Norfloxacin primary prophylaxis of bacterial infections in cirrhotic patients with ascites: a double-blind randomized trial

BACKGROUND/AIMS

Norfloxacin is useful to prevent infections in hospitalized cirrhotic patients with low ascitic fluid protein concentrations. It is also effective in preventing the recurrence of spontaneous bacterial peritonitis. The aim of our study was to determine the efficacy of norfloxacin in the primary prophylaxis of gram-negative bacilli infections in cirrhotic patients with low ascitic fluid protein levels (<15 g/l).

METHODS

One hundred and seven patients were randomized to receive norfloxacin (400 mg/day; n=53) or placebo (n=54) for 6 months. The patients had no history of infection since cirrhosis diagnosis and no active infection.

RESULTS

The probability of gram-negative infection was significantly lower among patients treated with norfloxacin than among those treated with placebo. Six gram-negative bacilli infections occurred in the placebo group and none in the treatment group. Severe infections (spontaneous bacterial peritonitis, neutrocytic ascites and bacteremia) developed in nine patients in the placebo group (17%) and in one patient in the norfloxacin group (2%; p<0.03). There was no between-group difference in the overall rate of infection or in survival. In ten patients from the norfloxacin group, gram-negative bacilli not present in baseline stool cultures were transiently isolated in follow-up cultures.

CONCLUSIONS

These data show that primary prophylaxis with norfloxacin for 6 months is effective in the prevention of infections caused by gram-negative bacilli in cirrhotic patients with low ascitic fluid total protein levels.

Baseline level and early suppression of serum HCV RNA for predicting sustained complete response to alpha-interferon therapy

The relationship between serum hepatitis C virus (HCV) RNA and the outcome of alpha-interferon (alpha-IFN) therapy in patients with chronic hepatitis C has important implications for therapeutic research and clinical care. Serum HCV RNA was tested for HCV genotype and quantified by a standardized reverse transcriptase-polymerase chain reaction assay as a measure of viral load in a cohort of 130 patients with chronic hepatitis C treated with alpha-IFN at a standard dose of 3 million units three times a week scheduled for 6 (n = 50) or 12 months (n = 76). Twenty-one of 126 evaluable patients (16.7%) developed a sustained complete response to alpha-IFN according to biochemical and virological criteria. The 3 pretreatment independent factors associated with a sustained complete response were a low baseline serum HCV RNA concentration, non-1 HCV genotype, and female sex. A multivariate logistic regression model, with pretreatment and month 1 variables, showed that a lower baseline serum HCV RNA concentration, female sex, and a greater suppression of RNA were the significant predictors of sustained complete response. The lowest baseline serum HCV RNA concentration was observed in patients with genotype 2 infection and the greatest decrease in HCV RNA from baseline to month 1 in those with genotype 3. The findings suggest that measuring HCV RNA in serum before and soon after beginning treatment can be helpful for selecting patients who are most likely to have a sustained complete response to standard schedule of alpha-IFN and for identifying patients in whom alternative strategies should be examined.

Genes of the major histocompatibility complex class II influence the outcome of hepatitis C virus infection

BACKGROUND & AIMS

The host's immune response may influence the course of hepatitis C virus (HCV) infection. The aim of this study was to investigate the distribution of HLA class II alleles in white subjects who spontaneously recovered from HCV infection compared with that in patients with persistent infection.

METHODS

HLA-DRB1 and -DQB1 typing were performed in 103 consecutive patients with persistent HCV infection (HCV antibody positive, HCV RNA positive) and in 25 subjects with transient HCV infection (HCV antibody positive, persistently negative HCV RNA).

RESULTS

No significant differences between subjects with transient or persistent infection were observed for age, sex, source of infection, or HCV serotype. The frequency of DQB1*0301 and DRB1*1101 alleles was higher in patients with transient infection than in those with persistent infection (84% vs. 30.8%, 40% vs. 9.8%; P < 0.01 and P < 0.02, respectively [Bonferroni correction]). DRB1 and DQB1 alleles did not influence viral load as an independent factor. Mean Knodell's scores were lower in patients with DQB1*0301 allele (6.12 +/- 0.4) than in those negative for DQB1*0301 (7.37 +/- 0.3; P < 0.05).

CONCLUSIONS

Our results suggest that host- rather than virus-related factors are probably involved in the spontaneous clearance of HCV.

