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1.
S D Med ; 73(2): 61-66, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32135053

RESUMO

While portal-systemic encephalopathy is a common entity in cirrhotic patients, it is less frequent in non-cirrhotic patients. We are reporting a case of a 68-year-old female who presented with unresponsiveness for the second time in six months. She underwent extensive evaluation for liver disease with ultrasonography and computerized tomography of the abdomen, testing for causes of liver disease including testing for viral hepatitis was negative. A liver biopsy was done clearing any doubt about the presence of significant liver disease or clinically significant portal hypertension. With absence of liver disease hence lower likelihood of portal-systemic encephalopathy (PSE) we evaluated for other causes of encephalopathy with unremarkable neuroimaging including brain MRI and head CT, unremarkable CSF analysis and EEG showing no seizure activity. Given the negative workup and the high ammonia level with the significant clinical response to ammonia lowering therapy we further evaluated the patient for other causes of PSE with Doppler ultrasonography of the liver and eventually angiography of the portal system with the high suspicion for a portosystemic shunt as a cause of her encephalopathy. A shunt from the inferior mesenteric vein to the left renal vein was diagnosed and successfully occluded utilizing coil embolization. The patient recovered normal mentation and was eventually discharged home. This case sheds light on the importance of diagnosing portosystemic shunts leading to encephalopathy, as occlusion of the shunt can correct the encephalopathy and help prevent further episodes.


Assuntos
Encefalopatias , Encefalopatia Hepática , Hipertensão Portal , Derivação Portossistêmica Cirúrgica , Idoso , Feminino , Encefalopatia Hepática/etiologia , Humanos , Derivação Portossistêmica Cirúrgica/efeitos adversos
2.
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
3.
Rinsho Shinkeigaku ; 59(10): 659-661, 2019 Oct 26.
Artigo em Japonês | MEDLINE | ID: mdl-31564702

RESUMO

A 49-year-old woman with hepatic failure owing to alcoholic liver cirrhosis went into a deep coma. Her serum ammonia concentration was elevated at 436 µg/dl, and she had a generalized convulsion. Electroencephalogram and cerebrospinal fluid examination did not suggest encephalitis and epilepsy. Hyperammonemia may be occur because of generalized convulsions; however, it can spontaneously resolve if the convulsions are stopped. If hyperammonemia is the primary cause of generalized convulsion, the serum ammonia concentration will remain high until the cause is eliminated. However, despite stopping the convulsions, her ammonia concentration remained high. Diffusion-weighted brain MRI revealed symmetric high-intensity lesions in the frontal, temporal, and parietal cortices, especially the cingulate and insular cortices of the bilateral hemispheres. These findings were in line with those of previous reports that revealed symmetric cortical lesions, including cingulate and insula cortices that are distinctive in acute hyperammonemic encephalopathy. Therefore, we diagnosed that the coma, generalized convulsions, and abnormal brain MRI findings were caused by acute hyperammonemic encephalopathy.


Assuntos
Córtex Cerebral/diagnóstico por imagem , Encefalopatia Hepática/diagnóstico por imagem , Encefalopatia Hepática/etiologia , Hiperamonemia/etiologia , Doença Aguda , Imagem de Difusão por Ressonância Magnética , Progressão da Doença , Doença Hepática Terminal/etiologia , Evolução Fatal , Feminino , Humanos , Cirrose Hepática Alcoólica/complicações , Pessoa de Meia-Idade , Insuficiência Renal/etiologia
4.
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
6.
World J Gastroenterol ; 25(33): 4933-4944, 2019 Sep 07.
Artigo em Inglês | MEDLINE | ID: mdl-31543684

