Hepatic venous pressure gradient predicts clinical decompensation in patients with compensated cirrhosis

Predictive factors for long-term survival in patients with clinically significant portal hypertension following resection of hepatocellular carcinoma

BACKGROUND

Hepatic resection for hepatocellular carcinoma (HCC) is not currently recommended for patients with clinically significant portal hypertension (PHT); however, recent studies have shown similar post-operative outcomes between patients with and without clinically significant PHT.

AIM

To clarify the post-operative prognostic relevance of clinically significant PHT in Child-Pugh A cirrhotic patients.

METHODS

A total of 100 Child-Pugh A cirrhotic patients who underwent curative resection of HCC were eligible for this analysis. Patients were divided into two groups: PHT group (n=47) and non-PHT group (n=53).

RESULTS

Clinicopathological variables showed no significant differences except for prothrombine time. Liver-related complications were significantly higher in the PHT group (P=0.015), and the 5-year overall survival rate was significantly higher in the non-PHT group (78.7 vs. 37.9%, P<0.001). The proportion of patients who died because of complications of cirrhosis was significantly higher in the PHT group (P=0.001). Multivariate analysis indicated that the presence of clinically significant PHT was the most powerful adverse prognostic factor for overall survival. Multivariate analysis of the 47 patients with clinically significant PHT indicated that gross vascular invasion and non-single nodular type were poor prognostic factors. The 5-year survival rate of patients with single nodular type and without gross vascular invasion (n=17) was 78.4%.

CONCLUSIONS

In Child-Pugh A cirrhotic patients, the presence of clinically significant PHT was significantly associated with post-operative hepatic decompensation and poor prognosis after resection of HCC. However, in patients with clinically significant PHT, those with single nodular tumours lacking gross vascular invasion may be good surgical candidates.

Invasive and non-invasive methods for the assessment of fibrosis and disease progression in chronic liver disease

Chronic liver diseases represent a major public health problem, accounting for significant morbidity and mortality worldwide. Their prognosis and management greatly depend on the amount and progression of liver fibrosis with the risk of developing cirrhosis. Liver biopsy, traditionally considered as the reference standard for staging of fibrosis, has been challenged over the past decade by the development of novel non invasive methodologies. These methods rely on two distinct but complementary approaches: i) a 'biological' approach based on the dosage of serum biomarkers of fibrosis; ii) a 'physical' approach based on the measurement of liver stiffness using transient elastography (TE). Non invasive methods have been initially studied and validated in chronic hepatitis C but are now increasingly used in other chronic liver diseases, resulting in a significant decrease in the need for liver biopsy. However, they will likely not completely abolish the need for liver biopsy and they should rather be employed as an integrated system with liver biopsy. This review is aimed at discussing the advantages and inconveniences of non invasive methods in comparison with liver biopsy for the management of patients with chronic liver diseases.

Accuracy of MELD scores in predicting mortality in decompensated cirrhosis from variceal bleeding, hepatorenal syndrome, alcoholic hepatitis, or acute liver failure as well as mortality after non-transplant surgery or TIPS

BACKGROUND

To systematically review literature on use of model for end-stage liver disease (MELD) score to determine severity and prognosis of liver disease in various clinical situations and to evaluate its use in decisions regarding therapeutic interventions.

METHODS

Computerized literature searches using key medical terms; review of authors' extensive files on this subject; and personal clinical experience.

RESULTS

The MELD score, a prospectively developed and validated scale for severity of end-stage liver disease, utilizes serum bilirubin, serum creatinine, and international normalized ratio to predict mortality in cirrhotic patients. It has proven clinically useful in increasingly varied clinical situations. The United Network for Organ Sharing uses MELD scores, with bonus points assigned for hepatocellular cancer, to prioritize allocation of deceased donor livers for liver transplantation. This work reviews recent data demonstrating that MELD scores relatively accurately predict mortality in patients with variceal bleeding, hepatorenal syndrome, alcoholic hepatitis, and acute liver failure, as well as assess risks of non-liver transplantation surgery or transjugular intrahepatic portosystemic shunts in cirrhotic patients. MELD scores fail to predict mortality in about 15% of patients with end-stage liver disease. Incorporation of additional parameters, including serum sodium level, serum albumin level, glucose intolerance, or APACHE II score, may potentially improve prognostic accuracy.

CONCLUSIONS

MELD scores relatively accurately assess severity of liver disease and prognosis in patients with advanced liver disease in general, and in patients with individual complications of liver disease. It is useful in making decisions on potential therapies. Incorporating additional parameters may further improve its prognostic accuracy.

Liver cirrhosis

Liver cirrhosis is a frequent consequence of the long clinical course of all chronic liver diseases and is characterized by tissue fibrosis and the conversion of normal liver architecture into structurally abnormal nodules. Portal hypertension is the earliest and most important consequence of cirrhosis and underlies most of the clinical complications of the disease. Portal hypertension results from an increased intrahepatic resistance combined with increased portal (and hepatic arterial) blood flow. The fibrotic and angio-architectural modifications of liver tissue leading to increased intrahepatic resistance and the degree of portal hypertension seem to be highly correlated until HVPG values of 10-12 mmHg are reached. At this stage, which broadly represents the turning point between 'compensated' and 'decompensated' cirrhosis, additional extra-hepatic factors condition the further worsening of PH. Indeed, a HVPG ≥10-12 mmHg represents a critical threshold beyond which chronic liver disease becomes a systemic disorder with the involvement of other organs and systems. The progressive failure of one of the fundamental functions of the liver, i.e. the detoxification of potentially harmful substances received from the splanchnic circulation and particularly bacterial end-products, is responsible for the establishment of a systemic pro-inflammatory state further accelerating disease progression. The biology of liver cirrhosis is characterized by a constant stimulus for hepatocellular regeneration in a microenvironment characterized by chronic inflammation and tissue fibrosis, thus representing an ideal condition predisposing to the development of hepatocellular carcinoma (HCC). In reason of the significant improvements in the management of the complications of cirrhosis occurred in the past 20 years, HCC is becoming the most common clinical event leading to patient death. Whereas evidence clearly indicates reversibility of fibrosis in pre-cirrhotic disease, the determinants of fibrosis regression in cirrhosis are not sufficiently clear, and the point at which cirrhosis is truly irreversible is not established, either in morphologic or functional terms. Accordingly, the primary end-point of antifibrotic therapy in cirrhotic patients should be the reduction of fibrosis in the context of cirrhosis with a beneficial impact on portal hypertension and the emergence of HCC.

