Liver cirrhosis

Preventative hepatology: minimising symptoms and optimising care

Most care of liver disease is in the ambulatory setting, and therefore the clinical needs of patients represent those of any other chronic illness. Emphasis must be given to preventative strategies such that liver lifetime (including pre-emptive strategies related to potential allograft survival) is maximised through timely intervention and avoidance of side effects. This review addresses the pertinent practical clinical concerns faced by clinicians as they manage adult patients with chronic liver disease, with an emphasis on preventing and managing symptoms and complications directly and indirectly related to the underlying disease.

Staging of portal hypertension and portosystemic shunts using dynamic nuclear medicine investigations

AIM

To explore portal hypertension and portosystemic shunts and to stage chronic liver disease (CLD) based on the pathophysiology of portal hemodynamics.

METHODS

Per-rectal portal scintigraphy (PRPS) was performed on 312 patients with CLD and liver angioscintigraphy (LAS) on 231 of them. The control group included 25 healthy subjects. We developed a new model of PRPS interpretation by introducing two new parameters, the liver transit time (LTT) and the circulation time between right heart and liver (RHLT). LTT for each lobe was used to evaluate the early portal hypertension. RHLT is useful in cirrhosis to detect liver areas missing portal inflow. We calculated the classical per-rectal portal shunt index (PRSI) at PRPS and the hepatic perfusion index (HPI) at LAS.

RESULTS

The normal LTT value was 24 +/- 1 s. Abnormal LTT had PPV = 100% for CLD. 27 non-cirrhotic patients had LTT increased up to 35 s (median 27 s). RHLT (42 +/- 1 s) was not related to liver disease. Cirrhosis could be excluded in all patients with PRSI < 5% (P < 0.01). PRSI > 30% had PPV = 100% for cirrhosis. Based on PRPS and LAS we propose the classification of CLD in 5 hemodynamic stages. Stage 0 is normal (LTT = 24 s, PRSI < 5%). In stage 1, LTT is increased, while PRSI remains normal. In stage 2, LTT is decreased between 16 s and 23 s, whereas PRSI is increased between 5% and 10%. In stage 3, PRSI is increased to 10%-30%, and LTT becomes undetectable by PRPS due to the portosystemic shunts. Stage 4 includes the patients with PRSI > 30%. RHLT and HPI were used to subtype stage 4. In our study stage 0 had NPV = 100% for CLD, stage 1 had PPV = 100% for non-cirrhotic CLD, stages 2 and 3 represented the transition from chronic hepatitis to cirrhosis, stage 4 had PPV = 100% for cirrhosis.

CONCLUSION

LTT allows the detection of early portal hypertension and of opening of transhepatic shunts. PRSI is useful in CLD with extrahepatic portosystemic shunts. Our hemodynamic model stages the evolution of portal hypertension and portosystemic shunts. It may be of use in the selection of patients for interferon therapy.

Operational options based on scoring system to treat upper gastrointestinal bleeding due to portal hypertension

AIM: To guide operation in treating upper gastrointestinal bleeding due to portal hypertension through building a scoring system.

METHODS: One hundred and seventy-eight patients with portal hypertension were admitted to our hospital from June 2004 to October 2007. The patients were scored according to the etiology, age, liver function, clinical characteristics, and operation history, and corresponding operations were selected based on the scores for the treatment of upper gastrointestinal bleeding due to portal hypertension.

RESULTS: Based on the scores, pericardial devascularisation was performed in 89 cases; lower esophageal transection plus reanastomosis was performed in 22 patients; trans-chest esophageal transection plus reanastomosis was performed in 2 patients; proximal splenorenal shunt was performed in 39 cases; restricted SMV-cava shunt was performed in 21 cases; lateral-lateral portal-cava shunt was performed in 5 cases. Peri-operational complications included reversed ascites (41 cases), plural effusion (8 cases), esophageal leakage (1 case), and esophageal stricture (1 case). Ninety-nine cases were followed up, and 16 were found with occasional black stool. Re-hematemesis occurred in 1 case and he died finally. Reversible hepatic encephalopathy occurred in 2 cases, and incisional hernia occurred in 1 case.

CONCLUSION: Operational selection based on scoring system can improve the operation effect and decrease complications in treating upper gastrointestinal bleeding due to portal hypertension.