RESUMO

BACKGROUND: Proton pump inhibitors (PPIs) are widely prescribed, often without clear indications. There are conflicting data on its association with mortality risk and hepatic decompensation in cirrhotic patients. Furthermore, PPI users and PPI exposure in some studies have been poorly defined with many confounding factors. AIM: To examine if PPI use increases mortality and hepatic decompensation and the impact of cumulative PPI dose exposure. METHODS: Data from patients with decompensated liver cirrhosis were extracted from a hospital database between 2013 to 2017. PPI users were defined as cumulative defined daily dose (cDDD) ≥ 28 within a landmark period, after hospitalisation for hepatic decompensation. Cox regression analysis for comparison was done after propensity score adjustment. Further risk of hepatic decompensation was analysed by Poisson regression. RESULTS: Among 295 decompensated cirrhosis patients, 238 were PPI users and 57 were non-users. PPI users had higher mortality compared to non-users [adjusted HR = 2.10, (1.20-3.67); P = 0.009]. Longer PPI use with cDDD > 90 was associated with higher mortality, compared to non-users [aHR = 2.27, (1.10-5.14); P = 0.038]. PPI users had a higher incidence of hospitalization for hepatic decompensation [aRR = 1.61, (1.30-2.11); P < 0.001]. CONCLUSION: PPI use in decompensated cirrhosis is associated with increased risk of mortality and hepatic decompensation. Longer PPI exposure with cDDD > 90 increases the risk of mortality.


Assuntos
Insuficiência Hepática Crônica Agudizada/epidemiologia , Infecções Bacterianas/epidemiologia , Encefalopatia Hepática/epidemiologia , Cirrose Hepática/mortalidade , Peritonite/epidemiologia , Inibidores da Bomba de Prótons/efeitos adversos , Insuficiência Hepática Crônica Agudizada/etiologia , Insuficiência Hepática Crônica Agudizada/terapia , Idoso , Infecções Bacterianas/etiologia , Infecções Bacterianas/terapia , Progressão da Doença , Feminino , Encefalopatia Hepática/etiologia , Encefalopatia Hepática/terapia , Humanos , Incidência , Fígado/efeitos dos fármacos , Fígado/patologia , Cirrose Hepática/complicações , Cirrose Hepática/patologia , Masculino , Pessoa de Meia-Idade , Admissão do Paciente/estatística & dados numéricos , Peritonite/etiologia , Peritonite/terapia , Estudos Retrospectivos , Fatores de Risco , Análise de Sobrevida , Fatores de Tempo
7.
World J Gastroenterol ; 25(35): 5257-5265, 2019 Sep 21.
Artigo em Inglês | MEDLINE | ID: mdl-31558871

RESUMO

Minimal hepatic encephalopathy (MHE) represents the mildest type of hepatic encephalopathy (HE). MHE is considered as a preclinical stage of HE and is part of a wide spectrum of typical neurocognitive alterations characteristic of patients with liver cirrhosis, particularly involving the areas of attention, alertness, response inhibition, and executive functions. MHE can be detected by testing the patients' psychometric performance, attention, working memory, psychomotor speed, and visuospatial ability, as well as by means of electrophysiological and other functional brain measures. MHE is very frequent, affecting from 20% up to 80% of patients tested, depending of the diagnostic tools used. Although subclinical, MHE is considered to be clinically relevant. In fact, MHE has been related to the patients' falls, fitness to drive, and working ability. As a consequence, MHE affects the patients and caregivers lives by altering their quality of life and even their socioeconomic status. Recently sarcopenia, a very common condition in patients with advanced liver disease, has been shown to be strictly related to both minimal and overt HE. Aim of this review is to summarize the most recently published evidences about the emerging relationship between sarcopenia and cognitive impairment in cirrhotic patients and provide suggestions for future research.


Assuntos
Disfunção Cognitiva/fisiopatologia , Encefalopatia Hepática/etiologia , Cirrose Hepática/complicações , Qualidade de Vida , Sarcopenia/etiologia , Encéfalo/fisiopatologia , Disfunção Cognitiva/diagnóstico , Disfunção Cognitiva/etiologia , Feminino , Encefalopatia Hepática/diagnóstico , Encefalopatia Hepática/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Testes Neuropsicológicos , Sarcopenia/fisiopatologia , Classe Social
8.
Nutrients ; 11(8)2019 Aug 06.
Artigo em Inglês | MEDLINE | ID: mdl-31390762