Carvedilol in the treatment of portal hypertension

Variceal bleeding is a major event in the natural history of end-stage liver disease with a subsequent high mortality rate. Non-selective β-blockers are currently the drugs of choice for preventing first variceal bleeding. Endoscopic rubber band ligation of high risk varices features as a first line option if cirrhotic patients cannot tolerate β-blockers. Despite adequate β-blockade, some patients may still present with variceal bleeding. The effect of carvedilol, a non-selective β and α-1 receptor-blocker, on lowering portal pressure has been investigated in several clinical trials and found to be superior to propranolol in both acute and chronic hemodynamic studies. Recently, carvedilol has also been compared with band ligation for primary prophylaxis against variceal bleeding with equivalent results to band ligation. Patient tolerance to carvedilol in advanced liver disease remains a source of concern. This review examines the place of carvedilol as an alternative to the currently recommended pharmacological therapy in prophylaxis against variceal bleeding.

Should we routinely measure portal pressure in patients with cirrhosis, using hepatic venous pressure gradient (HVPG) as a guide for prophylaxis and therapy of bleeding and rebleeding? No

Portal hypertension (PH) is a severe complication of liver cirrhosis. Measurement of the degree of portal hypertension is usually performed by measuring the hepatic venous pressure gradient (HVPG) which is the difference between the free hepatic venous pressure (FHVP) and the wedged hepatic venous pressure (WHPG). The HVPG accurately reflects the degree of PH in the majority of liver diseases. PH is defined by an increase of HVPG values above the normal upper limit of 5 mm Hg, while clinically significant PH is defined by an HVPG to ≥10 mm Hg. Although measurement of HVPG potentially has several applications, in clinical practice its major use has been related to the assessment of hemodynamic response to pharmacological therapy, in order to evaluate the efficacy of treatment and to predict the risk of rebleeding from esophageal varices. When properly performed, HVPG is a reliable, safe and good predictive tool in the management of portal hypertension. However, the need for appropriate equipment, sufficient and reliable operators and costs, have discouraged its use outside Liver Units specifically devoted to the clinical management of portal hypertension. This has diminished its applicability. Combining its use with transjugular liver biopsy and using the prognostic value of HVPG may help encourage its use.

Digital image analysis of liver collagen predicts clinical outcome of recurrent hepatitis C virus 1 year after liver transplantation

Clinical outcomes of recurrent hepatitis C virus after liver transplantation are difficult to predict. We evaluated collagen proportionate area (CPA), a quantitative histological index, at 1 year with respect to the first episode of clinical decompensation. Patients with biopsies at 1 year after liver transplantation were evaluated by Ishak stage/grade, and biopsy samples stained with Sirius red for digital image analysis were evaluated for CPA. Cox regression was used to evaluate variables associated with first appearance of clinical decompensation. Receiver operating characteristic (ROC) curves were also used. A total of 135 patients with median follow-up of 76 months were evaluated. At 1 year, median CPA was 4.6% (0.2%-36%) and Ishak stage was 0-2 in 101 patients, 3-4 in 23 patients, and 5-6 in 11 patients. Decompensation occurred in 26 (19.3%) at a median of 61 months (15-138). Univariately, CPA, tacrolimus monotherapy, and Ishak stage/grade at 1 year were associated with decompensation; upon multivariate analysis, only CPA was associated with decompensation (P = 0.010; Exp(B) = 1.169; 95%CI, 1.037-1.317). Area under the ROC curve was 0.97 (95%CI, 0.94-0.99). A cutoff value of 6% of CPA had 82% sensitivity and 95% specificity for decompensation. In the 89 patients with hepatic venous pressure gradient (HVPG) measurement, similar results were obtained. When both cutoffs of CPA > 6% and HVPG ≥ 6 mm Hg were used, all patients decompensated. Thus, CPA at 1-year biopsy after liver transplantation was highly predictive of clinical outcome in patients infected with hepatitis C virus who underwent transplantation, better than Ishak stage or HVPG.

Non-invasive assessment of liver fibrosis in chronic hepatitis C

Quantification of hepatic fibrosis is of critical importance in chronic hepatitis C not only for prognosis, but also for antiviral treatment indication. Two end points are clinically relevant: detection of significant fibrosis (indication for antiviral treatment) and detection of cirrhosis (screening for eosphageal varices and hepatocellular carcinoma). Until recently, liver biopsy was considered the reference method for the evaluation of liver fibrosis. Limitations of liver biopsy (invasiveness, sampling error, and inter-observer variability) have led to the development of non-invasive methods. Currently available methods rely on two different approaches: a "biological" approach based on the dosage of serum fibrosis biomarkers; and a "physical" approach based on the measurement of liver stiffness, using transient elastography (TE). This review is aimed at discussing the advantages and limits of non-invasive methods and liver biopsy and the perspectives for their rational use in clinical practice in the management of patients with chronic hepatitis C.

Decompensated cirrhosis after renal transplantation: a case report

Patients with end-stage liver disease with renal failure can be considered for simultaneous liver kidney transplantation. There are, however, no clear guidelines as to the management of the well-compensated cirrhotic patient with end-stage renal disease. We present the case of a patient with cirrhosis who decompensated after renal transplantation. With no indication for liver transplantation, can these patients safely undergo renal transplantation?

Comparison of balloon vs. straight catheter for the measurement of portal hypertension

BACKGROUND

The hepatic venous pressure gradient (HVPG) is used as an estimation of portal pressure (PP) in the management of patients with cirrhosis. Two methods are available using either a straight or a balloon catheter, but have never been compared head-to-head.

AIM

To compare the two methods of determining HVPG, straight and balloon catheter, regarding reproducibility and reliability.

METHODS

In 47 patients with liver cirrhosis, HVPG was assessed using both catheters in sequence. In another 29 patients, the wedged hepatic venous pressure (WHVP) determined either with straight or balloon catheter was correlated with a direct measurement of PP. Variation coefficient and intraclass correlation coefficient were calculated.

RESULTS

Variation coefficients for balloon catheter were 0.07 (HVPG), 0.02 (WHVP) and 0.06 [free hepatic venous pressure (FHVP)]. Variation coefficients for straight catheter were 0.17 (HVPG), 0.06 (WHVP) and 0.07 (FHVP), demonstrating a significantly wider variation of the HVPG and WHVP measurements (P < 0.001). Comparison of WHVP with PP revealed a correlation coefficient of 0.72 (P = 0.004) using balloon catheter and 0.58 (P = 0.011) using straight catheter.

