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1.
J Gastroenterol Hepatol ; 35(2): 278-283, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31222830

RESUMO

BACKGROUND AND AIM: This study aims to evaluate and compare the survival and other portal hypertension-related complications of patients with portal pressure gradient (PPG) ≥ 25 mmHg using transjugular intrahepatic portosystemic shunt (TIPS) as the first-line and second-line therapies in secondary prophylaxis of variceal hemorrhage. METHODS: Fifty patients diagnosed with liver cirrhosis were enrolled in this retrospective study, with 35 of whom received TIPS as the first-line therapy in secondary prophylaxis of variceal hemorrhage and 15 of whom as second-line treatment. We observed and analyzed the survival, occurrence of variceal rebleeding and hepatic encephalopathy (HE) of patients in the two groups during the follow up. RESULTS: The technical success rate was 100%. In a median follow-up time of 12 (1-37) and 15 (2-27) months, respectively, significant statistical difference was observed between the first-line group and the second-line group concerning cumulative survival rate (94.3% vs 66.7%, log-rank P = 0.01). But that was not the case when it comes to the cumulative rate of variceal rebleeding (8.6% vs 26.7%, log-rank P = 0.164) and HE (22.9% vs 20.0%, log-rank P = 0.793). And multivariate analysis indicated that group assignment (hazard ratio = 8.250, 95% confidence interval = 1.383-49.213, P = 0.021) was the only predictor of survival. Interestingly, we found that spleen diameter (hazard ratio = 0.578, 95% confidence interval = 0.393-0.849, P = 0.005) could be regarded as independent predictor of the occurrence of HE. CONCLUSIONS: For patients with PPG ≥ 25 mmHg who have recovered from an episode of acute esophageal variceal hemorrhage, utilizing TIPS as the first-line therapy to prevent rebleeding is demonstrated effective in improving the survival and therefore should be recommended to a wider range of clinical practice.


Assuntos
Varizes Esofágicas e Gástricas/prevenção & controle , Hemorragia Gastrointestinal/prevenção & controle , Derivação Portossistêmica Transjugular Intra-Hepática/métodos , Prevenção Secundária , Varizes Esofágicas e Gástricas/etiologia , Varizes Esofágicas e Gástricas/mortalidade , Seguimentos , Hemorragia Gastrointestinal/etiologia , Hemorragia Gastrointestinal/mortalidade , Humanos , Hipertensão Portal/complicações , Hipertensão Portal/mortalidade , Cirrose Hepática/complicações , Estudos Retrospectivos , Taxa de Sobrevida
2.
World J Gastroenterol ; 25(31): 4360-4382, 2019 Aug 21.
Artigo em Inglês | MEDLINE | ID: mdl-31496618

RESUMO

Hepatocellular carcinoma is one of the most frequent malignant tumors worldwide: Portal vein tumor thrombosis (PVTT) occurs in about 35%-50% of patients and represents a strong negative prognostic factor, due to the increased risk of tumor spread into the bloodstream, leading to a high recurrence risk. For this reason, it is a contraindication to liver transplantation and in several prognostic scores sorafenib represents its standard of care, due to its antiangiogenetic action, although it can grant only a poor prolongation of life expectancy. Recent scientific evidences lead to consider PVTT as a complex anatomical and clinical condition, including a wide range of patients with different prognosis and new treatment possibilities according to the degree of portal system involvement, tumor biological aggressiveness, complications caused by portal hypertension, patient's clinical features and tolerance to antineoplastic treatments. The median survival has been reported to range between 2.7 and 4 mo in absence of therapy, but it can vary from 5 mo to 5 years, thus depicting an extremely variable scenario. For this reason, it is extremely important to focus on the most adequate strategy to be applied to each group of PVTT patients.


Assuntos
Carcinoma Hepatocelular/terapia , Hipertensão Portal/terapia , Neoplasias Hepáticas/terapia , Recidiva Local de Neoplasia/epidemiologia , Trombose Venosa/terapia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Carcinoma Hepatocelular/complicações , Carcinoma Hepatocelular/mortalidade , Quimioembolização Terapêutica/métodos , Meios de Contraste/administração & dosagem , Intervalo Livre de Doença , Hepatectomia , Humanos , Hipertensão Portal/etiologia , Hipertensão Portal/mortalidade , Neoplasias Hepáticas/complicações , Neoplasias Hepáticas/mortalidade , Transplante de Fígado , Terapia Neoadjuvante/métodos , Invasividade Neoplásica/patologia , Recidiva Local de Neoplasia/patologia , Recidiva Local de Neoplasia/prevenção & controle , Seleção de Pacientes , Veia Porta/diagnóstico por imagem , Veia Porta/patologia , Prognóstico , Análise de Sobrevida , Trombectomia , Fatores de Tempo , Ultrassonografia/métodos , Trombose Venosa/etiologia , Trombose Venosa/mortalidade
3.
World J Gastroenterol ; 25(31): 4437-4451, 2019 Aug 21.
Artigo em Inglês | MEDLINE | ID: mdl-31496623

