Non-invasive predictors to grade esophageal varices in liver cirrhosis patients.

Background: Portal hypertension commonly occurs due to liver cirrhosis, and esophageal varices (EV) is one of the major complications associated with it. The most common cause of death in liver cirrhosis is EV bleeding. Hence, GE screening for EV is required, which is an invasive procedure. Regular use of endoscopy results in low compliance due to cost and discomfort for patients. Hence, identifying non-invasive markers that could grade EV provides a useful screening tool for family physicians and primary health centers (PHCs) by referring the patient to higher centers for definitive treatment, which could reduce mortality due to variceal bleeding in cirrhotic patients. Aims: To assess non-invasive predictors of grade EV in patients diagnosed with liver cirrhosis. Settings and Design: Cross-sectional study. Methods and Material: A total of 109 patients with liver cirrhosis underwent clinical and biochemical evaluation, USG abdomen with spleen bipolar diameter, ascitic fluid analysis, and upper GE with a grade of EV are recorded. Statistical Analysis Used: SPSS software with Student t-test, Chi-square t-test, analysis of variance, receiver operator characteristic (ROC) curves, and Spearman correlation with 95% CI is used. P <0.05 is considered significant. Results: Aminotransferase to Platelet count Ratio Index (APRI) score >1.815, PC/SD ≤909, and SAAG >1.1g/dl showed EV in liver cirrhosis (P < 0.05). The order of prediction with ROC curves shows APRI score > PC/SD > SAAG. In grading EV, APRI scores of 1.9-2.5 and >2.5 showed small and large EV, respectively (P < 0.05). Conclusions: APRI score may be used in PHC as an early intervention to grade EV and refer the patient to higher centers for definitive treatment. This would prevent the progression of varices to rupture and reduce mortality due to variceal bleeds in liver cirrhosis patients.

Negative Serum Ascites Albumin Gradient (SAAG) in the Setting of Cholangiocarcinoma: A Case Report.

Ascites is the accumulation of fluid in the peritoneal cavity which leads to abdominal distention. Malignant ascites may occur in several tumor types including liver, pancreas, colon, breast, and ovary. Serum ascites albumin gradient (SAAG) is the difference between albumin in the serum and ascitic fluid. A SAAG greater or equal to 1.1 g/dL is characteristic of portal hypertension. A SAAG less than 1.1 g/dL can be seen in hypoalbuminemia, malignancy, or an infectious process. We report a rare case of malignant ascites in a 61-year-old female patient who presented with a chief complaint of abdominal pain with distention that was preceded by a 25-pound weight loss over the last three months. The patient underwent a paracentesis after a computed tomography (CT scan) revealed a heterogenous liver mass with associated ascites. Ascitic fluid analysis revealed a SAAG of -0.4 g/dL. CT-guided core needle biopsy of the hepatic mass revealed a poorly differentiated carcinoma with immunostaining suggestive of an underlying cholangiocarcinoma. Cholangiocarcinoma is an extremely uncommon etiology of acute new-onset ascites and has not been shown to produce high protein ascites with a negative SAAG. It is therefore important for clinicians to get ascitic fluid analysis in order to calculate a SAAG to help develop differential diagnosis for the cause of ascitic fluid buildup.

A Rare Hemorrhagic, Orange-Colored Ascites, Challenging Traditional Ascitic Fluid Analysis.

Analysis of ascitic fluid can offer useful information in developing and supporting a differential diagnosis. As one of the most prevalent complications in patients with cirrhosis, ascitic fluid aids in differentiating a benign condition from malignancy. Both the gross appearance of the ascitic fluid, along with fluid analysis, play a major role in diagnosis. Here, we discuss a patient with liver cirrhosis, esophageal varices, hepatitis C, and alcohol abuse, who had a paracentesis performed, which revealed a turbid, viscous, orange-colored ascitic fluid that has not been documented in literature. Ascitic fluid is routinely analyzed based on gross appearance, cell count, and serum ascites albumin gradient (SAAG) score. An appearance of turbidity or cloudiness has commonly suggested an inflammatory process. In our case, fluid analysis revealed a red blood cell count of 24 250/mcL, further suggesting inflammation. However, it also revealed an insignificant number of inflammatory cells, with a total nucleated cell count of 14/mcL. This rich-orange color has posed a challenge in classification and diagnosis of the underlying cause of ascites, with one classification system suggesting inflammation, while another suggesting portal hypertension. Furthermore, we have traditionally relied on the SAAG score to aid in determining portal hypertension as an underlying cause of ascites. With a 96.7% accuracy rate, the SAAG score incorrectly diagnosed portal hypertension in this patient. In this article, we aim to explore how this rare, orange-colored ascitic fluid has challenged the traditional classification system of ascites.

