Platelet count/spleen diameter ratio to predict the presence of esophageal varices in pat…

[Read more →]

The management of low-risk primary upper gastrointestinal haemorrhage in the community: a…

[Read more →]

Acute pancreatitis in peritoneal dialysis: a case report with literature review.
…

[Read more →]

Effects of a single terlipressin administration on cardiac function and perfusion in cirrhosis.

Eur J Gastroenterol Hepatol. 2010 Sep;22(9):1085-92

Authors: Krag A, Bendtsen F, Mortensen C, Henriksen JH, Møller S

BACKGROUND: The vasoconstrictor terlipressin is widely used in the treatment of the hepatorenal syndrome and variceal bleeding. However, terlipressin may compromise cardiac function and induce ischemia. AIM: Therefore, we aimed to assess the effects of terlipressin on cardiac function and perfusion. METHODS: Twenty-four patients with cirrhosis and ascites participated, including nine with refractory ascites. Gated myocardial perfusion imaging, mean arterial blood pressure (MAP), cardiac output (CO), ejection fraction (EF), end-diastolic volume (EDV), perfusion, and motion of the myocardium were determined before and after a bolus injection of 2 mg terlipressin. RESULTS: MAP increased after terlipressin (P value of less than 0.001). EF and CO fell by -16 and -17%, respectively in the terlipressin group versus 1 and -2%, respectively in the placebo group (P value of less than 0.001 and P value of less than 0.01). In the terlipressin group, EDV increased by 18 versus -4% in the placebo group (P value of less than 0.01). Wall motion in the anterior and posterior walls fell by -18 and -22%, respectively after terlipressin treatment versus 0 and 0% in the placebo group (P value of less than 0.01). In contrast, myocardial perfusion and stroke volume were unaltered in both the groups. The change in EF during terlipressin treatment correlated significantly with the change in MAP (r=-0.60, P value <0.002). Patients with refractory ascites had a higher EF and lower EDV and ESV than the patients with nonrefractory ascites, both at baseline and after terlipressin treatment. The decrease in the left ventricular wall thickening and wall motion correlated with the Child–Pugh score, r=-0.59, P=0.005 and r=-0.48, P=0.03. CONCLUSION: In advanced cirrhosis, the increase in afterload and EDV after terlipressin treatment result in a decrease in left ventricular wall motion, resulting in reduced CO and EF, but myocardial perfusion is preserved. Alteration in cardiac function at baseline and after terlipressin treatment relates to the stage of decompensation.

PMID: 20453655 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Pulmonary oedema after therapeutic ascitic paracentesis: a case report and literature review of the cardiac complications of cirrhosis.

Eur J Gastroenterol Hepatol. 2010 Feb;22(2):241-5

Authors: Sharma A, Fletcher A, Lipscomb GR

In this study, we describe the development of acute pulmonary oedema and cardiac arrest after therapeutic ascitic paracentesis, in a gentleman with decompensated liver cirrhosis. There was no previous history of cardiorespiratory symptoms or disease. Postmortem examination revealed oedematous and congested lungs with bilateral pleural effusions; in addition, the right heart was dilated and congested. Micronodular cirrhosis was present with histological features of alpha1 antitrypsin deficiency. This is the first study of acute cardiac decompensation after large volume paracentesis. Owing to the postmortem findings, underlying asymptomatic cardiorespiratory disease may have been present. Cirrhosis is associated with cardiovascular complications including cirrhotic cardiomyopathy, portopulmonary hypertension and hepatopulmonary syndrome which may manifest or worsen under situations of haemodynamic stress. This report thus raises the question whether routine screening for cardiovascular abnormalities is warranted in patients with decompensated cirrhosis, particularly before the procedures such as paracentesis that impose significant haemodynamic strain.

PMID: 19801941 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

An open-label randomized controlled trial of lactulose and probiotics in the treatment of minimal hepatic encephalopathy.