RESUMO

INTRODUCTION: Hepatic encephalopathy (HE) is common in patients with cirrhosis and is characterised by reduced hepatic ammonia clearance. This is accompanied by alterations in gut bacteria that may be ameliorated with synbiotics (pro- and prebiotics). Branched chain amino acids (BCAAs) are thought to have a role in the detoxification of ammonia. We investigated the effects of the administration of synbiotics and/or BCAAs in treating HE. METHODS: Participants with overt HE were randomised in a blinded placebo-controlled study to receive synbiotics, BCAAs, or a combination of BCAAs and Synbiotics. Relevant biochemical and nutritional data and depression and anxiety scores (DASS-21) were collected at entry, 4 weeks, and on completion, at 8 weeks. The Trail Making Test (TMT) and Inhibitory Control Test (ICT) were used to assess cognitive function in patients withHE. Results were analysed using linear mixed effects regression analyses. RESULTS: Sixty-one participants were enrolled and 49 who returned for at least 1 follow-up review were included in the intention to treat analysis. The mean age was 55.8 ± 6.1 years and 86% were males. Despite evidence of a placebo effect, there was significant improvement in TMT B and ICT weighted lures in participants who received combined synbiotics/BCAAs treatment compared to placebo at study completion (p ≤ 0.05). Cognitive improvement occurred without a significant change in ammonia levels. CONCLUSION: To our knowledge, this is the first study reporting that combined synbiotics and BCAAs improve HE, and that may be beneficial in the management of HE. A larger study is needed to confirm these results.


Assuntos
Aminoácidos de Cadeia Ramificada/administração & dosagem , Encefalopatia Hepática/tratamento farmacológico , Simbióticos/administração & dosagem , Administração Oral , Suplementos Nutricionais , Método Duplo-Cego , Feminino , Encefalopatia Hepática/etiologia , Humanos , Cirrose Hepática/complicações , Masculino , Pessoa de Meia-Idade , Projetos Piloto
9.
Emerg Med Clin North Am ; 37(3): 511-527, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31262418

RESUMO

Patients with end-stage liver disease (ESLD) who require intensive care unit admission have high rates of mortality. This article reviews the pathophysiology and emergency department assessment and management of the most frequent conditions and complications encountered in critically ill ESLD patients including hepatic encephalopathy, gastrointestinal bleeding, sepsis and bacterial peritonitis, hepatorenal syndrome, severe coagulopathy, and hepatic hydrothorax.


Assuntos
Estado Terminal , Doença Hepática Terminal/complicações , Doença Hepática Terminal/terapia , Manuseio das Vias Aéreas/métodos , Coagulação Intravascular Disseminada/diagnóstico , Coagulação Intravascular Disseminada/etiologia , Coagulação Intravascular Disseminada/terapia , Medicina de Emergência , Varizes Esofágicas e Gástricas/complicações , Varizes Esofágicas e Gástricas/terapia , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/etiologia , Hemorragia Gastrointestinal/terapia , Encefalopatia Hepática/diagnóstico , Encefalopatia Hepática/etiologia , Encefalopatia Hepática/terapia , Síndrome Hepatorrenal/diagnóstico , Síndrome Hepatorrenal/etiologia , Síndrome Hepatorrenal/terapia , Humanos , Hidrotórax/diagnóstico , Hidrotórax/etiologia , Hidrotórax/terapia , Hiperamonemia/etiologia , Hiperamonemia/terapia , Unidades de Terapia Intensiva , Transplante de Fígado , Peritonite/diagnóstico , Peritonite/etiologia , Peritonite/terapia , Medição de Risco , Índice de Gravidade de Doença
11.
World J Gastroenterol ; 25(21): 2675-2682, 2019 Jun 07.
Artigo em Inglês | MEDLINE | ID: mdl-31210718

