Bacterial infection is independently associated with failure to control bleeding in cirrhotic patients with gastrointestinal hemorrhage

Antibiotic prophylaxis to prevent infection in patients with Child-Pugh A cirrhosis with upper gastrointestinal bleed: an open label randomised controlled trial

BACKGROUND AND AIMS

Although beneficial in reducing the risk of bacterial infections in patients with advanced decompensated cirrhosis after upper gastrointestinal (GI) bleed, the utility of prophylactic antibiotics in those with Child-Pugh A cirrhosis is not known. We studied if prophylactic antibiotics can be withheld in this cohort.

METHODS

This was a single-centre, open-label randomised-controlled-trial with non-inferiority design. Patients of Child-Pugh A cirrhosis with upper-GI bleed and hemodynamic stability were randomised to receive either no prophylactic antibiotics (test-group) or ceftriaxone [standard of care (SOC)] for 72 h alongside standard medical management. The primary outcome was infection at day-5 in both arms. Secondary outcomes included failure to control bleed, mortality at day-5, and at 6 weeks.

RESULTS

Eligible patients (n = 180; mean age 45.1 ± 13.1 years, 76.9% males; median MELDNa 9 [interquartile-range: 7-12]) of predominant non-viral etiology (alcohol: 43.4%; non-alcoholic steatohepatitis: 21.7%) were randomised, of whom outcomes could be reliably assessed for 172 and 140 patients at 5-day and 6-week follow-up, respectively. Rate of day-5 infections in test-group [7.0% (95% CI 2.8-15.1%)] was non-inferior to SOC arm [11.6% (95% CI 6.02-20.8%); absolute risk difference: -4.7% (95% CI -13.3% to 4.0%; non-inferior at 10% margin)]. Spontaneous bacterial peritonitis following post-bleed ascites was the most common site of infection in both groups (10/16; 66.7%). Rates of failure to control bleed [0% vs 4.9; absolute-risk-difference: -4.6% (95% CI -9.1% to 0.2%)], day-5 mortality [0% vs 2.5%; absolute-risk-difference: -2.3% (-5.5% to 0.9%)], and 6-week mortality [1.4% vs 2.5%; absolute-risk-difference: -1.6% (-6.5% to 3.2%)] were comparable in both arms.

CONCLUSION

Among patients with Child-Pugh A cirrhosis with hemodynamic stability, withholding prophylactic antibiotics after upper GI bleed was not associated with increased risk of post-bleed infections.

The effect of propranolol on gastrointestinal motility and permeability in patients with cirrhosis and significant portal hypertension

BACKGROUND

Patients with cirrhosis and portal hypertension may have alterations in intestinal barrier resulting in increased susceptibility for infections. We investigated the effect of propranolol in gastrointestinal motility, permeability and bacterial overgrowth in cirrhosis.

METHODS

Patients with cirrhosis and esophageal varices were studied before and after a build-up dose of propranolol according to standard guidelines. Serum TNF-a, IL-6, IL-1b, LPS and bacterial DNA were measured before and during propranolol therapy. Oro-caecal transit time (OCTT) and bacterial overgrowth (BO) have been evaluated with H2 breath testing. Intestinal paracellular (IP), cellular passive non-carrier (ICNC), cellular passive carrier-mediated (ICCM), and gastric permeability (GP) were evaluated by measurement of lactulose, mannitol, D-xylose and sucrose respectively in urine, with high performance liquid chromatography (HPLC).

RESULTS

35 patients with cirrhosis and portal hypertension with median age was 59.6 years (range 42-86) were included in the study. Twenty one had viral hepatitis and 25 were classified as having advanced cirrhosis (Child-Pugh B: 14 or C: 11). Median dose of administrated propranolol was 40 mg/day. After 7 days propranolol treatment BO was resolved in 15 out of 16 patients (93.7%, p = 0.0001) and OCTT was reduced significantly from 180 min to 139 min (SD 58.5, difference - 4 1 min, p = 0.0001). Serum IL-6 levels were reduced in 21/35 (60%) patients from 41.1 to 19 pg/ml (p = 0.01), TNF-a in 10/35 (28.5%) patients from 10.7 to 5.6 pg/ml (p = 0.007) and LPS in 20/35 (57%) from 7.1 to 5.2 mg/L (p = 0.1). No bacterial DNA was detected in serum of all patients either baseline or under propranolol treatment. IP was significantly reduced (0.2 to 0.16, p = 0.04) whereas ICNC (p = 0.9), ICCM (p = 0.4) and GP (p = 0.7) were not affected significantly. Intestinal Permeability (PI) index (Lactulose to Mannitol ratio) was significantly reduced (0.027 to 0.02, p = 0.03).

CONCLUSION

In patients with cirrhosis and portal hypertension, propranolol use is associated with reduction in BO, increase in intestinal motility and amelioration in intestinal permeability. Moreover IL-6 and LPS levels are being decreased in the majority of patients under propranolol.

Antibiotic prophylaxis in digestive endoscopy: Guidelines from the French Society of Digestive Endoscopy

Digestive endoscopy is a highly dynamic medical discipline, with the recent adoption of new endoscopic procedures. However, comprehensive guidelines on the role of antibiotic prophylaxis in these new procedures have been lacking for many years. The Guidelines Commission of the French Society of Digestive Endoscopy (SFED) convened in 2023 to establish guidelines on antibiotic prophylaxis in digestive endoscopy for all digestive endoscopic procedures, based on literature data up to September 1, 2023. This article summarizes these new guidelines and describes the literature review that fed into them.

A Noninferiority Trial Comparing 2 Days vs 5 Days of Terlipressin and Ceftriaxone in Terms of 5-Day Rebleeding for Patients With Acute Gastroesophageal Variceal Hemorrhage

INTRODUCTION

This trial was to shorten the duration of both vasoconstrictors and prophylactic antibiotics to only 2 days in the therapy of acute gastroesophageal variceal hemorrhage.

METHODS

After successful endoscopic hemostasis of gastroesophageal variceal hemorrhage, eligible patients were randomized to receive terlipressin infusion 1 mg per 6 hours and ceftriaxone 1 g daily for 5 days (group A) or a similar regimen for 2 days (group B). Primary end points were very early rebleeding at 5 days, and secondary end points included 48-hour hemostasis, 42-day rebleeding, and hospitalization days.

RESULTS

Group A comprised 48 patients, and group B comprised 52 patients. Both groups were comparable in the severity of liver disease. Forty-eight-hour initial hemostasis was 95.8% in group A and 100% in group B ( P = 0.13). Very early rebleeding between 3 and 5 days occurred in 1 patient (2.1%) in group A and 2 patients (3.8%) in group B ( P = 0.60). The difference was 1.8% and the 95% confidence interval was -1.31% to 2.08%, which demonstrated noninferiority. Forty-two-day rebleeding occurred in 5 patients (10.4%) in group A and 4 patients (7.7%) in group B ( P = 0.63). The median hospitalization days were 8.5 ± 3.8 days in group A vs 5.6 ± 2.6 days in group B ( P < 0.001).

DISCUSSION

After successful endoscopic hemostasis of acute variceal bleeding, combination of 2-day terlipressin infusion and ceftriaxone therapy was not inferior to the 5-day regimen in terms of very early rebleeding, with the advantage of shortening hospitalization stay.

Profiling plasma alterations of extracellular vesicles in patients with acutely decompensated cirrhosis and bacterial infection

BACKGROUND

Extracellular vesicles (EVs) modulate inflammation, coagulation and vascular homeostasis in decompensated cirrhosis.

AIM

To characterize the profile of plasmatic EVs in patients with decompensated cirrhosis and bacterial infections and evaluate the association between EVs and the development of hemostatic complications.

