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1.
Surgery ; 168(3): 434-439, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32600882

RESUMO

BACKGROUND: Pancreatoduodenectomy with synchronous resection of the portal vein/superior mesenteric vein confluence may result in the development of left-sided portal hypertension. Left-sided portal hypertension presents with splenomegaly and varices and may cause severe gastrointestinal bleeding. The aim of the study is to review the incidence, treatment, and preventive strategies of left-sided portal hypertension. METHODS: A systematic literature search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement to identify all studies published up to September 30, 2019 reporting data on patients with left-sided portal hypertension after pancreatoduodenectomy with venous resection. RESULTS: Eight articles including 829 patients were retrieved. Left-sided portal hypertension occurred in 7.7% of patients who had splenic vein preservation and 29.4% of those having splenic vein ligation. Fourteen cases of gastrointestinal bleeding owing to left-sided portal hypertension were reported at a mean interval of 28 months from pancreatoduodenectomy. Related mortality at 1 month was 7.1%. Treatment of left-sided portal hypertension consisted of splenectomy in 3 cases (21%) and colectomy in 1 (7%) case, whereas radiologic, endoscopic procedures or conservative treatments were effective in the other cases (71%). CONCLUSION: Left-sided portal hypertension represents a potentially severe complication of pancreatoduodenectomy with venous resection occurring at greater incidence when the splenic vein is ligated and not reimplanted. Left-sided portal hypertension-related gastrointestinal bleeding although rare can be managed depending on the situation by endoscopic, radiologic procedures or operative intervention with low related mortality.


Assuntos
Hipertensão Portal/epidemiologia , Veias Mesentéricas/cirurgia , Pancreaticoduodenectomia/efeitos adversos , Veia Porta/cirurgia , Complicações Pós-Operatórias/epidemiologia , Carcinoma Ductal Pancreático/cirurgia , Colectomia/estatística & dados numéricos , Tratamento Conservador/estatística & dados numéricos , Hemorragia Gastrointestinal/epidemiologia , Hemorragia Gastrointestinal/etiologia , Hemorragia Gastrointestinal/terapia , Humanos , Hipertensão Portal/etiologia , Hipertensão Portal/terapia , Incidência , Ligadura/efeitos adversos , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/métodos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Esplenectomia/estatística & dados numéricos , Esplenomegalia/epidemiologia , Esplenomegalia/etiologia , Esplenomegalia/terapia , Resultado do Tratamento
2.
Med Clin North Am ; 104(4): 647-662, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32505258

RESUMO

Hospitalists often care for patients with liver disease, including those with acute liver injury and failure and patients with complications of decompensated cirrhosis. Acute liver failure is a true emergency, requiring intensive care and oftentimes transfer of the patient to a liver transplant center. Patients with decompensated cirrhosis have complications of portal hypertension, including variceal hemorrhage, ascites, spontaneous bacterial peritonitis, and hepatic encephalopathy. These complications increase the risk of mortality among patients with decompensated cirrhosis. Comanagement by the hospitalist with gastroenterology/hepatology can optimize care, especially for patients being considered for liver transplant evaluation.


Assuntos
Varizes Esofágicas e Gástricas/etiologia , Hemorragia Gastrointestinal/etiologia , Cirrose Hepática/terapia , Falência Hepática Aguda/etiologia , Ascite/epidemiologia , Ascite/etiologia , Varizes Esofágicas e Gástricas/epidemiologia , Hemorragia Gastrointestinal/epidemiologia , Encefalopatia Hepática/epidemiologia , Encefalopatia Hepática/etiologia , Humanos , Hipertensão Portal/epidemiologia , Hipertensão Portal/etiologia , Cirrose Hepática/complicações , Cirrose Hepática/fisiopatologia , Falência Hepática Aguda/epidemiologia , Transplante de Fígado , Peritonite/epidemiologia , Peritonite/etiologia
3.
Medicine (Baltimore) ; 99(5): e18923, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32000404

RESUMO

To evaluate the risk of first upper gastrointestinal bleeding by computerized tomoscanning (CT) for esophageal varices patients with cirrhotic portal hypertension.One hundred thirty two esophageal varices patients with cirrhotic portal hypertension who are also complicated with gastrointestinal bleeding were recruited as bleeding group, while another 132 patients without bleeding as non-bleeding group. The diameter of esophageal varices, number of vascular sections, and total area of blood vessels were measured by CT scanning. The sensitivity and specificity of these indicators were calculated, and Youden index was adjusted with the critical point.The diameter of esophageal varices was 7.83 ±â€Š2.76 mm in bleeding group, and 6.57 ±â€Š3.42 mm in non-bleeding group. The Youden index was 0.32 with the critical point 5.55 mm. The area under the receiver operating characteristics (AUROC) was 0.72. The number of venous vessels was 4.5 ±â€Š2 in bleeding group, whereas being 4 ±â€Š2 in non-bleeding group. The Youden index was 0.35 with a critical point 4, and the area under the curve (AUC) was 0.68. The blood vessel area was 1.73 ±â€Š1.15 cm in bleeding group, and 1.12 ±â€Š0.89 cm in non-bleeding group. The Youden index was 0.48 with the critical point being 1.03 cm, and corresponding AUC was 0.82.Among all 3 indicators of the total area, diameter, and number of sections of the esophageal varices, the total area of esophageal varices showed more accuracy as a potential and novel indicator for bleeding prediction.