RESUMO

BACKGROUND: Several studies have been conducted to explore the association between the use of proton pump inhibitors (PPIs) and hepatic encephalopathy (HE) risk in patients with liver cirrhosis. However, their results are controversial. AIM: To perform a systematic review and meta-analysis to evaluate the HE risk among PPI users. METHODS: A systematic search on PubMed, Web of Science, EMBase, and ScienceDirect databases was conducted up to December 31, 2018 for eligible studies involving PPI use and HE risk. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using the fixed or random effects model. Publication bias was evaluated using Begg's test, Egger's test, and trim-and-fill method. RESULTS: Seven studies with 4574 patients were included in the present meta-analysis. The meta-analysis results indicated a significant association between the PPI use and HE risk (OR = 1.50; 95%CI: 1.25-1.75) with low heterogeneity (I 2 = 14.2%, P = 0.321). Although publication bias existed when Egger's tests were used (P = 0.005), the trim-and-fill method verified the stability of the pooled result. Sensitivity analyses suggested that the results of this meta-analysis were robust. CONCLUSION: The current evidence indicates that PPI use increases HE risk in patients with liver cirrhosis. Further studies with a large data set and well-designed models are needed to validate our findings.


Assuntos
Encefalopatia Hepática/epidemiologia , Cirrose Hepática/complicações , Inibidores da Bomba de Prótons/efeitos adversos , Encefalopatia Hepática/etiologia , Humanos , Incidência , Medição de Risco , Fatores de Risco
12.
World J Gastroenterol ; 25(21): 2683-2698, 2019 Jun 07.
Artigo em Inglês | MEDLINE | ID: mdl-31210719

RESUMO

BACKGROUND: Several studies have explored the association between the use of proton pump inhibitors (PPIs) and the risk of developing hepatic encephalopathy (HE) in patients with advanced liver disease. However, the evidence-based conclusions are controversial. We hypothesized that using PPIs may increase the risk of HE in patients with advanced liver disease. If confirmed, clinicians must strictly adhere to the indications for PPI treatment in this population. AIM: To evaluate the pooled risk of HE in patients with advanced liver disease who use PPIs. METHODS: Three electronic databases (PubMed, EMBASE, and the Cochrane Library) were searched from the date of database inception through January 8, 2019 to identify comparative studies evaluating the association between PPI use and the risk of HE. Data from the included studies were extracted. The random-effects model was used for pooling risk estimates and the corresponding 95% confidence intervals (CIs). Subgroup and sensitivity analyses were also performed. RESULTS: In total, 4342 patients from five case-control studies and 188053 patients from four cohort studies were included in this analysis. In patients with advanced liver disease, PPI use was associated with an elevated risk of developing HE, with significant heterogeneity. The pooled odds ratio for case-control studies was 2.58 (95%CI: 1.68-3.94, I 2 = 72%). The pooled RR for cohort studies was 1.67 (95%CI: 1.30-2.14, I 2 = 67%). The results of the subgroup analyses suggested that the heterogeneity may be the result of differences in the study designs and the definitions of PPI use. The sensitivity and subgroup analyses did not alter our findings. CONCLUSION: In patients with advanced liver disease, PPI use is associated with an elevated risk of HE. Future large prospective studies are needed to confirm this association.


Assuntos
Encefalopatia Hepática/epidemiologia , Cirrose Hepática/complicações , Inibidores da Bomba de Prótons/efeitos adversos , Progressão da Doença , Encefalopatia Hepática/etiologia , Humanos , Cirrose Hepática/patologia , Estudos Observacionais como Assunto , Prognóstico , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Fatores de Risco
13.
Hepatol Int ; 13(4): 353-390, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31172417