RESUMO

Portal vein thrombosis (PVT) represents a well-known complication during the natural course of liver cirrhosis (LC), ranging from asymptomatic cases to life-threating conditions related to portal hypertension and hepatic decompensation. Portal flow stasis, complex acquired hypercoagulable disorders and exogenous factors leading to endothelial dysfunction have emerged as key factors for PVT development. However, PVT occurrence remains unpredictable and many issues regarding its natural history, prognostic significance and treatment are still elusive. In particular although spontaneous resolution or disease stability occur in most cases of PVT, factors predisposing to disease progression or recurrence after spontaneous recanalization are not clarified as yet. Moreover, PVT impact on LC outcome is still debated, as PVT may represent itself a consequence of liver fibrosis and hepatic dysfunction progression. Anticoagulation and transjugular intrahepatic portosystemic shunt are considered safe and effective in this setting and are recommended in selected cases, even if the safer therapeutic option and the optimal therapy duration are still unknown. Nevertheless, their impact on mortality rates should be addressed more extensively. In this review we present the most debated questions regarding PVT, whose answers should come from prospective cohort studies and large sample-size randomized trials.


Assuntos
Anticoagulantes/administração & dosagem , Hipertensão Portal/terapia , Cirrose Hepática/complicações , Derivação Portossistêmica Transjugular Intra-Hepática , Trombose Venosa/terapia , Administração Oral , Anticoagulantes/efeitos adversos , Progressão da Doença , Feminino , Humanos , Hipertensão Portal/etiologia , Hipertensão Portal/mortalidade , Cirrose Hepática/mortalidade , Cirrose Hepática/terapia , Seleção de Pacientes , Veia Porta/patologia , Prognóstico , Estudos Prospectivos , Fatores de Tempo , Resultado do Tratamento , Trombose Venosa/etiologia , Trombose Venosa/mortalidade
4.
World J Gastroenterol ; 25(28): 3738-3752, 2019 Jul 28.
Artigo em Inglês | MEDLINE | ID: mdl-31391769

RESUMO

This review describes current approaches to the management of patients with cirrhotic ascites in relation to the severity of its clinical manifestations. The PubMed database, the Google Scholar retrieval system, the Cochrane Database of Systematic Reviews, and the reference lists from related articles were used to search for relevant publications. Articles corresponding to the aim of the review were selected for 1991-2018 using the keywords: "liver cirrhosis," "portal hypertension," "ascites," "pathogenesis," "diagnostics," and "treatment." Uncomplicated and refractory ascites in patients with cirrhosis were the inclusion criteria. The literature analysis has shown that despite the achievements of modern hepatology, the presence of ascites is associated with poor prognosis and high mortality. The key to successful management of patients with ascites may be the stratification of the risk of an adverse outcome and personalized therapy. Pathogenetically based approach to the choice of pharmacotherapy and optimization of minimally invasive methods of treatment may improve the quality of life and increase the survival rate of this category of patients.


Assuntos
Ascite/terapia , Doença Hepática Terminal/terapia , Hipertensão Portal/terapia , Cirrose Hepática/terapia , Agonistas de Receptores Adrenérgicos alfa 1/uso terapêutico , Ascite/diagnóstico , Ascite/etiologia , Ascite/mortalidade , Ensaios Clínicos como Assunto , Diuréticos/uso terapêutico , Doença Hepática Terminal/diagnóstico , Doença Hepática Terminal/etiologia , Doença Hepática Terminal/mortalidade , Humanos , Hipertensão Portal/diagnóstico , Hipertensão Portal/etiologia , Hipertensão Portal/mortalidade , Cirrose Hepática/complicações , Cirrose Hepática/diagnóstico , Cirrose Hepática/mortalidade , Transplante de Fígado , Paracentese/instrumentação , Paracentese/métodos , Derivação Portossistêmica Transjugular Intra-Hepática , Prognóstico , Qualidade de Vida , Medição de Risco , Índice de Gravidade de Doença , Taxa de Sobrevida , Resultado do Tratamento
5.
Scand J Gastroenterol ; 54(7): 899-904, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31203699

RESUMO

Background and aims: Accurate estimates of the long-term risks of adverse outcomes after transjugular intrahepatic portosystemic shunt (TIPS) treatment are needed. The aim of this cohort study was to estimate the risks of stent dysfunction, variceal bleeding, refractory ascites, hepatic encephalopathy (HE), and death after TIPS treatment. Methods: We extracted data from electronic medical records of 104 consecutive TIPS patients. Gore® Viatorr® TIPS endoprostheses were used in all patients. We conducted competing risks analysis of the risk of stent dysfunction and variceal bleeding, and Kaplan-Meier estimation of overall survival. Results: The overall 1-year survival after TIPS insertion was 82% (95% confidence interval [CI]: 73-88%), and the 1-year risk of stent dysfunction was 15% (95% CI: 9-22%). In patients who had a TIPS for variceal bleeding, the 1-year risk of rebleeding was 23% (95% CI: 13-35%). In patients who had a TIPS for refractory ascites, the risk of having an unsuccessful ascites outcome 1 year after TIPS for refractory ascites was 35% (95% CI: 21-52%). Overall, the 1-year risk of overt HE was 38% (95% CI: 32-43%). The risk of experiencing any of the defined complications during the first year was 56% (95% CI: 45-66%). Conclusion: TIPS is an effective treatment for variceal bleeding and refractory ascites in most cases, but more than half of the patients experience either death, stent dysfunction, recurrence of symptoms, or overt HE within the first year after the procedure.


