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1.
Medicine (Baltimore) ; 99(43): e22934, 2020 Oct 23.
Artigo em Inglês | MEDLINE | ID: mdl-33120850

RESUMO

INDUCTION: Liver transplantation (LT) is the only final therapy for patients with acute liver failure (ALF) that cannot be controlled by conservative treatment. Acute pancreatitis (AP) is a recognized complication of ALF. The pathogenesis of AP in ALF patients has not yet been elucidated. The appearance of AP complicates the patients condition and causes a significantly increased risk of mortality. PATIENT CONCERNS: We report 2 fatal cases who were both admitted with yellowing of skin and sclera with general weakness lasting for 2 weeks. DIAGNOSIS: After admission, the laboratory examination of case 1 showed liver dysfunction with serum levels of total bilirubin (TB) 270 µmol/l, alanine aminotransferase (ALT) 106 U/l. Abdominal computed tomography (CT) showed pelvic and peritoneal cavity fluids, occupation of left lateral lobe of liver and unclear margin of pancreas. The clinical laboratory findings of case 2 revealed TB 351.1 µmol/l, ALT 252 U/l, blood lactic acid 18 mmol/l, ammonia 209 µmol/l. And abdominal CT showed pancreatic exudation. They were both diagnosed with acute liver failure, hepatic encephalopathy and AP which was confirmed during the operation. INTERVENTIONS: They were both received a routine orthotopic LT. OUTCOMES: After the surgery, their liver functions recovered well, and they received conventional conservative treatment for pancreatitis. However, the treatment was not adequately effective, and the infection was too serious and both died of multiple organ failure despite emergency rescue efforts on day 21 and day 19 after LT. CONCLUSION: AP is a serious complication that can contribute to prohibitive morbidity and mortality in LT patients. For this reason, the vulnerable state of the pancreas and the scoring system must be defined to help clinicians decide whether a patient is suitable for liver transplantation, and the clinical experience in the treatment of pancreatitis after LT needs to be summarized as an optimal treatment guideline to facilitate better treatment.


Assuntos
Falência Hepática Aguda/etiologia , Falência Hepática Aguda/terapia , Transplante de Fígado/mortalidade , Pancreatite/complicações , Idoso , Alanina Transaminase/sangue , Bilirrubina/sangue , Tratamento Conservador/métodos , Evolução Fatal , Encefalopatia Hepática/diagnóstico , Humanos , Período Intraoperatório , Masculino , Pessoa de Meia-Idade , Pancreatite/diagnóstico , Pancreatite/terapia , Prognóstico , Tomógrafos Computadorizados
2.
Anticancer Res ; 40(9): 5271-5276, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32878816

RESUMO

BACKGROUND/AIM: Hepatic encephalopathy is an adverse event resulting from lenvatinib use in patients with hepatocellular carcinoma (HCC). We analyzed the influence of lenvatinib on portal venous flow velocity (PVV) and serum ammonia concentration. PATIENTS AND METHODS: Eleven patients with unresectable HCC were enrolled, including three with modified albumin-bilirubin (mALBI) grade 1, three with grade 2a, and five with grade 2b. PVV was measured by Doppler ultrasound sonography before and on day 2 of administration. RESULTS: Out of 11 patients, one developed hepatic encephalopathy. PVV was reduced in 10 patients, and the change from baseline was significantly correlated with lenvatinib dosage. The increase in serum ammonia concentration was affected by lenvatinib dose and baseline hepatic function as a threshold between mALBI grade 2a and 2b statistically. There was no correlation between changes in PVV and serum ammonia concentration. CONCLUSION: Lenvatinib might directly disturb hepatocyte metabolism to result in increased serum ammonia concentration.


Assuntos
Antineoplásicos/efeitos adversos , Carcinoma Hepatocelular/complicações , Carcinoma Hepatocelular/tratamento farmacológico , Hiperamonemia/etiologia , Neoplasias Hepáticas/complicações , Neoplasias Hepáticas/tratamento farmacológico , Compostos de Fenilureia/efeitos adversos , Inibidores de Proteínas Quinases/efeitos adversos , Quinolinas/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Antineoplásicos/administração & dosagem , Antineoplásicos/uso terapêutico , Bilirrubina/sangue , Carcinoma Hepatocelular/diagnóstico , Suscetibilidade a Doenças , Feminino , Encefalopatia Hepática/diagnóstico , Encefalopatia Hepática/etiologia , Humanos , Hiperamonemia/diagnóstico , Testes de Função Hepática , Neoplasias Hepáticas/diagnóstico , Masculino , Pessoa de Meia-Idade , Gradação de Tumores , Estadiamento de Neoplasias , Compostos de Fenilureia/administração & dosagem , Compostos de Fenilureia/uso terapêutico , Veia Porta/fisiopatologia , Inibidores de Proteínas Quinases/administração & dosagem , Inibidores de Proteínas Quinases/uso terapêutico , Quinolinas/administração & dosagem , Quinolinas/uso terapêutico , Fatores de Risco
3.
Am J Gastroenterol ; 115(7): 989-1002, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32618647