RESUMO

The first consensus report of the working party of the Asian Pacific Association for the Study of the Liver (APASL) set up in 2004 on acute-on-chronic liver failure (ACLF) was published in 2009. With international groups volunteering to join, the "APASL ACLF Research Consortium (AARC)" was formed in 2012, which continued to collect prospective ACLF patient data. Based on the prospective data analysis of nearly 1400 patients, the AARC consensus was published in 2014. In the past nearly four-and-a-half years, the AARC database has been enriched to about 5200 cases by major hepatology centers across Asia. The data published during the interim period were carefully analyzed and areas of contention and new developments in the field of ACLF were prioritized in a systematic manner. The AARC database was also approached for answering some of the issues where published data were limited, such as liver failure grading, its impact on the 'Golden Therapeutic Window', extrahepatic organ dysfunction and failure, development of sepsis, distinctive features of acute decompensation from ACLF and pediatric ACLF and the issues were analyzed. These initiatives concluded in a two-day meeting in October 2018 at New Delhi with finalization of the new AARC consensus. Only those statements, which were based on evidence using the Grade System and were unanimously recommended, were accepted. Finalized statements were again circulated to all the experts and subsequently presented at the AARC investigators meeting at the AASLD in November 2018. The suggestions from the experts were used to revise and finalize the consensus. After detailed deliberations and data analysis, the original definition of ACLF was found to withstand the test of time and be able to identify a homogenous group of patients presenting with liver failure. New management options including the algorithms for the management of coagulation disorders, renal replacement therapy, sepsis, variceal bleed, antivirals and criteria for liver transplantation for ACLF patients were proposed. The final consensus statements along with the relevant background information and areas requiring future studies are presented here.


Assuntos
Insuficiência Hepática Crônica Agudizada/terapia , Lesão Renal Aguda/etiologia , Insuficiência Hepática Crônica Agudizada/diagnóstico , Insuficiência Hepática Crônica Agudizada/etiologia , Transtornos da Coagulação Sanguínea/etiologia , Doença Hepática Induzida por Substâncias e Drogas/etiologia , Criança , Diagnóstico Diferencial , Varizes Esofágicas e Gástricas/etiologia , Hemorragia Gastrointestinal/etiologia , Encefalopatia Hepática/etiologia , Hepatite Autoimune/etiologia , Hepatite Viral Humana/prevenção & controle , Humanos , Transplante de Fígado/métodos , Hepatopatia Gordurosa não Alcoólica/etiologia , Obesidade/complicações , Guias de Prática Clínica como Assunto , Prognóstico , Sepse/etiologia
14.
Dig Dis ; 37(6): 509-517, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31170723

RESUMO

BACKGROUND: The pathogenesis of hepatic encephalopathy (HE) is only partially understood. Beside ammonia accumulation in brain, a proinflammatory component has been suggested as precipitating event. OBJECTIVES: To evaluate the role of cytokines in cirrhosis for development of HE. METHODS: Pro- and anti-inflammatory cytokine profiles were determined in rats with CCL4-induced cirrhosis and HE as well as in patients with cirrhosis either due to metabolic disorders or chronic hepatitis C virus (HCV) with various grades of concomitant HE and depression. RESULTS: In the rat model and human cirrhosis a proinflammatory cytokine pattern (elevation of interferon gamma, interleukin [IL]-1ß, IL-6) was registered which in humans correlated to the degree of HE and depression. The most prominent elevation of proinflammatory cytokines was observed in chronic HCV as an additional inflammatory stimulus. In all cases of cirrhosis a comparable background activation of anti-inflammatory cytokines (e.g., IL-4) was detected which was interpreted as a physiologic counterbalance mechanism. CONCLUSIONS: The degree of HE and depression correlated with a proinflammatory cytokine pattern. It suggests that beside ammonia elevation, inflammatory cytokines determine occurrence and severity of hepatic encephalopathies. Thus, it can be defined a preferential therapeutic target.


Assuntos
Encefalopatia Hepática/etiologia , Encefalopatia Hepática/patologia , Inflamação/complicações , Adulto , Idoso , Animais , Estudos de Casos e Controles , Citocinas/sangue , Citocinas/metabolismo , Depressão/epidemiologia , Modelos Animais de Doenças , Feminino , Humanos , Incidência , Mediadores da Inflamação/sangue , Cirrose Hepática/sangue , Cirrose Hepática/complicações , Masculino , Pessoa de Meia-Idade , Ratos Wistar
15.
Medicine (Baltimore) ; 98(18): e15464, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31045824

