Halitosis as a product of hepatic disease.

OBJECTIVES: This study evaluated halitosis in patients suffering from hepatic disease. MATERIAL AND METHODS: Twenty-five patients (12 males and 13 females) aged between 16 and 73 years who had undergone treatment for liver disease were included in this study. Three halimeter recordings were performed to measure methyl mercarptan and hydrogen sulphite. Mean values were calculated and compared with normal values (75-120 ppb). The level of significance was set at P < .05. Results: Thirteen of the 25 subjects (52%) had normal Volatile Sulphur Compound (VSC) values (75-120 ppb). Twelve subjects (48%) recorded values ranging from 132 to 1112 ppb. There was no correlation between hepatic pathology and halitosis. Fifty-two percent of all subjects had poor oral hygiene, strongly correlated with high VSC values (P<0.05) whereas the remaining 48% with good hygiene had normal levels of VSC. CONCLUSIONS: Within the limitations of this study, high values of VSC were not associated with the presence of hepatic disease.

Evaluation of periodontal status in alcoholic liver cirrhosis patients: a comparative study.

AIM: Bacterial infections are common complicating findings in course of liver cirrhosis, most of them being Gram-negative. Similarly periodontal pathogens are also mostly Gram-negative bacteria hence the objective was to evaluate the periodontal status in alcoholic liver cirrhosis patients and to compare the periodontal status of alcoholic liver cirrhosis patients in: a. Smokers with periodontitis and b. Nonsmokers with periodontitis. MATERIALS AND METHODS: A total of 150 patients made up the sample of this study. The sample size was divided into four groups. The first two groups comprised of 50 patients each comprising of patients with periodontitis who were nonsmokers and patients with periodontitis who were smokers respectively and the next two groups comprised of 25 patients each, which included patients diagnosed as suffering from alcoholic liver cirrhosis who are nonsmokers and patients diagnosed as suffering from alcoholic liver cirrhosis who are smokers. Screening examination included a proper medical history, dental history and Russell's periodontal index was done to evaluate and compare the periodontal status among the selected groups. RESULTS: The data obtained was subjected to statistical analysis using the ANOVA Fisher's F-test. Multiple group comparisons were made using the Tukey's HSD test. CONCLUSION: Conclusions that can be drawn from this study are: 1. Alcoholic liver cirrhosis patients demonstrated greater alveolar bone loss and increased periodontal destruction. 2. There is very high statistically significant difference on periodontal destruction in alcoholic liver cirrhosis patients (with or without smokers) when compared to the control group. CLINICAL SIGNIFICANCE: Periodontal diseases are bacterial infections associated with a bacterial load or insult to the host that elicits a strong inflammatory response cumulating to produce significant pathologic alterations in the systemic status of the host. Alcoholic liver cirrhosis patients as a consequence of liver dysfunction have elevated levels of serum cytokines. These are involved in the destructive process of periodontal disease probably through enhancement of collagenase and metalloproteinase activity. Hence, a study has been planned to evaluate periodontal status in patients with alcoholic liver cirrhosis.

Glue for sealing internal pancreatic fistula in a patient with liver cirrhosis: a useful technique.

CONTEXT: Pancreatic fistulae are uncommon and usually follow acute or chronic pancreatitis. While most of these are treated conservatively, some require surgery. Recently endoscopic therapy has emerged as an effective alternative treatment modality. CASE REPORT: We present a patient with internal pancreatic fistula due to alcohol related chronic pancreatitis. Endotherapy using glue resulted in resolution of the fistula. CONCLUSION: The use of endoscopic glue injection may be a safe and effective method for the successful therapy of internal pancreatic fistula.

[Treatment of refractory hepatic encephalopathy associated with insertion of a transjugular intrahepatic portosystemic shunt through new endovascular techniques: a case report]. / Tratamiento de la encefalopatía hepática resistente asociada a la creación de una derivación percutánea portosistémica intrahepática mediante nuevas técnicas endovasculares: a propósito de un caso clínico.

Insertion of a transjugular intrahepatic portosystemic shunt (TIPS) is an increasingly used treatment in the management of the complications of portal hypertension. However, one of the complications of this technique is refractory or recurrent hepatic encephalopathy, which poses a difficult clinical problem. We report the case of a patient who underwent TIPS insertion to control bleeding due to esophageal varices. The patient subsequently developed refractory hepatic encephalopathy, requiring reduction of the caliber of the shunt.