Assuntos
Ascite/cirurgia , Hemorragia Gastrointestinal/cirurgia , Hipertensão Portal/cirurgia , Cirrose Hepática/complicações , Derivação Portossistêmica Transjugular Intra-Hepática/efeitos adversos , Idoso , Ascite/etiologia , Ascite/mortalidade , Estudos de Coortes , Dinamarca/epidemiologia , Varizes Esofágicas e Gástricas/complicações , Varizes Esofágicas e Gástricas/mortalidade , Feminino , Hemorragia Gastrointestinal/etiologia , Hemorragia Gastrointestinal/mortalidade , Humanos , Hipertensão Portal/etiologia , Hipertensão Portal/mortalidade , Cirrose Hepática/mortalidade , Masculino , Pessoa de Meia-Idade , Recidiva , Stents/efeitos adversos , Análise de Sobrevida , Resultado do Tratamento
6.
Ter Arkh ; 91(2): 67-72, 2019 Mar 18.
Artigo em Inglês | MEDLINE | ID: mdl-31094174

RESUMO

AIM: To study prognostic factors for survival in patients of liver cirrhosis (LC) with portal hypertension (PG). MATERIALS AND METHODS: 155 patients (women - 49.4%, men - 50.6%, median age 56.4 years [51.3; 61.6]) were follow up for 36 months. Viral LC was diagnosed in 33.8%, alcohol LC - 22.1%, autoimmune LC - 15.6%, other causes and cryptogenic causes noted in - 28.5%. More than half of the patients had a class В of Child-Pugh (51.9%). RESULTS: During the study period 42 patients (28.3%) died. The analysis of survival by various factors for Kaplan-Mayer was carried out. Significant predictors: Child-Pugh class, LC etiology, comorbidity in Charlson scores, adherence to endoscopic treatment of esophageal varices were included in the model of proportional Cox risks. In a single-factor analysis, the risk of death is higher in patients who violate the timing of endoscopic treatment, but this factor has lost significance in the multifactor model. Patient with Child-Pugh C, alcoholic LC, comorbidity more 5 points by Charlson score have a higher mortality risk. CONCLUSION: Identification of risk factors that affect the survival of LC patients will allow to use of an individual plan for the LC treatment and prevention of PG complications.


Assuntos
Hipertensão Portal/complicações , Cirrose Hepática/complicações , Feminino , Humanos , Hipertensão Portal/mortalidade , Cirrose Hepática/mortalidade , Masculino , Pessoa de Meia-Idade , Prognóstico , Fatores de Risco
7.
J Gastroenterol Hepatol ; 34(12): 2164-2172, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31062417

RESUMO

BACKGROUND AND AIM: The nuclear farnesoid X receptor (FXR) regulates critical pathways of hepatic metabolism, inflammation, and gut mucosal barrier. Thus, we investigated the association of FXR-single nucleotide polymorphism (SNPs) with hepatic decompensation and liver-related mortality in patients with advanced chronic liver disease. METHODS: Two FXR-SNPs (rs56163822 G > T and rs35724 G > C) were genotyped in a cohort of 402 prospectively characterized patients with hepatic venous pressure gradient (HVPG) ≥ 6 mmHg. RESULTS: Only 19 patients (4.7%) harbored a rs56163822 T-allele and had less pronounced liver disease as indicated by lower Child-Pugh score (CPS, 6 ± 1 vs 7 ± 2 points, P = 0.034) and higher albumin levels (38.9 ± 4.9 vs 35.9 ± 5.9 g/L, P = 0.026). In contrast, n = 267 (66.4%) patients harbored minor rs35724 allele (G/C or C/C) and had more advanced liver disease, as indicated by a higher model of end-stage liver disease (11 ± 4 vs 10 ± 3, P = 0.016), while other baseline characteristics were similar across FXR-SNP genotypes. In compensated CPS-A patients, the rs35724 minor allele was independently protective for the development of ascites (adjusted hazard ratio [aHR] = 0.411, 95% confidence interval (95% CI): 0.191-0.885; P = 0.023) and tended to reduce the risk of hepatic decompensation (aHR = 0.625, 95% CI: 0.374-1.044, P = 0.072) in multivariate analyses. Of note, transplant-free survival was longer in patients with rs35724 minor allele and HVPG ≥ 10 mmHg (at 5 years: 68.2% vs 55.8%, P = 0.047) and those with HVPG ≥ 16 mmHg (63.3% vs 44.0%, P = 0.021). After adjusting for established risk factors, the rs35724 minor allele was independently associated with reduced liver-related mortality in the overall cohort (aHR = 0.658, 95% CI: 0.434-0.998, P = 0.049), in compensated CPS-A patients (aHR = 0.488, 95% CI: 0.252-0.946, P = 0.034), in patients with HVPG ≥ 10 mmHg (aHR = 0.547, 95% CI: 0.346-0.864, P = 0.010), and in patients with HVPG ≥ 16 mmHg (aHR = 0.519, 95% CI: 0.307-0.878, P = 0.014). CONCLUSION: The FXR-SNP rs35724 was associated with a reduced risk for development of ascites and liver-related mortality in patients with advanced chronic liver disease.