RESUMO

Management of hepatic encephalopathy (HE) remains challenging from a medical and psychosocial perspective. Members of the International Society for Hepatic Encephalopathy and Nitrogen Metabolism recognized 5 key unresolved questions in HE management focused on (i) driving, (ii) ammonia levels in clinical practice, (iii) testing strategies for covert or minimal HE, (iv) therapeutic options, and (v) nutrition and patient-reported outcomes. The consensus document addresses these topical issues with a succinct review of the literature and statements that critically evaluate the current science and practice, laying the groundwork for future investigations.


Assuntos
Encefalopatia Hepática/diagnóstico , Encefalopatia Hepática/terapia , Amônia/metabolismo , Condução de Veículo , Encefalopatia Hepática/metabolismo , Encefalopatia Hepática/fisiopatologia , Humanos , Apoio Nutricional , Medidas de Resultados Relatados pelo Paciente , Prognóstico , Sociedades Médicas
4.
Aliment Pharmacol Ther ; 51(12): 1397-1405, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32363684

RESUMO

BACKGROUND: Hepatic encephalopathy is a devastating complication of cirrhosis. AIM: To describe the outcomes after developing hepatic encephalopathy among contemporary, aging patients. METHODS: We examined data for a 20% random sample of United States Medicare enrolees with cirrhosis and Part D prescription coverage from 2008 to 2014. Among 49 164 persons with hepatic encephalopathy, we evaluated the associations with transplant-free survival using Cox proportional hazard models with time-varying covariates (hazard ratios, HR) and incidence rate ratios (IRR) for healthcare utilisation measured in hospital-days and 30-day readmissions per person-year. We validated our findings in an external cohort of 2184 privately insured patients with complete laboratory values. RESULTS: Hepatic encephalopathy was associated with median survivals of 0.95 and 2.5 years for those ≥65 or <65 years old and 1.1 versus 3.9 years for those with and without ascites. Non-alcoholic fatty-liver disease posed the highest adjusted risk of death among aetiologies, HR 1.07 95% CI (1.02, 1.12). Both gastroenterology consultation and rifaximin utilisation were associated with lower mortality, respective adjusted-HR 0.73 95% CI (0.67, 0.80) and 0.40 95% CI (0.39, 0.42). Thirty-day readmissions were fewer for patients seen by gastroenterologists (0.71 95% CI [0.57-0.88]) and taking rifaximin (0.18 95% CI [0.08-0.40]). Lactulose alone was associated with fewer hospital-days, IRR 0.31 95% CI (0.30-0.32), than rifaximin alone, 0.49 95% CI (0.45-0.53), but the optimal therapy combination was lactulose/rifaximin, IRR 0.28 95% CI (0.27-0.30). These findings were validated in the privately insured cohort adjusting for model for endstage liver disease-sodium score and serum albumin. CONCLUSIONS: Hepatic encephalopathy remains morbid and associated with poor outcomes among contemporary patients. Gastroenterology consultation and combination lactulose-rifaximin are both associated with improved outcomes. These data inform the development of care coordination efforts for subjects with cirrhosis.


Assuntos
Encefalopatia Hepática/diagnóstico , Encefalopatia Hepática/mortalidade , Idoso , Estudos de Coortes , Doença Hepática Terminal/complicações , Doença Hepática Terminal/diagnóstico , Doença Hepática Terminal/epidemiologia , Doença Hepática Terminal/terapia , Feminino , Encefalopatia Hepática/etiologia , Encefalopatia Hepática/terapia , Humanos , Tempo de Internação/estatística & dados numéricos , Cirrose Hepática/complicações , Cirrose Hepática/diagnóstico , Cirrose Hepática/epidemiologia , Masculino , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Prognóstico , Análise de Sobrevida , Estados Unidos/epidemiologia
5.
Artigo em Inglês | MEDLINE | ID: mdl-32455895

