVPG was compared with the endoscopic grade of esophageal varices (according to the general rules for recording endoscopic findings of esophagogastric varices), which was recorded within a month of the measurement of HVPG.
RESULTS: The study included 110 men and 36 women, with a mean age of 56.1 years (range, 43-76 years). The technical success rate of the pressure measurements was 100% and there were no complication related to the procedures. Mean HVPG was 15.3 mmHg as measured using the end hole catheter method and 16.5 mmHg as measured using the balloon catheter method. Mean HVPG (both EH-HVPG and B-HVPG) was not significantly different among patients with different characteristics, including sex and comorbid factors, except for cases with hepatocellular carcinoma (B-HVPG, P = 0.01; EH-HVPG, P = 0.02). Portal hypertension (> 12 mmHg HVPG) occurred in 66% of patients according to EH-HVPG and 83% of patients according to B-HVGP, and significantly correlated with Child’s status (B-HVPG, P < 0.000; EH-HVGP, P < 0.000) and esophageal varies observed upon endoscopy (EH-HVGP, P = 0.003; B-HVGP, P = 0.006). One hundred and thirty-five endoscopies were performed, of which 15 showed normal findings, 27 showed grade 1 endoscopic esophageal varices, 49 showed grade 2 varices, and 44 showed grade 3 varices. When comparing endoscopic esophageal variceal grades and HVPG using univariate analysis, the P value was 0.004 for EH-HVPG and 0.002 for B-HVPG.
CONCLUSION: Both EH-HVPG and B-HVPG showed a positive correlation with the endoscopic grade of esophageal varices, with B-HVPG showing a stronger correlation than EH-HVPG.
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Kihira S, Kagen AC, Vasudevan P, Jajamovich GH, Schiano TD, Andrle AF, Babb JS, Fischman A, Taouli B. Non-invasive prediction of portal pressures using CT and MRI in chronic liver disease. Abdom Radiol (NY) 2016; 41:42-9. [PMID: 26830610 DOI: 10.1007/s00261-015-0614-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE To assess the diagnostic value of a fast scoring system based on non-invasive cross-sectional imaging to predict portal hypertension (PH) in patients with liver disease. METHODS In this retrospective study, we included patients who underwent contrast-enhanced CT or MRI within 3 months of hepatic venous pressure gradient (HVPG) measurements. Two independent observers provided an imaging-based scoring system (max of 9): number of variceal sites, volume of ascites, and spleen size. ROC analysis was performed to predict the presence of PH (HVPG ≥ 5 mmHg) and clinically significant PH (HVPG ≥ 10 mmHg). RESULTS Our cohort consists of 143 patients with mean HVPG of 13.1 ± 2.0 mmHg. Mean PH scores from the two observers were 3.9 ± 2.7 and 3.2 ± 2.5. There was a significant correlation between PH score and HVPG (r = 0.58, p < 0.001 for both observers) with high inter-observer agreement (kappa 0.71). AUCs of 0.78-0.76 and 0.83-0.81 were observed for diagnosing HVPG ≥ 5 mmHg and HVPG ≥ 10 mmHg, respectively, for observers 1 and 2. CONCLUSIONS We have developed a fast PH imaging-based composite score, which could be used for non-invasive detection of clinically significant PH.
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Affiliation(s)
- Shingo Kihira
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, 1470 Madison Avenue, New York, NY, 10029, USA
| | - Alexander C Kagen
- Mount Sinai St. Luke's and Mount Sinai Roosevelt Hospitals, 1111 Amsterdam Ave, New York, NY, 10025, USA
| | - Prasanna Vasudevan
- Department of Radiology, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, 1470 Madison Avenue, New York, NY, 10029, USA
| | - Guido H Jajamovich
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, 1470 Madison Avenue, New York, NY, 10029, USA
| | - Thomas D Schiano
- Division of Liver Disease, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Anne-Fleur Andrle
- Olea Medical, 1955 Massachusetts Ave, Suite 14, Cambridge, MA, 02140, USA
| | - James S Babb
- Department of Radiology, NYU Langone Medical Center, New York, NY, 10016, USA
| | - Aaron Fischman
- Department of Radiology, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, 1470 Madison Avenue, New York, NY, 10029, USA
| | - Bachir Taouli
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, 1470 Madison Avenue, New York, NY, 10029, USA.
- Department of Radiology, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, 1470 Madison Avenue, New York, NY, 10029, USA.