Assuntos
Hipertensão Portal/genética , Cirrose Hepática/genética , Polimorfismo de Nucleotídeo Único , Receptores Citoplasmáticos e Nucleares/genética , Adulto , Idoso , Ascite/etiologia , Ascite/genética , Ascite/mortalidade , Ascite/prevenção & controle , Áustria/epidemiologia , Feminino , Seguimentos , Humanos , Hipertensão Portal/etiologia , Hipertensão Portal/mortalidade , Hipertensão Portal/fisiopatologia , Estimativa de Kaplan-Meier , Cirrose Hepática/complicações , Cirrose Hepática/mortalidade , Cirrose Hepática/fisiopatologia , Transplante de Fígado , Masculino , Pessoa de Meia-Idade , Pressão na Veia Porta/fisiologia , Estudos Retrospectivos , Fatores de Risco
8.
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
9.
Br J Surg ; 106(8): 1066-1074, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30990885

RESUMO

BACKGROUND: Indications for hepatectomy in patients with hepatocellular carcinoma (HCC) who have portal hypertension (PH) have been controversial. Some studies have concluded that PH is a contraindication to hepatectomy, whereas others have suggested that perioperative prophylactic management (PPM) can help overcome complications after hepatectomy associated with PH. The objective of this retrospective study was to assess the short- and long-term outcomes after hepatectomy for HCC in patients with PH, with or without PPM. METHODS: Records were reviewed of consecutive patients who underwent hepatectomy for HCC, with or without PPM of PH, in a single institution from 1994 to 2015. Patients were divided into three groups: those who received PPM for PH (PPM group), patients who had PH but did not receive PPM (no-PPM group) and those without PH (no-PH group). RESULTS: A total of 1259 patients were enrolled, including 123 in the PPM group, 181 in the no-PPM group and 955 in the no-PH group. Three- and 5-year overall survival rates were 74·3 and 53·1 per cent respectively in the PPM group, 69·2 and 54·9 per cent in the no-PPM group, and 78·1 and 64·2 per cent in the no-PH group (P = 0·520 for PPM versus no PPM, P = 0·027 for PPM versus no PH, and P < 0·001 for no PPM versus no PH). Postoperative morbidity and mortality rates were 26·0 and 0·8 per cent respectively in the PPM group, 29·8 and 1·1 per cent in the no-PPM group, and 20·3 and 0 per cent in the no-PH group. CONCLUSION: The present study has demonstrated acceptable outcomes among patients with HCC who received appropriate management for PH in an Asian population. Enhancement of the safety of hepatic resection through use of PPM may provide a rationale for expansion of indications for hepatectomy in patients with PH.


Assuntos
Carcinoma Hepatocelular/cirurgia , Hepatectomia/estatística & dados numéricos , Hipertensão Portal/complicações , Neoplasias Hepáticas/cirurgia , Assistência Perioperatória/métodos , Adulto , Idoso , Carcinoma Hepatocelular/complicações , Carcinoma Hepatocelular/mortalidade , Feminino , Hepatectomia/mortalidade , Humanos , Hipertensão Portal/mortalidade , Hipertensão Portal/terapia , Neoplasias Hepáticas/complicações , Neoplasias Hepáticas/mortalidade , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento
11.
Lancet ; 393(10181): 1597-1608, 2019 Apr 20.
Artigo em Inglês | MEDLINE | ID: mdl-30910320

RESUMO

BACKGROUND: Clinical decompensation of cirrhosis is associated with poor prognosis. Clinically significant portal hypertension (CSPH), defined by a hepatic venous pressure gradient (HVPG) ≥10 mm Hg, is the strongest predictor of decompensation. This study aimed at assessing whether lowering HVPG with ß blockers could decrease the risk of decompensation or death in compensated cirrhosis with CSPH. METHODS: This study on ß blockers to prevent decompensation of cirrhosis with portal hypertension (PREDESCI) was an investigator-initiated, double-blind, randomised controlled trial done in eight hospitals in Spain. We enrolled patients with compensated cirrhosis and CSPH without high-risk varices. All participants had HVPG measurements with assessment of acute HVPG-response to intravenous propranolol. Responders (HVPG-decrease ≥10%) were randomly assigned to propranolol (up to 160 mg twice a day) versus placebo and non-responders to carvedilol (≤25 mg/day) versus placebo. Doses were individually determined during an open-label titration period after which randomisation was done with 1:1 allocation by a centralised web-based system. The primary endpoint was incidence of cirrhosis decompensation (defined as development of ascites, bleeding, or overt encephalopathy) or death. Since death in compensated cirrhosis is usually unrelated to the liver, an intention-to-treat analysis considering deaths unrelated to the liver as competing events was done. This study is registered with ClinicalTrials.gov, number NCT01059396. The trial is now completed. FINDINGS: Between Jan 18, 2010, and July 31, 2013, 631 patients were evaluated and 201 were randomly assigned. 101 patients received placebo and 100 received active treatment (67 propranolol and 33 carvedilol). The primary endpoint occurred in 16 (16%) of 100 patients in the ß blockers group versus 27 (27%) of 101 in the placebo group (hazard ratio [HR] 0·51, 95% CI 0·26-0·97, p=0·041). The difference was due to a reduced incidence of ascites (HR=0·44, 95%CI=0·20-0·97, p=0·0297). The overall incidence of adverse events was similar in both groups. Six patients (four in the ß blockers group) had severe adverse events. INTERPRETATION: Long-term treatment with ß blockers could increase decompensation-free survival in patients with compensated cirrhosis and CSPH, mainly by reducing the incidence of ascites. FUNDING: Spanish Ministries of Health and Economy.


