[When should we give albumin in patients with cirrhosis?]. / Quand administrer de l'albumine aux malades atteints de cirrhose?

The beneficial effects of the use of albumin, either alone or combines with other treat- ments, have been demonstrated in patients with various complications of cirrhosis. Therefore, albumin should be administred in patients with spontaneous bacterial peritonitis in association with antibiotics, and in association with terlipressin in patients with type 1 hepatorenal syndrome. Albumin use reduces the occurrence of paracentesis-related circulatory dysfunction, in patients with large ascites undergoing paracentesis. So far, the beneficial effect of albumin has not been demonstrated, neither for infections other than spontaneous bacterial peritonitis nor for hepatic encephalopathy. This article provides an overview of the data evaluating the effects of albumin in patients with cirrhosis.

[Cell transplantation: current treatments and future prospects]. / Transplantation cellulaire: traitements actuels et perspectives d'avenir.

Regenerative medicine aims to replace a body function or specific cell loss. It includes therapies at the forefront of modem medicine, issuing from translational biomedical research. Transplantation of organs and cells has revolutionized the management of patients for whom medical treatment is a failure. Unfortunately, organ shortage is limiting treatment possibility. As an example, among the 15,000 patients with type I diabetes in Switzerland, only approximately 30 can receive a pancreas or an islet transplant per year. Second example, 500 patients die each year in Switzerland from alcoholic cirrhosis because no treatment is available. Transplantation of islet cells, hepatocytes, mesenchymal stem cells or dopaminergic neurons represents hope fora therapy available for large populations of patients.

[Management of liver diseases during pregnancy]. / Maladies hépatiques liées à la grossesse.

Liver tests abnormalities during pregnancy should encourage the clinician to seek liver diseases of pregnancy. The liver diseases of pregnancy are those proper to pregnancy including hyperemesis gravidarum, intrahepatic cholestasis of pregnancy, all the "hypertensive" related diseases and acute fatty liver of pregnancy. These pathologies can involve the vital prognosis of the mother and the child. An adequate management reduces maternal-fetal complications. Close monitoring of pregnancy with sometimes induction of labour and verification of the normalization of liver tests after childbirth are essential.

[Coagulation and cirrhosis: new insight]. / Coagulation et cirrhose: un nouveau regard.

The liver plays a key role in coagulation as all clotting factors except for factor VIII are synthetized by hepatocytes. In cirrhotic patients, there is a decrease of clotting factors and a thrombocytopenia. Those parameters usually modify routine coagulation tests and may suggest that cirrhotic patients are at a higher risk of bleeding. However, studies have shown that these patients are rather at risk for thrombosis. The reason is a concomitant decrease of coagulation inhibitors factors that is not detected in routine laboratory coagulation tests. The coagulation system in cirrhotic patient is a balance of pro and anti-coagulants. This balance may be affected by co-factors such as renal failure or infection. Artificial correction of laboratory values by transfusion of blood products may be rather deleterious (e.g. volume overload, TRALI).

[Albumin infusion for paracentesis in patients with cirrhosis: dogma or evidence?]. / Administration d'albumine lors de paracentèse évacuatrice dans la cirrhose: dogme ou évidence?

Large-volume paracentesis is the procedure of choice for refractory or symptomatic ascitis. However, there is a risk for Post-paracentesis Circulatory Dysfunction (PCD) leading to hyponatremia, renal failure, or worsening portal hypertension. PCD may be effectively prevented by volume expanders, essentially albumin, administered during and after the procedure, but the data regarding the impact of this treatment on mortality are still limited. For this reason, there is a debate about the true clinical benefit of preventing PCD, explaining some variations among published guidelines. The efficacy of molecules other than albumin is still under study but none has shown real superiority so far.

[Alcoholic steatohepatitis: what's new in 2012?]. / Stéatohépatite alcoolique: nouveautés 2012.

Alcoholic liver disease is a spectrum of lesions, of which the most severe is alcoholic steatohepatitis (ASH). Recent European guidelines define alcoholic hepatitis as a clinical syndrome: the recent onset of jaundice and/or ascites in a patient with ongoing alcohol misuse. Next to infection, the most frequent aetiology is ASH, a histological diagnosis. In case of severe ASH, as defined by prognostic scores, a biopsy is needed to confirm the diagnosis. Non-severe forms of ASH may improve with interruption of alcohol abuse only; however survival of severe forms of ASH is improved by the association of corticosteroids and N-acetylcysteine. In case of uncontrolled infection, pentoxifylline may be administered. The Lille score, measured at the 7th day of corticosteroid therapy, measures response to therapy and guides the total duration of treatment.