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Ramanathan S, Khandelwal N, Kalra N, Bhatia A, Dhiman RK, Duseja AK, Chawla YK. Correlation of HVPG level with ctp score, MELD Score, ascites, size of varices, and etiology in cirrhotic patients. Saudi J Gastroenterol 2016; 22:109-15. [PMID: 26997216 PMCID: PMC4817293 DOI: 10.4103/1319-3767.164185] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND/AIM This study intends to determine the correlation of a patient's hepatic venous pressure gradient (HVPG) measurement with six factors: Child-Turcotte-Pugh (CTP) score, model for end-stage liver disease (MELD) score, presence of ascites, size of varices, presence of variceal bleeding, and an etiology of cirrhosis. The study also aims to identify the predictors of higher HVPG measurements that can indirectly affect the prognosis of cirrhotic patients. PATIENTS AND METHODS Thirty patients diagnosed with cirrhosis were enrolled prospectively and each patient's HVPG level was measured by the transjugular catheterization of the right or middle hepatic vein. The wedged hepatic venous pressure (WHVP) and free hepatic venous pressure (FHVP) were measured using a 7F balloon catheter. The HVPG level was calculated as the difference between the WHVP and FHVP measurements. RESULTS The mean HVPG level was higher in alcoholic than in nonalcoholic cirrhosis (19.5 ± 7.3 vs 15.2 ± 4.5 mm Hg, P = 0.13). The mean HVPG was also higher in bleeders compared with nonbleeders (18.5 ± 5.3 vs 10.7 ± 3.1 mmHg, P = 0.001). Patients with varices had a higher mean HVPG level than those without varices (17.4 ± 5.8 vs 11.7 ± 3.9 mmHg, P = 0.04). The difference among the three categories of varices (small, large, and no varices) was statistically significant (P = 0.03). In addition, the mean HVPG level was higher in patients with ascites than in those without ascites (18.7 ± 4.7 vs 11 ± 5.3 mmHg, P = 0.002), and it was significantly higher in patients in CTP class C (21.8 ± 5.5 mmHg) as compared with those in CTP class B (16.9 ± 2.9 mmHg) and CTP class A (10.5 ± 4.1 mmHg; P ≤ 0.001). CONCLUSION HVPG levels were significantly higher in patients in CTP class C as compared with those in CTP classes A and B, thereby indicating that an HVPG measurement correlates with severity of liver disease. A high HVPG level signifies more severe liver disease and can predict the major complications of cirrhosis.
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Affiliation(s)
- Subramaniam Ramanathan
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, Haryana and Punjab, India
| | - Niranjan Khandelwal
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, Haryana and Punjab, India
| | - Naveen Kalra
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, Haryana and Punjab, India,Address for correspondence: Dr. Naveen Kalra, Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, Haryana and Punjab, India. E-mail:
| | - Anmol Bhatia
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, Haryana and Punjab, India
| | - Radha K. Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, Haryana and Punjab, India
| | - Ajay K. Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, Haryana and Punjab, India
| | - Yogesh K. Chawla
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, Haryana and Punjab, India
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Simultaneous measurement of hepatic and splenic stiffness using MR elastography: preliminary experience. ACTA ACUST UNITED AC 2015; 40:803-9. [PMID: 25294006 DOI: 10.1007/s00261-014-0255-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE To compare MR elastography (MRE) using a single and a dual driver excitation for the quantification of hepatic and splenic stiffness (HS and SS), and to investigate the performance of HS and SS measured with single or dual driver excitation for the detection of liver cirrhosis in subjects with liver disease. PATIENTS AND METHODS This prospective HIPAA compliant and IRB approved study involved 49 subjects who underwent MRE at 3.0T, comparing three different acquisition methods (single driver on the liver, single driver on the spleen and dual driver acoustic excitation). A Mann-Whitney test was used to assess changes in stiffness values. Bland-Altman analysis was used to compare single and dual driver configurations for each organ. Performance for detection of liver cirrhosis was assessed using ROC analysis. Pearson correlation was used to estimate the dependence of HS and SS on spleen size. RESULTS There were 40 noncirrhotic and 9 cirrhotic patients. There was good agreement between stiffness values measured with a single or a dual driver (Bland-Altman limits of agreement -14.3 % to 18.9 % and -18.1 % to 29.7 %, CV 6.4 % and 9.4 %, for HS and SS. respectively). HS and SS were higher in subjects with liver cirrhosis (p < 0.001), with excellent detection performance (AUROC range 0.87-0.93). SS correlated strongly with spleen size (r = 0.69, p < 0.001), while HS showed weak correlation (r = 0.38, p = 0.006). CONCLUSION Using a dual acoustic driver configuration, hepatic and splenic stiffness can be simultaneously estimated with good concordance with single driver measurement.