CONCLUSIONS

Measurements with the balloon catheter currently represent the most reliable and reproducible method to assess HVPG. The results are of particular clinical relevance if repeated measurements are required for therapeutic adjustments.

Ultrasound-based hepatic elastography: origins, limitations, and applications

A reliable, noninvasive marker to help clinicians evaluate hepatic fibrosis is urgently needed. The liver biopsy, an imperfect gold standard, has recognized limitations including sampling error and interobserver variability. Hepatic elastography (HE) is a novel sonographic method for assessing liver stiffness and has excellent accuracy in making the diagnosis of minimal fibrosis and cirrhosis. Several conditions intrinsic to the pathology of the liver compromise the positive predictive value of HE for fibrosis alone including acute hepatitis, obstructive cholestasis, and passive congestion. Technical considerations that hinder the performance of elastography include an advanced body mass index, the presence of ascites and narrow intercostal spaces. Despite these limitations, elastography has a role in staging fibrosis, prognosis of disease outcome, surveillance, and treatment decisions. HE is now being used in lieu of liver biopsy to investigate the natural history of chronic liver diseases. Additional studies are required to better define the appropriate role of HE in clinical practice.

Spontaneous bacterial peritonitis: from pathophysiology to prevention

Patients with cirrhosis present an increased susceptibility to bacterial infections, which are the cause of hospital admission in about 10% of patients and are present in about 40% of those admitted for ongoing complications. Lastly, about a third of patients develop nosocomial infections. Spontaneous bacterial peritonitis (SBP) is the most frequent infection in advanced cirrhosis; it is mostly caused by Gram-negative bacteria of intestinal origin, but Gram-positive cocci can be involved in nosocomial-acquired SBP. Its occurrence is associated with complications, such as renal and circulatory failure, cardiac dysfunction, coagulopathy, encephalopathy, and relative adrenal insufficiency, ultimately leading to multi-organ failure and death within a few days or weeks in about 30% of cases. The main mechanism underlying the development of SBP, as well as other bacterial infections in cirrhosis, is represented by bacterial translocation from the intestinal lumen to mesenteric lymph nodes or other extraintestinal organs and sites. This process is facilitated by several factors, including changes in intestinal flora, portal hypertension, and, mainly, impairment in local/systemic immune defense mechanisms. Bacterial infections in advanced cirrhosis evoke an enhanced systemic inflammatory response, which explains the ominous fate of PBS. Indeed, an exaggerated production of cytokines ensues, which ultimately activates vasodilating systems and generates reactive oxygen species. Primary antibiotic prophylaxis of PBS is warranted in those conditions implying an increased incidence of bacterial infections, such as gastro-intestinal bleeding and low protein content in ascites associated with severe liver and/or renal dysfunction. Fluoroquinolones are commonly employed, but the frequent occurrence of resistant bacterial strains make third generation cephalosporins preferable in specific settings. The high PBS recurrence indicates secondary antibiotic prophylaxis.

[Recent advances in diagnosis of portal hypertension]

Complications of portal hypertension are major concerns in liver cirrhosis and significant morbidity and mortality mainly because of variceal bleeding, ascites, bacterial infections, hepatic encephalopathy, and hepatorenal syndrome. Various modalities in the diagnosis of portal hypertension are reviewed. The measurement of hepatic venous pressure gradient (HVPG) is a simple, invasive, reproducible method and regarded as the gold standard for the diagnosis and staging of portal hypertension. Other tests such as transient elastography, per-endoscopic variceal pressure measurement, endoscopic ultrasonography, and Doppler ultrasonography may be complementary and promising.

Clinical pharmacology of portal hypertension

Portal hypertension is an increase in pressure in the portal vein and its tributaries. It is defined as a portal pressure gradient (the difference in pressure between the portal vein and the hepatic veins) greater than 5 mm Hg. Although this gradient defines portal hypertension, a gradient of 10 mm Hg or greater defines clinically significant portal hypertension, because this pressure gradient predicts the development of varices, decompensation of cirrhosis, and hepatocellular carcinoma. The most direct consequence of portal hypertension is the development of gastroesophageal varices that may rupture and lead to the development of variceal hemorrhage. This article reviews the pathophysiologic bases of the different pharmacologic treatments for portal hypertension in patients with cirrhosis and places them in the context of the natural history of varices and variceal hemorrhage.

Comparison study of Doppler ultrasound surveillance of expanded polytetrafluoroethylene-covered stent versus bare stent in transjugular intrahepatic portosystemic shunt

OBJECTIVE

This prospectively randomized controlled study aimed to assess with Doppler ultrasound (US) the shunt function of expanded polytetrafluoroethylene (ePTFE)-covered transjugular intrahepatic portosystemic shunt (TIPS) stent versus bare stent and to evaluate the usefulness of routine TIPS follow-up of ePTFE-covered stents.

METHODS

Sixty consecutive patients were randomized for bare or covered transjugular TIPS stenting in our institution between April 2007 and April 2009. Data of follow-up Doppler US, angiography, and portosystemic pressure gradient measurements were collected and analyzed.

RESULTS

The follow-up period was 8.34 + or - 4.42 months in the bare-stent group and 6.16 + or - 3.89 months in the covered-stent group. Baseline clinical characteristics were similar in both groups. Two hundred three US studies were performed in 60 patients, with a mean of 3.4 per patient, and demonstrated abnormalities in 28 patients (21 bare stents, 7 ePTFE-covered stents), 19 of them (13 in bare-stent group, 6 in covered-stent group) showing no clinical evidence of recurrence. Ten of 13 patients in the bare-stent group underwent balloon angioplasty or additional stent placement, whereas only one of six patients in the covered-stent group needed reintervention for intimal hyperplasia. The average peak velocity in the midshunt of ePTFE-covered stent was 139 + or - 26 cm/s after TIPS creation and 125 + or - 20 cm/s during follow-up, which was significantly higher than the bare-stent group (p < 0.05). The main portal vein and hepatic artery showed higher flow velocities in the ePTFE-covered stent group than in the bare-stent group. ePTFE-covered stents maintained lower portosystemic pressure gradient than bare stents (9.5 + or - 2.9 versus 13.2 + or - 1.5 mmHg, p < 0.05).