METHODS

We measured the levels of EVs using high-sensitivity flow cytometry and phospholipid-dependent clotting time (PPL) in a prospective cohort of hospitalized patients with acutely decompensated cirrhosis with versus without bacterial infections. A separate cohort of patients with bacterial infections without cirrhosis was also enrolled. We measured endothelium-, tissue factor (TF)-bearing, platelet- and leukocyte-derived EVs. In patients with infections, EVs were reassessed upon resolution of infection. Bleeding and thrombotic complications were recorded during 1-year follow-up.

RESULTS

Eighty patients with decompensated cirrhosis were recruited (40 each with and without bacterial infections). Electron microscopy confirmed the presence of plasma EVs. Despite no difference in total EVs and PPL, patients with cirrhosis and infection had significantly higher TF+ EVs, P-Selectin+ EVs (activated platelet-derived), CD14+ EVs (monocyte/macrophages derived) and CD14+ TF+ EVs versus those with cirrhosis without infection. Upon infection resolution, levels of these EVs returned to those without infection. Patients with infections showed a significant association between reduced P-Selectin+ EVs and bleeding complications (HR 8.0 [95%CI 1.3-48.1]), whereas high levels of leukocyte-derived EVs (CD45+) and CD14+ EVs were significantly associated with thrombotic complications (HR 16.4 [95%CI 1.7-160] and 10.9 [95%CI 1.13-106], respectively). Results were confirmed in a validation cohort.

CONCLUSION

Bacterial infections are associated with particular alterations of plasma EVs profile in decompensated cirrhosis. Bacterial infections trigger the release of EVs originating from various cell types, which may tip the precarious hemostatic balance of patients with acutely decompensated cirrhosis towards hyper- or hypocoagulability.

Association Between Bowel Wall Thickening and Long-Term Outcomes in Decompensated Liver Cirrhosis

INTRODUCTION

Bowel wall thickening is commonly observed in liver cirrhosis, but few studies have explored its impact on the long-term outcomes of patients with cirrhosis.

METHODS

Overall, 118 patients with decompensated cirrhosis were retrospectively enrolled, in whom maximum wall thickness of small bowel, ascending colon, transverse colon, descending colon, sigmoid colon, and rectum could be measured in computed tomography (CT) images. X-tile software was employed to determine the best cut-off values of each segment of bowel wall thickness for predicting the risk of further decompensation and death. Cumulative rates of further decompensation and death were calculated by Nelson-Aalen cumulative risk curve analyses. Predictors of further decompensation and death were evaluated by competing risk analyses. Sub-distribution hazard ratios (sHRs) were calculated.

RESULTS

Cumulative rates of further decompensation were significantly higher in patients with wall thickness of ascending colon ≥ 11.7 mm (P = 0.014), transverse colon ≥ 3.2 mm (P = 0.043), descending colon ≥ 9.8 mm (P = 0.035), and rectum ≥ 7.2 mm (P = 0.045), but not those with wall thickness of small bowel ≥ 8.5 mm (P = 0.312) or sigmoid colon ≥ 7.1 mm (P = 0.237). Wall thickness of ascending colon ≥ 11.7 mm (sHR = 1.70, P = 0.030), transverse colon ≥ 3.2 mm (sHR = 2.15, P = 0.038), and rectum ≥ 7.2 mm (sHR = 2.38, P = 0.045) were independent predictors of further decompensation, but not wall thickness of small bowel ≥ 8.5 mm (sHR = 1.19, P = 0.490), descending colon ≥ 9.8 mm (sHR = 1.53, P = 0.093) or sigmoid colon ≥ 7.1 mm (sHR = 0.63, P = 0.076). Small bowel, ascending colon, transverse colon, descending colon, sigmoid colon, and rectum wall thickness were not significantly associated with death.

CONCLUSIONS

Colorectal wall thickening, but not small bowel wall, may be considered for the prediction of further decompensation in cirrhosis.

Recent research advances on polysaccharide-, peptide-, and protein-based hemostatic materials: A review

Hemorrhage is a potentially life-threatening emergency that can occur at any time or place. Whether traumatic, congenital, surgical, disease-related, or drug-induced, bleeding can lead to severe complications or death. Therefore, the development of efficient hemostatic materials is critical. However, the results and prognosis demonstrated by clinical means of hemostasis do not reach expectations. With the development of technology, novel hemostatic materials have been developed from polysaccharides (chitosan, hyaluronic acid, alginate, cellulose, cyclodextrins, starch, dextran, and carrageenan), peptides (self-assembling peptides), and proteins (silk fibroin, collagen, gelatin, keratin, and thrombin). These new materials exhibit high hemostatic efficacy due to the enhancement or interaction of various hemostatic mechanisms. The main forms include adhesives, sealants, bandages, hemostatic powders, and hemostatic sponges. This article introduces the clotting process and principles of hemostatic methods and reviews the research on polysaccharide-, peptide-, and protein-based hemostatic materials in the last five years. The design ideas and hemostatic principles of polysaccharide-, peptide-, and protein-based hemostatic materials are mainly introduced. Finally, we summarize material designs, advantages, disadvantages, and challenges regarding hemostatic materials.

Thromboelastography characteristics in critically ill patients with liver disease

OBJECTIVE

The purpose of this study was to determine how thromboelastography (TEG) parameters differ by various clinical conditions that commonly occur in patients with cirrhosis, including sepsis, acute on chronic liver failure (ACLF), alcohol-associated hepatitis (AAH) and portal vein thrombosis (PVT).

BACKGROUND

TEG, a whole blood assay, is used to assess several parameters of coagulation and is becoming increasingly used in clinical practice.

STUDY

This study was a retrospective chart review of 155 patients admitted to the ICU with decompensated cirrhosis from 2017 to 2019.

RESULTS

The R time was significantly shorter in patients when they were septic compared to when they were not and longer in patients with vs. without ACLF grade 3. Alpha angle and maximum amplitude was decreased in patients with severe AAH compared to those without severe AAH; and maximum amplitude was increased in patients with acute PVT compared to those with chronic PVT. R time was positively correlated with Chronic Liver Failure Consortium Organ Failure and Chronic Liver Failure Consortium ACLF scores (rho = 0.22, P = 0.020), while alpha angle and maximum amplitude were negatively correlated with MELD-NA.

CONCLUSION

Findings suggest TEG parameters vary in several clinical conditions in patients with decompensated cirrhosis who are admitted to the ICU. Prospective research is needed to confirm our findings and to determine how this knowledge can be used to guide clinical practice, as well as blood product transfusions in the setting of bleeding or prior to invasive procedures.

Good Performance of Revised Scoring Systems in Predicting Clinical Outcomes of Aeromonas Bacteremia in the Emergency Department: A Retrospective Observational Study

BACKGROUND

Aeromonas species, Gram-negative, non-sporulating, facultative, and anaerobic bacilli, widely distributed in aquatic environments, derive various infections, including bacteremia. Most of these infections were opportunistic and found in patients with predisposing conditions. Among the infections, bacteremia remains with notable mortality, reported from 15% to 45%. However, predicting systems for assessing the mortality risk of this disease have yet to be investigated. We aimed to validate the performance of specific predictive scoring systems to assess the clinical outcomes of Aeromonas bacteremia and applied the revised systems to predict mortality risk.

METHODS

A retrospective observational study reviewed patients with bacteremia caused by Aeromonas spp. based on at least one positive blood culture sample collected in the emergency department from January 2012 to December 2020. The outcome was in-hospital mortality. We used seven predictive scoring systems to predict the clinical outcome. According to the effectiveness in predicting mortality, we revised three of the seven predictive scoring systems by specific characteristics to refine their risk-predicting performances.