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Lens S, Rincón D, García-Retortillo M, Albillos A, Calleja JL, Bañares R, Abraldes JG, Bosch J, Sanchez-Tapias JM, Forns X, García-Pagán JC. Association Between Severe Portal Hypertension and Risk of Liver Decompensation in Patients With Hepatitis C, Regardless of Response to Antiviral Therapy. Clin Gastroenterol Hepatol 2015; 13:1846-1853.e1. [PMID: 25912838 DOI: 10.1016/j.cgh.2015.04.013] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 03/17/2015] [Accepted: 04/09/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Hepatic venous pressure gradient (HVPG) is associated with a risk of liver events in patients with chronic hepatitis C. Antiviral therapies that lead to a sustained virologic response (SVR) reduce portal pressure and prevent liver disease progression. However, it is not clear to what extent the progression of hepatitis C is modified once patients develop cirrhosis with severe portal hypertension (CSPH) (HVPG ≥ 10 mm Hg). We assessed the effects of HVPG and SVR on the risk of liver decompensation, hepatocellular carcinoma, and/or death in patients with hepatitis C-related cirrhosis. METHODS We collected data from 100 patients with hepatitis C and compensated cirrhosis who underwent HVPG measurement 3 months or less before (baseline) and 24 weeks after therapy with pegylated interferon alfa-2a and ribavirin at 4 hospitals in Spain, from 2001 through 2009. SVR was defined as undetectable serum HCV RNA level 24 weeks after treatment ended. Clinical data were collected until death, liver transplantation, or December 2012 (median, 5 y; interquartile range, 1.4-7 y). RESULTS Seventy-four patients had CSPH at baseline and 35% of patients achieved an SVR. During the follow-up period, 19 patients developed liver decompensation (ascites, variceal bleeding, or encephalopathy). The actuarial probability values for liver decompensation at 1, 5, and 7 years were 3%, 19% and 22%, respectively. The baseline level of HVPG, but not SVR, was associated independently with the risk of liver decompensation. CONCLUSIONS Patients with CSPH, regardless of an SVR to therapy for hepatitis C, remain at risk for liver decompensation within the first 5 years after treatment; they should be monitored closely.
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Affiliation(s)
- Sabela Lens
- Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August-Pi-Sunyer, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivass, Spain
| | - Diego Rincón
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivass, Spain; Liver Unit, Hospital Gregorio Marañón, Madrid, Spain
| | | | - Agustín Albillos
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivass, Spain; Liver Unit, Hospital Ramón y Cajal, Madrid, Spain
| | | | - Rafael Bañares
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivass, Spain; Liver Unit, Hospital Gregorio Marañón, Madrid, Spain
| | - Juan González Abraldes
- Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August-Pi-Sunyer, Barcelona, Spain; Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Barcelona, Spain
| | - Jaume Bosch
- Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August-Pi-Sunyer, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivass, Spain; Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Barcelona, Spain
| | - Jose Maria Sanchez-Tapias
- Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August-Pi-Sunyer, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivass, Spain
| | - Xavier Forns
- Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August-Pi-Sunyer, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivass, Spain
| | - Juan Carlos García-Pagán
- Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August-Pi-Sunyer, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivass, Spain; Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Barcelona, Spain.
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Ferlitsch A, Bota S, Paternostro R, Reiberger T, Mandorfer M, Heinisch B, Salzl P, Schwarzer R, Sieghart W, Peck-Radosavljevic M, Ferlitsch M. Evaluation of a new balloon occlusion catheter specifically designed for measurement of hepatic venous pressure gradient. Liver Int 2015; 35:2115-20. [PMID: 25585656 DOI: 10.1111/liv.12783] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 01/09/2015] [Indexed: 12/26/2022]
Abstract
BACKGROUND & AIMS Despite the important clinical value of hepatic venous pressure gradient (HVPG) and its increasing use, no specific balloon occlusion catheters have been designed to cannulate liver veins. The aim of the study was to evaluate the clinical applicability of a novel balloon (NC) occlusion catheter specifically designed for HVPG measurement. METHODS Comparison of a new CE-certified 7 French balloon occlusion catheter with a 150° angled tip and radiopaque markers (NC, Pejcl Medizintechnik, Austria), to a commonly used straight balloon catheter (SC; Boston Scientific, USA). Successful liver vein cannulation rate, need for extra equipment and total fluoroscopy time were recorded. Experts (>200) and novices (<20) in HVPG measurements were evaluated separately. RESULTS 566 HVPG measurements taken by 11 investigators (five experts and six novices) were analysed. Overall, HVPG could be successfully measured in 98.7% of cases. The rate of successful liver vein cannulation at first attempt was significantly higher among experts when compared to novices (87.3% vs 67.3%, P < 0.001). Moreover, the rate of successful liver vein cannulation without need for any additional equipment was higher when using the NC, both among experts (NC:91.9% vs SC:80.6%, P = 0.03) and novices (NC:73.3% vs SC:50.7%, P = 0.001). The mean fluoroscopy time needed to cannulate the hepatic vein was significantly shorter in experts as compared to novices [2.37(0.10-26) vs 5.2(0.6-30.2] min, P < 0.0001), but not significantly different between catheters. CONCLUSIONS Both novices and experts achieve higher liver vein cannulation rates using the new specifically designed catheter. The use of the novel catheter might increase rates of successful liver vein cannulation and reduce the need for additional equipment, especially in novices.
