CORTICOSTEROID TREATMENT IN THE SETTING OF DECOMPENSATED LIVER CIRRHOSIS WITH RELATIVE ADRENAL INSUFFICIENCY: A CASE REPORT AND A BRIEF REVIEW OF THE LITERATURE.

Relative adrenal insufficiency (RAI) is the term used to describe inadequate production or action of glucocorticoids with respect to the severity of the illness. RAI is frequently found in critically ill patients particularly with septic complications and it is also present in both critically ill and stable patients with liver cirrhosis. In the following study a case report of a patient with decompensated cirrhosis and RAI is presented followed by a brief review of the literature. A 65-year-old male with liver cirrhosis of alcoholic etiology was admitted to hospital with bilateral leg edema, ascites, and marked weakness. At admission, his blood pressure was 82/52 mmHg and he had sinus tachycardia of 130/min. Laboratory analysis revealed hyponatremia (122 mmol/L), while ascites fluid analysis showed no infection. During the first 48 hours of hospitalization the patient remained persistently hypotensive despite adequate vascular filling and the addition of noradrenaline. A standard-dose short synacthen test was performed which revealed a poor cortisol response, which is a compatible criterion for the diagnosis of RAI. Intravenous hydrocortisone therapy was initiated, which resulted in a rapid improvement in patient's general condition, and increase in blood pressure. As the patient became hemodynamically stable without the need of noradrenaline, the hydrocortisone dose was weaned progressively, and he was discharged after 18 days of hospitalization in a stable condition.

Evaluation of whole cell fixation methods for the analysis of nanoscale surface features of Yersinia pestis KIM.

Manipulation of viable Yersinia pestis (etiologic agent of plague) in the laboratory usually necessitates elevated biosafety and biocontainment procedures, even with avirulent or vaccine strains. To facilitate downstream biochemical or physical analyses in a Biosafety Level 1 laboratory environment, effective inactivation without affecting its intrinsic properties is critical. Here, we report on the morphological and biochemical changes to Y. pestis surfaces following four different fixation methods that render the cells nonviable. The results, obtained at the single cell level, demonstrate that methanol inactivation is best able to preserve bacterial morphology and bioactivity, enabling subsequent analysis. This nanoscale evaluation of the effects of inactivation on cell morphology and surface bioactivity may provide a crucial preparatory approach to study virulent pathogens in the lab setting using high-resolution microscopic techniques such as atomic force microscopy.

NONSELECTIVE BETA-BLOCKERS IN PATIENTS WITH CIRRHOSIS: "THE THERAPEUTIC WINDOW".

For over 30 years, nonselective beta-blockers (NSBB) have been successfully used for preventing variceal bleeding in patients with cirrhosis and portal hypertension. Nevertheless, recent studies suggest that NSBB may be effective only within a particular "therapeutic window" in patients with advanced liver disease. Outside of this window, in early stages of cirrhosis and in very advanced cirrhosis, NSBB may be ineffective and even potentially harmful. In this paper we review the beneficial effects and potential harms of beta-blocker therapy in cirrhosis and underline the most recent recommendations for their use in very advanced cases of liver disease.

PLATELET INDICES AND LIVER FIBROSIS EVALUATION IN CHRONIC HEPATITIS C.

UNLABELLED: Recently, several studies have reported that the mean platelet volume and platelet distribution width may give information about liver fibrosis severity in chronic hepatitis C. The aim of the present study was to evaluate whether platelet indices correlate with hepatic fibrosis measured by transient elastography in patients with chronic hepatitis C. MATERIALS AND METHODS: Patients with chronic hepatitis C were prospectively enrolled. Samples for complete blood count and routine biochemical parameters were collected and analyzed in the same day with liver fibrosis assessment by transient elastography. Mean platelet volume, platelet large cell ratio and platelet distribution width were compared with stages of liver fibrosis. Statistical analysis was carried out using SPSS 17.0 software. A P-value of less than 0.05 was considered statistically significant. RESULTS: There were 139 patients with chronic hepatitis C (70.5% males, mean age 54.8 +/- 16.7 years). Compared with mild/moderate liver fibrosis patients, those with advanced liver fibrosis had an increased mean platelet volume (10.4 +/- 0.7 vs. 10.9 +/- 0.9, p < 0.002), platelet large cell ratio (28.5 +/- 5.3 vs. 32.5 +/- 7.2, P < 0.0001), and platelet distribution width (12.8 +/- 1.5 vs. 14.1 +/- 2.7, P = 0.003). CONCLUSIONS: Increased platelet indices were associated with advanced liver fibrosis stages evaluated by transient elastography in patients with chronic hepatitis C.