RESULTS

We enrolled 165 patients with bacteremia caused by Aeromonas spp., including 121 males (73.3%) and 44 females (26.7%), with a mean age of 66.1 ± 14.9 years and an average length of hospital stay of 12.4 ± 10.9 days. The overall mortality rate was 32.7% (54/165). The non-survivors had significantly higher scores in MEDS (6.7 ± 4.2 vs. 12.2 ± 3.3, p < 0.001), NEWS (4.0 ± 2.8 vs. 5.3 ± 3.0, p = 0.008), and qSOFA (0.3 ± 0.6 vs. 0.6 ± 0.7, p = 0.007). Regarding mortality risk prediction, the MEDS demonstrated the best predictive power with AUC of ROC measured up to 0.834, followed by NEWS (0.626) and qSOFA (0.608). We revised the MEDS, NEWS, and qSOFA by hemoglobin and lactate. We found that the revised scores had better powerful performance, including 0.859, 0.767, and 0.691 of the AUC of ROC, if the revised MEDS ≥10, revised NEWS ≥8, and revised qSOFA ≥2, respectively.

CONCLUSIONS

MEDS, NEWS, and qSOFA were good tools for predicting outcomes in patients with Aeromonas spp. bacteremia. The revised MEDS, NEWS, and qSOFA demonstrated more powerful predicting performance than the original scoring systems. We suggested that patients with higher scores in revised MEDS (≥10), revised NEWS (≥8), and revised qSOFA (≥2) received early goal-directed therapy and appropriate broad-spectrum antibiotic treatment as early as possible to reduce mortality.

Characteristics and Related Factors of Bacterial Infection Among Patients With Cirrhosis

Background

Infection causes cirrhosis to decompensate, affecting liver function and resulting in several complications, including esophageal variceal hemorrhage, hepatic encephalopathy, and hepatorenal syndrome. Objective: This study aimed to identify the prevalence, essential features, and related factors of bacterial infection among patients with cirrhosis in Vietnam.

Methods

This retrospective study included 317 patients diagnosed with cirrhosis, who were divided into two groups: group 1 including 125 patients with bacterial infection and group 2 including 192 patients without bacterial infection. Infection was diagnosed on the basis of its localization.

Results

Spontaneous bacterial peritonitis (SBP; 31.2%) and pneumonia (28.8%) were the most common infections identified. The procalcitonin (PCT) level had a strong diagnostic value with an area under the curve value of 0.868. The most common type of gram-negative bacteria was Escherichia coli, while the gram-positive bacteria seen were Staphylococcus, Enterococcus, and Streptococcus among the patients with infection. In the logistic regression analysis, Child-Pugh class B and C (p<0.001, OR=4.14, CI=1.90-9.03; OR=4.76, CI=2.03-11.16, respectively) and the presence of acute kidney injury (p=0.009, OR=2.57, CI=1.27-5.22) and gastrointestinal hemorrhage (p=0.035, OR=0.39, CI=0.16-0.94) significantly differed between the groups.

Conclusion

The most prevalent type of bacterial infection in patients with cirrhosis is SBP, with gram-negative bacteria being the most common cause. The PCT level is useful in identifying infection in patients with cirrhosis. Decompensated cirrhosis is linked to a higher risk of infection.

Real-world efficacy of antibiotic prophylaxis for upper gastrointestinal bleeding in cirrhotic patients in Japan

BACKGROUND AND AIMS

Antibiotic prophylaxis is recommended for cirrhotic patients with upper gastrointestinal bleeding (UGIB). However, the frequency of bacterial infection in such patients has remarkably decreased over the decades, which has reduced the necessity for prophylaxis. Therefore, here we investigated the real-world adherence and effectiveness of antibiotic prophylaxis in cirrhotic patients with UGIB in Japan.

METHODS

This population-based study was conducted with a Japanese real-world database of the Health, Clinic, and Education Information Evaluation Institute. We enrolled cirrhotic patients who were hospitalized for UGIB between April 2010 and March 2020. After those who died within 24 h and who had aspiration pneumonia at admission were excluded, 1232 patients were analyzed. Rates of 6-week mortality, in-hospital bacterial infection, 30-day readmission, and length of hospital stay were evaluated.

RESULTS

Prophylactic antibiotics were prescribed in 142 (11.5%) patients. Multivariate analysis revealed that antibiotic prophylaxis was not significantly associated with either 6-week mortality or bacterial infection. After propensity score matching, the rates of 6-week mortality (7.2% vs. 8.4%, P = 0.810), bacterial infection (9.6% vs. 4.2%, P = 0.082), and 30-day unexpected readmission (7.2% vs. 7.8%, P = 1.000) were similar in patients with and without prophylaxis, whereas the median length of hospital stay was significantly longer in patients with prophylaxis (17 days vs. 13 days, P = 0.013).

CONCLUSIONS

Under current real-world circumstances in Japan, prophylactic antibiotics were prescribed in only 11.5% of cirrhotic patients with UGIB and were not associated with better clinical outcomes.

Pathophysiology and management of liver cirrhosis: from portal hypertension to acute-on-chronic liver failure

Cirrhosis transcends various progressive stages from compensation to decompensation driven by the severity of portal hypertension. The downstream effect of increasing portal hypertension severity leads to various pathophysiological pathways, which result in the cardinal complications of cirrhosis, including ascites, variceal hemorrhage, and hepatic encephalopathy. Additionally, the severity of portal hypertension is the central driver for further advanced complications of hyperdynamic circulation, hepatorenal syndrome, and cirrhotic cardiomyopathy. The management of these individual complications has specific nuances which have undergone significant developments. In contrast to the classical natural history of cirrhosis and its complications which follows an insidious trajectory, acute-on-chronic failure (ACLF) leads to a rapidly downhill course with high short-term mortality unless intervened at the early stages. The management of ACLF involves specific interventions, which have quickly evolved in recent years. In this review, we focus on complications of portal hypertension and delve into an approach toward ACLF.

Gastrointestinal Bleeding in Children: Current Management, Controversies, and Advances

Upper gastrointestinal bleeding (UGIB) in children has many causes, with its prevalence varying by age. Often presenting as hematemesis or melena, the initial treatment is stabilization of the patient, including protection of the airway, fluid resuscitation, and a transfusion hemoglobin threshold of 7 g/L. Endoscopy should be performed with the goal of using combinations of therapies to treat a bleeding lesion, generally involving epinephrine injection along with either cautery, hemoclips, or hemospray. This review discusses the diagnosis and treatment of variceal and non-variceal gastrointestinal bleeding in children with a focus on current advances in the treatment of severe UGIB.

Gastroesophageal variceal hemorrhage in patients with chronic liver diseases attending university of Gondar Specialized comprehensive hospital in Ethiopia: Institutional based cross-sectional study

Introduction

Rupture and bleeding from Gastroesophageal Varices (GEVs) are major complications among patients with chronic liver disease (CLD) and are associated with a high mortality rate. Hence, identifying factors of Gastroesophageal Variceal Hemorrhage (GEVH) is essential for the management and prevention of this fatal outcome.

Objective

To assess the prevalence of GEVH and its associated factors among patients with CLD in Northwest Ethiopia.

Methods

An institutional based cross-sectional study design was employed on a total of 262 patients. The data was entered into Epi-Data version 3.1, and then exported and analyzed using STATA version 14. The distribution of variables was checked using kolmogorov-smirnov test. Bivariable logistic regression model was fitted to select variables for multivariable analysis. In the final model, adjusted odds ratio with 95% confidence level and P-value less than 0.05 were used to assess degree of association.