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Affiliation(s)
- Arnulf Ferlitsch
- Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Simona Bota
- Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Rafael Paternostro
- Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Mattias Mandorfer
- Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Birgit Heinisch
- Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Petra Salzl
- Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Remy Schwarzer
- Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Wolfgang Sieghart
- Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Markus Peck-Radosavljevic
- Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Monika Ferlitsch
- Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
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Quantification of hepatic blood flow using a high-resolution phase-contrast MRI sequence with compressed sensing acceleration. AJR Am J Roentgenol 2015; 204:510-8. [PMID: 25714279 DOI: 10.2214/ajr.14.12597] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE. The objective of our study was to evaluate the performance of a high-spatial-resolution 2D phase-contrast (PC) MRI technique accelerated with compressed sensing for portal vein (PV) and hepatic artery (HA) flow quantification in comparison with a standard PC MRI sequence. SUBJECTS AND METHODS. In this prospective study, two PC MRI sequences were compared, one with parallel imaging acceleration and low spatial resolution (generalized autocalibrating partial parallel acquisition [GRAPPA]) and one with compressed sensing acceleration and high spatial resolution (sparse). Seventy-six patients were assessed, including 37 patients with cirrhosis. Two observers evaluated PC image quality. Quantitative analyses yielded a mean velocity, flow, and vessel area for the PV and HA and an arterial fraction. The PC techniques were compared using the paired Wilcoxon test and Bland-Altman statistics. The sensitivity of the flow parameters to the severity of cirrhosis was also assessed. RESULTS. Vessel delineation was significantly improved using the PC sparse sequence (p < 0.034). For both in vitro and in vivo measurements, PC sparse yielded lower estimates for vessel area and flow, and larger differences between PC GRAPPA and PC sparse were observed in the HA. PV velocity and flow were significantly lower in patients with cirrhosis on both PC sparse (p < 0.001 and p = 0.042, respectively) and PC GRAPPA (p < 0.001 and p = 0.005, respectively). PV velocity correlated negatively with Child-Pugh class (r = -0.50, p < 0.001), whereas the arterial fraction measured with PC sparse was higher in patients with Child-Pugh class B or C disease than in those with Child-Pugh class A disease, with a trend toward significance (p = 0.055). CONCLUSION. A high-spatial-resolution highly accelerated compressed sensing technique (PC sparse) allows total hepatic blood flow measurements obtained in 1 breath-hold, provides improved delineation of the hepatic vessels compared with a standard PC MRI sequence (GRAPPA), and can potentially be used for the noninvasive assessment of liver cirrhosis.
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Khan AU, Irfanullah J, Shah SQ, Fatima S. (99m)Tc-phytate trans-splenic portal scintigraphy in the diagnosis of cirrhotic portal hypertension and compensatory circulation. ABDOMINAL IMAGING 2015; 40:258-264. [PMID: 25078060 DOI: 10.1007/s00261-014-0204-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND AND AIM The trans-splenic portal scintigraphy (TPS) was evaluated as a diagnostic tool in the post viral hepatitis cirrhotic patients of various classes of Child Pugh's (CP) classification. The main aim was to determine the portosystemic shunt index (PSSI) and to compare the results with various clinical grades of disease severity in liver cirrhosis. METHODS TPS was performed on 72 patients and 10 controls and PSSI was derived. All the 72 patients were categorized according to CP classification into three classes. The cirrhotic patients were categorized as CP A (n = 24),CP B (n = 22), and CP C (n = 26)according to CP criteria. PSSI was compared with different CP classes. RESULTS In the controlled population, the splenic vein was normal in shape and the mean PSSI was calculated to be 0.178 ± 0.031 (n = 10). For CP classes A, B, and C, the mean PSSI was 0.36 ± 0.04, 0.45 ± 0.05, and 0.54 ± 0.04 (n = 26), respectively. There was statistical significance among groups (p ≤ 0.01).The collateral vessels were mostly uphill or complex. The PSSI index increased as the CP score worsened from A to C. CONCLUSION PSSI is a useful and minimally invasive tool to detect and quantify the shunt severity, which correlates well with different clinical grades of disease severity.