RESUMO

There have been few studies comparing percutaneous transhepatic variceal embolization (PTVE) and transjugular intrahepatic portosystemic shunt (TIPS) for the prevention of recurrent gastric variceal bleeding (GVB).Compare the outcomes of these 2 procedures in patients with GVB.A total of 74 cirrhosis patients with GVB who underwent TIPS and modified PTVE were enrolled. The rebleeding and mortality rates, portal vein pressure (PVP) variation, and rates of hepatic encephalopathy (HE) were compared between the 2 groups.A total of 43 PTVE and 31 TIPS patients were enrolled in this study. The difference of rebleeding rate in the 2 groups was not statistically significant (P = .190). The difference of early rebleeding rates and cumulative rebleeding-free rates were all not statistically significant (P = .256, P = .200). The difference of mortality rates in the 2 groups was not statistically significant (χ = 1.206, P = .272). The rate of HE in TIPS group was statistically higher than that in PTVE group (P < .0001).Both PTVE and TIPS were effective for preventing rebleeding of GVs. There were no significant differences in rebleeding and mortality rates. The incidence of HE after TIPS was higher than PTVE.


Assuntos
Embolização Terapêutica/efeitos adversos , Varizes Esofágicas e Gástricas/cirurgia , Hemorragia Gastrointestinal/cirurgia , Fígado/cirurgia , Derivação Portossistêmica Transjugular Intra-Hepática/efeitos adversos , Adulto , Idoso , Embolização Terapêutica/métodos , Varizes Esofágicas e Gástricas/complicações , Varizes Esofágicas e Gástricas/mortalidade , Feminino , Hemorragia Gastrointestinal/etiologia , Hemorragia Gastrointestinal/mortalidade , Encefalopatia Hepática/epidemiologia , Encefalopatia Hepática/etiologia , Humanos , Incidência , Fígado/irrigação sanguínea , Masculino , Pessoa de Meia-Idade , Veia Porta/cirurgia , Derivação Portossistêmica Transjugular Intra-Hepática/métodos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
16.
J Vasc Interv Radiol ; 30(6): 876-884, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31126600

RESUMO

PURPOSE: To report the results of transjugular intrahepatic portosystemic shunt (TIPS) reductions for hepatic encephalopathy (HE), acute liver failure (ALF), and pulmonary hypertension (PH). MATERIALS AND METHODS: A single-institution retrospective review analysis was performed between 2007 and 2017 on patients undergoing TIPS reduction at single tertiary liver transplant center. A total of 27 patients (14 males and 13 females) underwent TIPS reduction for refractory HE (n = 18), ALF (n = 7), and PH (n = 2). The average age at time of reduction was 59 years (range, 23-73; standard deviation [SD], 8). Mean prereduction Model of End-State Liver Disease-Na and portosystemic pressure gradient were 19 (range, 11-29; SD, 6) and 9.4 mm Hg (range, -2 to 19; SD, 4.8), respectively. Comparison between responders and nonresponders was performed for multiple variables using a 2-tailed t test. Methods of reduction were compared in cases of HE. RESULTS: Technical success, defined as a decrease of at least 50% of the caliber of the shunt, was 100%. Clinical success rates in improving HE, ALF, and PH were calculated at 89%, 71%, and 100%, respectively. Eight patients had major and 10 had minor complications after the reductions. There were 3 shunt thrombosis. Pre- and postreduction Model of End-State Liver Disease-Na, portosystemic pressure gradient change, duration of indwelling TIPS, and reduction method were not significantly different between responders and nonresponders. Six-month survival rates were 80%, 20%, and 100% for HE, ALF, and PH, respectively. CONCLUSIONS: TIPS reduction is effective in reversing refractory HE, ALF, and PH after TIPS creation. TIPS reduction is associated with a high rate of complications and should be reserved for severe refractory overshunting complications.