ASSESSMENT OF ADRENOCORTICAL DYSFUNCTION IN PATIENTS WITH STABLE LIVER CIRRHOSIS.

INTRODUCTION: Relative adrenal insufficiency (RAI) is common in the setting of critical illness as well as in hemodynamically instable cirrhotic patients with sepsis. Several studies have also shown that RAI is frequent in patients with stable cirrhosis without sepsis. The aim of this study was to prospectively assess the incidence of RAI in patients with stable cirrhosis. PATIENTS AND METHODS: Forty-seven patients with hemodynamically stable liver cirrhosis without sepsis were prospectively included. RAI, assessed by using low dose-short Synacthen test (LD-SST), was defined as either a basal total cortisol concentration below 3.6 µg/dL or a peak total serum cortisol ≤ 16 µg/dL at 30 min after stimulation. RESULTS: RAI was present in 10 (21.3%) of 47 cirrhotic patients. Peak cortisol level was negatively correlated with the severity of cirrhosis evaluated by Child-Turcotte-Pugh (CTP) (r=-0.46; P=0.001) and Model for End-Stage Liver Disease (MELD) (r=-0.51; P=0.001) scores. The frequency of RAI increased from CTP-A (10%) to CTP-B (30%) to CTP-C (60%). CONCLUSION: RAI diagnosed by LD-SST is frequent in patients with stable cirrhosis and is related to the severity of liver disease. Further studies are needed to define clinical importance of RAI in stable cirrhotic patients.

Clostridium difficile infection in patients with liver disease: a review.

Over the past two decades, there has been a dramatic worldwide increase in both the incidence and severity of Clostridium difficile infection (CDI). Paralleling the increased incidence of CDI in the general population, there has been increased interest in CDI among patients with liver disease, particularly in those with liver cirrhosis and post liver transplantation. MEDLINE and several other electronic databases from January 1995 to December 2014 were searched in order to identify potentially relevant literature. Patients with cirrhosis and liver transplant recipients are at high risk for the development CDI because of antibiotics and proton pump inhibitors use, frequent and prolonged hospitalization, immunosuppressant therapy, and multiple comorbidities. Enzyme immunoassay to detect C. difficile toxins A and B in stool remains the most widely used test for CDI diagnosis, although, more recently, polymerase chain reaction (PCR)-based assays have become the preferred diagnostic test in many laboratories. Metronidazole and vancomycin, given orally, have proved to be effective in the treatment of CDI. Both cirrhotic patients and liver transplant recipients with CDI have longer length of hospital stay, increased mortality, and higher healthcare costs than those without CDI. A rapid diagnosis and adequate therapy of CDI are of paramount importance to improve liver disease patients' outcome. The aim of this review is to provide up-to-date information on the epidemiology, risk factors, pathogenesis, treatment, and outcomes in liver disease patients with CDI.

Randomised clinical trial: alisporivir combined with peginterferon and ribavirin in treatment-naïve patients with chronic HCV genotype 1 infection (ESSENTIAL II).

BACKGROUND: Alisporivir (ALV) is an oral, host-targeting agent with pangenotypic anti-hepatitis C virus (HCV) activity and a high barrier to resistance. AIM: To evaluate efficacy and safety of ALV plus peginterferon-α2a and ribavirin (PR) in treatment-naïve patients with chronic HCV genotype 1 infection. METHODS: Double-blind, randomised, placebo-controlled, Phase 3 study evaluating ALV 600 mg once daily [response-guided therapy (RGT) for 24 or 48 weeks or 48 weeks fixed duration] or ALV 400 mg twice daily RGT with PR, compared to PR alone. Following a Food and Drug Administration partial clinical hold, ALV/placebo was discontinued and patients completed treatment with PR only. At that time, 87% of patients had received ≥12 weeks and 20% had received ≥24 weeks of ALV/PR triple therapy. RESULTS: A total of 1081 patients were randomised (12% cirrhosis, 55% CT/TT IL28B). Addition of ALV to PR improved virological response in a dose-dependent fashion. Overall, sustained virological response (SVR12; primary endpoint) was 69% in all ALV groups vs. 53% in PR control. Highest SVR12 (90%) was achieved in patients treated with ALV 400 mg twice daily and PR for >24 weeks. Seven cases of pancreatitis were reported, with similar frequency between ALV/PR and PR control groups (0.6% vs. 0.8% respectively). Adverse events seen more frequently with ALV/PR than with PR alone were anaemia, thrombocytopenia, hyperbilirubinaemia and hypertension. CONCLUSIONS: Alisporivir, especially the 400 mg twice daily regimen, increased efficacy of PR therapy in treatment-naïve patients with HCV genotype 1 infection. The mechanism of action and pangenotypic activity suggest that alisporivir could be useful in interferon-free combination regimens.