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Affiliation(s)
- Aakif Ullah Khan
- Institute of Radiotherapy and Nuclear Medicine (IRNUM), Peshawar, Pakistan,
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Eisinger K, Krautbauer S, Wiest R, Weiss TS, Buechler C. Reduced serum chemerin in patients with more severe liver cirrhosis. Exp Mol Pathol 2015; 98:208-13. [PMID: 25595667 DOI: 10.1016/j.yexmp.2015.01.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 01/12/2015] [Indexed: 12/22/2022]
Abstract
Chemerin is a well-established modulator of immune cell function and its serum levels are induced in inflammatory diseases. Liver cirrhosis is associated with inflammation which is aggravated by portal hypertension. The objective of this study was to evaluate whether chemerin is induced in patients with more severe liver cirrhosis and portal hypertension. Chemerin has been measured by ELISA in the portal venous serum (PVS), systemic venous serum (SVS) and hepatic venous serum (HVS) of 45 patients with liver cirrhosis. Chemerin is higher in HVS compared to PVS in accordance with our recently published finding. SVS, HVS and PVS chemerin decline in patients with more advanced liver injury defined by the CHILD-PUGH score. Hepatic chemerin has been determined in a small cohort and is similarly expressed in normal and cirrhotic liver. MELD score and serum markers of liver and kidney function do not correlate with chemerin. There is a positive correlation of chemerin in all compartments with Quick prothrombin time and of SVS chemerin with systolic blood pressure. PVS chemerin is induced in patients with modest/massive ascites but this does not translate into higher HVS and SVS levels. Chemerin is not associated with variceal size. Reduction of portal pressure by transjugular intrahepatic portosystemic shunt does not affect chemerin levels. These data show that low chemerin in patients with more severe liver cirrhosis is associated with reduced Quick prothrombin time.
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Affiliation(s)
- Kristina Eisinger
- Department of Internal Medicine I, Regensburg University Hospital, Regensburg, Germany
| | - Sabrina Krautbauer
- Department of Internal Medicine I, Regensburg University Hospital, Regensburg, Germany
| | - Reiner Wiest
- Department of Visceral Surgery and Medicine, University Inselspital, Bern, Switzerland
| | - Thomas S Weiss
- Department of Pediatrics and Juvenile Medicine, Regensburg University Hospital, Regensburg, Germany
| | - Christa Buechler
- Department of Internal Medicine I, Regensburg University Hospital, Regensburg, Germany.
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Hshieh TT, Kaung A, Hussain S, Curry MP, Sundaram V. The international normalized ratio does not reflect bleeding risk in esophageal variceal hemorrhage. Saudi J Gastroenterol 2015; 21:254-8. [PMID: 26228370 PMCID: PMC4542425 DOI: 10.4103/1319-3767.161646] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND/AIMS The international normalized ratio (INR) has not been validated as a predictor of bleeding risk in cirrhotics. The aim of this study was to determine whether elevation in the INR correlated with risk of esophageal variceal hemorrhage and whether correction of the INR prior to endoscopic therapy affects failure to control bleeding. PATIENTS AND METHODS Patient records were retrospectively reviewed from January 1, 2000 to December 31, 2010. Cases were cirrhotics admitted to the hospital due to bleeding esophageal varices. Controls were cirrhotics with a history of non-bleeding esophageal varices admitted with ascites or encephalopathy. All variceal bleeders were treated with octreotide, antibiotics, and band ligation. Failure to control bleeding was defined according to the Baveno V criteria. RESULTS We analyzed 74 cases and 74 controls. The mean INR at presentation was lower in those with bleeding varices compared to non-bleeders (1.61 vs 1.74, P = 0.03). Those with bleeding varices had higher serum sodium (136.1 vs 133.8, P = 0.02), lower hemoglobin (9.59 vs 11.0, P < 0.001), and lower total bilirubin (2.47 vs 5.50, P < 0.001). Multivariable logistic regression showed total bilirubin to inversely correlate with bleeding (OR = 0.74). Bleeders received a mean of 1.14 units of fresh frozen plasma (FFP) prior to endoscopy (range 0-11 units). Of the 14 patients (20%) with failure to control bleeding, median INR (1.8 vs 1.5, P = 0.02) and median units of FFP transfused (2 vs 0, P = 0.01) were higher than those with hemostasis after the initial endoscopy. CONCLUSIONS The INR reflects liver dysfunction, not bleeding risk. Correction of INR with FFP has little effect on hemostasis.
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Affiliation(s)
- Tammy T. Hshieh
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston Massachusetts, US
| | - Aung Kaung
- Department of Medicine and Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, US
| | - Syed Hussain
- Division of Digestive Diseases, University of Cincinnati College of Medicine, Cincinnati, Ohio, US
| | - Michael P. Curry
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston Massachusetts, US
| | - Vinay Sundaram
- Department of Medicine and Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, US,Address for correspondence: Dr. Vinay Sundaram, 8900 Beverly Boulevard, Los Angeles, CA 90048. E-mail:
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Lee JY, Kim TY, Jeong WK, Kim Y, Kim J, Kim KW, Kim YH, Sohn JH. Clinically severe portal hypertension: role of multi-detector row CT features in diagnosis. Dig Dis Sci 2014; 59:2333-43. [PMID: 24723070 DOI: 10.1007/s10620-014-3149-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2013] [Accepted: 03/30/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND AIM To explore the CT signs which permit estimation of clinically severe portal hypertension (PH) [≥ 12 of hepatic vein pressure gradient (HVPG)]. METHODS One-hundred and seven consecutive patients who underwent HVPG measurement in the PH group and 52 controls were included. The diameters of main portal vein (øMPV), superior mesenteric vein (øSMV), splenic vein (øSV), and left gastric vein, øMPV/øSV, øSMV/øSV, as well as estimated spleen volumes were evaluated on the CT scan. The grade of varix and ascites were also evaluated semi-quantitatively. We explored the statistically significant CT features related to severe PH and performed a logistic regression analysis for an estimation model for severe PH. RESULTS øMPV/øSV and øSMV/øSV tended to gradually increase as the PH became severer, and the difference between severe and not severe groups was statistically significant (p = 0.015 and 0.038, respectively). According to the regression analysis, øSMV/øSV and the grade of esophageal varix and ascites were finally included as related variables for predicting severe PH. The odds ratio (OR) of øSMV/øSV was 4.596, and large esophageal varix (OR 4.135) and mild (OR 3.051) and large amount of ascites (OR 21.781) were statistically significantly related to severe PH. CONCLUSION Changing diameters of portal system, the grades of esophageal varices and ascites on multi-detector row computed tomography might be indicative features for clinically severe PH.