Underlying disease for percutaneous endoscopic gastrostomy tube placement predicts short- and long-term mortality.

Background: PEG (percutaneous endoscopic gastrostomy) is a well established endoscopic procedure for enteral feeding. However, patients with a shorter life expectancy will not benefit from PEG tube placement. Furthermore, some specific evolving diseases will never benefit from PEG. The aim of the study focuses on short and long term mortality rates after PEG tube placement in a referral gastroenterology centre (Geneva University Hospital). 219 patients were enrolled in this study. Patients and methods: All patients scheduled for a PEG procedure between January 2011 and December 2014 were included. Nine patient parameters were collected for further analysis as well as the main underlying disease requiring PEG tube placement. Patients were subsequently divided into 4 groups according to underlying disease: Group 1) swallowing disorders of neurologic origin; Group 2) swallowing disorders associated with upper digestive tract neoplasia ; Group 3) nutritional support for a non GI reason ; Group 4) Other. Results: 219 patients had undergone a PEG tube placement. 33 patients died within 60 days after the procedure. After one year, 71 patients died. Global survival was 870 days. The nutritional support group had the better survival rate with 1276 days compared to the swallowing groups and others. The multivariate analysis has highlighted the underlying disease as the only associated parameter with short and long term mortality. Conclusions: PEG tube placement is associated with high short and long term mortality depending on the underlying disease. We outlined the potential role of PEG tube insertion as a supportive transient approach for nutritional support.

Combined treatment of refractory ascites with an alfapump® plus hernia repair in the same surgical session: A retrospective, multicentre, European pilot study in cirrhotic patients.

INTRODUCTION: The treatment of symptomatic hernia in cirrhotic patients with refractory ascites is critical but challenging. The objective of this study was to assess the feasibility and safety of the implantation of alfapump® combined with concomitant hernia repair in cirrhotic patients with refractory ascites. METHODS: Using data from six European centres, we retrospectively compared patients treated with alfapump® system implantation and concomitant hernia repair [the combined treatment group (CT group, n=12)] or with intermittent paracentesis hernia repair [the standard treatment group (ST group, n=26)]. Some patients of the ST group had hernia repair in an elective setting (STel group) and others in emergency (STem group). The endpoints were requirement of peritoneal drainage, the rate of infectious complications, the in-hospital mortality, the length of stay, paracentesis-free survival. RESULTS: Postoperatively, none of the patients in the CT group and 21 patients (80%) in the ST group underwent peritoneal drainage for the evacuation of ascites fluid (P<0.0001). The overall incidence of infectious complications was not different between groups but there were fewer infections in the CT group than in the STem group (33% vs. 81%; P=0.01). There was no difference for in-hospital mortality. The length of stay was shorter in the CT group (P=0.03). Paracentesis-free survival was significantly better (P=0.0003) in the CT group than in the ST group. CONCLUSION: Implantation of alfapump combined with concomitant hernia repair seems feasible and safe in cirrhotic patients; however, larger and randomized study are required.

[Cirrhotic cardiomyopathy]. / La cardiomyopathie cirrhotique.

Cirrhotic cardiomyopathy is defined as structural and functional cardiac abnormalities occurring in patients with cirrhosis, in the absence of any other associated cardiac disease. Its main clinical features include systolic and diastolic dysfunctions, and electrophysiological changes. Cirrhotic cardiomyopathy is generally clinically latent and is unmasked when the patient is exposed to major physiological stress or after some procedures, thus leading to an overt cardiac failure. Pathogenic mechanisms include impaired beta-adrenergic receptor signal transduction and increased activity of cardio-depressor pathways. A certain reversibility has been shown in the medium-long term after a liver transplantation. This article proposes to review the physiopathological mechanisms underlying these abnormalities, their clinical impacts, and the management options.

[Portal hypertension and HIV infection]. / Hypertension portate et infection par le VIH.