Results

The mean age of the study subjects was found to be 37.76 years (SD ± 11.62). The prevalence of GEVH was found to be 52% (95% CI: 49.6-54.2). Patients with grade F2 and F3 varices have 3.41 times (AOR: 3.41, 95% CI: 2.33-4.74) and 3.33 times (AOR: 3.33, 95% CI: 2.55-4.12) higher odds of bleeding, respectively. Patients not taking beta blocker have 2.38 times (AOR: 2.38, 95% CI: 1.82-3.90) increased odds of bleeding. Patients with more than three years of duration of illness have 2 times (AOR: 2.19, 95% CI: 1.39-3.99) increased odds of bleeding. Patients with platelet number less than 50,000/μl have 3.46 times (AOR: 3.46, 95% CI: 2.55-4.17) higher odds of bleeding.

Conclusion

GEVH is found to be high in patients with CLD seen at university of Gondar Hospital. Higher grade of varices, non-use of beta blockers, presence of infection, platelet number and age are associated with higher occurrence of bleeding, pointing the possibility of averting this fatal complication, for most of the identified factors are preventable.

Review article: thromboelastography in liver diseases

BACKGROUND

Patients with liver diseases have complicated haemostatic alternations, resulting in both bleeding and thromboembolic complications, which cannot be sufficiently evaluated by conventional coagulation tests (CCTs), such as platelet count or prothrombin time. Thromboelastography (TEG) is a whole blood viscoelastic test which globally reflects changes in the haemostatic system, and its utility in evaluating patients with liver disease is increasingly recognised.

AIMS

To review the current evidence and clinical significance of TEG in liver diseases.

METHODS

Literature regarding TEG and liver diseases was comprehensively searched.

RESULTS

TEG is associated closely with the severity and aetiology of liver disease, the course of infection and the risk of bleeding and death, but not the risk of portal venous system thrombosis. Additionally, TEG-guided transfusion protocols can significantly decrease the requirement for blood products compared to those guided by CCTs.

CONCLUSION

TEG can reflect the haemostatic status of liver diseases more comprehensively than CCTs. It has the potential to assess the severity of liver diseases, predict the risk of bleeding and death in patients with liver disease and guide blood product transfusion. Future studies should standardise the use of TEG for assessing disease severity and development of clinical events and guiding blood product transfusion in patients with liver diseases.

Management of Portal Hypertension

Portal hypertension is the cause of the clinical complications associated with cirrhosis. The primary complications of portal hypertension are ascites, acute variceal bleed, and hepatic encephalopathy. Hepatic venous pressure gradient measurement remains the gold standard test for diagnosing cirrhosis-related portal hypertension. Hepatic venous pressure gradient more than 10 mmHg is associated with an increased risk of complications and is termed clinically significant portal hypertension (CSPH). Clinical, laboratory, and imaging methods can also aid in diagnosing CSPH non-invasively. Recently, deep learning methods have been demonstrated to diagnose CSPH effectively. The management of portal hypertension is always individualized and is dependent on the etiology, the availability of therapies, and the degree of portal hypertension complications. In this review, we discuss the diagnosis and management of cirrhosis-related portal hypertension in detail. Also, we highlight the history of portal hypertension and future research areas in portal hypertension.

Global hemostatic profiling in patients with decompensated cirrhosis and bacterial infections

Background & Aims

Bacterial infections in cirrhosis are associated with increased bleeding risk. To assess the factors responsible for bleeding tendency in patients with bacterial infections, we conducted a prospective study comparing all 3 aspects of hemostasis (platelets, coagulation, and fibrinolysis) in hospitalized patients with decompensated cirrhosis with vs. without bacterial infections.

Methods

Primary hemostasis assessment included whole blood platelet aggregation and von Willebrand factor (VWF). Coagulation assessment included procoagulant factors (fibrinogen, factor II, V, VII, VIII, IX, X, XI, XII, XIII), natural anticoagulants (protein C, protein S, antithrombin) and thrombomodulin-modified thrombin generation test. Fibrinolysis assessment included fibrinolytic factors (plasminogen, t-PA, PAI-1, α2-AP, TAFIa/ai) and plasmin-antiplasmin complex (PAP).

Results

Eighty patients with decompensated cirrhosis were included (40 with and 40 without bacterial infections). Severity of cirrhosis and platelet count were comparable between groups. At baseline, patients with cirrhosis and bacterial infections had significantly lower whole blood platelet aggregation, without significant differences in VWF. Regarding coagulation, bacterial infections were associated with reduced procoagulant factors VII and XII, and a significant reduction of all natural anticoagulants. However, thrombomodulin-modified thrombin generation was comparable between the study groups. Finally, although mixed potentially hypo-fibrinolytic (lower plasminogen) and hyper-fibrinolytic (higher t-PA) changes were present in bacterial infections, a comparable level of PAP was detected in both groups. Upon resolution of infection (n = 29/40), platelet aggregation further deteriorated whereas coagulation and fibrinolysis factors returned to levels observed in patients without bacterial infections.

Conclusion

In hospitalized patients with decompensated cirrhosis, bacterial infections are associated with reduced whole blood platelet aggregation and a significant decrease of all natural anticoagulants, which may unbalance hemostasis and potentially increase the risk of both bleeding and thrombosis.

Lay summary

Bacterial infections are a common issue in hospitalized patients with decompensated cirrhosis (i.e. patients hospitalized due to severe complications of advanced chronic liver disease). Patients with decompensated cirrhosis who acquire infections may be at increased risk of bleeding complications following invasive procedures (that is a procedure in which the body is penetrated or entered, for instance by a needle or a tube). As bleeding complications in decompensated cirrhosis are associated with a high risk of further decompensation and death, there is an urgent need to understand the factors responsible for such increased bleeding tendency. Herein, we investigated the alterations of hemostasis (that is the physiological process responsible for clot formation and stability) in patients with decompensated cirrhosis and bacterial infections. We found that development of bacterial infections in these patients is associated with alterations of hemostasis (particularly of platelets and clotting cascade) that may increase the risk of both bleeding and thrombotic complications.

Endotoxin Translocation and Gut Barrier Dysfunction Are Related to Variceal Bleeding in Patients With Liver Cirrhosis

Background

Bacterial infections are associated with the risk of variceal bleeding through complex pathophysiologic pathways.

Objectives

The primary objective of the present case-control study was to investigate the role of bacterial translocation and intestinal barrier dysfunction in the pathogenesis of variceal bleeding. A secondary objective was to determine independent predictors of key outcomes in variceal bleeding, including bleeding-related mortality.

Methods

Eighty-four (n = 84) consecutive patients participated in the study, 41 patients with acute variceal bleeding and 43 patients with stable cirrhosis, and were followed up for 6 weeks. Peripheral blood samples were collected at patient admission and before any therapeutic intervention.

Results

Child-Pugh (CP) score (OR: 1.868; p = 0.044), IgM anti-endotoxin antibody levels (OR: 0.954; p = 0.016) and TGF-β levels (OR: 0.377; p = 0.026) were found to be significant predictors of variceal bleeding. Regression analysis revealed that albumin (OR: 0.0311; p = 0.023), CRP (OR: 3.234; p = 0.034) and FABP2 levels (OR:1.000, p = 0.040), CP score (OR: 2.504; p = 0.016), CP creatinine score (OR: 2.366; p = 0.008), end-stage liver disease model (MELD), Na (OR: 1.283; p = 0.033), portal vein thrombosis (OR: 0.075; p = 0.008), hepatocellular carcinoma (OR: 0.060; p = 0.003) and encephalopathy (OR: 0.179; p = 0.045) were significantly associated with 6-week mortality.