CONCLUSIONS

ePTFE-covered stents resulted in higher patency rates and better hemodynamics than bare stents. Routine US surveillance may not be necessary in patients with ePTFE-covered TIPS stent.

Over-the-counter analgesics in cirrhotic patients: a case-control study examining the risk of hospitalization for liver-associated events

OBJECTIVE

To assess the association between over-the-counter analgesic (OTCA) use and hospitalization for liver-associated events in cirrhotic patients.

MATERIAL AND METHODS

Ninety adult cirrhotics admitted with liver-associated events and 126 non-hospitalized cirrhotic controls were enrolled prospectively into a case-control study. Standardized questionnaires were used to obtain predictor variables, including detailed 30-day OTCA use. Data were analyzed via logistic regression.

RESULTS

Hepatitis C (43%), alcohol (34%), and cryptogenic (13%) were the most common etiologies of cirrhosis. OTCA use was similar between cases and controls in the 30 days prior to enrollment (34% vs. 44%; odds ratio, OR = 0.66, 95% confidence interval, CI = 0.37-1.16, p = 0.148). Adjusted analyses also found no significant association between OTCA use and hospitalization for liver-associated events (OR = 0.73, 95% CI = 0.38-1.38, p = 0.330). Furosemide (p = 0.001), lactulose (p = 0.026), and number of prior liver-associated events (p = 0.002) were positively associated with hospitalization, while propranolol showed an inverse association (p = 0.008).

CONCLUSION

Our data suggest that non-excessive OTCA use is not significantly associated with hospitalization for liver-associated events.

The relationship between liver disease stage and liver fibrosis: a tangled web

The structural consequences of chronic liver disease are described as a series of liver disease 'stages' with scarring and architectural change that eventually destroys and replaces the normal lobular structure of the liver. Fibrosis ('excess collagen') and stage have been confused in histological staging systems. Fibrosis is part of increasing liver disease stage, but fibrosis and stage are different. Staging liver disease is important in routine histopathological assessment. Measurement of liver fibrosis is another process. The collagenous proportion of a liver biopsy [collagen proportionate area (CPA)] correlates with hepatic venous pressure gradient (HVPG), which is of recognized prognostic value. CPA at 1 year post-transplantation in hepatitis C virus-infected patients predicts subsequent clinical decompensation. CPA in cirrhotic patients predicts decompensation more accurately than staging or HVPG. The 'cirrhosis' stage category has poor prognostic power, and CPA effectively substages cirrhosis. CPA improves the description of liver disease stage. Proper validation of antifibrotic treatments and 'non-invasive markers of liver fibrosis' requires measurement of liver fibrosis (and not liver biopsy stage scores). It is unacceptable for the words 'fibrosis' and 'score' to remain next to each other. There are benefits to properly understanding liver fibrosis and liver disease stage and properly assessing each of them.

Evolving challenges in hepatic fibrosis

Continued elucidation of the mechanisms of hepatic fibrosis has yielded a comprehensive and nuanced portrait of fibrosis progression and regression. The paradigm of hepatic stellate cell (HSC) activation remains the foundation for defining events in hepatic fibrosis and has been complemented by progress in a number of new areas. Cellular sources of extracellular matrix beyond HSCs have been identified. In addition, the role of chemokine, adipokine, neuroendocrine, angiogenic and NAPDH oxidase signaling in the pathogenesis of hepatic fibrosis has been uncovered, as has the contribution of extracellular matrix stiffness to fibrogenesis. There is also increased awareness of the contribution of innate immunity and greater understanding of the complexity of gene regulation in HSCs and myofibroblasts. Finally, both apoptosis and senescence have been recognized as orchestrated programs that eliminate fibrogenic cells during resolution of liver fibrosis. Ironically, the progress that has been made has highlighted the growing disparity between advances in the experimental setting and their translation into new diagnostic tools and treatments. As a result, focus is shifting towards overcoming key translational challenges in order to accelerate the development of new therapies for patients with chronic liver disease.

Toll-like receptor 4 D299G polymorphism and the incidence of infections in cirrhotic patients

BACKGROUND

Toll-like receptor (TLR) 4 genetic polymorphisms, mainly D299G, have been associated with increased predisposition to infection in several populations.

AIM

To retrospectively analyse the relationship between the presence of the TLR4 D299G polymorphism and the incidence of bacterial infections in cirrhotic patients.

METHODS

We included 111 consecutive cirrhotic patients hospitalized with ascites and we determined the presence of the TLR4 D299G polymorphism by PCR-RFLP (polymerase chain reaction-restriction fragment length polymorphism) and its relationship with the incidence of previous bacterial infections.

RESULTS

Ten out of 111 (9%) cirrhotic patients presented with the TLR4 D299G polymorphism. The mean follow-up from first decompensation of cirrhosis until current admission was longer in D299G polymorphism patients than in wild-type patients (53.8 +/- 40.7 vs. 35.4 +/- 48.3 months, P = 0.03). D299G polymorphism patients showed a trend towards a higher incidence of history of previous infections (80% vs. 56.4%, P = 0.19), as well as a higher number of infections (2.8 +/- 2.3 vs. 1.0 +/- 1.3, P = 0.01) and bacteriaemias (0.4 +/- 1.0 vs. 0.04 +/- 0.2, P = 0.02) per patient than wild-type patients.

CONCLUSIONS

Toll-like receptor 4 D299G polymorphism could influence not only the predisposition to bacterial infections but also the evolution of the disease in cirrhotic patients. Further prospective studies in larger series of patients are warranted.

Right atrial pressure is not adequate to calculate portal pressure gradient in cirrhosis: a clinical-hemodynamic correlation study

Hepatic venous pressure gradient (HVPG), the difference between wedge and free hepatic venous pressure, is the preferred method for estimating portal pressure. However, it has been suggested that hepatic atrial pressure gradient (HAPG)--the gradient between wedge hepatic venous pressure and right atrial pressure (RAP)--might better reflect variceal hemodynamics. The aim of this study was to (1) investigate whether HAPG with nonselective beta-blockers correlates with prognosis in cirrhotic patients with portal hypertension at baseline and during treatment; (2) compare the prognostic value of HAPG with that of HVPG; and (3) investigate the agreement between portoatrial gradient (PAG) and portocaval gradient (PCG) in patients with transjugular intrahepatic portosystemic shunt (TIPS). We included 154 cirrhotic patients with varices with a complete hemodynamic study at baseline and on chronic treatment for primary (n = 71) or secondary (n = 83) prophylaxis for bleeding and 99 patients with TIPS. All patients were followed for up to 2 years; portal hypertensive-related bleeding and bleeding-free survival were analyzed. HVPG was equal or lower than HAPG in all patients (-3.2 mm Hg; P < 0.001). Agreement between HAPG and HVPG was modest, especially in patients with increased intra-abdominal pressure. One hundred two patients were HVPG nonresponders and 52 patients were HVPG responders to nonselective beta-blockers, whereas 101 patients were HAPG nonresponders and 53 patients were HAPG responders (k = 0.610). HVPG response revealed an excellent predictive value for bleeding risk and bleeding-free survival; HAPG did not. In our TIPS patients, 20% had a PCG < or =12 mm Hg and a PAG >12 mm Hg, which may have induced unnecessary overdilation of the TIPS.

