Prevalence of endoscopic findings in 510 consecutive individuals with cirrhosis evaluated prospectively

Bacterial load and cytokine profile in patients with cirrhosis following therapy with proton pump inhibitors: a prospective cohort study

Background

The aim of this study was to explore the presence of bacterial products and the cytokine profile in outpatients with cirrhosis before and after short-term (4-8 weeks) administration of proton pump inhibitors (PPIs).

Methods

Seventeen patients with cirrhosis—male/female: 12/5; age: median 59.2 years (49-65); etiology: HBV±HDV 23.5%, HCV 17.7%, alcohol 41.2%, other 17.6%; Child-Pugh score: median 7.5 (5-12); Model for End-stage Liver Disease: 10.5 (7-21); ascites (%): 3 (17.7)—attending the outpatient clinics were included. None had hepatocellular carcinoma. Indications for PPIs were: esophagitis (n=6, 35.3%), peptic ulcer (n=10, 58.6%) and other (n=1, 5.9%). Bacterial DNA in serum and the levels of endotoxin, lipopolysaccharide binding protein, transforming growth factor-β, interleukin -1β, -6, -8, -12, -10, tumor necrosis factor-α and nitric oxide were assessed at baseline (time 1) and at the end of treatment (time 2). The Wilcoxon signed rank test was used to evaluate significant differences in the parameters assayed before and after PPI administration.

Results

No patients developed infection during the study period. Bacterial DNA was not detected before or after treatment. No significant differences were observed between the concentrations of any indices between times 1 and 2 (P>0.05). Subgroup analysis according to Child-Pugh stage yielded similar results.

Conclusion

Short-term administration of PPIs had no effect on bacterial DNA, bacterial products or cytokine concentrations in patients with liver cirrhosis.

Portal hypertensive gastropathy: A systematic review of the pathophysiology, clinical presentation, natural history and therapy

AIM

To describe the pathophysiology, clinical presentation, natural history, and therapy of portal hypertensive gastropathy (PHG) based on a systematic literature review.

METHODS

Computerized search of the literature was performed via PubMed using the following medical subject headings or keywords: "portal" and "gastropathy"; or "portal" and "hypertensive"; or "congestive" and "gastropathy"; or "congestive" and "gastroenteropathy". The following criteria were applied for study inclusion: Publication in peer-reviewed journals, and publication since 1980. Articles were independently evaluated by each author and selected for inclusion by consensus after discussion based on the following criteria: Well-designed, prospective trials; recent studies; large study populations; and study emphasis on PHG.

RESULTS

PHG is diagnosed by characteristic endoscopic findings of small polygonal areas of variable erythema surrounded by a pale, reticular border in a mosaic pattern in the gastric fundus/body in a patient with cirrhotic or non-cirrhotic portal hypertension. Histologic findings include capillary and venule dilatation, congestion, and tortuosity, without vascular fibrin thrombi or inflammatory cells in gastric submucosa. PHG is differentiated from gastric antral vascular ectasia by a different endoscopic appearance. The etiology of PHG is inadequately understood. Portal hypertension is necessary but insufficient to develop PHG because many patients have portal hypertension without PHG. PHG increases in frequency with more severe portal hypertension, advanced liver disease, longer liver disease duration, presence of esophageal varices, and endoscopic variceal obliteration. PHG pathogenesis is related to a hyperdynamic circulation, induced by portal hypertension, characterized by increased intrahepatic resistance to flow, increased splanchnic flow, increased total gastric flow, and most likely decreased gastric mucosal flow. Gastric mucosa in PHG shows increased susceptibility to gastrotoxic chemicals and poor wound healing. Nitrous oxide, free radicals, tumor necrosis factor-alpha, and glucagon may contribute to PHG development. Acute and chronic gastrointestinal bleeding are the only clinical complications. Bleeding is typically mild-to-moderate. Endoscopic therapy is rarely useful because the bleeding is typically diffuse. Acute bleeding is primarily treated with octreotide, often with concomitant proton pump inhibitor therapy, or secondarily treated with vasopressin or terlipressin. Nonselective β-adrenergic receptor antagonists, particularly propranolol, are used to prevent bleeding after an acute episode or for chronic bleeding. Iron deficiency anemia from chronic bleeding may require iron replacement therapy. Transjugular-intrahepatic-portosystemic-shunt and liver transplantation are highly successful ultimate therapies because they reduce the underlying portal hypertension.

CONCLUSION

PHG is important to recognize in patients with cirrhotic or non-cirrhotic portal hypertension because it can cause acute or chronic GI bleeding that often requires pharmacologic therapy.