In the era of antiretroviral therapies, the outcome of patients with chronic HIV infection has considerably changed and their prolonged survival allows the development of chronic liver diseases as a major cause of mortality. Although viral hepatitis, alcoholic and non alcoholic steatohepatitis account forthe majority of chronic liver damage in these patients, there is a growing number of cases with unexplained liver disease, many of which are associated with clinical manifestations of portal hypertension. Inthissituation, nodularregenerative hyperplasia is a frequent finding, characterized at histology by the presence of a nodular architecture in the absence of significant fibrosis, resulting from progressive obliteration of small portal veins. This article describes the clinical presentation, diagnostic aspects, pathogenic mechanisms, as well as the management of this emergent non cirrhotic liver disease in HIV-infected patients.

Treatment of refractory ascites with an automated low-flow ascites pump in patients with cirrhosis.

BACKGROUND: Refractory ascites (RA) is a frequent complication of cirrhosis, requiring large volume paracentesis or placement of a transjugular intrahepatic portosystemic shunt (TIPSS). The automated low-flow ascites pump (alfapump, Sequana Medical AG, Zurich, Switzerland) is an innovative treatment option for patients with RA. AIM: To assess safety and efficacy of this treatment in patients with a contraindication to TIPSS. METHODS: Fifty-six patients (43 males; mean age 62 years) from centres in Germany, Switzerland, UK and Spain were included and followed for up to 24 months. Complications, device deficiencies, paracentesis frequency and patient survival were recorded. RESULTS: At the time of this analysis, 3 patients completed the 24-month observation period, monitoring of 3 was ongoing, 9 underwent liver transplantation, 17 patients were withdrawn due to serious adverse events and 23 patients died. Most frequently observed technical complication was blocking of the peritoneal catheter. Twenty-three pump-related reinterventions (17 patients) and 12 pump exchanges (11 patients) were required during follow-up. The pump system was explanted in 48% of patients (in 17 patients due to serious adverse events, in 9 at the time of liver transplantation and in 1 due to recovery from RA). Median frequency of paracentesis dropped from 2.17 to 0.17 per month. CONCLUSIONS: The alfapump can expand therapeutic options for cirrhotic patients with RA. Continuous drainage of ascites in a closed loop automated system led to significant reduction in paracentesis frequency. Technical and procedural improvements are required to reduce the rate of adverse events and reinterventions. https://clinicaltrials.gov/ct2/show/NCT01532427.

[Clinical management of a patient with alcoholic cirrhosis]. / Le suivi clinique d'un patient atteint de cirrhose alcoolique.

Prolonged abstinence from alcohol is crucial in the management and prognosis of a patient with alcoholic cirrhosis. It is also important to prevent complications such as variceal bleeding, hepatocellular and extrahepatic cancers, and malnutrition. Liver transplantation should be considered in patients with persistent liver failure in spite of complete cessation of alcohol consumption. We provide some recommendations in commonly encountered clinical situations for compensated and decompensated alcoholic cirrhosis.

[Alcoholic and nonalcoholic steatohepatitis: the same disease! II. Management]. / Stéatohépatites alcooliques et non alcooliques: la même maladie! II. Prise en charge thérapeutique.

Both alcoholic and non-alcoholic steatohepatitis share common histological findings and the risk of developing cirrhosis. Liver biopsy is required for the diagnosis, and the aim of treatment is to prevent cirrhosis. In alcoholic steatohepatitis, abstinence from alcohol is associated to prednisone in a severe form, as defined by a Maddrey's score > 32. Due to common pathogenic mechanisms, we recommend that coexisting metabolic alterations that are commonly observed in non-alcoholic steatohepatitis should also be treated in alcoholics. Thus, weight reduction, physical exercise, improvement of insulin sensitivity and reduction of oxidative stress, all may be beneficial both in alcoholic and non-alcoholic steatohepatitis.

[Alcoholic and nonalcoholic steatohepatitis: the same disease! I. Diagnosis and mechanisms]. / Stéatohépatites alcooliques et non alcooliques: la même maladie! I. Diagnostic et mécanismes.

Alcoholic steatohepatitis includes steatosis, inflammatory changes and hepatocellular damage. In severe form, jaundice and hepatic failure persist for several weeks, while non severe alcoholic steatohepatitis may follow an insidious course towards cirrhosis. Except for alcohol consumption, nonalcoholic steatohepatitis shares histological features and pathogenic mechanisms with alcoholic steatohepatitis, and is associated to the development of cirrhosis over time. Thus, given the increasing epidemics of the metabolic syndrome in industrialized countries, it is likely that alcoholic cirrhosis has been overdiagnosed in the past years. Obesity, insulin resistance and the oxidative stress including iron-mediated oxidative stress are involved both in alcoholic and non-alcoholic steatohepatitis.