Conclusions

Bacterial translocation and gut barrier impairment are directly related to the risk of variceal bleeding. Microbiota-modulating interventions and anti-endotoxin agents may be promising strategies to prevent variceal bleeding.

Recent Advances in the Management of Acute Variceal Hemorrhage

Gastrointestinal bleeding is one of the most relevant causes of death in patients with cirrhosis and clinically significant portal hypertension, with gastroesophageal varices being the most frequent source of hemorrhage. Despite survival has improved thanks to the standardization on medical treatment aiming to decrease portal hypertension and prevent infections, mortality remains significant. In this review, our goal is to discuss the most recent advances in the management of esophageal variceal hemorrhage in cirrhosis with specific attention to the treatment algorithms involving the use of indirect measurement of portal pressure (HVPG) and transjugular intrahepatic portosystemic shunt (TIPS), which aim to further reduce mortality in high-risk patients after acute variceal hemorrhage and in the setting of secondary prophylaxis.

Bacterial infections in patients with acute variceal bleeding in the era of antibiotic prophylaxis

BACKGROUND & AIMS

Antibiotic prophylaxis reduces the risk of infection and mortality in patients with cirrhosis and acute variceal bleeding (AVB). This study examines the incidence of, and risk factors for, bacterial infections during hospitalization in patients with AVB on antibiotic prophylaxis.

METHODS

A post hoc analysis was performed using the database of an international, multicenter, observational study designed to examine the role of pre-emptive transjugular intrahepatic portosystemic shunts in patients with cirrhosis and AVB. Data were collected on patients with cirrhosis hospitalized for AVB (n = 2,138) from a prospective cohort (October 2013-May 2015) at 34 referral centers, and a retrospective cohort (October 2011-September 2013) at 19 of these centers. The primary outcome was incidence of bacterial infection during hospitalization.

RESULTS

A total of 1,656 patients out of 1,770 (93.6%) received antibiotic prophylaxis; third-generation cephalosporins (76.2%) and quinolones (19.0%) were used most frequently. Of the patients on antibiotic prophylaxis, 320 patients developed bacterial infection during hospitalization. Respiratory infection accounted for 43.6% of infections and for 49.7% of infected patients, and occurred early after admission (median 3 days, IQR 1-6). On multivariate analysis, respiratory infection was independently associated with Child-Pugh C (odds ratio [OR] 3.1; 95% CI 1.4-6.7), grade III-IV encephalopathy (OR 2.8; 95% CI 1.8-4.4), orotracheal intubation for endoscopy (OR 2.6; 95% CI 1.8-3.8), nasogastric tube placement (OR 1.7; 95% CI 1.2-2.4) or esophageal balloon tamponade (OR 2.4; 95% CI 1.2-4.9).

CONCLUSION

Bacterial infections develop in almost one-fifth of patients with AVB despite antibiotic prophylaxis. Respiratory infection is the most frequent, is an early event after admission, and is associated with advanced liver failure, severe hepatic encephalopathy and use of nasogastric tube, orotracheal intubation for endoscopy or esophageal balloon tamponade.

LAY SUMMARY

Bacterial infections develop during hospitalization in close to 20% of patients with acute variceal bleeding despite antibiotic prophylaxis. Respiratory bacterial infections are the most frequent and occur early after admission. Respiratory infection is associated with advanced liver disease, severe hepatic encephalopathy and a need for a nasogastric tube, orotracheal intubation for endoscopy or esophageal balloon tamponade.

Clinical algorithms for the prevention of variceal bleeding and rebleeding in patients with liver cirrhosis

Portal hypertension (PH), a common complication of liver cirrhosis, results in development of esophageal varices. When esophageal varices rupture, they cause significant upper gastrointestinal bleeding with mortality rates up to 20% despite state-of-the-art treatment. Thus, prophylactic measures are of utmost importance to improve outcomes of patients with PH. Several high-quality studies have demonstrated that non-selective beta blockers (NSBBs) or endoscopic band ligation (EBL) are effective for primary prophylaxis of variceal bleeding. In secondary prophylaxis, a combination of NSBB + EBL should be routinely used. Once esophageal varices develop and variceal bleeding occurs, standardized treatment algorithms should be followed to minimize bleeding-associated mortality. Special attention should be paid to avoidance of overtransfusion, early initiation of vasoconstrictive therapy, prophylactic antibiotics and early endoscopic therapy. Pre-emptive transjugular intrahepatic portosystemic shunt should be used in all Child C10-C13 patients experiencing variceal bleeding, and potentially in Child B patients with active bleeding at endoscopy. The use of carvedilol, safety of NSBBs in advanced cirrhosis (i.e. with refractory ascites) and assessment of hepatic venous pressure gradient response to NSBB is discussed. In the present review, we give an overview on the rationale behind the latest guidelines and summarize key papers that have led to significant advances in the field.

Bacterial Infections in Cirrhosis as a Cause or Consequence of Decompensation?

Bacterial infections are ominous events in liver cirrhosis. Cirrhosis-associated immune dysfunction and pathologic bacterial translocation are responsible for the increased risk of infections. Bacteria induce systemic inflammation, which worsens circulatory dysfunction and induces oxidative stress and mitochondrial dysfunction. Bacterial infections, frequently associated with decompensation, are the most common precipitating event of acute-on-chronic liver failure (ACLF). After decompensation, patients with cirrhosis have an increased risk of developing infections. Bacterial infections should be ruled out in these patients and strategies to prevent infections should be implemented to prevent further decompensation. We review infections as a cause and consequence of decompensation in cirrhosis.

Bloodstream Infections Caused by Extended-Spectrum Beta-Lactamase-Producing Escherichia coli in Patients with Liver Cirrhosis

Background: This study aimed to investigate the frequency of sequence type (ST) 131 strains and outcome of cirrhotic patients with bloodstream infections (BSIs) caused by extended-spectrum beta-lactamase-producing Escherichiacoli (ESBLEC) and non-extended-spectrum beta-lactamase-producing Escherichiacoli (NESBLEC). Methods: The incidence of ST 131 strains, hospital stay, and 30-day re-admission/mortality were compared between 51 ESBLEC and 51 NESBLEC bacteremic patients with cirrhosis. Results: ST 131 strains were found in 35.3% of the ESBLEC group and 0% of the NESBLEC group (p < 0.001). Mean hospital stay was 26.5 days in the ESBLEC group and 17.1 days in the NESBLEC group (p = 0.006). Thirty-day re-admission rates were 11.8% in the ESBLEC group and 5.9% in the NESBLEC group (p = 0.5). ST 131 strains were associated with 30-day re-admission (odds ratio: 4.5, 95% confidence interval: 1.1–18.9). Thirty-day mortality rate was 31.4% in the ESBLEC group and 23.5% in the NESBLEC group (p = 0.4). Conclusion: In patients with cirrhosis, the ESBLEC BSIs group had a higher frequency of ST 131 strains and longer hospital stay than the NESBLEC BSIs group with similar 30-day re-admission/mortality. ST 131 strains were associated with 30-day re-admission.

High-density lipoprotein cholesterol is a predictor of survival in cirrhotic patients with acute gastrointestinal bleeding: a retrospective study

Background

Lipid profiles are declined in patients with viral liver cirrhosis and correlated with severity of liver disease. Hepatitis B virus (HBV) is the leading cause of liver cirrhosis in China. Our primary aim was to investigate whether serum lipids and lipoproteins associate with survival in patients with HBV-related cirrhosis and acute gastrointestinal bleeding, and develop a 6-week mortality risk score that incorporates it.