Clostridium difficile infection and inflammatory bowel disease: what gastroenterologists and surgeons should know.

Over the past two decades there has been a dramatic increase worldwide in both incidence and severity of Clostridium difficile infection (CDI). Paralleling the rising incidence of CDI in the general population, there has been an even higher increase in the incidence of CDI among patients with inflammatory bowel disease (IBD). CDI may mimic a flare of IBD as symptoms and laboratory parameters are often similar, and therefore, screening for CDI is recommended at every flare in such patients. Enzyme immunoassay to detect Clostridium difficile toxin A and B in stool is still the most widely used test for CDI diagnosis despite its low sensitivity. Metronidazole for mild/moderate CDI,and vancomycin for severe CDI are the preferred agents for the treatment of infection. CDI has a negative impact both on short- and long- term IBD outcomes, increasing the need for surgery, as well as the mortality rate and healthcare costs. All gastroenterologists and surgeons should have a high index of suspicion for CDI when evaluating a patient with IBD flare, as prompt diagnosis and adequate treatment of infection improve outcomes. Measures must be taken to prevent spreading of infection in gastroenterology /surgery settings.

Infectious complications in patients with liver cirrhosis.

Liver cirrhosis is the end stage of any chronic liver disease. Complications occurring in patients with liver cirrhosis may be specific to this pathology and to gastroenterology (upper gastrointestinal bleeding, hepatic encephalopathy) or may interfere with other specialties (hepatorenal syndrome, spontaneous bacterial peritonitis, and other localized infectious complications). Over the past few decades, major efforts have been made to increase survival in patients with cirrhosis, but unfortunately, few therapeutic methods have been proven effective. Bacterial infections are frequent and serious complications of liver cirrhosis, resulting in high morbidity and mortality, especially in hospitalized patients, despite significant progress in health care for those with advanced liver disease.

Assessing the risk of decompensation by ascites and spontaneous bacterial peritonitis in cirrhosis.

AIM: The current trend is to analyze predictive factors of transition from compensated to decompensated stage by the onset of ascites and later of spontaneous bacterial peritonitis (SBP), which would make possible an early diagnosis of liver cirrhosis at the compensated stage. The aim of the study is to evaluate patients with liver cirrhosis, assessing the rate and the risk factors of decompensation by ascites and SBP. MATERIAL AND METHODS: The prospective study included patients with cirrhosis of different etiologies admitted to a ward of the Institute of Gastroenterology and Hepatology of Iasi in the period 1st January 2010-31st December 2010, which were reassessed clinically and in laboratory for 2 years. The essential criteria for the diagnosis of SBP were the presence of > 250 PMN/mm3. Compensated cirrhosis was defined as the absence of ascites. The presence of ascites and/or upper gastrointestinal hemorrhage (UGH) marks the state of decompensated cirrhosis. To assess the severity of liver cirrhosis there were used Child-Pugh score and MELD score. Diagnostic paracentesis and ascitic fluid sampling were performed at admission to hospital and during hospitalization, in the event of signs and symptoms of SBP, after antibiotic treatment. Macroscopic, biochemical (albumin, protein), cytological (cellularity) and bacteriological (smear and culture) investigations of the ascetic fluid were performed. Lack of response to empirical treatment was considered in cases of general condition deterioration and decreased PMN < 25% of baseline. RESULTS: By comparing the mean values of patients with and without SBP, it is noted that bilirubin and creatinine were significantly higher in patients with SBP, and total protein, albumin and prothrombin time were significantly lower in patients with SBP, these biochemical parameters correlate with the degree of hepatic impairment and may be considered risk factors for SBP. In relation to the mentioned elements, the most important predictors of PBS risk are low protein concentration in ascitic fluid under 1g/dl, increased levels of serum bilirubin and low platelet count. Impaired liver function, infectious complications, and previous episodes of SBP, UGH are risk factors for an episode of SBP. Empirical therapy of nosocomial SBP with third-generation cephalosporins is often inefficient due to the high prevalence of multiresistant (MR) bacteria. CONCLUSIONS: Assessment of clinically significant portal hypertension (PHT) and the degree of hepatic impairment may stratify patients with cirrhosis according to the risk of decompensation, making possible the identification of high risk patients. The knowledge of the risk factors in SBP is important not only to identify patients who could benefit from preventive therapy, but also in understanding the pathogenesis of the disease.