Effect of intra-peritoneal induction of ascites fluid on the rate of postoperative intraabdominal adhesion in a rat model.

Introduction: Intra-abdominal adhesions (IAAs) are secondary to peritoneal injuries such as previous surgery or intra-abdominal infections (IAIs). Accordingly, it is crucial to employ fitting techniques to minimize the likelihood of adhesions in any surgery. Due to a paucity of similar data available, this study sought to explore the effects of induced high serum ascites albumin gradient (SAAG) and low serum ascites albumin gradient (SAAG) on the rate of post-operative microscopic and macroscopic adhesion in a mouse model. Material and methods: Sixty mice were compared in six groups of ten each. Control groups (1 &4) received normal saline, groups 2&5 received high SAAG ascites fluid, and groups 3&6 received low SAAG ascites fluid intraperitoneally. These groups underwent exploratory laparotomy on day zero, followed by the same procedure on the 10th (groups 1,2,3) and the 30th (Groups 4,5,6) day of surgery. Then, microscopic and macroscopic IAAs were evaluated. Data were analyzed in SPSS software and compared with a p-value less than 0.05. Results: By comparison, the least microscopic and macroscopic IAAs after 10 and 30 days were found in the low SAAG ascites group. Revealing a statistically significant difference compared to the other two groups (P = 0.01). After 10 days of surgery, macroscopic IAA in the high SAAG group was significantly lower compared to the control and Low SAAG ascites groups. Conclusion: Intraabdominal low SAAG ascites fluid can significantly decrease the probability of postoperative fibrosis and adhesion band formation. Protocol number: IR. BUMS.REC.1399.503.

Malignant Peritoneal Mesothelioma Presenting with High Protein, High Serum-Ascites Albumin Gradient.

Mesothelioma is a difficult-to-detect neoplasm that rarely develops in the peritoneum. In patients with unexplained ascites, pleural fluid analysis and ultrasonography is often the first step to achieving a diagnosis. This case report shares a unique presentation in which a patient who presented with unexplained ascites, was initially thought to have cirrhosis but was later found to have malignant peritoneal mesothelioma after cross-sectional imaging and tissue acquisition. This case illustrates the importance of a high clinical index of suspicion for mesothelioma given its variety of clinical presentations, as well as the utility of early cross-sectional imaging in such cases.

Heart Failure-Related Ascites With Low Serum-Ascites Albumin Gradient: Diagnostic Clues From Triphasic Abdominal Computed Tomography.

Serum-ascites albumin gradient (SAAG) is an initial and useful measure to differentiate causes of ascites. High gradient ascites (SAAG >1.1 g/dL) is one of the important features of heart failure. Low gradient ascites in heart failure is relatively rare and needs additional workups to rule out other serious causes, such as malignancy and infection. We herein report a case of a 42-year-old female with low-SAAG ascites from worsening congestive heart failure, which was confirmed to be portal hypertension-originated by triphasic abdominal computed tomography.

Post-operative ascites of unknown origin after laparoscopic cholecystectomy: Case report.

Introduction and importance: Post Laparoscopic cholecystectomy ascites is a rare complication that might be due to biliary leak, lymph duct injuries, infections, peritoneal reaction bowel injuries, malignancies and etc. Case presentation: Here we have reported post-cholecystectomy ascites presented with hypovolemic shock in a women of unknown origin. Different possible etiologies have been ruled out for her but her intra-peritoneal secretions had been decreased about one week of hospitalization and was discharged without figuring out its etiology. Clinical discussion: Post-cholecystectomy ascites is a rare condition that could be caused by biliary leak, lymphatic leak, ovarian hyper stimulation syndrome, infections, peritoneal reactions and malignancies that all of them should be considered for these patients to manage their problem. Conclusion: The exact cause of ascites in the presented case was still unknown and the condition was controlled by administration of corticosteroids, octreotide, albumin, and insertion of the stents in biliary ducts. More investigation esp. on immunologic causes are needed.

Delayed presentation of isolated ductal rupture of pancreatic head from blunt abdominal trauma managed conservatively: A case report.