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Affiliation(s)
- Ji Young Lee
- Department of Radiology, Hanyang University Guri Hospital, Hanyang University College of Medicine, Gyeongchun-ro 153, Guri-si, Gyeonggi-do, 471-701, Republic of Korea
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Zardi EM, Di Matteo FM, Pacella CM, Sanyal AJ. Invasive and non-invasive techniques for detecting portal hypertension and predicting variceal bleeding in cirrhosis: a review. Ann Med 2014; 46:8-17. [PMID: 24328372 PMCID: PMC4904298 DOI: 10.3109/07853890.2013.857831] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Portal hypertension is a severe syndrome that may derive from pre-sinusoidal, sinusoidal, and post-sinusoidal causes. As a consequence, several complications (i.e. ascites, oesophageal varices) may develop. In sinusoidal portal hypertension, hepatic venous pressure gradient (HVPG) is a reliable method for defining the grade of portal pressure, establishing the effectiveness of the treatment, and predicting the occurrence of complications; however, some questions exist regarding its ability to discriminate bleeding from non-bleeding varices in cirrhotic patients. Other imaging techniques (transient elastography, endoscopy, endosonography, and duplex Doppler sonography) for assessing causes and complications of portal hypertensive syndrome are available and may be valuable for the management of these patients. In this review, we evaluate invasive and non-invasive techniques currently employed to obtain a clinical prediction of deadly complications, such as variceal bleeding in patients affected by sinusoidal portal hypertension, in order to create a diagnostic algorithm to manage them. Again, HVPG appears to be the reference standard to evaluate portal hypertension and monitor the response to treatment, but its ability to predict several complications and support management decisions might be further improved through the diagnostic combination with other imaging techniques.
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Affiliation(s)
- Enrico Maria Zardi
- Department of Clinical Medicine, 'Campus Bio-Medico' University , Rome , Italy
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Grözinger G, Wiesinger B, Schmehl J, Kramer U, Mehra T, Grosse U, König C. Portosystemic pressure reduction achieved with TIPPS and impact of portosystemic collaterals for the prediction of the portosystemic-pressure gradient in cirrhotic patients. Eur J Radiol 2013; 82:2258-64. [DOI: 10.1016/j.ejrad.2013.08.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Revised: 07/27/2013] [Accepted: 08/09/2013] [Indexed: 02/07/2023]
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Gupta N, Kumar A, Sharma P, Garg V, Sharma BC, Sarin SK. Effects of the adjunctive probiotic VSL#3 on portal haemodynamics in patients with cirrhosis and large varices: a randomized trial. Liver Int 2013; 33:1148-57. [PMID: 23601333 DOI: 10.1111/liv.12172] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Accepted: 02/24/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Probiotics, by altering gut flora, may favourably alter portal haemodynamics in patients with cirrhosis. AIM To investigate the effect of probiotics on portal pressure in patients with cirrhosis. METHODS Randomized double-blind placebo-controlled trial conducted in G.B. Pant Hospital, New Delhi. A total of 94 cirrhotic patients having large oesophageal varices without history of variceal bleeding were randomized to three treatment groups and given 2 months' treatment with propranolol plus placebo, propranolol plus antibiotics (norfloxacin 400 mg BD) or propranolol plus probiotic (VSL#3, 900 billion/day) randomly assigned in 1:1:1 ratio. Outcome measures were change in Hepatic venous pressure gradient (HVPG): Response rate (Percentage of patients having a decrease from baseline of ≥20% or to ≤12 mm Hg) and changes from baseline; biochemical markers of inflammation: changes from baseline. RESULTS Adjunctive probiotics increased the response rate compared with propranolol alone (58% vs. 31%, P = 0.046), similar to adjunctive antibiotics (54%). The mean fall in HVPG was greater with either adjunctive probiotics (3.7 mm Hg vs. 2.1 mm Hg, P = 0.061) or adjunctive antibiotics (3.4 mm Hg) than with propranolol alone. Both adjunctive therapies were associated with greater decreases in TNF-α levels (in both peripheral and hepatic venous blood) that resulted from propranolol-only treatment. No clinically relevant between-group differences were observed in the type or frequency of adverse events. CONCLUSIONS Adjunctive probiotic (VSL#3) improved the response rate to propranolol therapy and was safe and well tolerated in patients with cirrhosis. Adjunctive probiotic therapy merits further study for reduction in portal pressure.