RESUMO

Background: Minimal hepatic encephalopathy (MHE) refers to a number of neuropsychiatric and neurophysiological disorders in patients with cirrhosis who do not show abnormalities on physical examination or in clinical tests. The aim of this study was to determine the prevalence, risk factors, and predictive value of minimal hepatic encephalopathy and the usefulness of the inhibitory control test (ICT) in the diagnosis. Methods: Seventy patients (mean age 53 years, range 24-77) with liver cirrhosis were enrolled in the study. MHE was diagnosed based on PHES (psychometric hepatic encephalopathy score) and ICT. PHES and ICT were validated in a group of 56 control subjects. Results: Minimal hepatic encephalopathy was diagnosed using PHES in 21 patients (30%). ICT diagnosed MHE in 30 patients (42%), and the test had a sensitivity of 65% and a specificity of 57% compared to PHES. The ICT score (lures/target accuracy rate) correlated with the age of subjects (R = 0.35, p = 0.002) and only slightly with education (education in years R = -0.22, p = 0.06). MHE diagnosed with PHES or ICT was associated with a significantly higher model of end-stage liver disease (MELD) score in the follow-up. MHE diagnosed with ICT was correlated with a significantly higher incidence of symptoms of decompensated cirrhosis (p = 0.02) in the follow-up. Conclusions: ICT had moderate sensitivity and specificity in diagnosing MHE compared to PHES. Importantly, MHE detected with PHES or ICT was associated with poorer survival and a more severe progression of the disease.


Assuntos
Encefalopatia Hepática , Cirrose Hepática , Psicometria , Adulto , Idoso , Encefalopatia Hepática/diagnóstico , Humanos , Cirrose Hepática/complicações , Masculino , Pessoa de Meia-Idade , Sensibilidade e Especificidade , Índice de Gravidade de Doença , Adulto Jovem
7.
Int J Infect Dis ; 93: 90-97, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32004691

RESUMO

BACKGROUND: Yellow fever (YF) is a viral hemorrhagic disease caused by an arbovirus from the Flaviviridae family. Data on the clinical profile of severe YF in intensive care units (ICUs) are scarce. This study aimed to evaluate factors associated with YF mortality in patients admitted to a Brazilian ICU during the YF outbreaks of 2017 and 2018. METHODS: This was a longitudinal cohort case series study that included YF patients admitted to the ICU. Demographics, clinical and laboratory data were analyzed. Cox regression identified independent predictors of death risk. RESULTS: A total of 114 patients were studied. The median age was 48 years, and 92.1% were males. In univariate analysis, jaundice, leukopenia, bradycardia, prothrombin time, expressed as a ratio to the international normalized ratio-(PT-INR), alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin, lactate, arterial pH and bicarbonate, Acute Physiology and Chronic Health Evaluation II (APACHE II) and Simplified Acute Physiology Score 3 (SAPS 3) severity scores, transfusion of fresh frozen plasma, acute renal failure (Acute Kidney Injury Network stage III (AKIN III)), hemodialysis, cumulative fluid balance at 72 h of ICU, vasopressor use, seizures and grade IV encephalopathy were significantly associated with mortality. In multivariate analysis, factors independently associated with YF mortality were PT-INR, APACHE II, and grade IV hepatic encephalopathy. CONCLUSIONS: In the large outbreak in Brazil, factors independently associated with death risk in YF were: PT-INR, APACHE II, and grade IV hepatic encephalopathy. Early identification of patients with YF mortality risk factors may be very useful. Once these patients with a poor prognosis have been identified, proper management should be promptly implemented.


Assuntos
Unidades de Terapia Intensiva , Febre Amarela/mortalidade , APACHE , Lesão Renal Aguda/diagnóstico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Brasil/epidemiologia , Surtos de Doenças , Feminino , Encefalopatia Hepática/diagnóstico , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Escala Psicológica Aguda Simplificada , Febre Amarela/diagnóstico , Febre Amarela/epidemiologia , Adulto Jovem
8.
World J Gastroenterol ; 26(1): 97-108, 2020 Jan 07.
Artigo em Inglês | MEDLINE | ID: mdl-31933517

RESUMO

BACKGROUND: Autotaxin (ATX) has been reported as a direct biomarker for estimating the evaluation of liver fibrosis. But available data on ATX as a useful biomarker for the complications of liver cirrhosis (LC) are scant. AIM: To assess the clinical usefulness of ATX for assessing the complications of LC. METHODS: This multicenter, retrospective study was conducted at six locations in Japan. We include patients with LC, n = 400. The ATX level was evaluated separately in men and women because of its high level in female patients. To assess the clinical usefulness of ATX for the complications of LC, the area under the curve (AUC) of ATX assessing for the severe complications was analyzed in comparison with the model for end-stage liver disease score, albumin-bilirubin (ALBI) score, fibrosis-4 index, and aspartate aminotransferase-to-platelet ratio index. RESULTS: The mean age was 68.4 ± 11.4 years, 240 patients (60.0%) were male. A total of 213 (53.3%) and 187 (46.8%) patients were compensated and decompensated, respectively. The numbers of patients with varix rupture, hepatic ascites, and hepatic encephalopathy were 35 (8.8%), 131 (32.8%), and 103 (25.8%), respectively. The AUCs of ATX in men for hepatic encephalopathy, hepatic ascites, and varix ruptures were 0.853, 0.816, and 0.706, respectively. The AUCs of ATX in women for hepatic encephalopathy, hepatic ascites, and varix rupture were 0.759, 0.717, and 0.697, respectively. The AUCs of ATX in men were higher than those in women, as were all the other biomarkers used to detect encephalopathy and varix ruptures. However, for detecting ascites, the AUC of ALBI in men was more effective than using ATX. CONCLUSION: ATX in men was more effective than any other biomarkers for detecting hepatic encephalopathy and varix ruptures.