Assuntos
Varizes Esofágicas e Gástricas/complicações , Varizes Esofágicas e Gástricas/diagnóstico por imagem , Hemorragia Gastrointestinal/diagnóstico por imagem , Hipertensão Portal/complicações , Cirrose Hepática/complicações , Tomografia Computadorizada por Raios X , Adulto , Idoso , Varizes Esofágicas e Gástricas/epidemiologia , Esôfago/diagnóstico por imagem , Feminino , Hemorragia Gastrointestinal/epidemiologia , Hemorragia Gastrointestinal/etiologia , Humanos , Hipertensão Portal/diagnóstico por imagem , Hipertensão Portal/epidemiologia , Cirrose Hepática/diagnóstico por imagem , Cirrose Hepática/epidemiologia , Masculino , Pessoa de Meia-Idade , Medição de Risco , Sensibilidade e Especificidade
4.
Dig Dis Sci ; 65(2): 406-415, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31489564

RESUMO

BACKGROUND: Primary biliary cholangitis (PBC) is a progressive autoimmune liver disease that can result in cirrhosis and end-stage liver disease. AIMS: We aim to evaluate hospitalization burden and in-hospital mortality among PBC patients in the USA. METHODS: Using data from the Nationwide Inpatient Sample from 2007 to 2014, hospitalizations among US adults with PBC were stratified by sex, age, and race/ethnicity. Overall in-hospital mortality was stratified by these variables and adjusted multivariate regression models evaluated for predictors of in-hospital mortality. RESULTS: From 2007 to 2014, there were 18,279 hospitalizations among adults with PBC (15.0% male, mean age 63.8 years, 41.3% cirrhosis). Among non-Hispanic whites, the proportion of total PBC hospitalizations increased from 57.8% in 2007 to 71.2% in 2014, compared to 4.1-6.3% for African-Americans, 8.6-10.9% for Hispanics, and 1.7-2.8% for Asians (p < 0.001 for all). While overall in-hospital mortality was low (4.2%), increasing age was associated with higher odds of in-hospital mortality (OR: 1.02, 95% CI 1.01-1.03, p < 0.001). Compared to non-Hispanic white PBC patients, higher in-hospital mortality was observed in African-American PBC patients (OR: 1.40, 95% CI 1.16-2.03, p < 0.05). Compared to patients with private/commercial insurance, significantly higher odds of in-hospital mortality were observed in patients with Medicaid insurance (OR 1.42, 95% CI 1.00-1.99, p < 0.05). CONCLUSION: In summary, among adults with PBC hospitalized in the USA from 2007 to 2014, the overall number of hospitalizations is increasing. Significant disparities in in-hospital mortality were observed; African-Americans with PBC and Medicaid patients with PBC have disproportionately higher odds of in-hospital mortality.


Assuntos
Grupos Étnicos/estatística & dados numéricos , Disparidades em Assistência à Saúde/etnologia , Mortalidade Hospitalar , Hospitalização/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Cirrose Hepática Biliar/mortalidade , Medicaid/estatística & dados numéricos , Adulto , Afro-Americanos/estatística & dados numéricos , Fatores Etários , Americanos Asiáticos/estatística & dados numéricos , Varizes Esofágicas e Gástricas/epidemiologia , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Feminino , Hemorragia Gastrointestinal/epidemiologia , Disparidades em Assistência à Saúde/estatística & dados numéricos , Hispano-Americanos/estatística & dados numéricos , Preços Hospitalares/estatística & dados numéricos , Hospitalização/economia , Humanos , Hipertensão Portal/epidemiologia , Cirrose Hepática Biliar/economia , Cirrose Hepática Biliar/epidemiologia , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Índice de Gravidade de Doença , Estados Unidos , Adulto Jovem
5.
PLoS One ; 14(11): e0224506, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31693695

RESUMO

BACKGROUND AND AIMS: Studies in animal models have suggested that hepatic steatosis impacts on portal pressure, potentially by inducing liver sinusoidal endothelial dysfunction and thereby increasing intrahepatic resistance. Thus, we aimed to evaluate the impact of hepatic steatosis on hepatic venous pressure gradient (HVPG) in patients with chronic liver disease. METHOD: 261 patients undergoing simultaneous HVPG measurements and controlled attenuation parameter (CAP)-based steatosis assessment were included in this retrospective study. RESULTS: The majority of patients had cirrhosis (n = 205; 78.5%) and n = 191 (73.2%) had clinically significant portal hypertension (CSPH; HVPG≥10mmHg). Hepatic steatosis (S1/2/3; CAP ≥248dB/m) was present in n = 102 (39.1%). Overall, HVPG was comparable between patients with vs. without hepatic steatosis (15.5±7.5 vs. 14.8±7.7mmHg; p = 0.465). Neither in patients with HVPG (<6mmHg; p = 0.371) nor in patients with mild portal hypertension (HVPG 6-9mmHg; p = 0.716) or CSPH (HVPG≥10mmHg; p = 0.311) any correlation between CAP and HVPG was found. Interestingly, in patients with liver fibrosis F2/3, there was a negative correlation between CAP and HVPG (Pearson's ρ:-0.522; p≤0.001). In multivariate analysis, higher CAP was an independent 'protective' factor for the presence of CSPH (odds ratio [OR] per 10dB/m: 0.92, 95% confidence interval [CI]:0.85-1.00; p = 0.045), while liver stiffness was associated with the presence of CSPH (OR per kPa: 1.26, 95%CI: 1.17-1.36; p≤0.001). In 78 patients, in whom liver biopsy was performed, HVPG was neither correlated with percentage of histological steatosis (p = 0.714) nor with histological steatosis grade (p = 0.957). CONCLUSION: Hepatic steatosis, as assessed by CAP and liver histology, did not impact on HVPG in our cohort comprising a high proportion of patients with advanced chronic liver disease. However, high CAP values (i.e. pronounced hepatic steatosis) might lead to overestimation of liver fibrosis by 'artificially' increasing transient elastography-based liver stiffness measurements.