Eur J Gastroenterol Hepatol. 2008 Jun;20(6):506-11

Authors: Sharma P, Sharma BC, Puri V, Sarin SK

BACKGROUND AND AIM: Minimal hepatic encephalopathy (MHE) is associated with poor quality of life and increased work disability. Treatment with lactulose and probiotics has shown some benefit. We compared lactulose with probiotics and a combination of lactulose plus probiotics in the treatment of MHE. PATIENTS AND METHODS: One hundred and ninety cirrhotic patients without overt encephalopathy [Child's A grade 71 patients (37.4%), Child's B grade 72 patients (37.9%), Child's C grade 47 patients (24.7%)] were evaluated by psychometry (number connection tests A and B or figure connection tests A and B) and P300 auditory event-related potential (P300ERP). MHE was diagnosed by abnormal psychometry and/or P300ERP. Patients were randomized to receive lactulose [group A (n=35): dose 30-60 ml/day], probiotics [group B (n=35): dose 1 capsule three times/day, each capsule contained Streptococcus faecalis 60 million, Clostridium butyricum 4 million, Bacillus mesentricus 2 million, lactic acid bacillus 100 million] and lactulose plus probiotics [group C (n=35)] for 1 month. Response was defined by normalization of the abnormal test parameters. RESULTS: MHE was diagnosed in 105 (55.2%) patients. Of the 105 patients, 75 (71%) had both abnormal psychometry and P300ERP, whereas 90 (86%) had abnormal psychometry alone, and 89 patients (85%) had abnormal P300ERP alone. Significant improvement was seen in abnormal psychometry tests (group A: n=31 vs. n=12, group B: n=29 vs. n=14, group C: n=30 vs. n=10), P300ERP (group A: 376.8+/-22.3 vs. 344.3+/-30.6 ms, group B: 385.4+/-28.5 vs. 355.5+/-27.9 ms, group C: 387.7+/-27.5 vs. 347.7+/-31.5 ms) and venous ammonia levels (group A: 102.3+/-63.1 vs. 69.3+/-33.3 micromol/l, group B: 108.2+/-37.5 vs. 75.7+/-33.0 micromol/l, group C: 96.3+/-27.7 vs. 68.7+/-28.4 micromol/l) in lactulose, probiotics and a combination of lactulose plus probiotics groups after treatment. Normalization of abnormal psychometry and P300ERP was seen in 54.8, 51.6 and 56.6% of patients treated with lactulose, probiotics and lactulose plus probiotics groups, respectively. CONCLUSION: A total of 55% of the patients with cirrhosis had MHE. Lactulose or probiotics or combinations of both are equally effective in the treatment of MHE.

PMID: 18467909 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Rifaximin versus nonabsorbable disaccharides in the management of hepatic encephalopathy: a meta-analysis.

Eur J Gastroenterol Hepatol. 2008 Nov;20(11):1064-70

Authors: Jiang Q, Jiang XH, Zheng MH, Jiang LM, Chen YP, Wang L

OBJECTIVE: To compare the positive and negative effects of rifaximin and nonabsorbable disaccharides in patients with hepatic encephalopathy. METHODS: We used the method recommended by The Cochrane Collaboration to perform a meta-analysis of comparative randomized trials of rifaximin and nonabsorbable disaccharides. RESULTS: Seven randomized controlled trials were identified, but only five trials involving 264 patients met all the inclusion criteria. There was no significant difference between rifaximin and nonabsorbable disaccharides on improvement in patients with hepatic encephalopathy [relative risk (RR) 1.08; 95% confidence interval (CI), 0.85-1.38; P=0.53]. RR was 0.98 (95% CI: 0.85-1.13; P=0.74) for acute hepatic encephalopathy in 157 patients and 0.87 (95% CI: 0.40-1.88; P=0.72) for chronic hepatic encephalopathy in 96 patients, respectively. There was no significant difference between rifaximin and nonabsorbable disaccharides on diarrhea (RR=0.90; 95% CI: 0.17-4.70; P=0.90). However, a significant difference in favor of rifaximin on abdominal pain (RR=0.28; 95% CI: 0.08-0.95; P=0.04) was identified. CONCLUSION: Rifaximin is not superior to nonabsorbable disaccharides for acute or chronic hepatic encephalopathy in the long-term or short-term treatment except that it may be better tolerated. Further studies on larger populations are required to provide more sufficient evidence for assessment of the use of rifaximin.