Assuntos
Antagonistas Adrenérgicos beta/administração & dosagem , Carvedilol/administração & dosagem , Hipertensão Portal/tratamento farmacológico , Cirrose Hepática/tratamento farmacológico , Propranolol/administração & dosagem , Administração Oral , Adulto , Idoso , Ascite/prevenção & controle , Método Duplo-Cego , Feminino , Hemorragia Gastrointestinal/prevenção & controle , Encefalopatia Hepática/prevenção & controle , Humanos , Hipertensão Portal/complicações , Hipertensão Portal/mortalidade , Cirrose Hepática/complicações , Cirrose Hepática/mortalidade , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Índice de Gravidade de Doença
12.
PLoS One ; 14(2): e0212658, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30811467

RESUMO

BACKGROUND: Transjugular intrahepatic portosystemic shunt (TIPS) creation is an established treatment option to management the complications of portal hypertension. Recent data on the long-term outcomes of TIPS are scarce. MATERIALS AND METHODS: In this single-institution retrospective study, 495 patients underwent TIPS with the Fluency stent-grafts between December 2011 and June 2015 were evaluated. The cumulative rates of TIPS dysfunction, hepatic encephalopathy (HE), survival, and variceal rebleeding were determined using the Kaplan-Meier method. Cox regression analysis was used to assess the parameters on TIPS patency, occurrence of HE and all-cause mortality. RESULTS: Technical success was 98.2%. TIPS-related complications occurred in 67 patients (13.5%) during the index hospital stay. TIPS creation resulted in an immediate decrease in mean portosystemic pressure gradient from 23.4 ± 7.1 mmHg to 7.6 ± 3.5 mmHg. The median follow-up period was 649 days. Primary TIPS patency rates were 93%, and 75.9% at 1 and 3 years, respectively. Previous splenectomy was associated with a higher risk of TPS dysfunction. The cumulative survival rates were 93.4% and 77.2% at 1 and 3 years, respectively. The 1- and 3-year probability of remaining free of variceal bleeding rates were 94.2% and 71.4%, respectively. CONCLUSIONS: This retrospective single-center experience with TIPS using the Fluency stent-grafts demonstrates good long-term patency and favorable good clinical results. Previous splenectomy strongly predicts shunt dysfunction.


Assuntos
Rejeição de Enxerto/epidemiologia , Hipertensão Portal/cirurgia , Derivação Portossistêmica Transjugular Intra-Hepática/efeitos adversos , Grau de Desobstrução Vascular/fisiologia , Adulto , Varizes Esofágicas e Gástricas/epidemiologia , Varizes Esofágicas e Gástricas/etiologia , Varizes Esofágicas e Gástricas/prevenção & controle , Feminino , Seguimentos , Hemorragia Gastrointestinal/epidemiologia , Hemorragia Gastrointestinal/etiologia , Hemorragia Gastrointestinal/prevenção & controle , Rejeição de Enxerto/etiologia , Rejeição de Enxerto/fisiopatologia , Encefalopatia Hepática/epidemiologia , Encefalopatia Hepática/etiologia , Encefalopatia Hepática/prevenção & controle , Humanos , Hipertensão Portal/complicações , Hipertensão Portal/mortalidade , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Politetrafluoretileno , Derivação Portossistêmica Transjugular Intra-Hepática/instrumentação , Derivação Portossistêmica Transjugular Intra-Hepática/métodos , Estudos Retrospectivos , Esplenectomia/efeitos adversos , Stents/efeitos adversos , Fatores de Tempo , Resultado do Tratamento
13.
J Vasc Interv Radiol ; 30(2): 187-194, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30717949

RESUMO

PURPOSE: To assess short- and long-term mortality and rebleeding with endoscopic cyanoacrylate (EC) versus balloon-occluded retrograde transvenous obliteration (BRTO). MATERIALS AND METHODS: A retrospective cohort comparison was conducted of 90 EC patients and 71 BRTO patients from 1997 through 2015 with portal hypertension who presented due to endoscopically confirmed bleeding cardiofundal gastric varices. Patients underwent either endoscopic intra-varix injection of 4-carbon-n-butyl-2-cyanoacrylate or sclerosis with sodium tetradecyl sulfate with balloon occlusion for primary variceal treatment. RESULTS: Seventy-one BRTO patients and 90 EC patients, of whom 89% had cirrhosis and 35% were women, were included, with a respective average Model for End-Stage Liver Disease (MELD) score of 13.4 and 14.4, respectively. Mortality at 6 weeks was 14.4% for EC patients and 13.1% for BRTO patients (Kaplan-Meier/Wilcoxon, P = .85). No long-term mortality difference was observed (Cox hazard ratio [HR] = 0.89, P = .64). Also, 5.1% of EC patients and 3.5% of BRTO patients (Kaplan-Meier/Wilcoxon, P = .62) rebled at 6 weeks, but at 1 year, 22.0% of EC patients and 3.5% of BRTO patients had rebled (Kaplan-Meier/Wilcoxon, P < .01). Lower rates of long-term rebleeding were found with BRTO (Cox HR = 0.25, P = .03). No difference was seen in the rate of new portal hypertensive complications (Cox HR = 1.21, P = .464). However, 16/71 patients who underwent BRTO had simultaneous transjugular intrahepatic portosystemic shunt. Age, sex, MELD score, and presence of cirrhosis were the primary predictors of mortality. One death in the EC group and 5 deaths in the BRTO group were deemed to be procedurally related (chi-square, P = .088). CONCLUSIONS: BRTO is associated with a lower rate of rebleeding but no change in mortality.