Assuntos
Hipertensão Portal/epidemiologia , Cirrose Hepática/epidemiologia , Hepatopatia Gordurosa não Alcoólica/complicações , Pressão na Veia Porta , Adulto , Idoso , Técnicas de Imagem por Elasticidade , Feminino , Humanos , Hipertensão Portal/diagnóstico , Hipertensão Portal/etiologia , Fígado/irrigação sanguínea , Fígado/diagnóstico por imagem , Fígado/patologia , Cirrose Hepática/diagnóstico , Cirrose Hepática/etiologia , Masculino , Pessoa de Meia-Idade , Hepatopatia Gordurosa não Alcoólica/patologia , Estudos Retrospectivos
6.
World J Gastroenterol ; 25(33): 4885-4891, 2019 Sep 07.
Artigo em Inglês | MEDLINE | ID: mdl-31543680

RESUMO

Portal hypertension, liver fibrosis, and angiosarcoma of the liver (ASL) have been reported among workers exposed to vinyl chloride monomer (VCM) since the 1970s. In 2007, the International Agency for Research on Cancer established the association of VCM with hepatocellular carcinoma (HCC), though only on the basis of the few cases available. Thereafter, recent reports from the United States cohort and a European sub-cohort of vinyl chloride workers provided compelling evidence of a strong association between cumulative VCM exposure and HCC risk. Further areas of research include the risk of liver cancer at lower levels of exposure and different patterns of risk of ASL and HCC with the time since exposure. The evidence of interaction between VCM exposure and other known liver carcinogens such as alcohol and chronic viral infection provides clues for the health surveillance of exposed workers. Notably, also the risk of VCM-associated chronic liver disease is modulated by alcohol consumption, viral infection, and genetic polymorphism. A counter-intuitive finding from cohort studies of exposed workers is the lower mortality from liver cirrhosis with respect to the general population; this can be attributed to the healthy worker effect and to the selection of liver cancer as the cause of death in the presence of concomitant chronic liver disease. Studies designed to overcome these intricacies confirmed an association between cumulative VCM exposure and the risk of liver cirrhosis.


Assuntos
Carcinógenos/toxicidade , Doenças Profissionais/epidemiologia , Exposição Ocupacional/efeitos adversos , Cloreto de Vinil/toxicidade , Consumo de Bebidas Alcoólicas/efeitos adversos , Consumo de Bebidas Alcoólicas/epidemiologia , Causas de Morte , Doença Crônica/epidemiologia , Europa (Continente)/epidemiologia , Hemangiossarcoma/epidemiologia , Hemangiossarcoma/etiologia , Hemangiossarcoma/patologia , Humanos , Hipertensão Portal/epidemiologia , Hipertensão Portal/etiologia , Hipertensão Portal/patologia , Cirrose Hepática/epidemiologia , Cirrose Hepática/etiologia , Cirrose Hepática/patologia , Neoplasias Hepáticas/epidemiologia , Neoplasias Hepáticas/etiologia , Neoplasias Hepáticas/patologia , Doenças Profissionais/etiologia , Doenças Profissionais/patologia , Fatores de Risco , Análise de Sobrevida , Estados Unidos/epidemiologia , Viroses/complicações , Viroses/epidemiologia
7.
Expert Rev Gastroenterol Hepatol ; 13(10): 1017-1022, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31393183

RESUMO

Background: Central obesity, due to the accumulation of visceral fat(VF), is one of the main risk factors for venous thrombosis. The aim of this study was to determine if VF may be a risk factor for development of portal vein thrombosis(PVT) in cirrhotic patients.Methods: A total of 214 cirrhotic patients at the outpatient clinic were consecutively included, undergoing an anthropometric evaluation, blood tests and bioimpedance.Results: Median MELDscore was10. Prior liver decompensation occurred in 44.9% of patients and 35.6% of patients had large esophageal varices. Mean body mass index was 28.7 Kg/m2 (39.3%were obese) and mean waist circumference(WC) was 103.8 cm. A 7.5% of patients had PVT at the time of inclusion. PVT was more frequent in males(93.8 vs. 68.2%, p = 0.03). Patients with PVT had a higher WC(111.9 vs. 103.2 cm, p = 0.02) and VF (17.1 vs. 14.5, p = 0.04). PVT was also more frequent in patients with prior decompensation (81.3 vs. 41.9%, p < 0.01) and with large esophageal varices(62.5 vs. 33.3%, p = 0.02). In the simplified multivariate analysis, PVT was independently associated with the presence of portal hypertension(OR 13, 95%CI 1.6-108.3, p = 0.02) and VF(OR 1.2, 95%CI 1.03-1.3, p = 0.01).Conclusion: VF was independently associated with PVT in cirrhotic patients. VF may be more reliable than conventional anthropometric measurements for cirrhotic patients.


Assuntos
Adiposidade , Gordura Intra-Abdominal/fisiopatologia , Cirrose Hepática/epidemiologia , Obesidade Abdominal/epidemiologia , Veia Porta , Trombose Venosa/epidemiologia , Idoso , Impedância Elétrica , Feminino , Humanos , Hipertensão Portal/epidemiologia , Cirrose Hepática/diagnóstico , Masculino , Pessoa de Meia-Idade , Obesidade Abdominal/diagnóstico , Obesidade Abdominal/fisiopatologia , Veia Porta/diagnóstico por imagem , Prevalência , Prognóstico , Medição de Risco , Fatores de Risco , Espanha/epidemiologia , Trombose Venosa/diagnóstico por imagem , Circunferência da Cintura
8.
Indian J Med Res ; 149(4): 468-478, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-31411170

RESUMO

In India, an unexplained enteropathy is present in a majority of non-cirrhotic intrahepatic portal hypertension (NCIPH) patients. Small intestinal bacterial contamination and tropical enteropathy could trigger inflammatory stimuli and activate the endothelium in the portal venous system. Groundwater contaminated with arsenic is an environmental factor of epidemic proportions in large areas of India which has similar consequences. Von Willebrand factor (a sticky protein) expressed by activated endothelium may promote formation of platelet microthrombi and occlusion of intrahepatic portal vein branches leading to NCIPH. Environmental factors linked to suboptimal hygiene and sanitation, which enter through the gastrointestinal (GI) tract, predispose to platelet plugging onto activated endothelium in portal microcirculation. Thus, NCIPH, an example of poverty linked thrombophilia, is a disease mainly affecting the lower socio-economic strata of Indian population. Public health measures to improve sanitation, provide clean drinking water and eliminate arsenic contamination of drinking water are urgently needed. Till such time as these environmental factors are addressed, NCIPH is likely to remain 'an Indian disease'.