PMID: 19047837 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Leucocyte esterase reagent strips for the diagnosis of spontaneous bacterial peritonitis: a systematic review.

Eur J Gastroenterol Hepatol. 2008 Nov;20(11):1055-60

Authors: Koulaouzidis A, Leontiadis GI, Abdullah M, Moschos J, Gasem J, Tharakan J, Maltezos E, Saeed AA

The reported incidence of spontaneous bacterial peritonitis (SBP) is 7-30% per annum in cirrhotic patients. Timely diagnosis and treatment is crucial to reduce mortality owing to this infection. Recently, leucocyte esterase reagent strips have been tested in the diagnosis of infection in the ascitic fluid. The objective was to evaluate the diagnostic value of leucocyte esterase reagent strips in SBP in cirrhotic patients with ascites, by systematically reviewing the evidence from prospective clinical studies. We performed a comprehensive literature search in Medline up to July 2007 for adult human prospective clinical studies. Two reviewers independently checked all identified studies for fulfillment of predefined inclusion criteria, extracted data and assessed methodological quality of included studies. We had decided a priori to pool the studies via meta-analysis, only if statistical heterogeneity was found to be nonsignificant (P>0.10). Seventeen studies were included. Statistical heterogeneity among studies was found to be highly significant (P<0.001) in all analyses, precluding pooling of data for meta-analysis. Compared with the manual polymorphonuclear count ('gold standard'), leucocyte esterase reagent strips were found to have sensitivity ranging from 45 to 100%, specificity ranging from 81 to 100%, positive predictive value ranging from 42 to 100% and negative predictive value ranging from 87 to 100%. Despite the wide variation in sensitivity and positive predictive value between studies, the consistently high negative predictive value of leucocyte esterase reagent strips in SBP diagnosis should gain it a place in the ascitic tap diagnostic algorithm.

PMID: 19047835 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Role of host and bacterial virulence factors in Escherichia coli spontaneous bacterial peritonitis.

Eur J Gastroenterol Hepatol. 2008 Sep;20(9):924-9

Authors: Cereto F, Herranz X, Moreno E, Andreu A, Vergara M, Fontanals D, Roget M, Simó M, González A, Prats G, Genescà J

OBJECTIVES: Host factors and bacterial virulence determinants may play a role in Escherichia coli (E. coli) spontaneous bacterial peritonitis. We evaluated the importance of these factors in the emergence of fluoroquinolone-resistant strains and outcome in cirrhotic patients with E. coli spontaneous bacterial peritonitis. METHODS: E. coli spontaneous bacterial peritonitis was detected in a 2-year period in three tertiary hospitals. Clinical and bacteriological data were obtained. Phylogenetic group and 15 virulence genes of E. coli strains were analyzed by polymerase gene reaction and compared with 50 isolates from pyelonephritis patients. RESULTS: Forty-seven E. coli spontaneous bacterial peritonitis patients were identified, 18 (38%) were fluoroquinolone-resistant, a 12% increase compared with our earlier series from 1997 to 2002. Fluoroquinolone resistance was associated with norfloxacin prophylaxis, increased resistance to trimethoprim-sulfamethoxazole and cefotaxime, and less bacterial virulence, as demonstrated by a higher prevalence of ‘nonpathogenic’ phylogenetic groups A+B1 (56 vs. 28%; P=0.04) and lower virulence scores in fluoroquinolone-resistant E. coli compared with fluoroquinolone-susceptible E. coli. E. coli strains from cirrhotic patients belonged more frequently to ‘nonpathogenic’ phylogenetic groups A+B1, had fewer virulence factors and higher rates of fluoroquinolone resistance than isolates from pyelonephytis patients. Immunosuppression was independently associated with in-hospital and 3-month mortality. Bacterial virulence factors were unrelated to mortality. CONCLUSION: Fluoroquinolone-resistant E. coli spontaneous bacterial peritonitis prevalence is increasing because of norfloxacin prophylaxis. Strains from peritonitis are less virulent than strains from pyelonephritis because of a higher prevalence of A+B1 phylogeny and quinolone resistance. Mortality is related to immunosuppression, but not to bacterial virulence factors.