Assuntos
Ascite/diagnóstico , Encefalopatia Hepática/diagnóstico , Cirrose Hepática/sangue , Diester Fosfórico Hidrolases/sangue , Índice de Gravidade de Doença , Idoso , Área Sob a Curva , Ascite/etiologia , Biomarcadores/sangue , Feminino , Encefalopatia Hepática/etiologia , Humanos , Japão , Fígado/patologia , Cirrose Hepática/complicações , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos
9.
Z Gastroenterol ; 58(1): 49-56, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31931540

RESUMO

BACKGROUND: Hepatic encephalopathy (HE) is a severe complication of liver cirrhosis with impairment of quality of life and prognosis. Management patterns among physicians have not been investigated yet. METHODS: A questionnaire containing 17 questions was sent out to 1468 gastroenterologists and 120 general practitioners (GPs). It included questions regarding diagnostic, therapeutic, and management strategies used in patients with overt HE (OHE) and covert HE (CHE). RESULTS: The response rate was 12 % (n = 172) for gastroenterologists and 45 % (n = 54) for GPs. Of gastroenterologists, 26.7 % examine patients with an initial diagnosis of liver cirrhosis regarding HE. Gastroenterologists favored a combination of different testing strategies (27.9 %) and clinical examination (23.0 %), while the biggest part of the GPs use clinical examination (55.3 %); 63.7 % of gastroenterologists and 28.3 % of GPs give correct nutritional advices to patients with HE. Treatment strategies for acute bouts of OHE and secondary prophylaxis varied widely in both groups. Preferred medication was lactulose followed by rifaximin or a combination therapy. More than half of the GPs (53.7 %) were not familiar with minimal HE (MHE). About one-third of both groups never tried to diagnose MHE. CONCLUSION: Our data strongly indicate that management of HE is very heterogeneous among gastroenterologists as well as selected GPs working in Germany and not driven by evidence-based international guidelines. Thus, the national guideline is more than welcome.


Assuntos
Gastroenterologistas , Fármacos Gastrointestinais/uso terapêutico , Clínicos Gerais , Encefalopatia Hepática/diagnóstico , Encefalopatia Hepática/terapia , Cirrose Hepática/complicações , Padrões de Prática Médica/estatística & dados numéricos , Gerenciamento Clínico , Alemanha , Encefalopatia Hepática/psicologia , Humanos , Lactulose/uso terapêutico , Cirrose Hepática/terapia , Qualidade de Vida , Rifaximina/uso terapêutico , Prevenção Secundária/métodos , Inquéritos e Questionários
10.
Am J Gastroenterol ; 115(5): 783-785, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-31449156

RESUMO

INTRODUCTION: Ammonia levels are used to assess hepatic encephalopathy, but their levels are highly variable in clinical practice. METHODS: We studied factors associated with variation in ammonia values in cirrhotic patients without previous hepatic encephalopathy and healthy volunteers (HVs). RESULTS: Ammonia increased by 12% and 18% at 1 and 2 hour, respectively, after a protein meal in 64 cirrhotic patients (P < 0.001). In 237 HVs, ammonia levels varied significantly between sites (P < 0.0001). New site-specific ammonia upper limits based on HV levels using a strict analysis protocol differed from routinely used values. Correlation between paired fresh samples was high (r = 0.83) but modest between fresh and frozen samples (r = 0.62). DISCUSSION: Sample handling, processing, and protein intake impact ammonia levels across sites.


Assuntos
Amônia/sangue , Ensaios Clínicos como Assunto , Encefalopatia Hepática/sangue , Cirrose Hepática/sangue , Adolescente , Adulto , Idoso , Biomarcadores/sangue , Progressão da Doença , Feminino , Voluntários Saudáveis , Encefalopatia Hepática/diagnóstico , Encefalopatia Hepática/etiologia , Humanos , Cirrose Hepática/complicações , Cirrose Hepática/diagnóstico , Masculino , Pessoa de Meia-Idade , Índice de Gravidade de Doença , Adulto Jovem
11.
PLoS One ; 14(12): e0226283, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31830113