Introduction: and Importance: Blunt abdominal injury causing significant and isolated major pancreatic injury is rare in adolescents and young adults, with a controversial approach to its management. Case presentation: We present our experience of diagnosis and management of the ductal injury of the pancreatic head (Grade III) in the setting of blunt abdominal trauma in a 20-year-old male diagnosed by a series of various tests including magnetic resonance cholangiopancreatography (MRCP) and managed by pigtail drainage and octreotide alone; contrary to the previous recommendations of management of high-grade pancreatic trauma through surgical approach or endoscopic retrograde cholangiopancreatography (ERCP) and stenting. Clinical discussion: Isolated ductal rupture of the pancreatic head can have delayed presentation within a window of time and can be diagnosed by a series of tests including hematological, biochemical, and radiological investigations. Conservative treatment is generally recommended for Grade I and II whereas a surgical approach is preferred for higher grade pancreatic injury. Conclusions: Pancreatic ductal injury must be kept in mind when present with vague symptoms in the setting of blunt abdominal trauma. Magnetic resonance cholangiopancreatography (MRCP) is the investigation of choice for the diagnosis of pancreatic ductal injury. Even higher-grade pancreatic injury (grade III) can be managed with a conservative approach with pigtail drainage and an appropriate dosage of octreotide.

Rifaximin Vs. Norfloxacin for Spontaneous Bacterial Peritonitis Prophylaxis: A Randomized Controlled Trial.

Background: Spontaneous bacterial peritonitis (SBP) heralds increased mortality in cirrhosis, mandating strategies for prophylaxis. Norfloxacin has been the recommended choice for SBP prevention. However, its use has raised concerns about antibiotic resistance. Rifaximin has been suggested as an alternative. We investigated the efficacy of rifaximin against norfloxacin in primary and secondary prophylaxis of SBP. Methods: In this open-labeled randomized trial, patients with either advanced cirrhosis having ascitic fluid protein levels (<1.5 g/l), Child-Pugh score ≥9 points, serum bilirubin ≥3 mg/dl or impaired renal function (primary prophylaxis group), or those with prior SBP (secondary prophylaxis group) received either norfloxacin (400 mg once daily) or rifaximin (550 mg twice daily). All patients were followed for six months, with the primary endpoint being the development of incident SBP. Results: 142 patients were assessed for eligibility, of which 132 met the enrolment criteria; 12 were lost to follow-up, while 4 discontinued treatment. In patients on primary prophylaxis, occurrence of SBP was similar (14.3% vs. 24.3%, P = 0.5), whereas in secondary prophylaxis SBP recurrence was lower with rifaximin (7% vs. 39% P = 0.004). Rifaximin significantly reduced the odds for SBP development in secondary prophylaxis [OR (95% CI0.14 (0.02-0.73; P = 0.02)]. Patients receiving rifaximin as secondary prophylaxis also had fewer episodes of hepatic encephalopathy (23.1% vs. 51.5%, P = 0.02). 180-day survival between the arms in either group was similar (P = 0.5, P = 0.2). Conclusion: In comparison to norfloxacin, rifaximin significantly reduces incident events of SBP, as well as HE when used as a secondary prophylaxis, whereas for primary prophylaxis both have similar effects (NCT03695705). Clinical trial registration: ClinicalTrials.gov number: NCT03695705.

Tuberculosis in Cirrhosis - A Diagnostic and Management Conundrum.

Background: Diagnosis and management of tuberculosis (TB) in patients with cirrhosis remains challenging. We studied the clinical spectrum, diagnosis, and management of TB along with the assessment of the diagnostic utility of various laboratory investigations in this cohort. Methods: A retrospective review of records of patients with cirrhosis (July 2017 and December 2019) was done. Out of 30 patients with cirrhosis and TB, 20 patients with pleural/peritoneal TB (cases) were compared with 20 consecutively selected spontaneous bacterial peritonitis (SBP) controls. Composite of clinical, laboratory, radiologic features and response to antituberculosis therapy (ATT) was taken as the gold standard to diagnose TB. Results: Extrapulmonary TB (EPTB) (n = 23, 76.7%) was more common. Overall, 9 (30%) patients presented with ATT-induced hepatitis. Patients with pleural/peritoneal TB had less severe hepatic dysfunction as compared to SBP group with significantly lower CTP [8 ± 1.5 vs. 9 ± 1.7 (P = 0.01)], MELD [16.3 ± 5.8 vs. 20.2 ± 6.6 (P = 0.02)] and MELD-Na [18.8 ± 5.9 vs. 22.5 ± 7.1 (P = 0.03)] scores. Median ascitic/pleural fluid total protein [2.7 (2.4-3.1) vs. 1.1 (0.9-1.2); P < 0.0001] and adenosine deaminase (ADA) levels [34.5 (30.3-42.7) vs. 15 (13-16); P < 0.0001] were significantly higher in the TB group. Total protein levels had a sensitivity and specificity 81% and 93.3%, respectively, at cut off value of >2 g/dl with an AUROC of 0.89 [(0.79-0.96); P < 0.001] whereas ADA levels at cutoff >26 IU/L showed 80% sensitivity and 90% specificity to diagnose pleural/peritoneal TB with an AUROC of 0.93 [(0.82-0.97); P < 0.001]. Only 11 (36.7%), and 8 (26.6%) patients showed positivity on GeneXpert and mTB-PCR, respectively. Patients with Child-Turcotte-Pugh scores of ≤7 and 8-10 tolerated well two and one hepatotoxic drugs, respectively. Conclusions: EPTB is more frequent in patients with cirrhosis. Relatively lower cutoffs of ascitic/pleural fluid total protein and ADA may be useful to diagnose EPTB in patients with high pretest probability. Individualized ATT with close monitoring and dynamic modifications is effective and well-tolerated.