[Intrahepatic porto-systemic shunt in the treatment of hemorrhage in portal hypertension]

PREVENT RECURRENT BLEEDING: Digestive hemorrhage due to portal hypertension is the cause of one-third of the mortality in cirrhosis. Transjugular intrahepatic portosystemic shunt (TIPS) creates a calibrated anastomosis between the portal vein and hepatic vein. The technique is now well established and a trained team can install a shunt in approximately 2 hours with a risk of failure of less than 10%.

RESULTS

TIPS can be effective for the treatment and prevention of variceal bleeding subsequent to portal hypertension. Preliminary results have not however provided the precise indications for this technique in the therapeutic armamentanium.

COMPLICATIONS

Hepatic encephalopathy and obstruction are the main complications. Encephalopathy can occur as an acute episode; frequency appears to fall off after endothelialization of the prosthesis. The degree of shunt obstruction can reach 40% at one year and remains the major problem with this technique. Its pathogenesis is unknown and there is no prevention. Regular surveillance is required to detect this complication and take the necessary steps.

Histopathologic analysis of transjugular intrahepatic portosystemic shunts

This prospective study was undertaken in 17 patients treated with 22 transjugular intrahepatic portosystemic shunt (TIPS) procedures and aimed to evaluate the nature and causes of short- and long-term shunt abnormalities. Specimens were collected after autopsy in 6 patients and after liver transplantation in 11 patients; the time from shunting ranging from 4 to 385 days. During the first 2 weeks the shunt surface was covered by poorly organized fibrin platelet clots that were mixed with inflammatory and red blood cells. Thereafter, a pseudointima developed, initially made of loose granulation tissue that was formed by edema, myofibroblasts, neo-capillaries, collagen fibers, and inflammatory cells. This pseudo-intima extended with time as the myofibroblasts increased in number, as the collagen fibers thickened, and as the inflammatory cells grew more scarce. Its thickness ranged from 50 to 3,500 microm, the maximal values being observed in the middle of the shunt. The shunt was obstructed by a clot in 4 patients (18%). In 7 shunts (31.8%) the pseudo-intima was thicker than 1,000 microm and was referred to as hyperplastic pseudo-intima. It showed more dense inflammatory infiltrate and anarchic deposition of more scarce collagen fibers. Pseudo-intima hyperplasia was associated with previously diagnosed thrombosis, which had been treated by dilatation in 2 cases and by biliary deposits in 3 cases, while it remained unexplained in 2 cases. Accordingly, this study confirms the following: 1) that early TIPS obstruction results from thrombosis; 2) that 2 weeks after insertion, the stent is covered by a smooth pseudo-intima; 3) that thereafter, pseudo-intimal hyperplasia is the main cause of TIPS stenosis or occlusion; and 4) that biliary secretions and previous thrombosis could be important triggering mechanisms for this pseudo-intima overgrowth.

Mutations in the MHC class I-like candidate gene for hemochromatosis in French patients

A candidate gene for hemochromatosis has recently been localized on the short arm of chromosome 6, about 4 megabases telomeric to the major histocompatibility complex. It encodes a protein that exhibits significant similarity to the HLA class I molecules and can be provisionally designated HLA-hc. Genotype analysis of 94 hemochromatosis patients living in France and a similar number of controls confirms that the disease is strongly associated with homozygosity at nucleotide 845 (72% of the patients and none of the controls carry two copies of the 845A variant). The data are consistent with hemochromatosis being a heterogeneous disease: about 79% of the cases in this sample would be caused by a defect in HLA-hc and 21% by an unrelated mechanism. A second variant (187 G) enriched on patient chromosomes that do not carry the 845A mutation might influence the affinity of a ligand for HLA-hc; the exact nature of this ligand remains to be discovered. The 845A variant is the best genetic marker for the disease identified to date, and the detection of 845A homozygosity should now permit diagnosis of a readily curable disease and the prevention of sometimes deadly complications in at least 72% of the patients.