CONCLUSION

The excellent prognostic information provided by HVPG response to drug therapy is lost if HAPG response is considered. RAP should not be used for the calculation of portal pressure gradient in patients with cirrhosis.

Capsule endoscopy in portal hypertension

Since the introduction of small bowel capsule endoscopy, and more recently of esophageal capsule endoscopy, these diagnostic tools have become available for the evaluation of the consequences of portal hypertension in the esophagus, stomach, and small intestine. The main advantage of the esophageal and the small bowel capsule is the relatively less invasiveness that could potentially increase patients' adherence to endoscopic screening/surveillance programs. When esophageal capsule endoscopy was compared with traditional gastroscopy, it showed good sensitivity and specificity in recognizing the presence and the size of esophageal varices. However, the results are not consistent among studies, and more data are needed.

Hepatic encephalopathy therapy: An overview

Type-C hepatic encephalopathy (HE) is a severe complication of cirrhosis, which seriously affects quality of life and is strongly related to patient survival. Treatment based on a classical pharmacological approach that is aimed at reducing the production of gut-derived toxins, such as ammonia, is still under debate. Currently, results obtained from clinical trials do not support any specific treatment for HE and our competence in testing old and new treatment modalities by randomized controlled trials with appropriate clinically relevant end-points urgently needs to be improved. On the other hand, patients who are at risk for HE are now identifiable, based on studies on the natural history of the disease. Today, very few studies that are specifically aimed at establishing whether HE may be prevented are available or in progress. Recent studies have looked at non absorbable disaccharides or antibiotics and other treatment modalities, such as the modulation of intestinal flora. In the treatment of severe stage HE, artificial liver supports have been tested with initial positive results but more studies are needed.

Clinical significance of worsening portal hypertension during long-term medical treatment in patients with cirrhosis who had been classified as early good-responders on haemodynamic criteria

BACKGROUND & AIMS

It is established that cirrhotic patients who respond to beta-blockers by lowering their hepatic venous pressure gradient (HVPG) to < or =12 mmHg or by > or =20% of the baseline values are protected from bleeding. However, it is not known whether the effect remains unchanged over the treatment period.

METHODS

A group of 24 patients with cirrhosis and oesophageal varices, treated with beta-blockers+/-nitrates, good-responders on haemodynamic criteria, were followed for up to 76 months with sequential HVPG measurements. Another group of 16 patients was used for validation.

RESULTS

HVPG worsened in 10 of the 24 patients during follow-up. Changes in HVPG correlated to concomitant changes in liver function parameters. Variceal bleeding occurred in four of the 10 patients whose HVPG had worsened (bleed; 3-21 months after the measured increase in HVPG) and in none of those with stable HVPG (p=0.02). Patients with increased HVPG also had shorter survival (p=0.05). Worsening of HVPG was an independent predictor of death, additive to Child-Pugh or MELD scores, in a time-dependent Cox's regression analysis. This relationship was confirmed in the validation group.

CONCLUSIONS

Worsening HVPG during follow-up in patients who had initially been good-responders to medical treatment is related to worsening in hepatic function. The maintenance of a good haemodynamic response to medical treatment of portal hypertension is an excellent predictor of outcome in these patients.

Outcome of recurrent hepatitis C virus after liver transplantation in a randomized trial of tacrolimus monotherapy versus triple therapy

Less potent immunosuppression is considered to reduce the severity of hepatitis C virus (HCV) recurrence after liver transplantation. An optimal regimen is unknown. We evaluated tacrolimus monotherapy versus triple therapy in a randomized trial of 103 first transplants for HCV cirrhosis. One hundred three patients who underwent transplantation for HCV were randomized to tacrolimus monotherapy (n = 54) or triple therapy with tacrolimus, azathioprine, and steroids (n = 49), which were tapered to zero by 3 to 6 months. Both groups had serial transjugular biopsies with hepatic venous pressure gradient (HVPG) measurement. The time to reach Ishak stage 4 was the predetermined endpoint. All factors documented in the literature as being associated with HCV recurrence and the allocated treatment were evaluated for reaching stage 4 and HVPG >or= 10 mm Hg. No significant preoperative, perioperative, or postoperative differences, including the frequency of biopsies between groups, were found. During a mean follow-up of 53.5 months, 9 monotherapy patients and 6 triple therapy patients died, and 5 monotherapy patients and 4 triple therapy patients underwent retransplantation. Stage 4 fibrosis was reached in 17 monotherapy patients and 10 triple therapy patients (P = 0.04), with slower fibrosis progression in the triple therapy patients (P = 0.048). Allocated therapy and histological acute hepatitis were independently associated with stage 4 fibrosis. HVPG increased to >or=10 mm Hg more rapidly in monotherapy patients versus triple therapy patients (P = 0.038). In conclusion, long-term maintenance immunosuppression with azathioprine and shorter term prednisolone with tacrolimus in HCV cirrhosis recipients resulted in a slower onset of histologically proven severe fibrosis and portal hypertension in comparison with tacrolimus alone, and this was independent of known factors affecting fibrosis.

Assessment of liver function in acute or chronic liver disease by the methacetin breath test: a tool for decision making in clinical hepatology

Patients suffering from acute or chronic liver disease require on-going assessment of disease progression in terms of the degree of hepatic fibrosis and overall liver impairment. This assessment is pivotal for determining the prognosis and for making decisions about medical treatment and liver transplantation. Currently available methods are either invasive, lack diagnostic accuracy or are limited by technical difficulties such as obesity or biochemical confounders. The metabolic breath test relies on the measurement of tagged metabolites of an organ-specific substrate in the exhaled breath. (13)C-methacetin is metabolized uniquely by the liver, and (13)CO(2) is measured continuously in the exhaled breath. Measuring this liver-specific substrate using molecular correlation spectroscopy provides a rapid, point-of-care, non-invasive method to assess liver function. The use of the (13)C-methacetin breath test (MBT) may provide a powerful tool for clinical hepatologists in decision making at the bedside. This paper reviews recent findings regarding the ability of the point-of-care (13)C-MBT to assess fibrosis, cirrhosis and hepatic functional reserve in patients with acute and chronic liver disease.