RESUMO

BACKGROUND AND AIM: Predicting overt hepatic encephalopathy (OHE) is important because the condition is frequent, often requires hospitalization and is potentially preventable. The risk of OHE is related to pre-existing discrete cognitive defects, and for clinical practice it is recommended to apply two different psychometric tests to detect such deficits. We used the continuous reaction time test (CRT) and the portosystemic encephalopathy (PSE) syndrome test and examined their single and combined value for OHE prediction in cirrhosis patients. PATIENTS AND METHODS: We studied 130 clinically mentally unimpaired cirrhosis patients by the two tests and followed them for an average of 38.5 months. The CRT measures velocity and stability of motor reaction times to 150 repeated auditory signals. The PSE is a five sub-set paper-and-pencil test battery evaluating cognitive and psychomotor processing, speed and vision-motor coordination. We collected data on episodes of OHE during follow-up. The clinical course was analysed in patient groups according to the outcome of each test and of both tests together. No anti-HE treatment was initiated except for cases with OHE. RESULTS: At baseline, the CRT test was abnormal in 74 patients and the PSE in 47. During follow-up 35 patients (27%) experienced 74 OHE events. 23 patients with abnormal CRT experienced OHE (prediction sensitivity 65%). The PSE predicted OHE in 14 patients (prediction sensitivity 40%). One or both tests were abnormal in 87/130 (67%) and this predicted OHE in 27 patients (21%) (prediction sensitivity 77%). CONCLUSION: The CRT test was clinically useful in identifying two-thirds of clinically mentally unimpaired cirrhosis patients who later experienced OHE, and the use of both the CRT and PSE showed satisfactory prediction by identifying three-fourths of later OHE cases.


Assuntos
Encefalopatia Hepática/diagnóstico , Cirrose Hepática/complicações , Derivação Portossistêmica Cirúrgica/métodos , Tempo de Reação , Adulto , Idoso , Cognição , Feminino , Encefalopatia Hepática/etiologia , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Psicometria , Curva ROC
12.
BMJ Case Rep ; 12(11)2019 Nov 26.
Artigo em Inglês | MEDLINE | ID: mdl-31776153

RESUMO

A 45-year-old man with alcohol-related decompensated cirrhosis presented with jaundice, fever, headache and altered sensorium. At presentation, he had tachycardia, disorientation to time and place, asterixis, icterus and upgoing plantar response. Investigations showed anaemia, thrombocytopenia, leucocytosis, hyperbilirubinemia and elevated arterial ammonia. Despite management with antihepatic coma measures and normalisation of ammonia, broad-spectrum antibiotics, 20% albumin, the patient worsened. On day 3, the patient developed generalised tonic-clonic seizure prompting mechanical ventilation. Examination showed right proptosis, chemosis and pupillary anisocoria. MRI brain showed multifocal infarcts in the right temporal lobe, right cerebellum and brainstem with inflammation in the right orbit, infratemporal fossa with right internal carotid artery thrombosis, and suspicious maxillary sinus thickening. Nasal scrapings showed aseptate fungal hyphae and serum galactomannan index was positive. Despite receiving liposomal amphotericin-B, patient had an unfavourable outcome. Intracranial invasive mycosis can mimic hepatic encephalopathy and is associated with high mortality in cirrhotics. A high index of suspicion, positive biomarkers and diagnostic radiology may provide the key to the diagnosis.


Assuntos
Encefalopatias/diagnóstico , Encefalopatias/microbiologia , Infecções Fúngicas do Sistema Nervoso Central/diagnóstico , Encefalopatia Hepática/diagnóstico , Infecções Fúngicas Invasivas/diagnóstico , Encefalopatias/complicações , Infecções Fúngicas do Sistema Nervoso Central/complicações , Diagnóstico Diferencial , Humanos , Infecções Fúngicas Invasivas/complicações , Cirrose Hepática/complicações , Masculino , Pessoa de Meia-Idade
13.
Medicine (Baltimore) ; 98(48): e18166, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31770264

RESUMO

RATIONALE: Hepatectomy is a treatment to increase survival and curability of patients with intrahepatic lesions or malignant tumors. However, posthepatectomy liver failure (PHLF) can occur. This case is a patient showing acute mental change in postanesthetic care unit (PACU) as an uncommon symptom of PHLF after extended right hepatectomy. PATIENT CONCERNS: A 68-year-old male patient was admitted for surgery of Klatskin tumor. He had hypertension and atrial fibrillation. His model for end-stage liver disease score was 16 pts. His serum bilirubin and ammonia levels were 4.75 mg/dL and 132.8 mcg/dL, respectively. Other laboratory data were nonspecific. He underwent extended right hepatic lobectomy including segments IV-VIII for 9 hours. Weight of liver specimen was 1028 g which was about 58% of total liver volume based on computed tomographic volumetry. The patient was extubated and moved to the PACU with stable vital sign and regular self-breathing. He could obey verbal commands. Fifteen minutes after admission to the PACU, the patient showed abruptly decreasing mental status and self-breathing. DIAGNOSES: Brain computed tomography, blood culture, and sputum culture were performed to diagnose brain lesions and sepsis for evaluating the sudden onset comatous mental status. Results showed nonspecific finding. INTERVENTIONS: He was intubated for securing airway and applying ventilatory care. The patient was moved to the intensive care unit. He received intensive conservative therapy including continuous renal replacement therapy and broad-spectrum antibiotics. OUTCOMES: The patient's condition was worsened. He expired on postoperative day 3. LESSONS: Acute mental change is uncommon and rare as initial symptoms of PHLF. Therefore, clinician may overlook the diagnosis of PHLF in patients with acute mental change after hepatectomy. Thus, clinician should plan an aggressive treatment for PHLF including liver transplantation by recognizing any suspicious symptom, although such symptom is rare.