Methods

From January 2008 to December 2015, consecutive cirrhotic patients with acute gastrointestinal bleeding admitted to our hospital were evaluated and randomly divided into the derivation (n = 629) and validation (n = 314) cohorts. A logistic regression model was established to confirm the association between lipoprotein cholesterol and mortality. Accuracy to predict mortality were assessed by area under the receiver operating characteristic curves (AUROCs) and compared using the Hanley and McNeil test.

Results

Among study subjects, the 6-week mortality rate was 10.6%. High-density lipoprotein cholesterol (HDL-C) level was found to correlate most strongly with prognostic scores. On ROC analysis, HDL-C showed excellent diagnostic accuracy for 6-week mortality. Logistic regression analysis provided a simple algorithm based on the combined use of 4 variables (total bilirubin (TBIL), HDL-C, International normalized ratio, and hemoglobin), allowing accurate discrimination of 3 distinct prognostic subgroups with 1.7% (low risk), 12.3% (intermediate risk), and 56.9% (high risk) mortality. Its accuracy was significantly better than that of Child–Pugh, model of end-stage liver disease, albumin-bilirubin score, D’Amico model, Augustin model, AIMS65 score and Glasgow-Blatchford score. Baseline HDL-C values ≤ 0.54 mmol/L were associated with markedly lower 6-week survival. Comparable results were found in the validation set.

Conclusion

HDL-C is a potential indicator for the prognosis of patients with cirrhosis and acute gastrointestinal bleeding. The new algorithm based on HDL-C allowed an accurate predictive assessment of 6-week mortality after bleeding attack.

[Prognosis of bleeding recurrence after endoscopic sclerotherapy of esophageal varices]

OBJECTIVE

To improve prediction of recurrent bleeding after endoscopic sclerotherapy of esophageal varices.

MATERIAL AND METHODS

A prospective, observational, case-control study was performed. Immediate and long-term results of endoscopic sclerotherapy of esophageal varices were studied in 91 patients for the period from 2002 to 2016. Multiple regression analysis with binary response model was applied to analyze the prediction models.

RESULTS

Recurrent bleeding occurred in 80.5 (20; 182) days after sclerotherapy (range 0-2557 days). Spearman's correlation analysis revealed a significant relationship between bleeding recurrence and erythrocyte count (R= -0.32), Child-Pugh class of liver cirrhosis (R=0.49), Child-Pugh score (5-15) (R=0.54), content of amino acids, HPro/Pro ratio (R=0.71). Prognostic indicators were selected by stepwise inclusion of predictors. Thus, the final version of regression equation is as follows: Y=exp (-0.17+0.93×Child-Pugh score-106.42×HPro/Pro)/[1+exp(-0.17+0.93×Child-Pugh score-106.42×HPro/Pro)]. High risk of recurrent bleeding from esophageal varices within 1 year after endoscopic sclerotherapy is determined by Y-value >0.5. An accuracy of this model is 89.6%, Se 94.3%, Sp 79.2%, PPV 90.9%, NPV 86.4%, OR 63.3, LR + 4.53, LR - 0.07.

CONCLUSION

Thus, the proposed method is highly informative, effective, available and can be widely used in clinical practice.

Universal antibiotic prophylaxis may no longer be necessary for patients with acute variceal bleeding: A retrospective observational study

A few decades ago, antibiotic prophylaxis for patients with acute variceal bleeding was reported beneficial. However, endoscopic and systemic therapy for variceal bleeding has dramatically improved since then, so the necessity of prophylactic antibiotics can be questioned. In this study, we reevaluated the efficacy of antibiotic prophylaxis in acute variceal bleeding, using the most recent data in our hospital.We retrospectively analyzed the medical records of 150 patients with acute variceal bleeding who were admitted to Kurashiki Central Hospital between January 2012 and December 2016. We compared the rates of bacterial infection, in-hospital mortality, 5-day rebleeding rate, and 30-day emergency readmission between patients treated or not treated with antibiotic prophylaxis.Forty-six patients (30.7%) received antibiotic prophylaxis; 104 (69.3%) did not. The rates of the outcomes in patients with antibiotic prophylaxis were 6.5% (bacterial infection), 4.3% (in-hospital mortality), 2.2% (5-day rebleeding), and 10.9% (30-day emergency readmission) and were not significantly different form the corresponding figures in those without antibiotic prophylaxis (1.9%, 7.7%, 1.9%, and 10.6%, respectively). Moreover, these rates in our patients, even without antibiotic prophylaxis, were much lower than rates reported in past years, perhaps because of improvements in care of patients with variceal hemorrhage.Antibiotic prophylaxis was not associated with significantly better outcomes of bacterial infection, mortality, rebleeding or readmission rate in patients with acute variceal bleeding. Universal antibiotic prophylaxis for patients with acute variceal bleeding should be reconsidered.

Bacterial Infection in Patients with Cirrhosis: Don't Get Bugged to Death

Bacterial infection remains a leading cause of mortality and morbidity for patients with cirrhosis, with hospitalization, alterations in the intestinal microbiota, and therapeutic drugs all implicated in its development. Bacterial infections also remain the most common precipitant of acute-on-chronic liver failure, with infection occurring as a direct consequence of the progression of this syndrome. Furthermore, recent epidemiological analyses have demonstrated that infections due to multidrug-resistant bacteria are occurring with increasing frequency in patients with cirrhosis. Despite significant advances in the understanding of the pathophysiological processes triggered by an infection in patients with cirrhosis, a demonstrable survival benefit for the sickest patients who require ICU admission has not yet occurred. Early diagnosis of infection and appropriate antimicrobial treatment is essential to ensuring optimal outcomes for these patients. This review provides an evidence-based analysis of both the current strategies for prevention and the recommended management of common bacterial infections in patients with cirrhosis.

Upper gastrointestinal bleeding in Egyptian patients with cirrhosis: Post-therapeutic outcome and prognostic indicators

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.

Thromboelastography Parameters Are Associated with Cirrhosis Severity

BACKGROUND

Coagulopathy in cirrhosis represents complex coagulation derangements, and thromboelastography (TEG) measures these complex derangements.

AIM

We sought to evaluate associations between TEG parameters and validated measures of cirrhosis severity, which have not been previously investigated.

MATERIALS AND METHODS

Adults with cirrhosis undergoing liver transplant (LT) were identified. Patients had TEG drawn immediately prior to LT. TEG parameters included reaction time (R), kinetic time (K), alpha angle (α), and maximum amplitude (MA). The validated measures of cirrhosis severity were MELD-Na and clinical stage of cirrhosis (classified using history of varices, variceal bleeding, or ascites). Multivariable linear and logistic regression analyses were conducted to evaluate the associations between TEG and stage of cirrhosis and MELD-Na.

RESULTS

Among 164 patients with cirrhosis, advancing stage of cirrhosis was associated with more hypocoagulable TEG parameters including longer K-time (p = 0.05) and lower MA (p < 0.001). Similarly, with increasing MELD-Na quartiles, K-time was longer (p < 0.001), and both MA and α-angle decreased (p < 0.001, for both). Variceal bleeding within 6 weeks prior to LT was associated with longer R-times (p = 0.02), longer K-times (p = 0.04), smaller α-angle (p = 0.03), and lower MA (p = 0.01). On multivariable analyses, decreasing MA remained statistically significantly associated with advancing stage of cirrhosis and increasing MELD-Na, after adjusting for multiple covariates including platelet count, (p = 0.02 and p < 0.0001, respectively).

CONCLUSIONS

Hypocoagulable TEG measurements are associated with advancing stage of cirrhosis and increasing MELD-Na among patients with cirrhosis. These data indicate that TEG, as an informative measure of complex hemostatic function, may be a useful objective marker of liver disease severity in cirrhosis.