Pharmacokinetic changes of drugs in a rat model of liver cirrhosis induced by dimethylnitrosamine, alone and in combination with diabetes mellitus induced by streptozotocin

Rats with liver cirrhosis induced by N-dimethylnitrosamine (LC) and rats with LC with diabetes mellitus induced by streptozotocin (LCD) have been developed as animal models for human liver cirrhosis and liver cirrhosis with diabetes mellitus, respectively. Changes in the pharmacokinetics of drugs (mainly non-renal clearance, CLNR) in LC and LCD rats reported in the literature compared with respective control rats were reviewed. This review mainly explains the changes in the CLNRs of drugs (which are mainly metabolized via hepatic microsomal cytochrome P450s, CYPs) in LC and LCD rats, in terms of the changes in in vitro hepatic intrinsic clearance (CLint; mainly due to the changes in CYPs in the disease state), free (unbound) fraction of a drug in the plasma (fp) and hepatic blood flow rate (QH) depending on the hepatic excretion ratio of the drug. Generally, changes in the CLNRs of drugs in LC and LCD rats could be well explained by the above-mentioned three factors. The mechanism of urinary excretion of drugs (such as glomerular filtration or renal active secretion or reabsorption) in LC and LCD rats is also discussed. The pharmacokinetics of the drugs reported in the LC and LCD rats were scarce in humans. Thus, the present rat data should be extrapolated carefully to humans.

Role of proton pump inhibitors in the occurrence and the prognosis of spontaneous bacterial peritonitis in cirrhotic patients with ascites

BACKGROUND

Proton pump inhibitors (PPIs) facilitate intestinal bacterial translocation. No robust data exist demonstrating that PPIs increase the risk of spontaneous bacterial peritonitis (SBP) and that PPIs worsen the prognosis of SBP patients. PPI use might be unsuitable for cirrhotic patients.

AIMS

To analyse: (i) the role of PPIs in the occurrence of SBP in cirrhotic patients; (ii) their impact on the prognosis of SBP patients; and (iii) the suitability of their use.

METHODS

In this retrospective case-control study, PPI use was first assessed in cirrhotic patients consecutively admitted with SBP (group I) and in a control group that included the same number of uninfected cirrhotic patients with ascites (group II). Afterwards, the impact of PPIs on SBP was assessed in group I by comparing survival of patients with and without PPIs.

RESULTS

A total of 102 patients were included, 51 in each group. (i) SBP patients were more frequently treated by PPIs than controls (49 vs. 25%, P = 0.014). (ii) In group I, patients with (n = 25) and without (n = 26) PPIs had similar survival rates at 1 month (64.0 ± 9.6% vs. 59.4 ± 10.0%), 3 months (41.2 ± 10.2% vs. 44.6 ± 10.6%), and 1 year (26.6 ± 9.6% vs. 28.9 ± 10.1%), and similar median age at death (53 vs. 57 years). (iii) The reason for PPI use was inappropriate or undocumented in 34% of group I and II.

CONCLUSIONS

Proton pump inhibitors were more frequently used in SBP patients than in controls, but did not influence the prognosis in SBP. Overuse of PPIs was encountered in one-third of cirrhotic patients and should be avoided.

The diminished expression of proangiogenic growth factors and their receptors in gastric ulcers of cirrhotic patients

Objectives

The pathogenesis of the higher occurrence of peptic ulcer disease in cirrhotic patients is complex. Platelets can stimulate angiogenesis and promote gastric ulcer healing. We compared the expressions of proangiogenic growth factors and their receptors in the gastric ulcer margin between cirrhotic patients with thrombocytopenia and those of non-cirrhotic patients to elucidate possible mechanisms.

Methods

Eligible cirrhotic patients (n = 55) and non-cirrhotic patients (n = 55) who had gastric ulcers were enrolled. Mucosa from the gastric ulcer margin and non-ulcer areas were sampled and the mRNA expressions of the proangiogenic growth factors (vascular endothelial growth factor [VEGF], platelet derived growth factor [PDGF], basic fibroblast growth factor [bFGF]) and their receptors (VEGFR1, VEGFR2, PDGFRA, PDGFRB, FGFR1, FGFR2) were measured and compared. Platelet count and the expressions of these growth factors and their receptors were correlated with each other.

Results

The two groups were comparable in terms of gender, ulcer size and infection rate of Helicobacter pylori. However, the cirrhotic group were younger in age, had a lower platelet count than those in the non-cirrhotic group (p<0.05). The cirrhotic patients had diminished mRNA expressions of PDGFB, VEGFR2, FGFR1, and FGFR2 in gastric ulcer margin when compared with those of the non-cirrhotic patients (p<0.05). Diminished expressions of PDGFB and VEGFR2, FGFR1, and FGFR2 were well correlated with the degree of thrombocytopenia in these cirrhotic patients (ρ>0.5, p<0.001).

Conclusions

Our findings implied that diminished activity of proangiogenic factors and their receptors may contribute to the pathogenesis of gastric ulcers in cirrhotic patients.

Cirrhotic patients at increased risk of peptic ulcer bleeding: a nationwide population-based cohort study

BACKGROUND

Few large population-based studies have compared the occurrence of peptic ulcer bleeding (PUB) in cirrhotic and noncirrhotic patients.

AIMS

To investigate if cirrhotic patients have higher risk of PUB than the general population and to identify possible risk factors of PUB in cirrhotic patients.

METHODS

Using the National Health Insurance Research Database, a nationwide population-based dataset in Taiwan and matching age, gender, comorbidities and ulcerogenic medication by propensity score, 4013 cirrhotic patients, 8013 chronic hepatitis patients and 7793 normal controls were compared. The log-rank test was used to analyse differences in accumulated PUB-free survival rates between the groups. Cox proportional hazard regressions were performed to evaluate independent risk factors for PUB in all patients and identified risk factors of PUB in cirrhotic patients.