Alcoholic liver disease--epidemiology and risk factors.

Alcoholic liver disease (ALD) accounts for the majority of chronic liverdiseases in Occidental countries and remains a major cause of liver-related mortality in worldwide. The spectrum of ALD includes steatosis in patients which consume over 80g of alcohol per day, alcoholic steatohepatitis and liver cirrhosis in approximately 15% of patients. Once cirrhosis is established, the annual risk for hepatocellular carcinoma is about 1-2%. Environmental factors such as drinking patterns, coexisting liver disease, obesity, diet and co-medication may affect the natural course of ALD. Abstinence is the hallmark of therapy for ALD, and nutritional therapy is the first line in therapeutical intervention.

Different profile of peripheral antioxidant enzymes and lipid peroxidation in active and non-active inflammatory bowel disease patients.

BACKGROUND: The role of oxidative stress in inflammatory bowel diseases (IBD) has been extended lately from a simple consequence of inflammation to a potential etiological factor, but the data are still controversial. Active disease has been characterized before by an enhanced production of reactive oxygen species and the increased peroxidation of lipids, but patients in remission were generally not considered different from healthy people in terms of oxidative stress. AIMS: We evaluated the antioxidant defense capacity and lipid peroxidation status in the serum of patients with active and non-active disease compared with healthy matched control subjects. METHODS: The study included 20 patients with confirmed IBD in clinical and biological remission, 21 patients with active disease, and 18 controls. We determined the serum levels of two antioxidant enzymes, superoxide dismutase (SOD) and glutathione peroxidase (GPX), and a lipid peroxidation marker, malondialdehyde (MDA). RESULTS: Active disease patients had an increased activity of both SOD and GPX, as well as significant high values of MDA versus controls. Furthermore, patients being in remission had significantly lower values of antioxidant enzymes (SOD and GPX) and increased lipid peroxidation measured by MDA serum levels, as compared with healthy control subjects. CONCLUSIONS: Our study confirmed the presence of high oxidative stress in active IBD. More importantly, we have demonstrated a lower antioxidant capacity of patients in remission versus control group. This may represent a risk factor for the disease and can be an additional argument for the direct implication of oxidative stress in the pathogenesis of IBD.

The influence of antibiotic treatment on the dynamics of oxidative stress in spontaneous bacterial peritonitis.

UNLABELLED: Bacterial infections play an important role in liver cirrhosis complications, being together with variceal bleeding and hepatic encephalopathy an important cause of morbidity and mortality in cirrhotic patients. Spontaneous bacterial peritonitis (SBP) is a major complication of liver cirrhosis, with a significant mortality. Recent studies have demonstrated the involvement of oxygen free radicals in the pathogenesis of liver cirrhosis, but the role of oxidative stress in the development of SBP is not very clear yet. PURPOSE: This study aims to evaluate the role of oxidative stress in the pathogenesis of spontaneous bacterial peritonitis and its changes after therapy. MATERIAL AND METHODS: The study is a prospective case-control, which included 33 patients divided into 3 groups: group I- 10 patients with decompensated cirrhosis and SBP, group II - 17 patients diagnosed with decompensated liver cirrhosis with ascites, and group Ill - 6 patients with compensated liver cirrhosis. The control group consisted of 19 healthy subjects recruited from hospital staff, adapted to patients by age and sex. Malonildyaldehida (MDA), a product of lipid peroxidation, was dosed in the blood and ascitic fluid of patients by assay thiobarbituric acid reactive substances (TBARS). RESULTS: Serum MDA significantly increased in the group with decompensated cirrhosis and SBP compared with the control group. MDA levels in ascitic fluid showed a statistically significant increase in the SBP group compared with patients without SBP. There was a decrease of MDA after 6 months of antibiotic treatment compared with the initial stage, while MDA values increased in the absence of treatment. CONCLUSIONS: The study demonstrates the increased oxidative stress markers in the blood and ascitic fluid of cirrhotic patients with SBP, which can be considered a predictor of SBP and also a marker of treatment response. KEYWORDS: SPON-

Platelet indices in patients with de novo portal vein thrombosis and liver cirrhosis.

