Recommendations on the Diagnosis and Initial Management of Acute Variceal Bleeding and Hepatorenal Syndrome in Patients with Cirrhosis.

Cirrhosis is a serious and life-threatening condition which imposes a significant socioeconomic burden on affected individuals and healthcare systems. Cirrhosis can result in portal hypertension, which may lead to major complications, including acute variceal bleeding and hepatorenal syndrome. Without prompt treatment, these complications may be life-threatening. Over the past 2 decades, new treatment modalities and treatment strategies have been introduced, which have improved patients' prognosis, but the initial management of these severe complications continues to present a challenge. The present recommendations aim to increase clinicians' knowledge on the importance of early diagnosis and treatment, and to provide evidence-based management strategies to potentially, further improve patient outcomes. Special attention was given to the role of terlipressin. A comprehensive non-systematic literature search was undertaken to evaluate the evidence for the diagnosis and initial management of acute variceal bleeding and hepatorenal syndrome in patients with cirrhosis. Recommendations on the diagnosis and initial management of acute variceal bleeding and hepatorenal syndrome in patients with cirrhosis have been developed based on the best available evidence and the expert opinion of the consensus panel following a comprehensive review of the available clinical data. Prompt identification and timely treatment of acute variceal bleeding and hepatorenal syndrome are essential to reduce the burden.

[Causes of non-cardiac chest pain: multidisciplinary perspective]. / Causas de dolor torácico no cardiaco.

BACKGROUND: Non-cardiac chest pain (NCCP) is defined by recurrent episodes of substernal chest pain non related to ischemic heart disease, it's origin being in many cases the gastrointestinal tract; however, it may be associated to psychosomatic disorder. OBJECTIVES: To investigate the main causes of NCCP and to evaluate associated psychiatric comorbidity. METHODS: Patients with NCCP referred by a cardiologist were assessed underwent an upper endoscopy, ambulatory pH monitoring and stationary esophageal manometry. NCCP was considered gastro esophageal reflux disease (GERD) positive when the endoscopy and/or ambulatory pH monitoring were abnormal. When all results were normal, the symptom was considered as a functional chest pain (FCP). Patients were assessed by the Psychiatry service and diagnosed in accordance to the Diagnostic and Statistics Manual of Mental Diseases, fourth edition (DSM-IV). Several other test were applied for the assessment of anxiety and depression. RESULTS: Thirty-four patients were included (25 women and nine men; average age: 46.2 +/- 11.56 years). Three patients were eliminated because of refusal of the psychiatric evaluation. In 21 (68%) patients, NCCP was GERD-positive and in 10 (32%) to FCP. The most common symptoms associated to chest pain were: heartburn in 23 (74%), regurgitation in 21 (68%) and dysphagia in 15 (48%) patients. Upper endoscopy was abnormal in four cases; ambulatory pH monitoring was abnormal in 21 (67.7%) patients. The frequency of psychiatric disorders related to NCCP was 52%, in 10 patients with GERD-positive (48%) and six patients with FCP (60%). Mayor depression was the most common diagnoses identified among both groups. CONCLUSION: The high frequency of GERD and psychiatric disorders found in NCCP supports the multidisciplinary approach to NCCP.