Assuntos
Neoplasias dos Ductos Biliares/cirurgia , Hepatectomia , Encefalopatia Hepática , Tumor de Klatskin/cirurgia , Falência Hepática , Fígado , Complicações Pós-Operatórias , Idoso , Neoplasias dos Ductos Biliares/patologia , Tomografia Computadorizada de Feixe Cônico/métodos , Tratamento Conservador/métodos , Evolução Fatal , Hepatectomia/efeitos adversos , Hepatectomia/métodos , Encefalopatia Hepática/diagnóstico , Encefalopatia Hepática/etiologia , Encefalopatia Hepática/fisiopatologia , Humanos , Tumor de Klatskin/patologia , Fígado/diagnóstico por imagem , Fígado/patologia , Fígado/cirurgia , Falência Hepática/diagnóstico , Falência Hepática/etiologia , Falência Hepática/psicologia , Testes de Função Hepática/métodos , Masculino , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/psicologia
14.
Sci Rep ; 9(1): 16462, 2019 11 11.
Artigo em Inglês | MEDLINE | ID: mdl-31712684

RESUMO

Artificial liver support systems (ALSS) are widely used to treat patients with hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF). The aims of the present study were to investigate the subgroups of patients with HBV-ACLF who may benefit from ALSS therapy, and the relevant patient-specific factors. 489 ALSS-treated HBV-ACLF patients were enrolled, and served as derivation and validation cohorts for classification and regression tree (CART) analysis. CART analysis identified three factors prognostic of survival: hepatic encephalopathy (HE), prothrombin time (PT), and total bilirubin (TBil) level; and two distinct risk groups: low (28-day mortality 10.2-39.5%) and high risk (63.8-91.1%). The CART model showed that patients lacking HE and with a PT ≤ 27.8 s and a TBil level ≤455 µmol/L experienced less 28-day mortality after ALSS therapy. For HBV-ACLF patients with HE and a PT > 27.8 s, mortality remained high after such therapy. Patients lacking HE with a PT ≤ 27.8 s and TBil level ≤ 455 µmol/L may benefit markedly from ALSS therapy. For HBV-ACLF patients at high risk, unnecessary ALSS therapy should be avoided. The CART model is a novel user-friendly tool for screening HBV-ACLF patient eligibility for ALSS therapy, and will aid clinicians via ACLF risk stratification and therapeutic guidance.


Assuntos
Insuficiência Hepática Crônica Agudizada/terapia , Vírus da Hepatite B/isolamento & purificação , Hepatite B Crônica/complicações , Fígado Artificial/estatística & dados numéricos , Medição de Risco/métodos , Insuficiência Hepática Crônica Agudizada/etiologia , Insuficiência Hepática Crônica Agudizada/patologia , Bilirrubina/metabolismo , Estudos de Coortes , Feminino , Seguimentos , Encefalopatia Hepática/diagnóstico , Encefalopatia Hepática/etiologia , Encefalopatia Hepática/mortalidade , Hepatite B Crônica/virologia , Humanos , Testes de Função Hepática , Masculino , Pessoa de Meia-Idade , Prognóstico , Tempo de Protrombina/estatística & dados numéricos , Análise de Regressão , Taxa de Sobrevida
15.
Ann Clin Transl Neurol ; 6(11): 2282-2290, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31631586