Assuntos
Hipertensão Portal/epidemiologia , Fígado/patologia , Veia Porta/patologia , Trombofilia/epidemiologia , Arsênico/toxicidade , Plaquetas/efeitos dos fármacos , Endotélio/efeitos dos fármacos , Meio Ambiente , Humanos , Hipertensão Portal/etiologia , Hipertensão Portal/patologia , Índia/epidemiologia , Fígado/efeitos dos fármacos , Cirrose Hepática/epidemiologia , Cirrose Hepática/patologia , Pobreza , Trombofilia/etiologia , Trombofilia/patologia
9.
Liver Int ; 39(9): 1768-1775, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31152478

RESUMO

BACKGROUND & AIMS: Sclerosing cholangitis (SC) is a severe liver disease leading to destruction of bile ducts. It is believed to run a milder course in children than in adults. To test this assumption, we evaluated time-to-complication curves in two independent paediatric-onset cohorts from the same geographical area. METHODS: Short-term disease outcomes were evaluated with an online clinical registry that was filled with data on children with SC diagnosed between 2000 and 2017 and who were followed bi-annually thereafter. Long-term disease outcomes were evaluated in a paediatric-onset subcohort derived from a previously published population-based study from the Netherlands. Time-to-complication in the first cohort was defined as the time from diagnosis until portal hypertension, biliary obstructions and infections, development of malignancy, or liver transplantation, whichever came first. In the second cohort time-to-complication was defined as the time until liver transplantation or PSC-related death. RESULTS: Median age at diagnosis in the first cohort (n = 86) was 12.3 years. In the first 5 years post-diagnosis 23% of patients developed complications. The patients in the population-based study (n = 683) were stratified into those diagnosed before the age of 18 years ('paediatric-onset' subcohort, n = 43) and those diagnosed after the age of 18 years ('adult-onset' subcohort, n = 640). Median age at diagnosis was 14.6 and 40.2 years, respectively. Median time-to-complication in the paediatric-onset and adult-onset subcohorts was not statistically different. CONCLUSION: Paediatric and adult-onset SC run a similar long-term disease course. Paediatricians who treat children with SC should monitor them closely to recognize early complications and control long-term sequelae.


Assuntos
Colangite Esclerosante/epidemiologia , Hepatite Autoimune/epidemiologia , Hipertensão Portal/epidemiologia , Adolescente , Adulto , Idade de Início , Criança , Colangite Esclerosante/diagnóstico , Colangite Esclerosante/mortalidade , Estudos de Coortes , Progressão da Doença , Feminino , Hepatite Autoimune/diagnóstico , Hepatite Autoimune/mortalidade , Humanos , Fígado/patologia , Transplante de Fígado , Modelos Logísticos , Masculino , Países Baixos/epidemiologia , Prognóstico , Sistema de Registros , Adulto Jovem
10.
Eur Heart J ; 40(31): 2632-2653, 2019 08 14.
Artigo em Inglês | MEDLINE | ID: mdl-31116395

RESUMO

Identification and management of patients at high bleeding risk undergoing percutaneous coronary intervention are of major importance, but a lack of standardization in defining this population limits trial design, data interpretation, and clinical decision-making. The Academic Research Consortium for High Bleeding Risk (ARC-HBR) is a collaboration among leading research organizations, regulatory authorities, and physician-scientists from the United States, Asia, and Europe focusing on percutaneous coronary intervention-related bleeding. Two meetings of the 31-member consortium were held in Washington, DC, in April 2018 and in Paris, France, in October 2018. These meetings were organized by the Cardiovascular European Research Center on behalf of the ARC-HBR group and included representatives of the US Food and Drug Administration and the Japanese Pharmaceuticals and Medical Devices Agency, as well as observers from the pharmaceutical and medical device industries. A consensus definition of patients at high bleeding risk was developed that was based on review of the available evidence. The definition is intended to provide consistency in defining this population for clinical trials and to complement clinical decision-making and regulatory review. The proposed ARC-HBR consensus document represents the first pragmatic approach to a consistent definition of high bleeding risk in clinical trials evaluating the safety and effectiveness of devices and drug regimens for patients undergoing percutaneous coronary intervention.


Assuntos
Stents Farmacológicos/efeitos adversos , Terapia Antiplaquetária Dupla/efeitos adversos , Hemorragia/etiologia , Intervenção Coronária Percutânea/efeitos adversos , Stents/efeitos adversos , Síndrome Coronariana Aguda/complicações , Síndrome Coronariana Aguda/epidemiologia , Síndrome Coronariana Aguda/fisiopatologia , Idoso , Idoso de 80 Anos ou mais , Anemia/complicações , Anemia/epidemiologia , Anemia/fisiopatologia , Ásia/epidemiologia , Tomada de Decisão Clínica , Ensaios Clínicos como Assunto , Consenso , Europa (Continente)/epidemiologia , Fibrose/complicações , Fragilidade/complicações , Fragilidade/epidemiologia , Fragilidade/fisiopatologia , Hemorragia/epidemiologia , Humanos , Hipertensão Portal/epidemiologia , Hipertensão Portal/fisiopatologia , Adesão à Medicação/estatística & dados numéricos , Metais , Intervenção Coronária Percutânea/instrumentação , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/epidemiologia , Insuficiência Renal Crônica/fisiopatologia , Medição de Risco , Segurança , Trombocitopenia/complicações , Trombocitopenia/epidemiologia , Trombocitopenia/fisiopatologia , Resultado do Tratamento , Estados Unidos/epidemiologia
11.
Ter Arkh ; 91(2): 73-81, 2019 Mar 18.
Artigo em Inglês | MEDLINE | ID: mdl-31094175