Pseudomembranous colitis: an unusual cause of neutrocytic ascites.

Severe cases of pseudomembranous colitis (PMC) may be associated with intraperitoneal fluid accumulation. However, the characteristics of the liquid are seldom described. Specifically, neutrocytic ascites has only been reported once. We report a case of a severe PMC complicated by a highly neutrocytic ascites which remained culture-negative. We discuss the possible mechanisms leading to ascites formation in this condition and review ascitic fluid characteristics in patients with PMC.

Biliary migration of hepatocellular carcinoma fragment after transcatheter arterial chemoembolization therapy.

Occasional side-effects of transcatheter arterial chemoembolization therapy in hepatocellular carcinoma are essentially related to tissue necrosis. We report the case of a patient with hepatocellular carcinoma who experienced an acute common bile duct obstruction a few weeks after such a procedure, in the absence of obvious biliary tract invasion. An endoscopic sphincterotomy relieved the obstruction. At histology, the intra-biliary material was identified as a fragment of hepatocellular carcinoma. We discuss the causes of obstructive jaundice in the setting of hepatocellular carcinoma as well as in the specific situation of transcatheter arterial chemoembolization therapy.

Procalcitonin is not an accurate marker of spontaneous bacterial peritonitis in patients with cirrhosis.

BACKGROUND/AIMS: The clinical features of peritonitis are usually absent in cirrhotic patients with an ascitic fluid infection, raising the interest for specific biological markers of inflammation. METHODOLOGY: We prospectively measured the plasma and ascitic fluid levels of procalcitonin, an innovative infection parameter, interleukin-6, and C-reactive protein in 20 cirrhotics with or without spontaneous bacterial peritonitis. The patient's condition was followed-up for 12 weeks after paracentesis. RESULTS: None of the 10 patients with spontaneous bacterial peritonitis presented with severe systemic signs of infection. Procalcitonin level in plasma, but not in ascites, was significantly higher in patients with spontaneous bacterial peritonitis compared to controls (0.74 +/- 0.6 vs. 0.2 +/- 0.1 ng/mL, P < 0.05). Interleukin-6 levels in ascites were similar between groups. C-reactive protein concentrations were higher both in plasma and in ascitic fluid in patients with spontaneous bacterial peritonitis compared to controls (85.3 +/- 63 vs. 18.6 +/- 19 mg/dL, 24.6 +/- 25 vs. 4.5 +/- 4 mg/dL, P < 0.05, respectively). Three patients with spontaneous bacterial peritonitis died, but the outcome was not related to the concentrations of biological markers. CONCLUSIONS: In spontaneous bacterial peritonitis, procalcitonin measurement is not an accurate diagnostic test, possibly due to the absence of systemic inflammatory response syndrome in this condition. In addition, the diagnostic value of C-reactive protein is limited by the wide overlap between values.

Noninvasive diagnosis of Caroli syndrome associated with congenital hepatic fibrosis using hepatobiliary scintigraphy.

A patient who was studied for portal hypertension had an enlarged liver and multiple hepatic cysts on abdominal CT scan. He underwent hepatobiliary scintigraphy using Tc-99m mebrofenin which documented communication of the cysts with the main biliary tree and allowed a noninvasive diagnosis of Caroli syndrome associated with congenital hepatic fibrosis.

[Brain oedema and acute liver failure]. / Oedème cérébral et insuffisance hépatique fulminante.

Brain oedema leading to intracranial hypertension occurs in a significant proportion of patients with acute liver failure in whom it is a leading cause of death. Although precise pathogenic mechanisms associated to this severe complication remain incompletely understood, increasing evidence points to gut-derived neurotoxins including ammonia as key mediators in cerebral osmotic and perfusion disturbances. The management of brain oedema and intracranial hypertension requires a multidisciplinar approach in a center where liver transplantation is available, as this option is the only treatment modality that provides improvement in outcome. This article reviews the most common causes of acute liver failure and the standard of supportive care management, and describes future potential therapeutic aspects of brain oedema and intracranial hypertension.