Emerging drugs for hepatic encephalopathy

BACKGROUND

Hepatic encephalopathy (HE) is a severe complication of cirrhosis, seriously affecting the patients' quality of life. The classical approach aimed at reducing the production of gut-derived toxins, such as ammonia, is under debate as, at the moment, the information obtained from the clinical trials does not support any specific treatment for HE.

OBJECTIVES

i) To discuss present therapeutic strategies and possible future developments; ii) to identify areas of medical needs and iii) to suggest the ideal design and methodology for randomized controlled trials (RCTs) in HE.

METHODS

Current approaches were obtained from already available RCTs or from experimental animal studies. Those approaches developed from studies on HE pathophysiology were considered as working hypotheses for future therapies.

RESULTS/CONCLUSION

Our competence in testing old and new treatment modalities by RCTs with appropriate clinically relevant end points should urgently be improved. The patients at risk of HE are identifiable, and studies specifically aimed at establishing whether HE may be prevented or not are needed. As far as new treatment modalities are concerned, RCTs on the modulators of the intestinal bacterial flora and on the molecular adsorbent recirculating system are already available, but further studies are needed to confirm these promising approaches.

Non invasive diagnosis of portal hypertension in cirrhotic patients

The measure of disease progression in chronic liver disease represents a key challenge in any of the different stages of evolution. Indeed, a correct and reliable measure of the stage of the disease has relevant implications for assessing the effectiveness of the current therapeutic regimens and for predicting the occurrence of complication. Accordingly, a current major effort is directed at evaluating methodologies characterized by no or low invasiveness to be employed as clinical discriminators in patients populations potentially requiring invasive assessment. This appears particularly relevant in patients with compensated cirrhosis, where the only reference standard is the measurement of portal pressure by hepatic venous pressure gradient (HVPG). In this particular context, transient elastography (TE) appears to be promising and needs to be further investigated, possibly in combination with other non-invasive methodologies such as serum markers algorithms and/or imaging techniques. On the other hand, the application of non-invasive methods for monitoring the response to vasoactive treatment for the reduction of portal pressure and the prevention of related complications seems at the moment not realistic.

The clinical use of HVPG measurements in chronic liver disease

Portal hypertension is a severe, almost unavoidable complication of chronic liver diseases and is responsible for the main clinical consequences of cirrhosis. Measurement of the hepatic venous pressure gradient (HVPG) is currently the best available method to evaluate the presence and severity of portal hypertension. Clinically significant portal hypertension is defined as an increase in HVPG to >or=10 mmHg; above this threshold, the complications of portal hypertension might begin to appear. Measurement of HVPG is increasingly used in clinical hepatology, and numerous studies have demonstrated that the parameter is a robust surrogate marker for hard clinical end points. The main clinical applications for HVPG include diagnosis, risk stratification, identification of patients with hepatocellular carcinoma who are candidates for liver resection, monitoring of the efficacy of medical treatment, and assessment of progression of portal hypertension. Patients who experience a reduction in HVPG of >or=20% or to <12 mmHg in response to drug therapy are defined as 'responders'. Responders have a markedly decreased risk of bleeding (or rebleeding), ascites, and spontaneous bacterial peritonitis, which results in improved survival.

Targeting liver fibrosis: strategies for development and validation of antifibrotic therapies

We have made striking progress in our understanding of the biochemistry and cell biology that underlies liver fibrosis and cirrhosis, including the development of strategies and agents to prevent and reverse fibrosis. However, translation of this knowledge into clinical practice has been hampered by (1) the limitation of many in vitro and in vivo models to confirm mechanisms and to test antifibrotic agents, and (2) the lack of sensitive methodologies to quantify the degree of liver fibrosis and the dynamics of fibrosis progression or reversal in patients. Furthermore, whereas cirrhosis and subsequent decompensation are accepted hard clinical endpoints, fibrosis and fibrosis progression alone are merely plausible surrogates for future clinical deterioration. In this review we focus on an optimized strategy for preclinical antifibrotic drug development and highlight the current and future techniques that permit noninvasive assessment and quantification of liver fibrosis and fibrogenesis. The availability of such noninvasive methodologies will serve as the pacemaker for the clinical development and validation of potent antifibrotic agents.

Antiviral therapy reduces portal pressure in patients with cirrhosis due to HBeAg-negative chronic hepatitis B and significant portal hypertension

BACKGROUND/AIMS

Lamivudine improves liver histology in patients with chronic hepatitis B (CHB), but its effects on portal pressure remain unknown. We evaluated the effect of lamivudine monotherapy on hepatic venous pressure gradient (HVPG) in CHB-related cirrhosis with significant portal hypertension.

METHODS

We studied 19 patients with cirrhosis due to HBeAg-negative CHB and HVPG >or=10 mm Hg treated with oral lamivudine (100mg daily). Liver biochemistry, Child-Pugh and MELD score were determined every 3 months, alpha-fetoprotein and HBV DNA every 6 months and HVPG at baseline and at 12 months after lamivudine initiation. Diuretics, beta-blockers, antibiotics and/or endoscopic therapy were used for routine indications.

RESULTS

At 12 months, a significant reduction was observed in ALT (p=0.001), HBV DNA (p=0.002), Child-Pugh (p=0.012) and MELD score (p=0.006). Four patients developed virological breakthrough during treatment. At 12 months, HVPG decreased in all but one patient [baseline: 14.4+/-3.9 and 12 months: 12.4+/-3.3 mm Hg (p=0.007)]. HVPG decreased >20% or below the 12 mm Hg threshold in 10 of 13 patients with baseline HVPG >or=12 mm Hg. HVPG increased in a patient with hepatic flare after virological breakthrough.

CONCLUSION

In conclusion, in patients with cirrhosis due to HBeAg-negative CHB, lamivudine monotherapy reduces HVPG, especially when virological suppression and biochemical remission is achieved.