Assuntos
Oclusão com Balão , Embucrilato/administração & dosagem , Varizes Esofágicas e Gástricas/terapia , Hemorragia Gastrointestinal/terapia , Hemostase Endoscópica/métodos , Adulto , Idoso , Oclusão com Balão/efeitos adversos , Oclusão com Balão/mortalidade , Embucrilato/efeitos adversos , Varizes Esofágicas e Gástricas/diagnóstico , Varizes Esofágicas e Gástricas/etiologia , Varizes Esofágicas e Gástricas/mortalidade , Feminino , Seguimentos , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/etiologia , Hemorragia Gastrointestinal/mortalidade , Hemostase Endoscópica/efeitos adversos , Hemostase Endoscópica/mortalidade , Humanos , Hipertensão Portal/complicações , Hipertensão Portal/mortalidade , Masculino , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
14.
J Dig Dis ; 20(2): 89-96, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30629804

RESUMO

OBJECTIVE: To compare the efficacy of transjugular intrahepatic portosystemic shunts (TIPS) and endoscopic variceal ligations (EVL) plus propranolol in decreasing rebleeding and improving survival rates in cirrhotic patients with cavernous transformation of the portal vein (CTPV). METHODS: Cirrhotic patients with CTPV and a history of variceal bleeding who were treated for recurrent variceal bleeding between June 2010 and July 2016 were identified and classified based on the treatment they received (TIPS or EVL plus propranolol). Their characteristics and clinical data were recorded. The rebleeding and long-term survival rates between the two groups were analyzed. RESULTS: A total of 51 patients were included, of whom 25 were treated with TIPS and 26 with EVL plus propranolol. The mean duration of follow up was 21 months (range 1-47 months) in the former group and 27 months (range 6-73 months) in the latter group. The recurrent variceal bleeding-free rate increased remarkably in the TIPS group compared with the EVL + propranolol group (P = 0.047). Three (14.3%) patients died in the TIPS group, and one (3.8%) in the EVL plus propranolol group (P = 0.305). Hepatic encephalopathy occurred in 14.3% (3/21) of the patients in the TIPS group and in 3.8% (1/26) in the EVL + propranolol group (P = 0.202). CONCLUSION: TIPS appeared to be more effective in preventing rebleeding in cirrhotic patients with CTPV compared with EVL plus propranolol, without improving survival.


Assuntos
Varizes Esofágicas e Gástricas/cirurgia , Hemorragia Gastrointestinal/cirurgia , Hipertensão Portal/cirurgia , Ligadura/mortalidade , Veia Porta/anormalidades , Derivação Portossistêmica Transjugular Intra-Hepática/mortalidade , Adulto , Idoso , Anti-Hipertensivos/uso terapêutico , Varizes Esofágicas e Gástricas/etiologia , Varizes Esofágicas e Gástricas/mortalidade , Feminino , Seguimentos , Hemorragia Gastrointestinal/etiologia , Hemorragia Gastrointestinal/mortalidade , Humanos , Hipertensão Portal/complicações , Hipertensão Portal/mortalidade , Ligadura/métodos , Cirrose Hepática/etiologia , Masculino , Pessoa de Meia-Idade , Veia Porta/cirurgia , Propranolol/uso terapêutico , Recidiva , Taxa de Sobrevida , Resultado do Tratamento
15.
Liver Transpl ; 25(4): 640-657, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30697907

RESUMO

Approximately 5%-10% of patients with cystic fibrosis (CF) will develop advanced liver disease with portal hypertension, representing the third leading cause of death among patients with CF. Cystic fibrosis with advanced liver disease and portal hypertension (CFLD) represents the most significant risk to patient mortality, second only to pulmonary or lung transplant complications in patients with CF. Currently, there is no medical therapy to treat or reverse CFLD. Liver transplantation (LT) in patients with CFLD with portal hypertension confers a significant survival advantage over those who do not receive LT, although the timing in which to optimize this benefit is unclear. Despite the value and efficacy of LT in selected patients with CFLD, established clinical criteria outlining indications and timing for LT as well as disease-specific transplant considerations are notably absent. The goal of this comprehensive and multidisciplinary report is to present recommendations on the unique CF-specific pre- and post-LT management issues clinicians should consider and will face.