UNLABELLED: Platelet indices are markers of platelet reactivity used for thrombotic risk assessment in patients with cardiovascular diseases, and recently in venous thrombosis. AIM: To assess the diagnostic value of platelet indices in patients with non-malignant de novo portal vein thrombosis and liver cirrhosis. MATERIAL AND METHODS: We conducted a prospective, case-control study on patients admitted to a tertiary center in the interval January, 2010 - December, 2012. Included in the study were 54 patients with portal vein thrombosis (PVT) and 54 controls. Patients with known malignancy, sepsis, thrombophilia, on anticoagulant or antiaggregant therapy, acute or chronic inflammatory diseases, severe anemia, renal failure, acute coronary syndrome, and chronic pulmonary disease were excluded from the study. RESULTS: Both groups were comparable for baseline characteristics. Mean platelet volume, platelet distribution width (PDW) and plateletcrit were higher in the PVT group. In a multivariate logistic regression analysis, significant predictors of the presence of PVT were mean platelet volume (MPV), PDW, and procalcitonin (PCT). CONCLUSION: Our data suggest that increased platelet indices contribute to the prethrombotic state in liver cirrhosis and that larger platelets may play a specific role in thrombosis despite thrombocytopenia.

A prospective study of pre-illness diet in newly diagnosed patients with Crohn's disease.

BACKGROUND: Environmental factors, including diet, seem to participate in the etiology of inflammatory bowel disease. The kind of dietetic habits before the appearance of the illness in patients with Crohn's disease (CD) has not been studied extensively. AIM: To prospectively assess the kind of food consumption in patients with CD exactly at the time of diagnosis and to identify dietary constituents as risk factors for development of CD. PATIENTS - METHODS: Twenty eight patients with a newly established diagnosis of CD (2-4 weeks), (12 men and 16 women), 30 patients with previously (between 2 - 11 years) established diagnosis of CD (14 men and 16 women) and 38 age- and sex-matched healthy controls (16 men and 22 women) were included in the study. Dietary intake was assessed by means of special questionnaire. RESULTS: Comparisons between controls and newly diagnosed patients showed that increased consumption of milk and yogurt (P = 0.042), fruits (P = 0.0001), citrus (P = 0.0001), vegetables (P = 0.0001), carrots (P = 0.0001), legumes (P = 0.036), fish and selfish (P = 0.001), honey (P = 0.003), and nuts (P = 0.038), was associated with decreased risk for CD. On the other hand, significantly increased intake of fat (P = 0.041), olive oil (P = 0.038), margarine (P = 0.038), sugar (P = 0.02), alcohol drinks (P = 0.009), fried food (P = 0.0001), and pasta (P = 0.0001), was noticed on recently diagnosed patients in comparison with the healthy control group. On logistic regression analysis foods remaining statistically significant were: margarine, pasta, fried foods, fat, olives, sugar (increased risk), and yogurt, honey, fruits, nuts, fish, and citrus fruits (decreased risk). Newly diagnosed patients were significantly overweighed (64%) compared to healthy people (26%) and old patients (7%). CONCLUSION: Significant differences in many kinds of food between newly diagnosed patients with CD, patients with established CD and normal people certainly exist. Our results suggest that specific dietary patterns could be associated with higher or lower risks for CD in adults. However, whether these dietary factors are important for the development of CD or modulate the effect of other environmental factors is unknown.

[Non-invasive evaluation of liver fibrosis in chronic hepatitis C].

Chronic hepatitis C (CHC) is a major public health concern, with around 180 million individuals affected worldwide. Liver fibrosis and its end-point cirrhosis are the main causes of morbidity and mortality in patients with CHC. Liver biopsy (LB) has traditionally been considered the "gold standard" for pre-treatment evaluation of liver fibrossis in patients with CHC. However, LB is an invasive procedure with several shortcomings (intra- and interobserver variability, sampling errors, expensive) and the risk of rare but potentially life-threatening complications (biliary peritonitis, hemo-peritoneum, and death in 1/10,000). The aforementioned shortcomings of LB have led to development of several non-invasive methods for the assessment of liver fibrosis in CHC. Among the non-invasive methods, Fibrotest and Fibroscan are the most widely used in our country and offer a viable alternative to LB for pre-treatment assessment of liver fibrosis in patients with CHC. This review aims to discuss the advantages and usefulness of non-invasive methods of liver fibrosis in CHC.