Nodular amyloidosis in a patient with liver cirrhosis.

A 43-year-old Japanese man with alcoholic liver cirrhosis developed a nodule on the face 1 year prior to presentation. Histopathological examination showed amyloid deposition in the entire dermis, with numerous plasma cells. Nodular primary localized cutaneous amyloidosis is a rare form of amyloidosis, which needs long-term follow-up because of the possibility of the development of systemic amyloidosis. Also, this type of cutaneous amyloidosis may have other complications.

Intraabdominal Hemorrhage from Ruptured Ectopic Varices Treated by Antegrade Embolization via a Recanalized Paraumbilical Vein.

A 49-year-old man with alcoholic liver cirrhosis was admitted to our hospital with abdominal pain. Contrast-enhanced CT demonstrated massive hemorrhagic ascites and ectopic varices fed by right colic and ileocolic veins. The varices were treated with selective embolization via a recanalized paraumbilical vein using N-butyl cyanoacrylate. Currently, no complications and rebleeding have occurred for 7 months. Antegrade embolization via a recanalized paraumbilical vein is feasible and less-invasive in a patient with massive ascites. Flow reduction may be effective for intraabdominal hemorrhage from ruptured ectopic varices. LEVEL OF EVIDENCE: Level 5, case report.

"Hemosuccus pancreaticus"--primarily ultrasound-guided successful intervention using transcutaneous fibrin glue application and histoacryl injection.

There is a broad spectrum of causes for upper gastrointestinal (GI) bleeding that can be stopped by various approaches. On the basis of the report of an extraordinary case, the favorable minimally invasive approach of applying fibrin glue and histoacryl/lipiodol to the vascular basis of a bleeding pseudoaneurysm leading to "Hemosuccus pancreaticus" as a rare cause of recurrent bleeding in the upper GI tract and dangerous complications in the case of chronic pancreatitis is described. There were recurrent bleeding episodes within the upper GI tract in a 40-year-old female patient. Her medical history was significant for chronic pancreatitis and pseudocyst. Abdominal ultrasound plus duplex ultrasonography revealed a pseudoaneurysm within the tail of the pancreas as the cause of "Hemosuccus pancreaticus". Ultrasound guidance was used to repeatedly apply 2 ml of fibrin glue and 2 x 2 ml of the mixture of lipiodol and histoacryl to the basis of the pseudoaneurysm which led to complete and permanent cessation of the bleeding. Immediate and follow-up control duplex ultrasonographies (up to one year) demonstrated sufficient exclusion of the pseudoaneurysm but a preservation of the lienal artery with no disturbance of the blood perfusion in the splenic parenchyma. In conclusion, this is one of the first reports of the successful cessation of recurrent bleeding into a pseudocyst out of pseudoaneurysm ("Hemosuccus pancreaticus") by an ultrasound-guided transcutaneous fibrin glue and histoacryl/lipiodol application, which 1. is recommended as an alternative but feasible and safe therapeutic tool, 2. can provide sufficient and permanent cessation of bleeding but preserve the perfusion of the natural vessel as an initial step in the possible therapeutic algorithm, and 3. can avoid, in case of success, more invasive approaches such as angiography-guided embolization with coils or implantation of a prosthesis and even open surgical intervention, in particular, in high-risk patients.

Portal Hypertensive Vesiculopathy: A Rare Cause of Hematuria and a Unique Management Strategy.

Portosystemic collaterals are common sequelae of portal hypertension. These often present as gastroesophageal varices. Ectopic varices can rarely be seen in duodenum, jejunum, rectum, and sites of surgical anastomoses. Bladder varices are extremely rare presenting with recurrent hematuria, with only a few reported cases. We report here a management of an unusual case of hematuria managed with blood transfusion, intravenous terlipressin, and endoscopic N-butyl cyanoacrylate glue injection.

Successful Embolization of Bleeding Ileal Varices with N-butyl Cyanoacrylate via a Recanalized Paraumbilical Vein.