Overview of Complications in Cirrhosis.

Background: Cirrhosis is the outcome of chronic liver disease of any etiology due to progressive liver injury and fibrosis. Consequently, cirrhosis leads to portal hypertension and liver dysfunction, progressing to complications like ascites, variceal bleeding, hepatic encephalopathy, hepatorenal syndrome, hepatopulmonary syndrome, cirrhotic cardiomyopathy, sarcopenia, hepatocellular carcinoma, and coagulation disorders. End-stage liver disease leads to an impaired quality of life, loss of social and economic productivity, and reduced survival. Methods: This narrative review explains the pathophysiology of complications of cirrhosis, the diagnostic approach and innovative management, with focus on data from India. A comprehensive literature search of the published data was performed in regard with the spectrum, diagnosis, and management of cirrhosis and its complications. Results: There is a change in the epidemiology of metabolic syndrome, lifestyle diseases, alcohol consumption and the spectrum of etiological diagnosis in patients with cirrhosis. With the advent of universal vaccination and efficacious long-term viral suppression agents for chronic hepatitis B, availability of direct-acting antiviral agents for chronic hepatitis C, and a booming liver transplantation programme across the country, the management of complications is essential. There are several updates in the standard of care in the management of complications of cirrhosis, such as hepatorenal syndrome, hepatocellular carcinoma, and hepatic encephalopathy, and new therapies that address supportive and palliative care in advanced cirrhosis. Conclusion: Prevention, early diagnosis, appropriate management of complications, timely transplantation are cornerstones in the management protocol of cirrhosis and portal hypertension. India needs improved access to care, outreach of public health programmes for viral hepatitis care, health infrastructure, and disease registries for improved healthcare outcomes. Low-cost initiatives like immunization, alcohol cessation, awareness about liver diseases, viral hepatitis elimination, and patient focused decision-making algorithms are essential to manage liver disease in India.

Docetaxel-induced fluid retention during adjuvant chemotherapy with S-1 plus docetaxel.

S-1 plus docetaxel is the standard postoperative adjuvant chemotherapy regimen for patients with stage III gastric cancer in Japan, which has increased the use of docetaxel. One of the most common adverse events of docetaxel, which is widely used to treat several malignancies, is fluid retention. Conversely, the most worrisome cause of ascites in patients who receive adjuvant chemotherapy is recurrence. Sometimes, the differential diagnosis of ascites is difficult if ascitic cytology is negative. In this study, we presented the case of a patient with massive ascites that appeared during adjuvant chemotherapy with S-1 plus docetaxel.

Budd-Chiari syndrome caused by latent hepatic metastasis from a thymoma.

A 34-year-old woman visited our hospital because she had had abdominal bloating for 2 months. She had been diagnosed with invasive thymoma (WHO pathological type B2), for which she had undergone chemotherapy and total thymectomy 10 years previously. Six years previously, pleural dissemination was diagnosed and she had undergone right extra-pleural pneumonectomy. On presentation to our hospital, abdominal computed tomography and ultrasound scans revealed abundant ascites and a huge liver lesion, likely a metastasis from her thymoma, obstructing the inferior vena cava. The serum-ascites albumin gradient was high at 1.4 g/dL, which indicated portal hypertension. We diagnosed Budd-Chiari syndrome caused by liver metastasis from a previous thymoma. Steroid therapy resulted in shrinkage of her liver tumor and a marked decrease in her ascites. Although rare, Budd-Chiari syndrome caused by liver metastasis from a thymoma is a possible serious complication of advanced invasive thymoma.