Assuntos
Fibrose Cística/complicações , Hipertensão Portal/terapia , Cirrose Hepática/terapia , Transplante de Fígado/normas , Transplante de Pulmão/normas , Adolescente , Adulto , Distribuição por Idade , Biópsia , Criança , Pré-Escolar , Agonistas dos Canais de Cloreto/administração & dosagem , Fibrose Cística/mortalidade , Fibrose Cística/terapia , Feminino , Seguimentos , Humanos , Hipertensão Portal/diagnóstico , Hipertensão Portal/etiologia , Hipertensão Portal/mortalidade , Lactente , Fígado/diagnóstico por imagem , Fígado/patologia , Cirrose Hepática/diagnóstico , Cirrose Hepática/etiologia , Cirrose Hepática/mortalidade , Transplante de Fígado/métodos , Transplante de Fígado/estatística & dados numéricos , Transplante de Pulmão/métodos , Transplante de Pulmão/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Cuidados Pós-Operatórios/métodos , Cuidados Pós-Operatórios/normas , Guias de Prática Clínica como Assunto , Cuidados Pré-Operatórios/métodos , Cuidados Pré-Operatórios/normas , Encaminhamento e Consulta/normas , Índice de Gravidade de Doença , Taxa de Sobrevida , Fatores de Tempo , Tempo para o Tratamento , Resultado do Tratamento , Adulto Jovem
16.
Acta Gastroenterol Belg ; 82(4): 487-493, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31950803

RESUMO

INTRODUCTION AND AIM: Endothelial dysfunction is involved in the pathogenesis of portal hypertension and in the progression of liver disease. As an indicator of endothelial dysfunction, von Willebrand factor (vWF-Ag) can be a useful mortality predictor in patients with liver cirrhosis. The aim of the study is to compare the predictive value of vWF-Ag with the predictive value of MELD score regarding the three-month mortality in patients with liver cirrhosis. MATERIALS AND METHODS: In 70 patients with cirrhosis and portal hypertension we measured the vWF-Ag concentration and we followed the patients for 90 days. We registered all manifestations and complications of liver cirrhosis and the three-month mortality was the main end-point. RESULTS: We registered mean vWF-Ag of 341.9±155.8%, median 312%, IQR (214-410), vWF-Ag significantly correlated with MELD score (R=0.3713 ; p<0.05) and vWF-Ag median was higher in the uncensored compared to the median in the censored patients (p<0.0067). vWF-Ag and MELD score were significantly associated with three-month mortality, with no significant difference in the diagnostic performance between the two parameters [AUC=0.735, p=0.007 for vWF-Ag ; AUC=0.885, p=0.000 for MELD score], (Z=1.473, p=0.1407). CONCLUSION: In patients with liver cirrhosis vWF-Ag is a relevant predictor of three-month mortality that equals the MELD score.


Assuntos
Hipertensão Portal/sangue , Hipertensão Portal/mortalidade , Cirrose Hepática/sangue , Cirrose Hepática/mortalidade , Fator de von Willebrand/metabolismo , Biomarcadores/sangue , Humanos , Hipertensão Portal/fisiopatologia , Cirrose Hepática/patologia , Valor Preditivo dos Testes , Prognóstico , Fatores de Tempo
17.
J Gastroenterol Hepatol ; 34(6): 1093-1099, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30221390

RESUMO

BACKGROUND AND AIMS: Patients with cirrhosis and portal hypertension often develop complications relating to hepatic excretory dysfunction. The standard measurement of the hepatic excretion is the constant infusion indocyanine green clearance (ICGCI ) technique. The ICG 15-min retention test (ICG-r15) is faster, more patient friendly, and cheaper. The aims were to compare the ICG-r15 test with the standard method, to assess relations to patient characteristics and survival, and to assess the ICG-r15 level in healthy control subjects. METHODS: This study included 68 patients with cirrhosis and portal hypertension (Child class A/B/C:17/37/14). All patients underwent a full liver vein catheterization and hemodynamic evaluation with determination of ICG-r15 and ICGCI as the reference in a subset of 38 patients. Sixteen healthy control subjects were included for compiling a reference interval. RESULTS: The ICG-r15 was increased in the cirrhotic patients with increasing values in parallel with liver dysfunction (15/41/58%) in Child class A/B/C compared with 7% in the controls (P < 0.001). ICG-r15 correlated highly significantly with the ICGCI (r = -0.96, P < 0.0001) and in a multivariate regression analysis with hepatic venous pressure gradient, markers of liver dysfunction and hyperdynamic circulation (P < 0.05-0.005). In the control group, normal reference values ranged from 0% to 13%. In addition, ICG-r15 was significantly related to mortality in the patient group (P = 0.02). CONCLUSIONS: Indocyanine green-r15 reflects portal hypertension, the degree of hepatic failure, and survival and may replace the standard ICGCI . A more elaborated reference interval needs to be compiled, and the prognostic value of ICG-r15 should be validated.


Assuntos
Hipertensão Portal/diagnóstico , Verde de Indocianina , Cirrose Hepática/diagnóstico , Testes de Função Hepática/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Hipertensão Portal/complicações , Hipertensão Portal/mortalidade , Cirrose Hepática/complicações , Cirrose Hepática/mortalidade , Falência Hepática/diagnóstico , Masculino , Taxa de Depuração Metabólica , Pessoa de Meia-Idade , Sensibilidade e Especificidade , Índice de Gravidade de Doença , Taxa de Sobrevida
18.
J Cyst Fibros ; 18(3): 385-389, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30558881

