Cholangiopathy in critically ill patients surviving beyond the intensive care period: a multicentre survey in liver units.

BACKGROUND: The outcome of cholangiopathy developing in intensive care unit (ICU) is not known in patients surviving their ICU stay. AIM: To perform a survey in liver units, in order to clarify the course of cholangiopathy after surviving ICU stay. METHODS: The files of the liver units affiliated to the French network for vascular liver disease were screened for cases of ICU cholangiopathy developing in patients with normal liver function tests on ICU admission, and no prior history of liver disease. RESULTS: Between 2005 and 2015, 16 cases were retrieved. Extensive burns were the cause for admission to ICU in 11 patients. Serum alkaline phosphatase levels increased from day 11 (2-46) to a peak of 15 (4-32) × ULN on day 81 (12-511). Magnetic resonance cholangiography showed irregularities or frank stenosis of the intrahepatic ducts, and proximal extrahepatic ducts contrasting with a normal aspect of the distal common bile duct. Follow-up duration was 20.6 (4.7-71.8) months. Three patients were lost to follow-up; 2 patients died from liver failure and no patient was transplanted. One patient had worsening strictures of the intrahepatic bile ducts with jaundice. Nine patients had persistent but minor strictures of the intrahepatic bile ducts on MR cholangiography, and persistent cholestasis without jaundice. One patient had normal liver function tests. CONCLUSIONS: In patients surviving their ICU stay, ICU cholangiopathy is not uniformly fatal in the short term or clinically symptomatic in the medium term. Preservation of the distal common bile duct appears to be a finding differentiating ICU cholangiopathy from other diffuse cholangiopathies.

[Non-surgical treatment of biliary stenoses after hepatic transplantation]. / Traitement non chirurgical des sténoses biliaires après transplantation hépatique.

We report the initial and long-term results of non surgical procedures performed for the treatment of biliary strictures in liver transplant patients. Twelve liver transplant patients with biliary strictures underwent 16 interventional radiological procedures. Initial technical success was achieved in 11 of 12 patients (91%). Within long-term, with a follow-up of 27 months, primary success rate (only one procedure) was 58% (7 of 12 patients). Three restenoses occurred. They were all treated by interventional radiological procedures. The secondary success rate (one or more procedures) was 83% (10 of 12 patients). Two complications occurred including one pancreatitis and one cholangitis. Non surgical management may be performed for patients with biliary strictures after liver transplantation.

Systemic antibiotic prophylaxis after gastrointestinal hemorrhage in cirrhotic patients with a high risk of infection.

In cirrhotic patients with gastrointestinal hemorrhage, bacterial infections are frequent and play a significant role in mortality. We have previously found that patients with a Child-Pugh's class C or a rebleeding are a subgroup of cirrhotic patients with a high risk of infection. The aims of the study were (1) to validate these indicators and (2) to assess the effectiveness of a systemic antibiotic treatment in preventing bacterial infections in bleeding cirrhotics with a high risk of infection. One hundred and nineteen bleeding cirrhotic patients were divided into 3 groups. Patients with a Child-Pugh's class A-B and no rebleeding (i.e., with a low risk of infection) constituted group 1 (n = 55). Patients with a high risk of infection were randomly allocated to serve as controls (group 2, n = 34) or to receive the ciprofloxacin and a combination of amoxicillin and clavulanic acid for 3 days after hemorrhage (group 3, n = 30). This antibiotic prophylaxis was administered first intravenously and then orally when the bleeding was controlled. The study period was defined as 10 days after hemorrhage. Incidence of bacterial infections was significantly higher in patients from group 2 than in patients from group 1 (52.9% vs. 18.2%; P < .001). Moreover, infections were more severe in group 2: a sepsis syndrome or a septic shock developed in 66.7% of infected patients from this group, but in only 20% of infected patients from group 1. Incidence of bacterial infections was much lower in patients from group 3 than in those from group 2 (13.3% vs. 52.9%; P < .001). Eight patients from group 2 (23.5%) and 4 patients from group 3 (13.3%) died during the first four weeks (P-not significant). Septic shock was the cause of death in 3 patients from group 2 and in only 1 patient from group 3. The cost of antibiotic therapy, including antibiotic prophylaxis in group 3, was $208 +/- $63 per patient in group 2 and $167 +/- $42 per patient in group 3 (P < .05). We conclude that (1) patients with a Child-Pugh's class C and/or a rebleeding are a subgroup of cirrhotic patients with a high risk of infection after gastrointestinal hemorrhage and that (2) in these patients, a prophylactic treatment with systemic antibiotics is very effective in preventing bacterial infections.