Granulomatous Tubercular Hepatitis Presenting as Secondary Hemophagocytic Lymphohistiocytosis: A Case Report and Systematic Review of the Literature.

Hemophagocytic lymphohistiocytosis is a life-threatening disorder characterized by persistent pathologic activation of cytotoxic T lymphocytes, natural killer cells, and macrophages. We present details of a young patient who presented with high-grade fever, jaundice, and breathlessness. On investigations, he had hepatitis, anemia, neutropenia, and coagulopathy. He also had hypertriglyceridemia, hypofibrinogenemia, and hyperferritinemia. Bone marrow aspiration revealed histiocytosis, and transjugular liver biopsy revealed necrotizing granulomas positive for Mycobacterium tuberculosis on acid-fast bacilli staining. He was successfully managed with a combination of immunosuppressants and antitubercular therapy. Tuberculosis associated hemophagocytosis syndrome is rare and should be considered in patients with unexplained hemophagocytosis syndrome, especially in tuberculosis-endemic regions. Prompt recognition and treatment with antitubercular treatment and immunosuppressants are associated with good outcomes.

Admission Serum Urea is a Better Predictor of Mortality than Creatinine in Patients With Acute-On-Chronic Liver Failure and Acute Kidney Injury.

BACKGROUND: The occurrence of acute kidney injury (AKI) in acute-on-chronic liver failure (ACLF) negatively impacts the survival of patients. There are scant data on the impact of serum urea on outcomes in these patients. We performed this study to evaluate the relationship between admission serum urea and the survival in patients with ACLF and AKI. METHODS: A prospective study was conducted on patients with ACLF (as per Asian Pacific Association for the Study of the Liver criteria) and AKI (as per Acute Kidney Injury Network criteria) hospitalized in the gastroenterology ward between October 2016 and May 2018. Demographic, clinical and laboratory parameters were recorded, and outcomes were compared in patients with respect to the admission serum urea level. RESULTS: A total of 103 of 143 hospitalized patients with ACLF had AKI and were included as study subjects. The discrimination ability between survivors and the deceased was similar for serum urea levels (area under the receiver operating characteristic curve [AUROC] [95% confidence interval {CI}]: 28 days survival, 0.76 [0.67-0.85]; 90 days survival, 0.81 [0.72-0.91]) and serum creatinine levels (AUROC [95% CI]: 28 days survival, 0.75 [0.66-0.84]; 90 days survival: 0.77 [0.67-0.88]) in patients with ACLF and AKI. However, on multivariate analysis, admission serum urea (not serum creatinine) was an independent predictor of mortality in these patients both at 28 days (p = 0.001, adjusted hazard ratio [AHR]: 1.013 [1.005-1.021]) and 90 days (p = 0.001, AHR: 1.014 [1.006-1.022]). CONCLUSION: Over two-thirds of patients with ACLF had AKI. The discrimination ability between survivors and the deceased was similar for both serum urea and serum creatinine levels. However admission serum urea was found to be a better predictor of mortality than serum creatinine in patients with ACLF and AKI.

Spontaneous Bacterial Peritonitis in Cardiogenic Ascites.

The most common cause of ascites is liver cirrhosis. Additional causes such as heart failure, cancer, and pancreatitis among others can also precipitate this abnormality. Spontaneous bacterial peritonitis (SBP) is an infection of ascitic fluid that happens without any evidence of an intra-abdominal surgically-treatable cause. Ascites of cardiac origin can also be complicated by SBP. Here we present a case of a 62-year-old male with extensive cardiac history who presented to our service with ongoing dyspnea and orthopnea. He also had significant abdominal distention and pitting edema. The patient was found to have constrictive pericarditis and was admitted for pericardiectomy. Ascitic fluid was consistent with a transudative process. Lab and imaging did not show evidence of liver or kidney disease. Ascitic fluid was indicative of ascites of cardiac origin. Postoperatively patient developed intermittent fevers initially thought to be due to pericarditis but later found to be due to SBP complicating his recurrent ascites. Such a temporal association of SBP that complicates ascites after pericardiectomy has not been discussed frequently in literature.

Placing a lumen-apposing metal stent despite ascites: feasibility and safety.