RESUMO

AIM: To build a predictive model for PVT in cirrhotic patients. MATERIALS AND METHODS: A single centre case-control study was carried out. From the database of 1512 cirrhotic patients 94 with newly diagnosed PVT based on contrast-enhanced computed tomography were referred to the Case group. Malignant PVT was an exclusion criterion. Patients without PVT were stratified and matched according to sex, age and etiology of cirrhosis; case-control ratio was 1 : 3-4. The prevalence of PVT in the database, clinical, laboratory, instrumental parameters of the groups were evaluated. Logistic regression model was used to estimate association between variables and PVT. RESULTS: The overall prevalence of PVT was 6.2% with the highest rates among the patients with HBV infection - 16.7%, nonalcoholic steatohepatitis - 15.6%, alcohol abuse in combination with HCV infection - 11.7%. The best predictive model included variables: Child-Pugh classes B-C (coefficient of regression ß=1.853, р=0.001), ascites (ß=0.460, р=0.003), hepatocellular carcinoma without vascular invasion (ß=2.126, р=0.0001), endoscopic band ligation (ß=0.774, р=0.003), azygoportal disconnection (ß=2.734, р=0.001), portal hypertensive gastropathy (ß=0.793, р=0.017), portal vein diameter (ß=0.203, р=0.004), and local factors - ulcerative colitis flare, Clostridium difficile enterocolitis, spontaneous bacterial peritonitis, colorectal cancer, splenectomy, cholecystectomy (ß=2.075, р=0.017). The model had accuracy 85.8% (95% CI 81.7-89.4%), sensitivity - 55.1% (95% CI 43.4-66.4%), specificity - 95% (95% CI 91.6-97.3%), and AUC - 0.871 (95% CI 0.826-0.916). CONCLUSION: Child-Pugh classes B-C, severe portal hypertension, hepatocellular carcinoma without vascular invasion, and local factors were estimated as risk factors of PVT in cirrhotic patients.


Assuntos
Cirrose Hepática/complicações , Cirrose Hepática/fisiopatologia , Veia Porta/diagnóstico por imagem , Veia Porta/patologia , Trombose Venosa/etiologia , Trombose Venosa/fisiopatologia , Adulto , Estudos de Casos e Controles , Feminino , Humanos , Hipertensão Portal/epidemiologia , Cirrose Hepática/epidemiologia , Neoplasias Hepáticas/epidemiologia , Masculino , Pessoa de Meia-Idade , Prevalência , Fatores de Risco , Tomografia Computadorizada por Raios X , Trombose Venosa/complicações , Trombose Venosa/epidemiologia
12.
Ann Hepatol ; 18(4): 553-562, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31126882

RESUMO

Liver disease during pregnancy is more common than expected and may require specialized intervention. It is important to determine if changes in liver physiology may develop into liver disease, to assure early diagnosis. For adequate surveillance of mother-fetus health outcome, liver disease during pregnancy might require intervention from a hepatologist. Liver diseases have a prevalence of at least 3% of all pregnancies in developed countries, and they are classified into two main categories: related to pregnancy; and those non- related that are present de novo or are preexisting chronic liver diseases. In this review we describe and discuss the main characteristics of those liver diseases associated with pregnancy and only some frequent pre-existing and co-incidental in pregnancy are considered. In addition to the literature review, we compiled the data of liver disease occurring during pregnancies attended at the National Institute of Perinatology in Mexico City in a three-year period. In our tertiary referral women hospital, liver disease was present in 11.24 % of all pregnancies. Associated liver disease was found in 10.8% of all pregnancies, mainly those related to pre-eclampsia (9.9% of pregnancies). Only 0.56% was due to liver disease that was co-incidental or preexisting; the acute or chronic hepatitis C virus was the most frequent in this group (0.12%). When managing pregnancy in referral hospitals in Latin America, it is important to discard liver alterations early for adequate follow up of the disease and to prevent adverse consequences for the mother and child.


Assuntos
Hepatopatias/terapia , Complicações na Gravidez/terapia , Síndrome de Budd-Chiari/epidemiologia , Síndrome de Budd-Chiari/fisiopatologia , Síndrome de Budd-Chiari/terapia , Colestase Intra-Hepática/epidemiologia , Colestase Intra-Hepática/fisiopatologia , Colestase Intra-Hepática/terapia , Fígado Gorduroso/epidemiologia , Fígado Gorduroso/fisiopatologia , Fígado Gorduroso/terapia , Feminino , Síndrome HELLP/epidemiologia , Síndrome HELLP/fisiopatologia , Síndrome HELLP/terapia , Hepatite Viral Humana/epidemiologia , Hepatite Viral Humana/fisiopatologia , Hepatite Viral Humana/terapia , Degeneração Hepatolenticular/epidemiologia , Degeneração Hepatolenticular/fisiopatologia , Degeneração Hepatolenticular/terapia , Humanos , Hiperêmese Gravídica/epidemiologia , Hiperêmese Gravídica/fisiopatologia , Hiperêmese Gravídica/terapia , Hipertensão Portal/epidemiologia , Hipertensão Portal/fisiopatologia , Hipertensão Portal/terapia , Recém-Nascido , Cirrose Hepática/epidemiologia , Cirrose Hepática/fisiopatologia , Cirrose Hepática/terapia , Hepatopatias/epidemiologia , Hepatopatias/fisiopatologia , Transplante de Fígado , México/epidemiologia , Pré-Eclâmpsia/epidemiologia , Pré-Eclâmpsia/fisiopatologia , Pré-Eclâmpsia/terapia , Gravidez , Complicações na Gravidez/epidemiologia , Complicações na Gravidez/fisiopatologia , Complicações Infecciosas na Gravidez/epidemiologia , Complicações Infecciosas na Gravidez/fisiopatologia , Complicações Infecciosas na Gravidez/terapia , Centros de Atenção Terciária
13.
J Gastroenterol Hepatol ; 34(9): 1604-1610, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30937995