RESUMO

OBJECTIVE: Cognitive impairment, detected in up to 80% of patients with liver cirrhosis, is associated with negative health outcomes but is underdiagnosed in the clinical setting due to the lack of practical testing method. This single-center prospective observational study aimed to test the feasibility and prognostic utility of in-clinic cognitive assessment of patients with liver cirrhosis using the NIH Toolbox cognition battery (NIHTB). METHODS: Patients recruited from a hepatology/transplant clinic underwent cognitive assessments using West-Haven Grade (WHG) and NIHTB between November 2016 and August 2018 and were prospectively followed until December 2018. The primary outcome was a composite end point of hospitalization related to overt hepatic encephalopathy (OHE) and all-cause mortality during follow-up, evaluated by a Cox proportional hazards regression model that adjusted for a priori covariates (age and MELD-Na). RESULTS: Among 127 patients (median age 60 years, 48 [38%] women) assessed, cognitive performance was significantly impaired in 82 [78%] patients with WHG 0 and 22 [100%] patients with WHG 1 and 2. Over a median of 347 days follow-up, 18 OHE and 8 deaths were observed. Lower cognitive performance was associated with an increased risk of OHE/death adjusting for age and MELD-Na. Subclinical cognitive impairment detected by NIH Toolbox in WHG 0 patients was significantly associated with greater mortality. Median time to complete the two prognostically informative NIH Toolbox tests was 9.4 min. INTERPRETATION: NIH Toolbox may enable a rapid cognitive screening in the outpatient setting and identify patients at high risk for death and hospitalization for severe encephalopathy.


Assuntos
Encefalopatia Hepática/diagnóstico , Cirrose Hepática/complicações , Cirrose Hepática/mortalidade , Testes Neuropsicológicos , Idoso , Disfunção Cognitiva/diagnóstico , Disfunção Cognitiva/etiologia , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco
16.
Aliment Pharmacol Ther ; 50(10): 1112-1119, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31583743

RESUMO

BACKGROUND: Systemic inflammation is a driving force for the development of hepatic encephalopathy and recent studies demonstrated that elevated Interleukin-6 (IL-6) serum levels are associated with the presence of minimal hepatic encephalopathy in patients with liver cirrhosis. AIM: To test the hypothesis that IL-6 is a suitable marker to identify patients with liver cirrhosis at high risk for the development of overt hepatic encephalopathy. METHODS: 201 patients were included into this prospective cohort study and were followed for a mean time of 322 days. Covert hepatic encephalopathy was diagnosed according to the West-Haven criteria (hepatic encephalopathy grade 1) and with the portosystemic encephalopathy (PSE) test. RESULTS: The cumulative incidence of overt hepatic encephalopathy was higher in patients with IL-6 levels above the median of 9 pg/mL than in patients with IL-6 levels at or below the median (35.6% vs 1.9%, P < .001). After adjustment for covert hepatic encephalopathy, history of overt hepatic encephalopathy, C-reactive protein (CRP) and model for end-stage liver disease (MELD), IL-6 levels above the median remained independently associated with the development of overt hepatic encephalopathy. The predictive performance of IL-6 regarding the development of overt hepatic encephalopathy during the next 180 days (AUROC, 0.931) was numerically higher than that of MELD (AUROC, 0.841) or CRP (AUROC, 0.835). In patients without prior overt hepatic encephalopathy, the predictive performance of IL-6 (AUROC, 0.966) was even significantly higher than that of MELD (AUROC 0.843) or CRP (AUROC 0.850). The ideal cut-off for IL-6 in this setting was 23.5 pg/mL with a sensitivity and specificity of 89.3% and 89.5% respectively. CONCLUSION: IL-6 serum levels are closely linked to the development of overt hepatic encephalopathy in patients with liver cirrhosis.


Assuntos
Biomarcadores/sangue , Encefalopatia Hepática/diagnóstico , Encefalopatia Hepática/etiologia , Interleucina-6/sangue , Cirrose Hepática/complicações , Cirrose Hepática/diagnóstico , Idoso , Proteína C-Reativa/análise , Proteína C-Reativa/metabolismo , Diagnóstico Diferencial , Feminino , Humanos , Inflamação/sangue , Inflamação/complicações , Inflamação/diagnóstico , Cirrose Hepática/patologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Sensibilidade e Especificidade , Regulação para Cima
17.
World J Gastroenterol ; 25(36): 5403-5422, 2019 Sep 28.
Artigo em Inglês | MEDLINE | ID: mdl-31576089

RESUMO

The Chinese Society of Hepatology developed the current guidelines on the management of hepatic encephalopathy in cirrhosis based on the published evidence and the panelists' consensus. The guidelines provided recommendations for the diagnosis and management of hepatic encephalopathy (HE) including minimal hepatic encephalopathy (MHE) and overt hepatic encephalopathy, emphasizing the importance on screening MHE in patients with end-stage liver diseases. The guidelines emphasized that early identification and timely treatment are the key to improve the prognosis of HE. The principles of treatment include prompt removal of the cause, recovery of acute neuropsychiatric abnormalities to baseline status, primary prevention, and secondary prevention as soon as possible.