BACKGROUND AND AIMS: Placing a lumen-apposing metal stent (LAMS) through ascites carries serious risks, including death from leakage around the LAMS and failure to create a mature fistula between the 2 lumens. However, sometimes no options exist or are equally dangerous. We present 5 patients who underwent LAMS placement despite ascites in 2 different locations. METHODS: This is a retrospective review of 5 patients who underwent LAMS placement despite ascites in 2 different locations from 2016 to 2018. RESULTS: Three patients with cholecystitis and 2 patients with afferent limb syndrome and severe ascites were treated with a combination of preprocedural and intraprocedural paracentesis. Serum ascites albumin gradient was measured. Weight was recorded daily. Patients were encouraged to sleep at an incline, and periodic paracentesis (every 3-7 days) was performed when ascites reaccumulated over 4 weeks. Median volume of ascites aspirated was 2 L preprocedurally and 300 mL intraprocedurally. Only 1 patient had ascites with a high serum ascites albumin gradient and was treated with diuretics. Technical and clinical success was achieved in all 5 patients without any adverse events over a median follow-up of 28 weeks. CONCLUSIONS: In situations in which no better options remain, LAMS placement appears to be safe after adequate and aggressive treatment of the underlying ascites pre-, intra-, and postprocedurally. Larger studies are needed to establish the safety of this approach.

The Value of Ultrasound in Characterizing and Determining the Etiology of Ascites.

BACKGROUND: The aim of this study was to assess the role of transabdominal ultrasonography in characterizing and determining the etiology of ascites in comparison with laboratory ascitic fluid analysis and other methods used to establish the final diagnosis. METHODS: A prospective descriptive study was conducted on 61 patients with ascites attending outpatient department (OPD) or admitted to wards of Tikur Anbesa Specialized Hospital (TASH) and referred to radiology department for imaging from June 2017 to November 2017. Data were collected following the internationally recommended scanning technique in consecutive bases. The data were analyzed using SPSS version 20. The comparison of ultrasound and laboratory findings with final clinical diagnosis was analyzed using Chi-square test (X2). RESULTS: Of 61 patients with ascites enrolled in this study, females were 35(57.4%) with age range of 16 to 75 and mean age of 43.2±14.11. The cause of ascites was established in 59 cases using a combination of clinical, pathological, imaging evidences and tumor markers. However there were two cases who had ascites with indeterminate cause. US suggested the diagnosis in 54(91.5%) patients. Excluding mixed and indeterminate cases, ultrasound characterized ascites correctly as exudate and transudate in 95% cases. CONCLUSION: Ultrasound has significant accuracy to distinguish transudate and exudate ascites and in suggesting the underlying cause. It can be a valuable method of investigation of ascites in places where CT and MRI are not available, and it is the best complement for laboratory investigations on ascites in suggesting the etiology based on ascitic fluid texture and ancillary findings.

Natural History of Cirrhosis of Liver after First Decompensation: A Prospective Study in India.

BACKGROUND AND AIMS: As liver cirrhosis is a dynamic condition, it is possible to improve survival in decompensated cirrhosis. Hence, we planned a prospective study to determine the natural history of cirrhosis after first decompensation. METHODS: We enrolled all patients of liver cirrhosis who presented with first episode of decompensation defined by the presence of ascites, either overt or detected by Ultrasonography (UD), Gastroesophageal Variceal Bleeding (GEVB), and Hepatic Encephalopathy (HE). All patients were followed up to death/liver transplant or at least for the period of 1 year. Multivariable Cox proportional hazards regression was used to analyze the risk of failure (death or Orthotopic Liver Transplantation (OLT)). RESULTS: In total of 110 cirrhotic patients (93 males, mean age 50 ± 11 years), the most frequent etiology was alcohol (48%), followed by nonalcoholic steatohepatitis/cryptogenic (26%), hepatitis B (10%), autoimmune hepatitis (7%), and hepatitis C (6%). The distribution of CTP classes was: 4%, 56%, and 41% in class A, B, and C, respectively. Ascites was the most common decompensation found in 88 patients (80%) followed by HE (14%) and GEVB (6%). At 1-year follow up, transplant free survival was 78%, 2 underwent OLT, 4 developed hepatocellular carcinoma, and 24 died. Cumulative incidence of failure (death or OLT) by type of decompensation after 1 year was: 22% overt ascites, 50% GEVB, 28% UD ascites, 20% HE, and 33% ascites and GEVB concomitant. CONCLUSIONS: Patients with UD ascites do not have a negligible mortality rate as compared to overt ascites. Patients with cirrhosis after first decompensation have better transplant free survival with treatment of etiology and complications than previously mentioned in literature.