[Gastric protein loss and alcoholic cirrhosis. Study by measurement of gastric clearance of alpha 1-antitrypsin]. / Pertes protéiques gastriques et cirrhose alcoolique. Etude par la mesure de la clairance gastrique de l' alpha 1-antitrypsine.

OBJECTIVE: The aim of the study was to assess gastric protein loss in alcoholic cirrhotic patients, and to determine its role in the low serum albumin levels frequently observed in these patients. METHODS: Twenty-six alcoholic cirrhotic patients with ascites and serum albumin levels < 30 g/L were studied and compared to 6 healthy volunteers. Gastric protein loss was determined by measuring gastric clearance of alpha 1-antitrypsin. RESULTS: Gastric clearance of alpha 1-antitrypsin was 0.96 +/- 1.42 mL/h (median : 0.52; range: 0.11-6.54) in cirrhotic patients and 0.48 +/- 0.20 mL/h (median: 0.51) in healthy volunteers. Values in cirrhotic patients were not significantly different from healthy volunteers. However, 3 cirrhotic patients had high values of gastric clearance of alpha 1-antitrypsin (2.84, 3.99 and 6.54 mL/h). Their serum albumin and protein levels were significantly lower than those in the 23 other patients (P < 0.05 and < 0.03, respectively). Severe portal hypertensive gastropathy was present in two out of these 3 patients and in two out of the 23 other patients. CONCLUSION: Gastric protein loss is not significantly increased in liver cirrhosis. However, in a few patients, this loss is high and may play a role in low serum albumin levels.

Emergency liver transplantation for acute liver failure. Evaluation of London and Clichy criteria.

Two sets of prognostic indicators were recently proposed for selection of patients with acute liver failure for emergency liver transplantation. According to the London criteria, patients with non-paracetamol-induced acute liver failure should be referred for liver transplantation when the prothrombin time is > 100 s or when any three of the following prognostic indicators are present: age < 10 or > 40 yr; non-A, non-B hepatitis, halothane hepatitis or idiosyncratic drug reaction; duration of jaundice before onset of encephalopathy > 7 days; prothrombin time > 50 s; serum bilirubin > 300 mumol/l. According to the Clichy criteria, in acute viral hepatitis, liver transplantation should be decided in patients with coma or confusion, and Factor V < 20% (age < 30 yr) or < 30% (age > 30 yr). To assess the accuracy of these criteria, 81 non-transplanted patients with non-paracetamol-induced acute liver failure were retrospectively studied. The mortality rate was 0.81. The predictive accuracies, respectively on admission and 48 h before death, were 0.80 and 0.79 for the London criteria, and 0.60 and 0.73 for the Clichy criteria. The positive and negative predictive values, 48 h before death, were 0.89 and 0.47 for the London criteria, and 0.89 and 0.36 for the Clichy criteria, respectively. In the 49 patients with acute viral liver failure, the results of the Clichy criteria were similar. In a subgroup of 24 patients who had not received either fresh frozen plasma or sedative-hypnotic drug, the positive predictive values were equal to 1 for the two sets of prognostic indicators, but the predictive accuracies only slightly increased.(ABSTRACT TRUNCATED AT 250 WORDS)