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Affiliation(s)
- Nitin Gupta
- Department of Gastroenterology, G.B. Pant Hospital, New Delhi, India
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Eisinger K, Krautbauer S, Wiest R, Karrasch T, Hader Y, Scherer MN, Farkas S, Aslanidis C, Buechler C. Portal vein omentin is increased in patients with liver cirrhosis but is not associated with complications of portal hypertension. Eur J Clin Invest 2013; 43:926-32. [PMID: 23855493 DOI: 10.1111/eci.12122] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Accepted: 06/03/2013] [Indexed: 01/12/2023]
Abstract
BACKGROUND Omentin is a visceral fat-derived adipokine associated with endothelium-dependent vasodilation. Impaired endothelial function is a major cause of portal hypertension in liver cirrhosis. The aim was to assess associations of omentin with systemic markers of endothelial function, namely arginine and asymmetric dimethylarginine (ADMA) and complications of portal hypertension in liver cirrhosis. MATERIALS AND METHODS Systemic omentin was measured by ELISA in portal venous serum (PVS), systemic venous serum (SVS) and hepatic venous serum (HVS) of 40 patients with liver cirrhosis and 10 liver-healthy controls. ADMA and arginine were determined in SVS of the patients by ELISA. RESULTS Omentin is elevated in PVS and tends to be increased in SVS and HVS of patients with liver cirrhosis compared with controls. Omentin is principally expressed in visceral fat, and PVS omentin tends to be higher than SVS levels. Lower HVS than PVS omentin suggests that omentin may be partly removed from the circulation by the liver. Omentin in serum is not associated with stages of liver cirrhosis defined by CHILD-POUGH or MELD score and is not affected in patients with ascites. HVS omentin tends to be reduced in patients with large varices compared with patients without/with small varices. Arginine/ADMA ratio is reduced in patients with massive ascites but is not associated with variceal size. Further, Arginine/ADMA ratio does not correlate with omentin. CONCLUSION Current data show that PVS omentin is increased in liver cirrhosis but is not associated with complications of portal hypertension.
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Affiliation(s)
- Kristina Eisinger
- Department of Internal Medicine I, Regensburg University Hospital, Germany
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Sharma P, Kirnake V, Tyagi P, Bansal N, Singla V, Kumar A, Arora A. Spleen stiffness in patients with cirrhosis in predicting esophageal varices. Am J Gastroenterol 2013; 108:1101-7. [PMID: 23629600 DOI: 10.1038/ajg.2013.119] [Citation(s) in RCA: 129] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Accepted: 02/04/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Screening for esophageal varices (EV) is recommended in patients with cirrhosis. Noninvasive tests had shown varying sensitivity (Se) and specificity (Sp) for predicting EV. Splenomegaly is a common finding in liver cirrhosis because of portal and splenic congestion. These changes can be quantified by transient elastography; hence, the aim of this study was to investigate the utility of spleen stiffness (SS) in evaluating EV in comparison with other noninvasive tests. METHODS We measured SS and liver stiffness (LS) by using FibroScan in 200 consecutive cirrhotic patients who met the inclusion criteria. Patients were also assessed by hepatic venous pressure gradient (HVPG), upper gastrointestinal endoscopy, LS-spleen diameter to platelet ratio score (LSPS), and platelet count to spleen diameter ratio (PSR). RESULTS Of 200 patients enrolled, 174 patients had valid LS and SS measurement, and 124 (71%) patients had EV (small, n=46 and large n=78). There was a significant difference in median LS (51.4 vs. 23.9 kPa, P=0.001), SS (54 vs. 32 kPa, P=0.001), LSPS (6.1 vs. 2.5, P=0.001), and PSR (812 vs. 1,165, P=0.001) between patients with EV and those without EV. LS ≥27.3 kPa had an Se of 91%, Sp of 72%, positive predictive value (PPV) of 89%, negative predictive value (NPV) of 76%, and a diagnostic accuracy of 86% in predicting EV. LSPS ≥3.09 had Se and Sp of 89% and 76%, respectively, and a PSR cutoff value of 909 or less had Se of 64%, Sp of 76%, and diagnostic accuracy of 68% in predicting EV. SS ≥40.8 kPa had Se (94%), Sp (76%), PPV (91%), NPV (84%), and diagnostic accuracy of 86% for predicting EV. SS was significantly higher in patients who had large varices (56 vs. 49 kPa, P=0.001) and variceal bleed (58 vs. 50.2 kPa, P=0.001). Combining LS+SS (27.3+40.8 kPa) had Se of 90%, Sp 90%, PPV 96%, NPV 79%, and a diagnostic accuracy of 90%. HVPG (n=52) showed significant correlation with SS (r=0.433, P=0.001), LSPS (r=0.335, P=0.01), and PSR (r=-0.270, P=0.05), but not with LS (r=0.178, P=0.20). CONCLUSIONS Measurement of SS can be used for noninvasive assessment of EV and can differentiate large vs. small varices and nonbleeder vs. bleeder.