Haemodynamic effects of molsidomine and propranolol in patients with cirrhosis

Propranolol and molsidomine have both been shown to decrease the hepatic venous pressure gradient in patients with cirrhosis. The present study aimed at assessing the effects of the combination of these two drugs on splanchnic and systemic haemodynamics of cirrhotic patients. Fifteen patients with biopsy proven alcoholic cirrhosis had haemodynamic measurements under basal conditions, 60 min after oral administration of 4 mg molsidomine then 15 min after intravenous administration of 15 mg propranolol. As compared with baseline values, molsidomine was found to decrease mean arterial pressure (-7.9%, (P < 0.01), cardiac output (-7.3%, P < 0.01), pulmonary wedged pressure (-45.8%, (P < 0.05) and hepatic venous pressure gradient (-11.7%, P < 0.01). Propranolol decreased heart rate (-21%, P < 0.01), further decreased cardiac output (-20.6%, (P < 0.01) and hepatic venous pressure gradient (-10.5%, P < 0.01). As a whole, molsidomine plus propranolol decreased mean arterial pressure (-8%, P < 0.01), heart rate (-19%, P < 0.01), cardiac output (-26.5%, P < 0.01) and hepatic venous pressure gradient (-21%, P < 0.01). Pulmonary wedged pressure, liver blood flow and hepatic intrinsic clearance of indocyanine green were not significantly changed by the association of molsidomine and propranolol. We conclude that in patients with cirrhosis, molsidomine and propranolol potentiate their effects on hepatic venous pressure gradient. Such a combination could therefore prove useful in the treatment of portal hypertension.

Involvement of calcium in macrophage leukotriene release during experimental cirrhosis

The aim of the present study was to assess the mechanism of 5-lipoxygenase metabolites (LT) secretion by peritoneal macrophages in rats wih CC14 induced cirrhosis. After stimulation with calcium ionophore A23187 or opsonized zymosan, [3H] arachidonic acid labeled macrophages from cirrhotic rats presented a significantly greater secretion of LT than macrophages from healthy controls. In addition, the phorbol ester TPA (protein kinase C activator) increased LT production only in macrophages from cirrhotic animals and not in controls. Although Ca2+ is thought to be involved in 5 lipoxygenase activation, the role of Ca2+ in LT production was studied. The use of a Ca2+-free medium as well as the addition of TMB-8 (an inhibitor of intra-cellular Ca2+ movements and of plasma membrane Ca2+ fluxes) resulted in a fall in LT production greater for macrophages from cirrhotic animals than for controls. The measurement of cytosolic Ca2+ concentration by cytofluorimetry showed that Fluo-3 loaded macrophages from cirrhotic rats had a greater cytosolic CA2+ concentration than macrophages from control animals both in basal conditions and after A23187 stimulation. Study of 45Ca2+ uptake suggest, that extra-cellular Ca2+ is implicated in the elevated cytosolic Ca2+ observed in macrophages from cirrhotic animals as compared to healthy controls. The greater Ca2+ concentration observed in macrophages from cirrhotic rats was not related to a difference in phospholipase C activation because inositol phosphate production did not differ between macrophages from healthy and cirrhotic animals. Taken together these results suggest that as compared to healthy animals, the greater LT production during cirrhosis could be dependent upon a difference in 5-lipoxygenase activation related to a rise in cytosolic Ca2+ concentration independently of inositol phosphates generation.

[Natural history of esophageal varices and prevention of hemorrhage]

More than one third of cirrhotic patients will experience variceal bleeding, of whom two thirds will die. The most reliable predictive factor for variceal rupture is the presence of large oesophageal varices at upper endoscopy. Non cardio-selective beta blockers have been proved to be effective in preventing bleeding. Cirrhotic patients should therefore be entered in an endoscopy screening program. Should no varices or small varices be found in the oesophagus, endoscopy should be repeated every year. Patients found to have large varices should be given beta-blockers.

Severe portal hypertensive gastropathy and antral vascular ectasia are distinct entities in patients with cirrhosis

BACKGROUND/AIMS

Whereas severe portal hypertensive gastropathy and gastric antral vascular ectasia (GAVE) have been separately defined in patients with cirrhosis, there is much confusion in the literature because they are both characterized by red spots at endoscopy. This prospective study compared clinical, biochemical, and pathological features of these syndromes.

METHODS

Three groups of patients with cirrhosis and either GAVE (n = 14), severe portal hypertensive gastropathy (n = 14), or no gastric features at endoscopy (controls; n = 10) were included.