RESUMO

BACKGROUND AND AIM: Upper gastrointestinal bleeding (UGIB) is a serious complication of portal hypertension in cirrhotic patients. The objective of this study is to identify the risk factors for morbidity and mortality occurring after an UGIB attack. METHODS: A total of 1097 UGIB attacks in 690 patients with liver cirrhosis were studied. Their clinical, laboratory, and endoscopic data were reviewed. RESULTS: Mean age 53.2 ± 10.6 (20-90) years, 78% men and the main cause of liver disease was hepatitis C (94.9%). Complications occurred after 467 attacks (42.6%): hepatic encephalopathy 31.4%, spontaneous bacterial peritonitis 18%, renal impairment 13.2%, and re-bleeding in 7.8%, while 199 patients (18.1%) died. Complications followed 78.4% of bleeding from gastric varices, 75% of post-interventional ulcers, 10.8% of peptic ulcers, and 5.9% of telangiectasias. By univariate analysis: packed red blood cells units transfused, transaminases, Child-Pugh (CP), model of end-stage liver disease (MELD), and albumin-bilirubin (ALBI) scores, beside the presence of hepatocellular carcinoma (HCC), previous hemorrhage in the previous 6 months, and the source of bleeding, were associated with occurrence of complications. By multivariate analysis, independent predictors of complications were CP, MELD, and ALBI scores (odds ratio, 95% confidence interval: 5.63, 3.55-8.93; 1.15, 1.11-1.19; and 2.11, 1.4-3.19, respectively) beside the presence of HCC (4.89, 2.48-9.64). Mortality predictors were packed red blood cells units transfused (1.11, 1.01-1.24), CP (5.1, 1.42-18.25) MELD (1.27, 1.21-1.32) scores, and presence of HCC (6.62, 2.93-14.95). CONCLUSION: High CP, MELD, and ALBI scores beside the presence of HCC could predict poor outcome of UGIB. In the absence of these risk factors, early discharge could be considered if the source of bleeding is peptic ulcer or telangiectasia.


Assuntos
Varizes Esofágicas e Gástricas/terapia , Hemorragia Gastrointestinal/terapia , Técnicas Hemostáticas , Hipertensão Portal/terapia , Cirrose Hepática/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Progressão da Doença , Egito/epidemiologia , Varizes Esofágicas e Gástricas/diagnóstico , Varizes Esofágicas e Gástricas/epidemiologia , Varizes Esofágicas e Gástricas/mortalidade , Feminino , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/epidemiologia , Hemorragia Gastrointestinal/mortalidade , Humanos , Hipertensão Portal/diagnóstico , Hipertensão Portal/epidemiologia , Hipertensão Portal/mortalidade , Tempo de Internação , Cirrose Hepática/diagnóstico , Cirrose Hepática/epidemiologia , Cirrose Hepática/mortalidade , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
14.
J Pediatr ; 209: 107-115.e5, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30902421

RESUMO

OBJECTIVES: To evaluate the diagnostic accuracy of ultrasound elastography with acoustic radiation force impulse (ARFI) to detect congenital hepatic fibrosis and portal hypertension in children with autosomal recessive polycystic kidney disease (ARPKD). STUDY DESIGN: Cross-sectional study of 25 children with ARPKD and 24 healthy controls. Ultrasound ARFI elastography (Acuson S3000, Siemens Medical Solutions USA, Inc, Malvern, Pennsylvania) was performed to measure shear wave speed (SWS) in the right and left liver lobes and the spleen. Liver and spleen SWS were compared in controls vs ARPKD, and ARPKD without vs with portal hypertension. Linear correlations between liver and spleen SWS, spleen length, and platelet counts were analyzed. Receiver operating characteristic analysis was used to evaluate diagnostic accuracy of ultrasound ARFI elastography. RESULTS: Participants with ARPKD had significantly higher median liver and spleen SWS than controls. At a proposed SWS cut-off value of 1.56 m/s, the left liver lobe had the highest sensitivity (92%) and specificity (96%) for distinguishing participants with ARPKD from controls (receiver operating characteristic area 0.92; 95% CI 0.82-1.00). Participants with ARPKD with portal hypertension (splenomegaly and low platelet counts) had significantly higher median liver and spleen stiffness than those without portal hypertension. The left liver lobe also had the highest sensitivity and specificity for distinguishing subjects with ARPKD with portal hypertension. CONCLUSIONS: Ultrasound ARFI elastography of the liver and spleen, particularly of the left liver lobe, is a useful noninvasive biomarker to detect and quantify liver fibrosis and portal hypertension in children with ARPKD.


Assuntos
Técnicas de Imagem por Elasticidade/métodos , Doenças Genéticas Inatas/diagnóstico por imagem , Hipertensão Portal/epidemiologia , Cirrose Hepática/diagnóstico por imagem , Rim Policístico Autossômico Recessivo/diagnóstico por imagem , Rim Policístico Autossômico Recessivo/patologia , Ultrassonografia Doppler/métodos , Adolescente , Criança , Pré-Escolar , Comorbidade , Estudos Transversais , Feminino , Doenças Genéticas Inatas/epidemiologia , Doenças Genéticas Inatas/patologia , Hospitais Pediátricos , Humanos , Hipertensão Portal/diagnóstico por imagem , Hipertensão Portal/patologia , Cirrose Hepática/epidemiologia , Cirrose Hepática/patologia , Masculino , Philadelphia , Rim Policístico Autossômico Recessivo/epidemiologia , Curva ROC , Valores de Referência , Sensibilidade e Especificidade , Índice de Gravidade de Doença
15.
J Pediatr Surg ; 54(5): 1076-1082, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30792095