Liver stiffness as a predictor of esophageal varices requiring therapy in HIV/hepatitis C virus-coinfected patients with cirrhosis

BACKGROUND

Liver stiffness (LS) measured by transient elastometry is associated with portal pressure in hepatitis C virus (HCV)-monoinfected patients and could predict the presence of esophageal varices in these subjects. The aim of this study was to assess the ability of LS to predict esophageal varices requiring preventive therapy for bleeding in HIV/HCV-coinfected patients.

METHODS

One hundred two HIV/HCV-coinfected patients with liver cirrhosis (LS >or= 14 kPa) underwent an upper gastrointestinal endoscopy (UGE) examination. The diagnostic performance of LS for esophageal varices requiring therapy (>or=F2 or F1 with red signs or Child-Pugh-Turcotte class C) was assessed by receiver operating receptor characteristic curves.

RESULTS

Nineteen patients (19%) harbored varices requiring therapy. LS in patients with and without varices needing treatment was 48 (33-71) kPa and 32 (18-48) kPa (P = 0.004). The area under the receptor operating characteristic curve (95% confidence interval) of LS for the occurrence of varices that should be treated was 0.71 (0.60 to 0.82). There was no cutoff level of LS with good positive predictive value for the presence of varices requiring therapy, but LS of 21 kPa had a negative predictive value of 100%. Twenty-six percent of patients with LS measurement and UGE showed LS <21 KPa.

CONCLUSIONS

LS is higher in HIV/HCV-coinfected patients with cirrhosis who show esophageal varices requiring therapy than in those who do not. A cutoff value of LS of 21 kPa could be useful to identify patients with very low probability of varices at risk for bleeding. UGE for screening could be spared in these patients until LS increases above 21 kPa.

Prognostic value of acute hemodynamic response to i.v. propranolol in patients with cirrhosis and portal hypertension

BACKGROUND/AIMS

Cirrhotic patients chronically treated with beta-blockers who achieve a decrease of hepatic venous pressure gradient (HVPG) > or =20% from baseline or to < or =12 mmHg have a marked reduction of first bleeding or re-bleeding. However, two HVPG measurements are needed to evaluate response. This study was aimed at investigating the predictive role of acute HVPG response to i.v. propranolol for bleeding and survival.

METHODS

We retrospectively studied 166 cirrhotic patients with varices with HVPG response to i.v. propranolol (0.15 mg/kg). All patients subsequently received non-selective beta-blockers to prevent first bleeding (n=78) or re-bleeding (n=88).

RESULTS

Thirty-seven patients developed a portal hypertension-related bleeding over 2 years of follow-up. Decrease (12%) in HVPG was the best cut-off for bleeding risk discrimination. This parameter was used to classify patients in responders (n=95) and non-responders (n=71). In primary prophylaxis (54 responders vs. 24 non-responders) the actuarial probability of bleeding was half in responders than in non-responders (12% vs. 23% at 2 years; ns). In secondary prophylaxis (41 responders vs. 47 non-responders) a good hemodynamic response was also significantly and independently associated with a 50% decrease in the probability of re-bleeding (23% at 2 years vs. 46% in non-responders; p=0.032) and a better survival (95% vs. 65%; p=0.003).

CONCLUSION

The evaluation of acute HVPG response to i.v. propranolol before initiating secondary prophylaxis for variceal bleeding is a useful tool in predicting the efficacy of non-selective beta-blockers. If adequately validated, this might be a more cost-effective strategy than the chronic evaluation of HVPG response and might be useful to guide therapeutic decisions in these patients.

Acute hemodynamic response to beta-blockers and prediction of long-term outcome in primary prophylaxis of variceal bleeding

BACKGROUND & AIMS

Studies of variceal bleeding have shown that a hemodynamic response to treatment of portal hypertension is appropriate when the hepatic venous pressure gradient (HVPG) decreases below 12 mmHg or by > 20% from baseline. However, in primary prophylaxis, many nonresponders do not bleed and 2 invasive procedures are needed to assess response. We investigated the long-term prognostic value of an acute response to beta-blockers and whether the target reduction in HVPG can be improved in primary prophylaxis.

METHODS

An initial hemodynamic study was performed in patients with large varices and without previous bleeding. After baseline measurements were made, propranolol was administered intravenously and measurements were repeated 20 minutes later. Patients were given nadolol daily and a second hemodynamic study was performed.

RESULTS

Of 105 patients, 15% had variceal bleeding. Using receiver operating characteristic curve analysis, a decrease of HVPG > or = 10% was the best value to predict bleeding. In the initial study, 75 patients (71%) were responders (HVPG decreased to < or = 12 mmHg or by > or = 10%) and had a lower probability of first bleeding than nonresponders (4% vs 46% at 24 months; P < .001). Acute responders also had a lower risk of developing ascites (P = .001). Chronic responders had a lower probability of bleeding than nonresponders (P < .001). There was a correlation between acute and chronic changes in HVPG (r = 0.62; P = .01).

CONCLUSION

The acute hemodynamic response to beta-blockers can be used to predict the long-term risk of first bleeding. An HVPG reduction > 10% from baseline is the best target to define response in primary prophylaxis.

Simultaneous liver-kidney transplantation in the MELD era

Impaired kidney function is common in liver transplant candidates and portends heightened risk for both postoperative chronic kidney disease and mortality. The weighting of serum creatinine in the Model of End-stage Liver Disease classification for liver allocation has been accompanied by a proliferation of simultaneous liver-kidney transplants in recent years. In the absence of standardized criteria for allocating kidneys in this setting, there is a wide variation in combined organ transplants across transplant centers. This review discusses the issues surrounding simultaneous liver-kidney transplantation and proposes a strategy for selecting patients to receive both organs.

Incidence, prevalence, and clinical significance of abnormal hematologic indices in compensated cirrhosis

BACKGROUND & AIMS

Patients with cirrhosis develop abnormal hematologic indices (HI) from multiple factors, including hypersplenism. We aimed to analyze the sequence of events and determine whether abnormal HI has prognostic significance.

METHODS

We analyzed a database of 213 subjects with compensated cirrhosis without esophageal varices. Subjects were followed for approximately 9 years until the development of varices or variceal bleeding or completion of the study; 84 subjects developed varices. Abnormal HI was defined as anemia at baseline (hemoglobin, < or =13.5 g/dL for men and 11.5 g/dL for women), leukopenia (white blood cell counts, < or =4000/mm3), or thrombocytopenia (platelet counts, < or =150,000/mm3). The primary end points were death or transplant surgery.