RESULTS

No difference was found between patients with gastropathy and controls. Patients with GAVE presented with the following significant differences compared with other patients: a higher Child-Pugh score, a lower blood level of hemoglobin and gastrin, and a higher intestinal blood loss. At pathological examination, these patients more frequently had vascular ectasia (P = 0.04), spindle cell proliferation (P < 0.01), fibrohyalinosis (P = 0.004), and Gilliam's score of > or = 2 (P < 0.05); thrombi were encountered only in patients with GAVE (P = 0.006). Using discriminant analysis, spindle cell proliferation and fibrohyalinosis were the only significant variables yielding a diagnostic accuracy of 85% for GAVE and gastropathy.

CONCLUSIONS

GAVE and severe portal hypertensive gastropathy are two distinct entities.

Transjugular intrahepatic portosystemic shunts using the Wallstent prosthesis: a follow-up study

PURPOSE

The aim of the present study was to assess the efficacy of transjugular intrahepatic portosystemic shunts (TIPS) in 45 patients with cirrhosis during a mean follow-up of 7 months.

METHODS

Forty-five consecutive patients treated by TIPS and who had been followed for at least 6 months after TIPS or until death, were included. Mean follow-up was 7.2 +/- 5.0 months. Shunt patency was assessed at 1 week and 1 month, then every 3 months after the procedure by Doppler US and angiography whenever needed.

RESULTS

Thirty-six patients had been stented for refractory bleeding from ruptured esophagogastric varices. Of these, 8 patients (22%) rebled, 7 of whom were treated by a second shunt. Nine patients were treated for refractory ascites. Three patients had recurrent ascites due to shunt obstruction. All were treated by a second shunt which occluded in 2 patients. As a whole, 14 (31.1%) patients developed shunt obstruction within a mean of 120 +/- 136 days, 4 of whom remained asymptomatic. Other complications were septicemia by Staphylococcus aureus in 1 patient, transient encephalopathy in 9 patients, and disseminated intravascular coagulation in 1 patient.

CONCLUSIONS

TIPS appears to be a relatively safe and effective technique in treating complications of portal hypertension in patients with cirrhosis. Shunt obstruction in 31% of our patients probably represents the most important limitation of this technique.

Hemodynamic and pharmacokinetic study of tertatolol in patients with alcoholic cirrhosis and portal hypertension

Tertatolol, a recently developed beta 1-beta 2-blocker has two advantages: it does not induce withdrawal syndrome after abrupt cessation, and it preserves renal function. It has been suggested that the kinetics of tertatolol in patients with hepatic dysfunction are altered. Therefore, the hemodynamic effects and pharmacokinetics following the acute administration of tertatolol were studied in cirrhotic patients with portal hypertension. Systemic, splanchnic and renal hemodynamics were evaluated before and 30 min after the simultaneous administration of 2.5 mg tertatolol p.o. and 1.25 mg deuterated tertatolol i.v. in 10 cirrhotic patients with esophageal varices. The pharmacokinetics of tertatolol were evaluated over a 4-day period. Tertatolol significantly decreased heart rate (-22 +/- 10%), cardiac output (-26 +/- 8%), and hepatic blood flow (-27 +/- 23%). The hepatic venous pressure gradient decreased from 15.7 +/- 5.0 to 12.9 +/- 4.0 mmHg (-17 +/- 13%, P < 0.01). Three out of 10 patients were non-responders to tertatolol. Renal blood flow (-9 +/- 28%) and intrinsic hepatic clearance of indocyanin green (-9 +/- 25%) were not significantly modified. The duration of effective beta-blockade was far less than 12 h. Tertatolol was rapidly absorbed with a Cmax of 70 +/- 51 micrograms/l at a peak time of 0.75 +/- 0.26 h. In comparison with healthy volunteers referred to in literature sources, plasma clearance was reduced to 49 +/- 28 ml/min, bioavailability was increased to 72 +/- 20%, and the volume of distribution was increased to 50 +/- 34 l, probably due, in part, to a weaker protein binding -85%--effect.(ABSTRACT TRUNCATED AT 250 WORDS)

Diffuse vascular ectasia of the antrum, duodenum, and jejunum in a patient with nodular regenerative hyperplasia. Lack of response to portosystemic shunt or gastrectomy

The case is reported of a 70 year old man who presented with severe anaemia because of chronic gastrointestinal blood loss. This loss was ascribed to vascular ectasia resembling the gastric antral vascular ectasia syndrome but extended to include the antrum, the duodenum, the jejunum, and, possibly, the cardiac area. This condition was associated with portal hypertension as a result of nodular regenerative hyperplasia. Consecutive treatments including sucralfate, prostaglandin E2, propranolol, organic nitrates, pentoxyphilline, corticosteroids, endoscopic sclerotherapy, portosystemic shunt, total gastrectomy, proved ineffective.