Primary and secondary prophylaxis of spontaneous bacterial peritonitis: current state of the art

Introduction: Spontaneous bacterial peritonitis represents a frequent and severe complication in cirrhotic patients with ascites. In daily practice, the diagnosis of spontaneous bacterial peritonitis might be challenging in the absence of the typical signs and symptoms of infection such as fever or leukocytosis. Areas covered: Aim of this review is to revise the current state of the art on primary and secondary spontaneous bacterial peritonitis. Literature search in Medline/Pubmed was performed. Expert opinion: Historically, gram-negative bacteria were the most frequent etiologic agents of spontaneous bacterial peritonitis, with Escherichia coli and Klebsiella spp. being the most frequently isolated bacteria. However, major changes in this regard occurred over the last few decades with an increasing prevalence of gram-positive, quinolone-resistant, and multidrug-resistant bacteria. In particular, the increasing prevalence of quinolone-resistant bacteria challenged the prominent role of norfloxacin in spontaneous bacterial peritonitis prevention. Given the high mortality rate and the risk of developing the hepatorenal syndrome, prophylaxis of spontaneous bacterial peritonitis is indicated in three high-risk populations: patients with acute gastrointestinal hemorrhage, patients with low total protein content in ascitic fluid and advanced cirrhosis, and patients with a previous history of spontaneous bacterial peritonitis (secondary prophylaxis).

Antibiotic use in cirrhotic children with acute upper gastrointestinal bleeding: A retrospective study using the pediatric health information system (PHIS) database

Prior studies have demonstrated positive impacts of antibiotic use on reducing mortality, rebleeding events, and length of hospitalization in adult cirrhotic patients with acute upper gastrointestinal bleeding (UGIB). We aimed to investigate the use of antibiotics in cirrhotic children with acute UGIB and its impact on patient outcomes.This was a retrospective study using the Pediatric Health Information System database. Cirrhotic patients aged 0 to 18 years with acute UGIB, admitted between October 2005 and September 2015, were identified based on ICD-9 codes. Patients with no documented endoscopy during admission were excluded.Forty-four (23 females) cirrhotic children were eligible for data analysis. The median patient age was 6 years. Etiology of acute UGIB included esophageal varices (n = 37), non-variceal bleeding (n = 4), and both (n = 3). A significant proportion of cirrhotic children with acute UGIB (n = 30, 68%) were given intravenous antibiotics within 48 hours of admission. Among children who did not develop bacteremia, 68% received antibiotics vs. 32% who did not (P = .6). The rate of readmission within 30 days of discharge was 7% in patients with antibiotics vs. 21% in those without antibiotics (P = .3).This study suggested that antibiotic use within 48 hours of admission in cirrhotic children with acute UGIB might have a positive impact on the percentage of children free of bacteremia and the readmission rate. A prospective study should investigate whether prophylactic antibiotics should be targeted only to a subgroup of cirrhotic children with acute UGIB who are particularly at high risk for bacterial infection.

Management of acute variceal hemorrhage

Gastrointestinal bleeding is one of the major causes of death in patients with cirrhosis, and gastroesophageal varices represent the main source of hemorrhage. Even though in the last decades survival has been improved because of the widespread adoption of effective treatments and optimization of general medical care, mortality is still significantly high, and decompensated patients pose a complex challenge requiring a multidisciplinary approach that is crucial to improve survival. The aims of this commentary are to review the most recent advances in the management of esophageal variceal bleeding and to highlight useful information to aid hepatologists in clinical practice.

[Spontaneous Bacterial Peritonitis]

Spontaneous bacterial peritonitis (SBP) is defined as bacterial infections that occur in patients with cirrhosis and ascites without any significant intraperitoneal infection, accounting for approximately 10-30% of bacterial infections in hospitalized patients. SBP develops in patients with liver cirrhosis because bacterial translocations are increased by changes in the intestinal bacteria and mucosal barriers. In addition, the decreased host immune response cannot remove the bacteria and their products. The most common cause of SBP is Gram-negative bacteria, such as Escherichia coli and Klebsiella species, and infections by Gram-positive bacteria are increasing. SBP is diagnosed by the presence of >250 polymorphonuclear leukocyte/mm³ in ascites after paracentesis. If SBP is diagnosed, empirical antibiotic therapy should be started immediately. Empirical antibiotic treatment should distinguish between community acquired infections and nosocomial infections. Cirrhotic patients with gastrointestinal bleeding or low ascitic protein concentrations should consider primary prevention and those who recover from SBP should consider secondary prevention. This review describes the pathophysiology, diagnosis, treatment, and prevention of SBP.

Immune Dysfunction and Albumin-Related Immunity in Liver Cirrhosis

Liver cirrhosis yearly causes 1.2 million deaths worldwide, ranking as the 10th leading cause of death in the most developed countries. High susceptibility to infections along with a significant risk for infection-related mortality justifies the description of liver cirrhosis as the world's most common immunodeficiency syndrome. Liver cirrhosis is an end-stage organic disease hallmarked by a multifaceted immune dysfunction due to deterioration of antimicrobial recognition and elimination mechanisms in macrophages along with an impaired antigen presentation ability in circulating monocytes. Bacterial translocation supports—and is supported by—uncontrolled activation of immune cell responses and/or loss of toll-like receptor (TLR) tolerance, which can turn exaggerated inflammatory responses to systemic inflammation. Lipopolysaccharide (LPS) or endotoxin boosts systemic inflammatory activity through activation of TLR-2- and TLR-4-dependent pathways and facilitate a massive production of cytokines. This, in turn, results into elevated secretion of reactive oxygen species (ROS), which further enhances intestinal hyperpermeability and thus sustains a vicious circle of events widely known as “leaky gut.” Albumin can be of particular benefit in cirrhotic patients with spontaneous bacterial peritonitis and/or hepatorenal syndrome type of acute kidney injury (HRS-AKI) due to anti-inflammatory and antioxidative stress as well as volume-expanding properties and endothelial-stabilizing attributes. However, presence of autoantibodies against albumin in patients with liver cirrhosis has been described. Although previous research suggested that these antibodies should be regarded as naturally occurring antibodies (NOA), the origin of the antialbumin immune response is obscure. High occurrence of NAO/albumin complexes in patients with liver disease might reflect a limited clearance capacity due to bypassing portal circulation. Moreover, high burden of oxidized albumin is associated with less favorable outcome in patients with liver cirrhosis. To date, there is no data available as to whether oxidized forms of albumin result in neoepitopes recognized by the immune system. Nevertheless, it is reasonable to hypothesize that these alterations may have the potential to induce antialbumin immune responses and thus favor systemic inflammation.

Spontaneous bacterial peritonitis in patients with cirrhosis: incidence, outcomes, and treatment strategies

Spontaneous bacterial peritonitis is the most frequent bacterial infection in patients with cirrhosis. The reported incidence varies between 7% and 30% in hospitalized patients with cirrhosis and ascites, representing one of their main complications. Outcomes in patients with spontaneous bacterial peritonitis are poor since acute kidney injury, acute-on-chronic liver failure, and death occur in as much as 54%, 60%, and 40% of the patients, respectively, at midterm. Early antibiotic treatment of spontaneous bacterial peritonitis is crucial. However, the landscape of microbiological resistance is continuously changing, with an increasing spread of multidrug-resistant organisms that make its current management more challenging. Thus, the selection of the empirical antibiotic treatment should be guided by the severity and location where the infection was acquired, the risk factors for multidrug-resistant organisms, and the available information on the local expected bacteriology. The use of albumin as a complementary therapy for selected high-risk patients with spontaneous bacterial peritonitis is recommended in addition to antibiotics. Even though antibiotic prophylaxis has proven to be effective to prevent spontaneous bacterial peritonitis, a careful selection of high-risk candidates is crucial to avoid antibiotic overuse. In this article we review the pathogenesis, risk factors, and prognosis of spontaneous bacterial peritonitis, as well as the current evidence regarding its treatment and prophylaxis.