RESUMO

BACKGROUND: Up to 10% of patients with Cystic Fibrosis develop cirrhotic CF-related liver disease with portal hypertension: CF cirrhosis (CFC). In a nationwide study, we aimed to determine the role of CFC on survival in the Netherlands between 1 and 1-2009 and1-1-2015. METHODS: We identified all CFC patients in the Netherlands, based on ultrasonographic liver nodularity and portal hypertension. A non-cirrhotic control group was obtained from the national Dutch CF patient registry. We compared groups with regards to baseline lung function and nutritional status and survival and age at death over a 6-year period. In case of death of CFC patients, the clinical reported cause was recorded. RESULTS: At baseline, we found no significant difference in lung function and nutritional status between the CFC patients (N = 95) and controls (N = 980). Both the 6-year survival rate (77 vs. 93%; P < .01) and the median age at death (27 vs. 37 years; P = .02) was significantly lower in CFC compared to controls. In the deceased CFC patients, the reported primary cause of death was pulmonary in 68% of cases, and liver failure related in 18% of cases. CONCLUSIONS: In the Netherlands, the presence of CFC is associated with a higher risk for early mortality and an approximately 10-year lower median age at death. This substantial poorer outcome of CFC patients was not reflected in a lower baseline lung function or a diminished nutritional status. However, in the case of mortality, the reported primary cause of death in CFC patients is predominantly pulmonary failure and not end-stage liver disease.


Assuntos
Fibrose Cística , Hipertensão Portal , Cirrose Hepática , Fígado , Adulto , Fatores Etários , Causas de Morte , Fibrose Cística/complicações , Fibrose Cística/mortalidade , Fibrose Cística/fisiopatologia , Feminino , Humanos , Hipertensão Portal/diagnóstico , Hipertensão Portal/etiologia , Hipertensão Portal/mortalidade , Fígado/diagnóstico por imagem , Fígado/patologia , Cirrose Hepática/diagnóstico , Cirrose Hepática/etiologia , Cirrose Hepática/mortalidade , Masculino , Países Baixos/epidemiologia , Estado Nutricional , Testes de Função Respiratória , Análise de Sobrevida
19.
Am J Surg ; 217(4): 664-669, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30578032

RESUMO

BACKGROUND/AIM: We aim to study the impact of PH in patients undergoing gastrointestinal surgery (GI). METHODS: We queried the ACS-NSQIP database from 2005 through 2010 for patients undergoing GI surgery with PH. Esophageal varices (EV) diagnosis was used as a surrogate of PH. RESULTS: A total of 192,296 patients underwent GI surgery, of which 379 had PH. Regression analyses revealed that patients with PH had a 6-fold (95% CI 4.6-7.9) increase in 30-day mortality, a 3-fold (95% CI 2.5-3.7) increase in morbidity, a 3.2-fold (95% CI 2.6-3.9) increase in critical care complications (CCC), and a 6.5-day (95% CI 5.1-7.8) increase in hospital LOS. After PSM, the impact of PH on the outcomes remained. These differences were significant regardless of the emergent or elective status of the procedure. AUC analysis demonstrated that MELD and MELDNa + score greater than 10.5 was the most predictive of peri-operative mortality in elective PH cases. CONCLUSIONS: PH is associated with an increased risk of poor surgical outcomes in patients undergoing elective and emergent gastrointestinal surgery.


Assuntos
Procedimentos Cirúrgicos do Sistema Digestório , Hipertensão Portal/complicações , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Procedimentos Cirúrgicos do Sistema Digestório/mortalidade , Feminino , Humanos , Hipertensão Portal/mortalidade , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Pontuação de Propensão , Estados Unidos/epidemiologia
20.
Asian J Surg ; 42(1): 338-342, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30316666

RESUMO

OBJECTIVE: Emergency surgery is a risk factor for mortality in cirrhotic patients. Portal hypertension is an essential feature of decompensated cirrhosis. This study aimed to assess the value of portal venous pressure (PVP) measurement in prediction of 1-month mortality in cirrhotic patients undergoing emergency laparotomy. METHODS: This prospective study included 121 adults with liver cirrhosis subjected to an emergency laparotomy. Child-Turcotte-Pugh (CTP) score and model for end-stage liver disease (MELD) score were used for preoperative patient evaluation. PVP was measured directly at the beginning of surgery. Portal hypertension (PHT) is diagnosed when PVP is greater than 12 mmHg. The primary outcome measure was the risk of mortality within one month after surgery. RESULTS: PVP ranged from 5 to 27 mmHg; 82 patients (67.8%) had PHT. Fifty-five patients (45.5%) died within 1 month. Mortality was significantly associated with increasing CTP Class, MELD score and PHT (p < 0.001 for all). PHT predicts mortality with a sensitivity of 83.6% and specificity of 92.8%. PHT was the only independent predictor of mortality (OR: 23.0, 95%CI: 8.9-59.4). CONCLUSION: In patients with liver cirrhosis, emergency laparotomy carries a substantial risk of mortality within one month. Portal hypertension is an independent predictor of risk of mortality in these patients.


Assuntos
Determinação da Pressão Arterial , Serviços Médicos de Emergência , Hipertensão Portal/diagnóstico , Hipertensão Portal/mortalidade , Laparotomia/mortalidade , Cirrose Hepática/mortalidade , Cirrose Hepática/cirurgia , Pressão na Veia Porta , Adolescente , Adulto , Idoso , Emergências , Feminino , Humanos , Hipertensão Portal/etiologia , Cirrose Hepática/complicações , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Curva ROC , Fatores de Risco , Sensibilidade e Especificidade , Fatores de Tempo , Adulto Jovem
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