Colon capsule endoscopy compared to colonoscopy for colorectal neoplasms diagnosis: an initial experience and a brief review of the literature.

Conventional colonoscopy is regarded as the gold standard procedure for the diagnosis of colorectal neoplasms despite its several limitations including invasiveness, discomfort and potential complications. Colon capsule endoscopy (CCE) could be an attractive alternative method to the invasive colonoscopy for the diagnosis of colorectal cancer and polyps. Publications regarding the use of CCE for detecting colorectal cancer and polyps, as well as our experience, were reviewed. The new second-generation CCE (PillCam COLON 2) has improved accuracy compared with the first-generation system for detecting colorectal neoplasms.

The risk of thrombotic events in patients with liver cirrhosis.

AIM: To evaluate the incidence and risk factors for thrombotic events (deep vein thrombosis and portal vein thrombosis) in patients with liver cirrhosis. MATERIAL AND METHODS: we studied patients diagnosed with liver cirrhosis admitted in our department between January 2010-December 2011, which were divided in two groups: liver cirrhosis with thrombotic events and without thrombotic events. RESULTS: we included 3108 patients, the incidence of deep vein thrombosis was 0.99% and portal vein thrombosis was 1.51%, the incidence of all thrombotic events was 2.5%. In the univariate analysis serum albumin was significantly lower in cases than controls, and MELD score, mean platelet volume were higher in cases than controls. The presence of sepsis and diabetes mellitus were demonstrated like risk factors by the univariate analysis. In multivariate analysis, albumin level< 3mg/dl (HR=1.65, CI 1.10-2.51, p=0.018) and MELD score >13 (HR=2.94, CI 1.61-5.47, p=0.001) remained independently predictive of thrombotic events. CONCLUSIONS: The incidence of thrombotic events in patients with liver cirrhosis was 2.5%. Low serum albumin and high MELD score could predict the development of thrombotic events in patients with liver cirrhosis.

Efficacy of Helicobacter pylori eradication therapy in cirrhotic patients with peptic ulcer disease.

UNLABELLED: Few studies have been focused on the role of Helicobacter pylori eradication in cirrhotic patients with peptic ulcer and the reported results are conflicting. AIM: To evaluate the efficacy of proton pump inhibitor (PPI)-based triple therapy on peptic ulcer course in patients with liver cirrhosis. MATERIAL AND METHODS: This prospective study was carried out in a tertiary-care hospital. Of the 63 consecutive cirrhotic patients with peptic ulcer identified by endoscopy 39 (22 males, 14 females, aged 53 to 62 years) entered the study. The patients with peptic ulcer and H. pylori infection received eradication therapy, while H. pylori negative patients received PPI treatment. H. pylori eradication was confirmed by rapid urease test and histological examination. Follow-up endoscopies were performed at 6 and 12 months. The patients with peptic ulcer recurrence were treated with PPI. RESULTS: Of the 39 selected patients 22 (56.4%) were H. pylori positive, and 17 (43.6%) were H. pylori negative. H. pylori was eradicated in 63.6% (14/22) of the patients. During the follow-up period 2 H. pylori negative patients died from variceal bleeding and hepatic encephalopathy, respectively, and one H. pylori positive patient did not return for further assessment). Ulcers recurring within 1 year were found in 14 of 36 (38.8%) patients. Peptic ulcer recurred in 4 of 21 (19.0%) H. pylori positive patients and in 10 of 15 (47.6%) H. pylori negative patients at study entry. Patients' age (p = 0.018), Child-Pugh stage (p = 0.019), peptic ulcer site (p = 0.008), and H. pylori negative status (p = 0.004) were significantly related to ulcer recurrence. CONCLUSIONS: Eradication of H. pylori infection in patients with liver cirrhosis and peptic ulcer disease could be helpful, but does not protect all cirrhotic patients from peptic ulcer recurrence. Most relapsed ulcers were gastric ulcers in H. pylori negative patients.