Assuntos
Angioplastia com Balão , Implante de Prótese Vascular , Encefalopatia Hepática/cirurgia , Hipertensão Pulmonar/cirurgia , Falência Hepática Aguda/cirurgia , Derivação Portossistêmica Transjugular Intra-Hepática/efeitos adversos , Adulto , Idoso , Angioplastia com Balão/efeitos adversos , Angioplastia com Balão/instrumentação , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Bases de Dados Factuais , Feminino , Encefalopatia Hepática/etiologia , Encefalopatia Hepática/fisiopatologia , Humanos , Hipertensão Pulmonar/etiologia , Hipertensão Pulmonar/fisiopatologia , Falência Hepática Aguda/etiologia , Falência Hepática Aguda/fisiopatologia , Masculino , Pessoa de Meia-Idade , Reoperação , Estudos Retrospectivos , Fatores de Risco , Stents , Texas , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
17.
Ter Arkh ; 91(2): 52-58, 2019 Mar 18.
Artigo em Inglês | MEDLINE | ID: mdl-31094172

RESUMO

AIM: Study of the social consequences of cognitive disorders in minimal hepatic encephalopathy (MHE) in patients with chronic genotype 1 hepatitis C and the possibilities of their pharmacological correction with L-ornithine-L-aspartate (LOLA, Hepa-Merz). MATERIALS AND METHODS: The study group included 60 male patients diagnosed with chronic hepatitis C, genotype 1 with fibrosis stage F1 according to the METAVIR scale, and presented with MHE. The average age of the patients was 34.2±5.3 years. The control group included 20 healthy men aged 34.1±5.8 years without liver disease. Intermittent treatment with LOLA was given to the study group at 15 g once daily in the morning for 2 months with 2-month off-treatment intervals, with the total treatment duration of 12 months. In the course of treatment, MHE dynamics was assessed using the critical flicker fusion frequency (CFF) test and the number connecting test (NCT), as well as by serum concentrations of ammonium ion. The LOLA efficacy endpoint was the change in the frequency of violations of traffic rules (traffic code). RESULTS: A significant decrease in the concentration of ammonium ion was observed after 5 months of treatment (135.53 and 82.9 µmol/L, p=0.002) and maintained throughout the study. The results of the CFF test significantly improved by the end of the 1st month of LOLA treatment (p=0.008), remaining at the achieved level for 9 months. The NCT parameters reached their minimum values after 5 months (p<0.001) and remained at this level throughout the study. During the study period, the frequency of traffic code violations by participants decreased from 60 to 40% (р=0.03). CONCLUSION: Fractional treatment with LOLA leads to a decrease in the blood concentration of ammonium ion and, consequently, to an improvement in psychometric test results and a decrease in the frequency of traffic code violations. The result achieved can have an impact on the accident rate reduction.


Assuntos
Dipeptídeos/uso terapêutico , Encefalopatia Hepática/tratamento farmacológico , Hepatite C Crônica/complicações , Hiperamonemia/tratamento farmacológico , Adulto , Amônia/sangue , Estudos de Casos e Controles , Encefalopatia Hepática/diagnóstico , Encefalopatia Hepática/etiologia , Humanos , Hiperamonemia/diagnóstico , Masculino , Resultado do Tratamento
18.
Turk J Gastroenterol ; 30(5): 398-407, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31060994

RESUMO

Minimal hepatic encephalopathy (MHE) is a major neuropsychiatric complication of liver cirrhosis and portosystemic shunting. Although MHE produces a spectrum of cognitive impairments in the domains of short-term attention, working memory, and executive function, it generally does not present with obvious clinical manifestation on conventional assessments. Paper-and-pencil psychometric tests, such as the psychometric hepatic encephalopathy score and the repeatable battery for the assessment of neuropsychological status, are recommended to diagnose MHE. However, these tests are neither rapid nor convenient to use in practice. To facilitate repeated testing in clinic and follow-up, computer-aided psychometric tests, such as the scan test, Cognitive Drug Research assessment battery, inhibitory control test, EncephalApp Stroop App, and critical flicker frequency, have been used to screen for MHE among patients with liver cirrhosis. The aim of this review was to describe the progression from the utility of paper-and-pencil to computer-aided psychometric tests for MHE screening in clinical practice.