RESULTS

Most subjects had thrombocytopenia at baseline. Kaplan-Meier analysis showed that leukopenia occurred by 30 months (95% confidence interval, 18.5-53.6), and anemia occurred by 39.6 months (95% confidence interval, 24.1-49.9). Baseline thrombocytopenia (P = .0191) and leukopenia (P = .0383) were predictors of death or transplant, after adjusting for baseline hepatic venous pressure gradient (HVPG), and Child-Pugh scores. After a median of 5 years, a significant difference in death or transplant, mortality, and clinical decompensation was observed in patients who had leukopenia combined with thrombocytopenia at baseline compared with patients with normal HI (P < .0001). HVPG correlated with hemoglobin and white blood cell count (hemoglobin, r = -0.35, P < .0001; white blood cell count, r = -0.31, P < .0001).

CONCLUSIONS

Thrombocytopenia is the most common and first abnormal HI to occur in patients with cirrhosis, followed by leukopenia and anemia. A combination of leukopenia and thrombocytopenia at baseline predicted increased morbidity and mortality.

Hepatic venous pressure gradient: worth another look?

Portal hypertension is one of the most important complications of chronic liver disease and accounts for significant morbidity and mortality. Measurement of the hepatic venous pressure gradient (HVPG) is a simple, invasive, and reproducible method of assessing portal venous pressure. Measurement of HVPG provides the clinician an estimate of the degree of intrahepatic portal flow resistance, guides therapy for variceal bleeding (primary and secondary prophylaxis), assesses feasibility of resection in patients with hepatocellular cancer, and predicts response to therapy of patients with chronic hepatitis C. Achieving hemodynamic targets of reducing the HVPG to <10 mmHg or a 20% reduction from baseline virtually eliminates complications related to portal hypertension from chronic liver disease. This review explores the role of HVPG measurement in the contemporary treatment of patients with cirrhosis and portal hypertension.

Simvastatin lowers portal pressure in patients with cirrhosis and portal hypertension: a randomized controlled trial

BACKGROUND & AIMS

Simvastatin improves liver generation of nitric oxide and hepatic endothelial dysfunction in patients with cirrhosis, so it could be an effective therapy for portal hypertension. This randomized controlled trial evaluated the effects of continuous simvastatin administration on the hepatic venous pressure gradient (HVPG) and its safety in patients with cirrhosis and portal hypertension.

METHODS

Fifty-nine patients with cirrhosis and portal hypertension (HVPG > or =12 mm Hg) were randomized to groups that were given simvastatin 20 mg/day for 1 month (increased to 40 mg/day at day 15) or placebo in a double-blind clinical trial. Randomization was stratified according to whether the patient was being treated with beta-adrenergic blockers. We studied splanchnic and systemic hemodynamics and variables of liver function and safety before and after 1 month of treatment.

RESULTS

Simvastatin significantly decreased HVPG (-8.3%) without deleterious effects in systemic hemodynamics. HVPG decreases were observed in patients who were receiving beta-adrenergic blockers (-11.0%; P = .033) and in those who were not (-5.9%; P = .013). Simvastatin improved hepatic, fractional, and intrinsic clearance of indocyanine green, showing an improvement in effective liver perfusion and function. No significant changes in HVPG and liver function were observed in patients receiving placebo. The number of patients with adverse events did not differ significantly between groups. No patient was withdrawn from the study based on adverse events.

CONCLUSIONS

Simvastatin decreased HVPG and improved liver perfusion in patients with cirrhosis. These effects were additive with those of beta-adrenergic blockers. The beneficial effects of simvastatin should be confirmed in long-term clinical trials for portal hypertension.

Portal hypertension

PURPOSE OF REVIEW

Portal hypertension is the most common complication of cirrhosis accounting for significant morbidity and mortality mainly because of variceal hemorrhage, ascites, bacterial infections, hepatic encephalopathy, and hepatorenal syndrome. Advances in the diagnosis and management of portal hypertension over the last year are reviewed.

RECENT FINDINGS

The measurement of the hepatic venous pressure gradient provides important prognostic information in patients with portal hypertension. Noninvasive testing with transient elastography, capsule endoscopy, and computed tomography scanning for the diagnosis of esophageal varices is promising but more information is needed. Easily obtainable clinical data have been identified in patients with acute variceal bleeding that provides important information in determining initial response to therapy and prognosis. New therapies for patients with dilutional hyponatremia with vasopressin antagonists are promising and may improve the management of this condition. Terlipressin is the best medical therapy currently available for the management of hepatorenal syndrome as confirmed in recent studies. Patients with advanced liver disease benefit from the long-term administration of norfloxacin as it prevents the development of hepatorenal syndrome and improves survival.

SUMMARY

The ongoing advances in the diagnosis and management of patients with cirrhosis and portal hypertension will improve the high morbidity and mortality of the complications of cirrhosis

Intestinal decontamination improves liver haemodynamics in patients with alcohol-related decompensated cirrhosis

BACKGROUND

Endotoxaemia is commonly seen in cirrhotic patients with ascites and this may be associated with increased portal pressure.

AIM

To investigate the effect of intestinal decontamination on liver haemodynamics in alcohol-related cirrhotic patients with ascites.

METHODS

We included 30 patients. At day 0, systemic and splanchnic circulation endotoxin levels were determined and HVPG measurement performed. Patients received rifaximin (1200 mg/day) for 28 days. At day 29, systemic and splanchnic circulation endotoxin levels were determined and HVPG measurement performed again.

RESULTS

Median (range) plasma endotoxin levels decreased significantly after rifaximin administration both in systemic [1.45(0-3.1) vs. 0.7(0-2.7), P < 0.0001] and splanchnic circulation [1.8(0-3.4) vs. 0.8(0-2.1), P < 0.0001]. Meanwhile, the difference seen in endotoxin levels between the splanchnic and systemic circulation at day 0 (P = 0.001) was not noted at day 29 (P = 0.137). HVPG measurement was possible in 28 patients. Median (range) HVPG values were 18 mmHg (12.7-26.3) on day 0 vs. 14.7 mmHg (7-20) on day 29 (P < 0.0001). HVPG decreased after rifaximin in 23, remained stable in two and increased in three patients.

CONCLUSION

Hepatic venous pressure gradient values decreased significantly after intestinal decontamination with rifaximin in patients with alcohol-related decompensated cirrhosis and this might have been achieved through significant reduction of plasma endotoxin levels.