PMID: 18794608 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Effects of biliary obstruction on the penetration of ciprofloxacin and cefotaxime.

Eur J Gastroenterol Hepatol. 2008 Feb;20(2):127-30

Authors: Dhalluin-Venier V, Bazin C, Massias L, Farah RB, Boytchev I, Fritsch J, Choury AD, Prat F, Buffet C, Furlan V, Pelletier G

OBJECTIVE: To evaluate the biliary penetration of ciprofloxacin and cefotaxime in patients with obstructed bile ducts and to determine simple predictive markers of effective biliary concentrations of these drugs. METHODS: Sixty-two patients treated with endoscopic biliary drainage were prospectively included in a nonrandomized way and received intravenous ciprofloxacin (200 mg twice daily) or cefotaxime (1 g three times a day) for more than 24 h before exploration. Blood and bile samples were collected at the time of drainage. Ciprofloxacin and cefotaxime concentrations were measured using high-performance liquid chromatography. Biliary penetration was assessed by the bile-to-plasma ratio of the concentrations of both antibiotics. RESULTS: Biliary penetration ranged from 0.06 to 42.7 for ciprofloxacin and from 0.01 to 1.14 for cefotaxime. The ratio was more than one in only 10 patients (35%) and three patients (9%) in ciprofloxacin and cefotaxime groups, respectively. Biliary concentration of the drug was more than 10 times the minimal inhibitory concentration in only 10 patients (35%) and in 12 patients (35%) in ciprofloxacin and cefotaxime groups, respectively. Serum bilirubin, alkaline phosphatase or gamma-glutamyl-transpeptidase were not good predictive markers of the biliary diffusion of the antibiotics. CONCLUSION: In patients with obstructed bile ducts, the biliary penetration of ciprofloxacin is poor and reaches effective biliary concentrations in a minority of patients. Cefotaxime biliary penetration is even poorer. No liver test can predict accurately the biliary penetration of the drugs.

PMID: 18188033 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Do the benefits of metal stents justify the costs? A systematic review and meta-analysis of trials comparing endoscopic stents for malignant biliary obstruction.

Eur J Gastroenterol Hepatol. 2007 Dec;19(12):1119-24

Authors: Moss AC, Morris E, Leyden J, MacMathuna P

BACKGROUND: A variety of stent designs has been studied for endoscopic stenting of the bile duct in patients with malignant biliary obstruction. Although metal stents are associated with longer patency, their costs are significantly higher than plastic stents. AIMS: To compare clinical outcome and cost-effectiveness of endoscopic metal and plastic stents for malignant biliary obstruction by a systematic review and meta-analysis of all randomized controlled trials in this area. METHODS: We conducted searches to identify all randomized controlled trials in any language from 1966 to 2006 using electronic databases and hand-searching of conference abstracts. Meta-analysis was performed with RevMan software [Review Manager (RevMan) version 4.2 for Windows. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2003]. RESULTS: Seven randomized controlled trials were identified that met the inclusion criteria, and 724 participants were randomized to either metal or plastic endoscopic stents. No significant difference between the two stent types in terms of technical success, therapeutic success, 30-day mortality or complications was observed. Metal stents were associated with a significantly less relative risk (RR) of stent occlusion at 4 months than plastic stents [RR, 0.44; 95% confidence interval (CI) 0.3, 0.63; P<0.01]. The overall risk of recurrent biliary obstruction was also significantly lower in patients treated with metal stents (RR, 0.52; 95% confidence interval 0.39, 0.69; P<0.01). The median incremental cost-effectiveness ratio of metal stents was $1820 per endoscopic retrograde cholangiopancreatography prevented. CONCLUSION: Endoscopic metal stents for malignant biliary obstruction are associated with significantly higher patency rates than plastic stents as early as 4 months after insertion. Metal stents will be cost-effective if the unit cost of additional endoscopic retrograde cholangiopancreatographies per patient exceeds $1820.

PMID: 17998839 [PubMed - indexed for MEDLINE]

[Read more →]