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Affiliation(s)
- Praveen Sharma
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital, New Delhi, India.
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Aoyama T, Oka S, Aikata H, Nakano M, Watari I, Naeshiro N, Yoshida S, Tanaka S, Chayama K. Small bowel abnormalities in patients with compensated liver cirrhosis. Dig Dis Sci 2013; 58:1390-6. [PMID: 23247799 PMCID: PMC3661038 DOI: 10.1007/s10620-012-2502-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Accepted: 11/20/2012] [Indexed: 12/22/2022]
Abstract
BACKGROUND Although capsule endoscopy is available as a minimally invasive imaging technique that contributes significantly to the detection of small bowel lesions, there are only a very few published descriptions of small bowel abnormalities in patients with portal hypertension. AIMS The aim of this study was to characterize the occurrence of small bowel lesions by means of capsule endoscopy in patients with portal hypertension, particularly those with compensated liver cirrhosis and associated anemia. METHODS Sixty consecutive patients who met our criteria underwent capsule endoscopy. The frequency, type, and distribution of small bowel lesions were determined, and clinical factors associated with the lesions were examined. RESULTS Small bowel abnormalities were found in 40 patients (67 %), including erythema (n = 32, 53 %), erosion (n = 10, 17 %), angioectasia (n = 9, 15 %), varices (n = 4, 7 %), and villous edema (n = 4, 7 %). Most lesions were located in the proximal or middle small bowel. Factors associated with the lesions were Child-Pugh class B (vs. class A, P = 0.0023), ascites (vs. no ascites, P = 0.0085), and portal hypertensive gastropathy (vs. no portal hypertensive gastropathy, P = 0.0434). CONCLUSIONS We found capsule endoscopy to be a useful diagnostic modality for detecting clinically significant small bowel lesions in patients with compensated liver cirrhosis. Based on our results, we suggest that this procedure should be especially considered for patients with Child-Pugh class B disease, ascites, and/or portal hypertensive gastropathy if they show evidence of gastrointestinal blood loss and/or iron-deficiency anemia.
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Affiliation(s)
- Taiki Aoyama
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551 Japan
| | - Shiro Oka
- Department of Endoscopy, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551 Japan
| | - Hiroshi Aikata
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551 Japan
| | - Makoto Nakano
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551 Japan
| | - Ikue Watari
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551 Japan
| | - Noriaki Naeshiro
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551 Japan
| | - Shigeto Yoshida
- Department of Endoscopy, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551 Japan
| | - Shinji Tanaka
- Department of Endoscopy, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551 Japan
| | - Kazuaki Chayama
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551 Japan
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Kim BK, Fung J, Yuen MF, Kim SU. Clinical application of liver stiffness measurement using transient elastography in chronic liver disease from longitudinal perspectives. World J Gastroenterol 2013; 19:1890-1900. [PMID: 23569334 PMCID: PMC3613104 DOI: 10.3748/wjg.v19.i12.1890] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Revised: 08/29/2012] [Accepted: 09/28/2012] [Indexed: 02/06/2023] Open
Abstract
Accurate determination of the presence and degree of fibrosis in liver is of great importance, because the prognosis and management strategies for chronic liver disease depend mainly on these factors. To date, liver biopsy (LB) remains the "gold standard" for assessing the severity of liver fibrosis; however, LB is often limited by its invasiveness, sampling error, and intra/inter-observer variability in histological interpretation. Furthermore, repeated LB examinations within a short time interval are indeed ineligible in a real clinical practice. Thus, due to the pressing need for non-invasive surrogates for liver fibrosis, transient elastography (TE), as a novel ultrasound based technology, has allowed a noninvasive measurement of liver stiffness and has gained in popularity over recent years. In the past few years, additional roles for transient TE beyond the initial purpose of a non-invasive surrogate for LB have included the prediction of the most two critical consequences of fibrosis progression: the development of portal hypertension-related complications and hepatocellular carcinoma. This indicates that the role of transient TE is not merely limited to reducing the need for LB, but transient TE can enable the establishment of tailored management strategies by providing more detailed prognostic information. In particular, under the concept in which the clinical course of liver fibrosis is dynamic and bidirectional, especially when appropriate intervention is commenced, transient TE can be used to track the dynamic changes in fibrotic burden during antiviral or antifibrotic treatment. This review discussed extended applications of transient TE in prediction of the development of real clinical endpoints from a longitudinal perspective.
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