RESUMO

BACKGROUND: The management of portal hypertension (PHT) in children with well compensated cirrhosis and cystic fibrosis (CF) is controversial. We present our experience with distal splenorenal shunting (DSRS) for the treatment of PHT as an alternative to liver transplantation (LT). METHODS: Between 2008 and 2017, 5 CF children underwent a DSRS at a pediatric hepatobiliary and transplantation referral center. LT (n = 9) was reserved for patients with decompensated cirrhosis. Statistical analysis was done using the paired t-test (p < 0.05 considered significant). RESULTS: Mean PELD/MELD score was significantly lower for DSRS patients than LT (3 ±â€¯6 vs 28 ±â€¯4, p < 0.001). All 5 DSRS patients had grade III-IV varices. One bled prior to surgery. After DSRS, spleen size decreased significantly from 8.4 ±â€¯1.5 cm to 4.4 ±â€¯1.8 cm (p = 0.019). Mean platelet count remained stable (87.8 ±â€¯48 to 91.8 ±â€¯35, p = 0.9). There were no postoperative complications. No DSRS patient experienced variceal bleeding following shunt creation. Liver function tests remained stable in the DSRS group, and no patient required a liver transplant (median follow up 4.65 years, range 1.24-7.79). CONCLUSIONS: Patients with cystic fibrosis who have well-compensated cirrhosis and symptomatic portal hypertension can be palliated with distal splenorenal shunting and do not need liver transplants. These patients can undergo shunting with minimal morbidity. TYPE OF STUDY: Case series with no comparison group. LEVEL OF EVIDENCE: IV.


Assuntos
Fibrose Cística , Hipertensão Portal , Cirrose Hepática , Transplante de Fígado/estatística & dados numéricos , Derivação Esplenorrenal Cirúrgica/estatística & dados numéricos , Criança , Estudos de Coortes , Fibrose Cística/complicações , Fibrose Cística/epidemiologia , Humanos , Hipertensão Portal/complicações , Hipertensão Portal/epidemiologia , Hipertensão Portal/cirurgia , Fígado/patologia , Fígado/cirurgia , Cirrose Hepática/complicações , Cirrose Hepática/epidemiologia , Cirrose Hepática/cirurgia , Baço/patologia , Baço/cirurgia
16.
Clin Transl Gastroenterol ; 10(1): e00002, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30702490

RESUMO

OBJECTIVES: Common nucleotide-binding oligomerization domain containing 2 (NOD2) gene variants have been associated with bacterial infections (BIs) in cirrhosis, in particular, spontaneous bacterial peritonitis, and mortality. Our aim was to evaluate the independent association of NOD2 variants with BI according to the decompensation stage. METHODS: Consecutive patients with cirrhosis in 2 academic medical centers were included and genotyped for the NOD2 variants p.R702W, p.G908R, and c.3020insC. Electronic medical records were screened for BI (requiring antibiotic therapy) and past and present decompensation (as defined by variceal bleeding, encephalopathy, ascites, and/or jaundice). Clinically significant portal hypertension (CSPH) was assessed with liver stiffness and/or hepatic venous pressure gradient measurements. RESULTS: Overall, 735 patients were recruited (men 65%; interquartile age range 53-68 years). Alcoholic cirrhosis was the predominant etiology (n = 406, 55%), and most patients were in the decompensated stage (n = 531, 72%). In total, 158 patients (21%) carried at least one NOD2 variant. BIs were detected in 263 patients (36%), and NOD2 variants were associated with BI (odds ratio = 1.58; 95% confidence interval 1.11-2.27; P = 0.02). In compensated patients, the combination of NOD2 variants and presence of CSPH was the best independent predictors of BI, whereas other factors, such as spleen size and hemoglobin, and decompensations including hepatic encephalopathy or jaundice, gained relevance in decompensated patients. CONCLUSIONS: NOD2 risk variants are associated with BI in cirrhosis. The genetic effect on BI is strongest in compensated patients, whereas in decompensated patients their presence is less relevant. In this situation, CSPH becomes an independent factor associated with BI.


Assuntos
Infecções Bacterianas/epidemiologia , Predisposição Genética para Doença , Hipertensão Portal/epidemiologia , Cirrose Hepática/complicações , Proteína Adaptadora de Sinalização NOD2/genética , Idoso , Alelos , Infecções Bacterianas/genética , Progressão da Doença , Feminino , Alemanha/epidemiologia , Humanos , Hipertensão Portal/etiologia , Cirrose Hepática/diagnóstico , Masculino , Pessoa de Meia-Idade , Polimorfismo de Nucleotídeo Único , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença
17.
Eur J Gastroenterol Hepatol ; 31(7): 836-844, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30614882

RESUMO

OBJECTIVES: We aimed to confirm the clinical effectiveness of postoperative adjuvant transcatheter arterial chemoembolization (PA-TACE) in patients with hepatocellular carcinoma after liver resection, and further identify the patients who could benefit most from PA-TACE. PATIENTS AND METHODS: Propensity score matching at a ratio of 1 : 2 was used between hepatectomy patients with and without receiving PA-TACE. Kaplan-Meier analysis was performed to compare overall survival and recurrence-free survival between two groups. Univariate COX regression and stratified analyses were performed to screen and identify survival predictors for PA-TACE patients. The identified predictive markers were validated in an external cohort. RESULTS: The propensity analysis matched 116 patients in PA-TACE group to 232 in the control group. Visible protective effect of PA-TACE was shown by survival curves in matched series (log-rank P=0.009 and 0.008), with hazard ratio of being 0.599 (95% confidence interval: 0.420-0.855) and 0.623 (95% confidence interval: 0.449-0.866), respectively, for overall survival and recurrence-free survival. The identified prognostic predictors for PA-TACE included TNM stage, tumor size and number, hepatitis B infection, spleen diameter, preoperative serum α-fetoprotein, alkaline phosphatase, γ-glutamyl transpeptidase and monocyte, and three risk signatures (aspartate aminotransferase-to-alanine aminotransferase ratio, neutrophil-to-lymphocyte ratio, and systemic immune-inflammation index). CONCLUSION: The treatment effectiveness of adjuvant transcatheter arterial chemoembolization for patients with hepatocellular carcinoma after surgery was validated in this study, and the best candidates for PA-TACE were identified as well, including patients with late-stage tumor, portal hypertension, and high preoperative serum levels of α-fetoprotein, alkaline phosphatase, γ-glutamyl transpeptidase, and monocytes.


Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/administração & dosagem , Carcinoma Hepatocelular/terapia , Quimioembolização Terapêutica , Hepatectomia , Neoplasias Hepáticas/terapia , Alanina Transaminase/sangue , Fosfatase Alcalina/sangue , Aspartato Aminotransferases/sangue , Camptotecina/administração & dosagem , Camptotecina/análogos & derivados , Carcinoma Hepatocelular/sangue , Carcinoma Hepatocelular/epidemiologia , Carcinoma Hepatocelular/patologia , Quimioterapia Adjuvante , Intervalo Livre de Doença , Epirubicina/administração & dosagem , Feminino , Fluoruracila/administração & dosagem , Hepatite B Crônica/epidemiologia , Humanos , Hipertensão Portal/epidemiologia , Contagem de Leucócitos , Neoplasias Hepáticas/sangue , Neoplasias Hepáticas/epidemiologia , Neoplasias Hepáticas/patologia , Contagem de Linfócitos , Masculino , Pessoa de Meia-Idade , Monócitos , Estadiamento de Neoplasias , Neutrófilos , Prognóstico , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Taxa de Sobrevida , Carga Tumoral , alfa-Fetoproteínas/metabolismo , gama-Glutamiltransferase/sangue
18.
Pancreas ; 48(2): 187-192, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30629031

RESUMO

OBJECTIVE: The aim of the study was to study the prevalence and characteristics of sinistral portal hypertension (SPH) in acute pancreatitis (AP) and its correlation with the severity of AP. METHODS: Retrospectively studied 633 patients with AP admitted to our institution and underwent magnetic resonance imaging (MRI). Diagnosis of SPH was based on clinical manifestations, laboratory tests, and MRI. The venous system and pancreatitis were evaluated on T1 weighted imaging, T2 weighted imaging, and dynamic-enhancement MRI. Data on patients' demographics, etiology, organ failure, MR severity index, and clinical outcomes were all collected. RESULTS: The SPH was detected in 21 patients (3.3%, 21/633). There was no statistical difference in organ failure between patients with SPH and without SPH (P > 0.05). The prevalence of SPH in males and females was 5.1% (17/336) versus 1.3% (4/297) (χ(2) = 6.775, P = 0.009), in edematous and necrotizing AP was 0.4% (2/510) versus 15.5% (19/123) (χ(2) = 65.413, P = 0.000), and in mild, moderate, and severe AP, based on MR severity index, were 0.6% (2/334) versus 2.9% (8/276) versus 47.8% (11/23) (χ(2) = 55.977, P = 0.000), respectively. CONCLUSIONS: The SPH rarely occurs in AP, and its risk is higher in males. Its presence is strongly associated with the local conditions of pancreatitis.


Assuntos
Hipertensão Portal/diagnóstico por imagem , Imagem por Ressonância Magnética , Pancreatite/diagnóstico por imagem , Doença Aguda , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , China/epidemiologia , Feminino , Humanos , Hipertensão Portal/epidemiologia , Masculino , Pessoa de Meia-Idade , Pancreatite/epidemiologia , Valor Preditivo dos Testes , Prevalência , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Fatores Sexuais , Adulto Jovem
19.
Dis Mon ; 65(4): 95-103, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30274930
20.
J Gastroenterol Hepatol ; 34(8): 1417-1423, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30462857

RESUMO

BACKGROUND AND AIM: Idiopathic portal hypertension (IPH) refers to a relatively rare condition characterized by intrahepatic portal hypertension in the absence of underlying disease such as liver cirrhosis. METHODS: We retrospectively reviewed 338 patients with IPH that were diagnosed at the pathological consultation center of our hospital. RESULTS: The ratio of male to female patients was 1:1. Mean age at onset was 35.1 ± 16.5 years; male patients on average were 12 years younger than female patients at onset. The median duration from onset to IPH diagnosis was 12 months. In 50 patients, medication use may have been an etiological factor. The most common clinical manifestations were splenomegaly (91.3%) and hypersplenism (68.9%); 57.0% patients presented varicosis, while 25.1% patients had a history of variceal bleeding. Nodular regenerative hyperplasia was found in 22.2% liver biopsies. Among patients for whom laboratory data were available, 65.0%, 50.3%, and 71.4% patients presented leukopenia, anemia, and thrombocytopenia due to hypersplenism. Liver function was mostly in the compensated stage. Female patients showed worse leukopenia and anemia, while male patients were more likely to have abnormal serum transaminase and bilirubin levels. Sixty-seven patients received surgical or interventional treatment. CONCLUSIONS: High-quality liver biopsy, detailed clinical information, and expert pathologist are necessary for diagnosis of IPH. IPH can occur concurrently with other liver disease such as hepatitis and drug-induced liver injury. Medication appears to be an important etiological factor for IPH in China. Management approach was largely focused on treatment of portal hypertension and its complications.


Assuntos
Hipertensão Portal/patologia , Cirrose Hepática/patologia , Fígado/patologia , Pancitopenia/patologia , Esplenomegalia/patologia , Adolescente , Adulto , Biópsia , China/epidemiologia , Feminino , Humanos , Hipertensão Portal/epidemiologia , Hipertensão Portal/fisiopatologia , Hipertensão Portal/terapia , Cirrose Hepática/epidemiologia , Cirrose Hepática/fisiopatologia , Cirrose Hepática/terapia , Testes de Função Hepática , Masculino , Pessoa de Meia-Idade , Pancitopenia/epidemiologia , Pancitopenia/fisiopatologia , Pancitopenia/terapia , Pressão na Veia Porta , Valor Preditivo dos Testes , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Esplenomegalia/epidemiologia , Esplenomegalia/fisiopatologia , Esplenomegalia/terapia , Adulto Jovem
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