Assuntos
Diagnóstico por Computador/métodos , Encefalopatia Hepática/diagnóstico , Cirrose Hepática/psicologia , Testes Neuropsicológicos , Psicometria/métodos , Encefalopatia Hepática/etiologia , Humanos
19.
Gastroenterol Nurs ; 42(3): 277-285, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31145253

RESUMO

Hepatic encephalopathy is a complication of liver failure characterized by neuropsychiatric dysfunction ranging from disorientation to coma. There is a need for more treatment options and preventive care interventions to reduce the incidence of hepatic encephalopathy and mitigate its socioeconomic impact on families and strain on healthcare resources. Currently, there is no consensus on a single pathophysiological mechanism responsible for the development of this neurocognitive disorder. Ammonia toxicity remains a significant factor, but there is now increased recognition that hyperammonemia acts synergistically with systemic inflammation, oxidative stress, and gut microbiota imbalance in the development of hepatic encephalopathy. This article provides an overview of current and emerging therapies that target these factors in the treatment and management of this condition. Because of its complex pathogenesis, a multipronged approach to treating hepatic encephalopathy may be highly beneficial.


Assuntos
Encefalopatia Hepática/diagnóstico , Encefalopatia Hepática/terapia , Fármacos Gastrointestinais/uso terapêutico , Encefalopatia Hepática/etiologia , Humanos , Hiperamonemia/complicações , Hiperamonemia/terapia , Lactulose/uso terapêutico
20.
Hepatobiliary Pancreat Dis Int ; 18(3): 237-241, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31029554

RESUMO

BACKGROUND: Cirrhotic patients are susceptible to Clostridium difficile infection (CDI), however, the high risk factors are not clear. The present study aimed to identify the risk factors in cirrhotic patients with CDI. METHODS: A total of 526 cirrhotic patients admitted to our hospital between May 2015 and October 2015 were included in this study. Stool samples were collected upon admission for the detection of CDI and toxin. CDI was monitored during the hospital stay. In total, 34 cases showed CDI. Then we analyzed the effects of age, sex, C. difficile colonization (CDC), multiple hospitalization, extended hospital stay, elevation of total bilirubin (TBIL), creatinine (Cr), Child-Pugh grade C, hepatic encephalopathy, hepatorenal syndrome, upper gastrointestinal hemorrhage, and exposure of antibiotics and proton pump inhibitor (PPI) on the CDI in cirrhotic patients. RESULTS: Patients in the CDI group had more frequent CDC, multiple hospitalization, and extended hospital stay compared to those in the non-C. difficile infection (NCDI) group. Patients in the CDI group had higher TBIL and Cr, and higher frequency of Child-Pugh grade C, hepatic encephalopathy, upper gastrointestinal hemorrhage compared with those in the NCDI group. Multiple logistic regression analysis indicated that age >60 years (OR=1.689; 95% CI: 1.135-3.128), multiple hospitalization (OR=3.346; 95% CI: 1.392-8.043), length of hospital stay >20 days (OR=1.564; 95% CI: 1.113-2.563), hypoproteinemia (OR=4.962; 95% CI: 2.053-11.996), CDC (OR=18.410; 95% CI: 6.898-49.136), hepatic encephalopathy (OR=1.357; 95% CI: 1.154-2.368), and exposure of antibiotics (OR=1.865; 95% CI: 1.213-2.863) and PPI (OR=3.125; 95% CI: 1.818-7.548) were risk factors of CDI. CONCLUSIONS: Age >60 years, multiple hospitalization, length of hospital stay >20 days, hypoproteinemia, CDC, hepatic encephalopathy, and exposure of antibiotics and PPI were risk factors for CDI in cirrhotic patients. These may contribute to the early diagnosis and monitoring of CDI in clinical practice.


Assuntos
Infecções por Clostridium/microbiologia , Cirrose Hepática/complicações , Adulto , Idoso , Antibacterianos/efeitos adversos , Infecções por Clostridium/diagnóstico , Infecções por Clostridium/terapia , Feminino , Encefalopatia Hepática/etiologia , Humanos , Tempo de Internação , Cirrose Hepática/diagnóstico , Cirrose Hepática/terapia , Masculino , Pessoa de Meia-Idade , Admissão do Paciente , Readmissão do Paciente , Prognóstico , Inibidores da Bomba de Prótons/efeitos adversos , Medição de Risco , Fatores de Risco
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