Assuntos
Doença Hepática Terminal/complicações , Gastroenterologia/normas , Encefalopatia Hepática/terapia , Cirrose Hepática/complicações , Sociedades Médicas/normas , China , Consenso , Doença Hepática Terminal/terapia , Gastroenterologia/métodos , Encefalopatia Hepática/diagnóstico , Encefalopatia Hepática/etiologia , Humanos , Cirrose Hepática/terapia , Prognóstico , Prevenção Secundária/métodos , Prevenção Secundária/normas , Fatores de Tempo
18.
Clin Liver Dis ; 23(4): 607-623, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31563214

RESUMO

Hepatic encephalopathy (HE) is an important cause of morbidity and mortality in patients with cirrhosis. The impact of HE on the health care system is similarly profound. The number of hospital admissions for HE has increased in the last 10-year period. HE is a huge burden to the patients, care givers, and the health care system. HE represents a "revolving door" with readmission, severely affects care givers, and has effects on cognition that can persists after liver transplant. This article reviews the current literature to discuss the challenges and diagnostic and therapeutic approaches to HE.


Assuntos
Embolização Terapêutica/métodos , Fármacos Gastrointestinais/uso terapêutico , Encefalopatia Hepática/terapia , Desintoxicação por Sorção/métodos , Aminoácidos de Cadeia Ramificada/uso terapêutico , Amônia/metabolismo , Cuidadores , Efeitos Psicossociais da Doença , Dipeptídeos/uso terapêutico , Encefalopatia Hepática/diagnóstico , Encefalopatia Hepática/epidemiologia , Hospitalização , Humanos , Lactulose/uso terapêutico , Neomicina/uso terapêutico , Readmissão do Paciente , Rifaximina/uso terapêutico , Índice de Gravidade de Doença , Benzoato de Sódio/uso terapêutico , Zinco/uso terapêutico
19.
Mo Med ; 116(4): 308-312, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31527980

RESUMO

Hepatic encephalopathy is a well-recognized complication of decompensated cirrhosis. It is a reversible state of neurocognitive decline, the etiology of which is multifactorial. Diagnosis is predominantly clinical and usually a diagnosis of exclusion. The identification of precipitating factors and their correction is an essential part of the management along with medical therapies such as lactulose and rifaxmin.


Assuntos
Encefalopatia Hepática/diagnóstico , Encefalopatia Hepática/etiologia , Encefalopatia Hepática/terapia , Médicos Hospitalares , Humanos , Pacientes Internados
20.
PLoS One ; 14(9): e0223061, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31560724

RESUMO

BACKGROUND: Cirrhosis can alter several metabolic pathways. Metabolomics could prognosticate outcomes like hepatic encephalopathy (HE), transplant, hospitalization and death. AIM: Determine changes in serum and urine metabolomics in cirrhotics who develop outcomes. METHODS: Cirrhotic outpatients underwent data, serum/urine collection and were followed for 90 days. Demographics, cirrhosis details and medications were collected. Metabolomics was performed on urine/serum using GC/MS with subsequent bioinformatics analyses (ChemRICH, MetaMAPP and PLS-DA). Logistic regression adjusting for covariates (demographics, alcohol etiology, prior HE, PPI, SBP prophylaxis, rifaximin/lactulose) were performed and ROC curves comparing MELD to adjusted serum & urine metabolites were created. RESULTS: 211 patients gave serum, of which 64 were hospitalized, 19 developed HE, 13 were transplanted and 11 died. 164 patients gave urine of which 56 were hospitalized, 18 developed HE, 12 were transplanted and 11 died. Metabolomics: Saturated fatty acids, amino acids and bioenergetics-related metabolites differentiated patients with/without outcomes. After regression, 232, 228, 284 and 229 serum metabolites were significant for hospitalization, HE, death and transplant. In urine 290, 284, 227 & 285 metabolites were significant for hospitalization, HE, death and transplant respectively. AUC was higher for serum metabolites vs MELD for HE (0.85 vs.0.76), death (0.99 vs.0.88), transplant (0.975 vs.0.94) and hospitalizations (0.84 vs.0.83). Similarly, urinary metabolite AUC was also higher than MELD for HE (0.87 vs.0.72), death (0.92 vs 0.86), transplant (0.99 vs.0.90) and hospitalizations (0.89 vs.0.84). CONCLUSIONS: In this exploratory study, serum and metabolites focused on lipid, bioenergetics and amino acid metabolism are altered in cirrhotics who develop negative outcomes.


Assuntos
Encefalopatia Hepática/diagnóstico , Cirrose Hepática/diagnóstico , Transplante de Fígado/estatística & dados numéricos , Metabolômica/métodos , Índice de Gravidade de Doença , Adulto , Idoso , Biomarcadores/sangue , Biomarcadores/metabolismo , Biomarcadores/urina , Feminino , Encefalopatia Hepática/epidemiologia , Hospitalização/estatística & dados numéricos , Humanos , Cirrose Hepática/sangue , Cirrose Hepática/complicações , Cirrose Hepática/urina , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos
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