Strategies to avoid empiric blood product administration in liver transplant surgery

Massive blood loss has been a dreaded complication of liver transplantation, and the accompanying transfusion is associated with adverse outcomes in the form of decreased patient and graft survival. With advances in both surgical techniques and anesthetic management during transplantation, blood and blood products requirements reduced significantly. However, transfusion practices vary among different centers. The altered coagulation parameters in patients with liver cirrhosis results in a state of “rebalanced hemostasis” and patients are just as likely to clot as they are to bleed. Commonly used coagulation tests do not always reflect this new state and can, therefore, be misleading. Transfusion of blood products solely to correct abnormal parameters may worsen the coagulation status, thus adversely affecting patient outcome. Point-of-care tests such as thromboelastometry more reliably predict the risk of bleeding in these patients and in addition may provide quicker turnaround times compared to routine tests. Perioperative management should also include the possibility of thrombosis in these patients, and the use of low-molecular-weight heparin correlates with better patient survival. This review article aims to highlight the concept of rebalanced hemostasis, limitation of routine coagulation tests, and harmful effect of empiric transfusion of blood products.

Management of Coagulation and Anticoagulation in Liver Transplantation Candidates

Hemostasis is a complex balance of clot formation and dissolution that is largely modulated by protein synthesis and degradation in the liver. In the state of end-stage liver disease, there is a disruption of the hemostatic system due to hepatic protein synthetic dysfunction. Because historical clinical laboratory testing often only analyzes a portion of the hemostasis system, the clinician may be misled into believing that cirrhosis patients are imbalanced with a tendency toward bleeding. The modern understanding of hemostasis in cirrhosis involves a rebalance of hemostasis with a tenuous equilibrium between clotting and bleeding, but an equilibrium nonetheless. The clinician should be aware of this rebalance and not depend on limited and flawed laboratory testing in making judgments about the tendency for bleeding or clotting based on these values alone. Prophylactic protocol transfusions including large doses of fresh frozen plasma to "correct" the international normalized ratio are good examples of ineffective and potentially harmful interventions based on an outdated understanding of hemostasis in cirrhosis. Conversely, a thrombotic state is increasingly recognized in patients with cirrhosis, and conditions such as portal vein thrombosis are now becoming important therapeutic targets in many liver transplantation (LT) candidates and other patients with chronic liver disease. This article will introduce the reader to the modern understanding of hemostasis in cirrhosis, describe the common pitfalls and opportunities in treating hemostasis system abnormalities in the LT candidate particularly in regards to preprocedural prophylactic transfusions, and discuss therapeutic targets and interventions for thrombotic complications in the end-stage liver disease population.

Emergency Management of Spontaneous Bacterial Peritonitis - A Clinical Review

Spontaneous bacterial peritonitis (SBP) has a high mortality rate; early antimicrobial therapy is essential for improving patient outcomes. Given that cirrhotic patients are often coagulopathic, the perceived risk of bleeding may prevent providers from performing a paracentesis and ruling out this potentially deadly disease. We examine the pathophysiology and risk factors for SBP, and current guidelines for its diagnosis and treatment. We then review the time-sensitive nature of performing a paracentesis, and the current controversies and contraindications for performing this procedure in patients at risk for SBP. Cirrhotic patients with ascites and clinical suspicion for SBP-abdominal pain or tenderness, fever or altered mental status-should have a diagnostic paracentesis. Although most patients with cirrhosis and liver dysfunction will have prolonged prothrombin time, paracentesis is not contraindicated. Limited data support platelet administration prior to paracentesis if <40,000-50,000/μL. Timely antimicrobial therapy includes a third-generation cephalosporin for community-acquired infection; nosocomial infections should be treated empirically with a carbapenem or with piperacillin-tazobactam, or based on local susceptibility testing. Patients with gastrointestinal (GI) hemorrhage should receive ceftriaxone prophylactically for GI hemorrhage. SBP has a high mortality rate. Early diagnosis and antimicrobial therapy are essential for improving patient outcomes. Cirrhotic patients with ascites with clinical suspicion for SBP, abdominal pain or tenderness, altered mental status or fever should have a diagnostic paracentesis performed prior to admission unless platelets <40,000-50,000/μL.

Prevention and management of gastroesophageal varices

Bleeding from gastroesophageal varices is a serious complication in patients with liver cirrhosis and portal hypertension. Although there has been significance improvement in the prognosis of variceal bleeding with advancement in diagnostic and therapeutic modalities for its management, mortality rate still remains high. Therefore, appropriate prevention and rapid, effective management of bleeding from gastroesophageal varices is very important. Recently, various studies about management of gastoesophageal varices, including prevention of development and aggravation of varices, prevention of first variceal bleeding, management of acute variceal bleeding, and prevention of variceal rebleeding, have been published. The present article reviews published articles and practice guidelines to present the most optimal management of patients with gastroesophageal varices.

Pathogenesis, prevention, and management of bleeding and thrombosis in patients with liver diseases

Patients with liver diseases may develop alterations in all components of the hemostatic system. Thrombocytopenia, low levels of coagulation factors and inhibitors, low levels of fibrinolytic proteins, and increased levels of endothelial-derived proteins such as von Willebrand factor are all part of the coagulopathy of liver disease. Due to concomitant changes in pro- and antihemostatic drivers, the net effects of these complex hemostatic changes have long been unclear. According to current concepts, the hemostatic system of patients with liver disease is in an unstable balance, which explains the occurrence of both bleeding and thrombotic complications. This review will discuss etiology and management of bleeding and thrombosis in liver disease and will outline unsolved clinical questions. In addition, we will discuss the role of intrahepatic activation of coagulation for progression of liver disease, a novel paradigm with potential consequences for the general management of patients with liver disease.

Variceal bleeding in cirrhotic patients

Variceal bleeding is one of the major causes of death in cirrhotic patients. The management during the acute phase and the secondary prophylaxis is well defined. Recent recommendations (2015 Baveno VI expert consensus) are available and should be followed for an optimal management, which must be performed as an emergency in a liver or general intensive-care unit. It is based on the early administration of a vasoactive drug (before endoscopy), an antibiotic prophylaxis and a restrictive transfusion strategy (hemoglobin target of 7 g/dL). The endoscopic treatment is based on band ligations. Sclerotherapy should be abandoned. In the most severe patients (Child Pugh C or B with active bleeding during initial endoscopy), transjugular intrahepatic portosystemic shunt (TIPS) should be performed within 72 hours after admission to minimize the risk of rebleeding. Secondary prophylaxis is based on the association of non-selective beta-blockers (NSBBs) and repeated band ligations. TIPS should be considered when bleeding reoccurs in spite of a well-conducted secondary prophylaxis or when NSBBs are poorly tolerated. It should also be considered when bleeding is refractory. Liver transplantation should be discussed when bleeding is not controlled after TIPS insertion and in all cases when liver function is deteriorated.

Gastrointestinal Issues in Liver Disease

Gastrointestinal (GI) complications of cirrhosis are frequent in patients who require intensive care support and are often the primary indication for intensive care unit (ICU) admission. Perhaps the most worrisome GI complication for the intensivist is variceal hemorrhage. Bleeding from esophageal or gastric varices represents a life-threatening event for cirrhotic patients and provides management challenges for the ICU team. Nonvariceal GI bleeding, impaired GI motility, and malnutrition also provide significant challenges for the intensivist. This article reviews GI issues that present in critically ill cirrhotic patients and their management in the acute setting.