A 48-year-old woman with alcoholic liver cirrhosis was admitted to our hospital because of hematochezia and severe anemia. She had been hospitalized many times over the past year for hematochezia of unknown etiology. Contrast-enhanced CT demonstrated ileal varices, which were fed by several ileal veins. These feeding veins were selectively embolized with N-butyl cyanoacrylate (NBCA) via a recanalized paraumbilical vein. The paraumbilical vein instead of the portal vein was punctured to decrease the risk of bleeding complications because she had coagulopathy and ascites. We consider antegrade embolization of ileal varices with NBCA to be a feasible and effective treatment. Access via a paraumbilical vein is an alternative to the transhepatic approach.Level of Evidence Level V, case report.

[A case of successful endoscopic injection sclerotherapy with N-butyl-2-cyanoacrylate for ruptured duodenal varices].

Duodenal varix is a rare cause of hemorrhage in patients with portal hypertension, however their rupture is serious and often life threatening. Treatments for duodenal variceal bleeding include endoscopic procedures, surgery, or interventional radiologic procedures. We report a case of duodenal varices rupture in a 45-year-old man with alcoholic liver cirrhosis who presented with melena and dizziness. Emergent upper endoscopy revealed large nodular varices with a ruptured erosion on the top in the distal second portion of duodenum. Two consecutive injections with 1.0 mL of n-butyl-2-cyanoacrylate (Histoacryl; Braun-Melsungen, Germany) mixed with 1.0 mL of lipiodol (Laboratoire-Guerbet, France) were performed intravariceally and achieved successful hemostasis. This suggests that endoscopic injection sclerotherapy with histoacryl may be an effective therapeutic option for the control of ruptured duodenal variceal bleeding.

Characteristics and outcomes of transjugular intrahepatic portosystemic shunt recipients in the VA Healthcare System.

BACKGROUND AND AIMS: Transjugular intrahepatic portosystemic shunt (TIPS) placement is an effective treatment for complications of portal hypertension. We aimed to describe post-TIPS mortality and its predictors in the modern era of covered stents. PATIENTS AND METHODS: We identified patients with cirrhosis who underwent TIPS insertion at Veterans Affairs Healthcare facilities nationally from 2004 to 2014 (n=703), most of which (95%) were performed as elective procedures. We followed patients until the date of death, transplantation, or the end of the observation period. RESULTS: TIPS recipients had a mean age of 59.3 years (SD 8) and 97% were men. The mean Model for End Stage Liver Disease (MELD) score was 13 (SD 4.8); 47% had hepatitis C virus (HCV) infection, 48% had variceal hemorrhage, and 40% had ascites. During a mean follow-up of 1.72 years (SD 1.9), 57.5% of TIPS recipients died (n=404) and only 5.3% underwent liver transplantation (n=37). The median survival after TIPS was 1.74 years (interquartile range 0.3-4.7). Thirty-day mortality after TIPS was 11.6% [95% confidence interval (CI) 9.4-14.2], 1-year mortality was 40.3% (95% CI 36.7-44.2), and 3-year mortality was 61.9% (95% CI 57.9-66.0). Independent predictors of post-TIPS mortality included medical comorbidity burden, low albumin, HCV infection, and high MELD score (or high international normalized ratio and bilirubin when the components of the MELD score were analyzed individually). TIPS revision was performed at least once in 27.3% of TIPS recipients. CONCLUSION: TIPS should not be considered simply as a bridge to transplantation. Burden of extra-hepatic comorbidities, HCV infection, and low serum albumin strongly predict post-TIPS mortality in addition to the MELD score.

Partial portacaval shunt for variceal hemorrhage: longitudinal analysis of effectiveness.

OBJECTIVE: To determine rates of survival, long-term patency, and recurrent variceal hemorrhage among patients with alcoholic cirrhosis treated by partial portacaval shunt. DESIGN: Single-institution cohort follow-up study of 72 consecutive patients who underwent small-diameter portacaval H-graft shunt with collateral ablation during a 10-year period (1981 through 1990). Subjects were enrolled and followed up for up to 15 years. Shunt patency was assessed by portography and/or ultrasonography. We performed 7-year Kaplan-Meier analyses of survival (in 65 patients in Child classes A and B), shunt patency, and absence of variceal bleeding. SETTING: Tertiary academic referral center of the US Department of Veterans Affairs. PATIENTS: Patients with alcoholic cirrhosis were considered for operation after at least 1 proven episode of variceal hemorrhage. Patients with portal vein thrombosis were excluded; patients in Child class C underwent operation only for compelling indications. Of the 72 who underwent partial shunting, 38 were in Child class A, 27 were in class B, and 7 were in class C. INTERVENTIONS: Partial portacaval shunt (6-, 8- or 10-mm polytetrafluoroethylene H-graft with collateral ablation) and serial follow-up. MAIN OUTCOME MEASURES: Study end points were death, recurrent variceal hemorrhage, and unavailability for follow-up. Other measures included graft patency and nonvariceal rebleeding. RESULTS: Cumulative probability of 7-year patency for grafts at risk was 95%. The 7-year probability for absence of variceal bleeding in patients at risk was 92%. In 65 patients in Child classes A and B, operative mortality was 7.7% and the cumulative probability of 7-year survival was 54%. CONCLUSION: For variceal bleeding associated with alcoholic cirrhosis, the small-diameter polytetrafluoroethylene portacaval H-graft with collateral ablation affords durable patency and protection against variceal rebleeding.