Transjugular intrahepatic portosystemic shunt: evaluation with Doppler sonography

To assess the potential role of ultrasound (US) in evaluating transjugularly inserted intrahepatic portosystemic shunts, the authors performed sonographic, including duplex and color Doppler, studies in 23 patients. Imaging was performed before, during the first week after, and 2-3 months after shunt placement. The prostheses were readily visualized and shunt patency was easily determined with Doppler US in all patients. The mean of the maximum blood flow velocity in the main portal vein increased from 7 (range, 3-16) cm/sec before shunting to 24 (range, 18-47) cm/sec 2-3 months after shunting. Flow reversal was detected in the intrahepatic portal branches in 16 (69%) of the 23 patients. US allowed prompt detection and management of two cases of incomplete stent expansion and one case of shunt stenosis due to pseudo-intimal hyperplasia. Sonography is a valuable tool for evaluation of changes in hepatic hemodynamics after transjugular intrahepatic shunt placement.

Color Doppler-US guidance in transjugular placement of intrahepatic portosystemic shunts

Percutaneous placement of portosystemic shunts requires access to the portal system from a transjugular approach. Color Doppler sonography was used to direct the transjugular puncture in intrahepatic portosystemic shunt procedures in four patients. In each case, the technique allowed quick, safe transjugular puncture of the portal vein and close real-time monitoring of the procedure.

Propranolol reduces the rebleeding rate during endoscopic sclerotherapy before variceal obliteration

In patients treated with sclerotherapy, most rebleeding episodes are observed before variceal obliteration. This prospective randomized study aimed to assess if propranolol together with sclerotherapy could reduce the rebleeding rate before variceal obliteration. Seventy-five patients (59 male, 16 female; mean age, 54 +/- 15 years) with cirrhosis (from alcohol abuse in 91%) admitted with upper gastrointestinal bleeding, which was endoscopically proven to originate from ruptured esophageal varices, were included. After initial control of bleeding, the patients were randomized into the following two groups: group 1 treated with sclerotherapy alone (36 patients) and group 2 treated with sclerotherapy plus propranolol (39 patients). They were followed up to variceal obliteration. In group 2, 7 patients rebled as compared with 14 patients treated with sclerotherapy alone (P less than 0.005). When considering only rebleedings from esophageal varices, 4 patients rebled in group 2 vs. 10 in group 1 (P less than 0.10). The total number of rebleeding episodes was lower in group 2 than in group 1 whether considering all causes (8 vs. 17; P less than 0.07) or variceal rebleedings alone (4 vs. 13; P less than 0.01). Mean total blood requirement per patient was lower in group 2 than in group 1 (1.4 +/- 3.4 vs. 2.79 +/- 6.4 units of blood, respectively; P less than 0.01). Mortality was similar in both groups of patients (14% vs. 13% in groups 1 and 2, respectively, NS). It is concluded that patients treated with sclerotherapy should be given propranolol before variceal obliteration.

Systemic and splanchnic hemodynamic effects of molsidomine in rats with carbon tetrachloride-induced cirrhosis

Molsidomine, a long-acting vasodilator mainly used as an antianginal agent, was reported to decrease the portohepatic venous pressure gradient in patients with alcoholic cirrhosis. This study investigated the effects of linsidomine, the active metabolite of molsidomine, on systemic and splanchnic hemodynamics in rats with CCl4-induced cirrhosis using the microsphere technique. Compared with placebo-treated rats, linsidomine-treated animals were found to have a significant decrease in portal venous pressure (-18%, p less than 0.01) and in mean arterial pressure (-16%, p less than 0.01), smaller peripheral resistances (p less than 0.01), greater portal venous inflow (p less than 0.05), smaller splanchnic arteriolar resistances (p less than 0.01) and smaller protocol-lateral resistances (p less than 0.05). Cardiac output, hepatic arterial blood flow, portal blood flow and estimated hepatic blood flow were not significantly different between the two groups of animals. Linsidomine-treated rats exhibited a trend toward greater collateral blood flow compared with controls, but this difference was not significant. We conclude that linsidomine decreases portal venous pressure by reducing portocollateral resistances without affecting liver blood flow. These effects should be beneficial for patients with cirrhosis and portal hypertension.