Successful combination therapy--flunarizine, pentoxifylline, and cholestyramine--for spur cell anemia.

Spur cell anemia, a hemolytic anemia observed in patients with alcoholic cirrhosis, is characterized by unusual erythrocyte morphology and an increased ratio of free cholesterol to phospholipid in the erythrocyte membrane. The prognosis of spur cell anemia is usually extremely poor, however, we describe here a patient with spur cell anemia who was successfully treated with combination therapy consisting of flunarizine, pentoxifylline, and cholestyramine. Initial therapy with flunarizine alone for 6 weeks did not significantly decrease the number of spur cells on peripheral blood smears. So pentoxifylline was added to the regimen. The patient recovered from the anemia, showed remarkable improvement with regard to the hyperbilirubinemia, and the changes were accompanied by a significant decrease in the number of spur cells in peripheral blood smears. To correct the hypercholesterolemia, cholestyramine was added to the regimen, which resulted in a reduction in the serum level of free cholesterol and an increase in the molar ratio of free cholesterol to phospholipid in erythrocyte membrane. However, 6 months later a skin eruption developed that was considered an adverse reaction to the drugs, so the flunarizine and pentoxifylline were discontinued. With cholestyramine therapy alone, the remission of spur cell anemia was maintained for more than 11 months. These observations suggest that non-invasive combination therapy with flunarizine, pentoxifylline, and cholestyramine is effective and valuable in the treatment of patients with spur cell anemia.

Development of early squamous cell carcinoma of the esophagus after endoscopic injection sclerotherapy for esophageal varices.

A 56-year-old Japanese man with liver cirrhosis was admitted to Kyushu University Hospital in September, 1986 for the treatment of large esophageal varices. Endoscopy revealed four tortuous folds of large esophageal varices, extending proximally from the esophagocardial junction to 34 cm from the dental arch. Endoscopic injection sclerotherapy was performed on the lower esophagus using 5% ethanolamine oleate, and esophageal varices were completely eradicated in 5 sessions with a total of 70 ml of sclerosant. In March 1991, 4 years and 6 months after the treatment, endoscopy revealed a mild redness and an irregular surface 33 cm from the dental arch. The histologic diagnosis was squamous cell carcinoma. The possible relationship between sclerotherapy and the development of esophageal carcinoma should be considered.

[Elective sclerotherapy in hepatocellular carcinoma complicated by digestive hemorrhage]. / Evaluation de la sclérothérapie élective dans les carcinomes hépatocellulaires compliqués d'hémorragie digestive.

Between April 1984 and October 1988, 10 patients with hepatocellular carcinoma who bled from esophageal varices were included in a polidocanol sclerotherapy program, after the cessation of bleeding. Sixty cirrhotic patients without hepatocellular carcinoma were included as controls in the same sclerotherapy program for the same period. According to Okuda's classification, 1 patient was grade I, and 9 were grade II. At 1 year, 41 percent of patients with hepatocellular carcinoma and 51 percent of controls had rebled (non significant). Varices were obliterated in 7 of 10 patients with hepatocellular carcinoma and in 41 of 60 control patients (non significant). At one year, treatment failed (rebleeding or death) in 54 percent patients with hepatocellular carcinoma and in 59 percent control patients (non significant). Child-Pugh's score was the principal prognostic factor for treatment failure in both groups. Portal vein thrombosis was found in 2 of the 3 hepatocellular carcinoma patients who rebled. Unlike propranolol, elective sclerotherapy treatment might be proposed to patients with hepatocellular carcinoma without portal thrombosis.