RESULTS

During the 7-year follow-up, cirrhotic patients had significantly higher incidences of PUB than chronic hepatitis patients and controls, respectively (P < 0.001 by log-rank test). By Cox proportional hazard regression analysis, cirrhosis was independently associated with increased risk of PUB (hazard ratio: 4.22; 95% CI 3.37-5.29, P < 0.001) after adjusting for age, gender, economic status, underlying comorbidities and ulcerogenic medication. Age, male, diabetes, chronic renal disease, history of gastro-oesophageal variceal bleeding and use of nonsteroidal anti-inflammatory drugs were risk factors for PUB in cirrhotic patients.

CONCLUSION

Cirrhotic patients have a significantly higher risk of peptic ulcer bleeding after adjustments for possible confounding factors like age, gender, economic status, underlying comorbidities and ulcerogenic medication.

[Association between Helicobacter pylori infection and gastroduodenal lesions in patients with chronic liver disease]

CONTEXT

The relationship between Helicobacter pylori infection and gastroduodenal lesions in chronic liver disease remains controversial.

OBJECTIVE

Evaluate the evidence of the role of H. pylori infection in gastroduodenal lesions in patients with chronic liver disease.

METHODS

Forty-six patients with chronic liver disease were matched with 27 dyspeptic persons for age and sex. The gastroduodenal lesions were portal hypertension gastropathy, erosion and peptic ulcer. All patients underwent upper endoscopy: two biopsies were taken in the antrum and in the gastric body. The biopsies were used for Giemsa staining.

RESULTS

A gastroduodenal lesions were found in 38 (82.6%) patients with liver disease and was significantly more frequent than among controls (P = 0.002). H. pylori infection was detected at histological assessment in 13 (28.2%) patients with chronic liver disease and in 17 (62.9%) controls. The odds ratio (OR) showed an interaction statistically significant between gastroduodenal lesions and chronic liver disease (P = 0.04; OR = 5.1; 95% CI = 1.6-17.3). When adjusted for the presence of H. pylori OR was significantly with H. pylori negative (OR 13.0 IC 95%, 1.4-327.9).

CONCLUSION

Patients with chronic liver disease showed higher risk of developing gastroduodenal lesions regardless of the presence of the H. pylori infection.

Association of proton pump inhibitor therapy with spontaneous bacterial peritonitis in cirrhotic patients with ascites

OBJECTIVES

Spontaneous bacterial peritonitis (SBP) is a frequent complication of cirrhosis. Bacterial contamination of ascites fluid leading to SBP is caused by bacterial translocation with subsequent bacteremia. Proton pump inhibitors (PPIs) suppress gastric acid secretion, allowing bacterial colonization of the upper gastrointestinal tract, and may predispose to bacterial overgrowth and translocation. The aim of this study was to determine whether PPI use in cirrhotics with ascites is associated with SBP.

METHODS

A retrospective case-control study was performed. Seventy cirrhotics admitted with paracentesis-proven SBP between 2002 and 2007 were matched 1:1 (for age and Child's class) with comparable cirrhotics with ascites who were admitted for conditions other than SBP. We excluded patients on chronic antibiotic prophylaxis or with antecedent gastrointestinal bleeding. Outpatient PPI use at the time of admission was compared between groups, and the effect of covariates was analyzed.

RESULTS

Patients with SBP had a significantly higher rate of prehospital PPI use (69%) compared with ascitic cirrhotics hospitalized without SBP (31%, P = 0.0001). There was no significant difference in demographics, diabetes, etiology, or survival between groups. On multivariate analysis, PPI use was independently associated with SBP (odds ratio (OR) 4.31, confidence interval (CI) 1.34-11.7), and ascitic fluid protein was protective (OR 0.1, CI 0.03-0.25). In total, 47% of cirrhotic patients receiving PPI in this study had no documented indication for PPI treatment.

CONCLUSIONS

PPI therapy is associated with SBP in patients with advanced cirrhosis. Prospective studies are needed to determine whether PPI avoidance can reduce the incidence of SBP and improve outcomes.

Pathogenesis of portal hypertensive gastropathy: translating basic research into clinical practice

Portal hypertensive gastropathy (PHG) is often seen in patients with portal hypertension, and can lead to transfusion-dependent anemia as well as acute, life-threatening bleeding episodes. This Review focuses on the mechanisms that underlie the pathogenesis of PHG that provide reasonable grounds for the treatment of this condition, and ultimately enable translation of basic research into clinical practice. Increased portal pressure associated with cirrhosis and liver dysfunction is critical for the development of clinically significant PHG, and leads to impaired gastric mucosal defense mechanisms that render the stomach susceptible to mucosal injury. The use of pharmacological agents such as beta-blockers reduces the frequency of bleeding episodes in PHG. As a last resort, surgical decompression of the portal system, transjugular intrahepatic stent placement and liver transplantation can resolve this condition. Elimination of known risk factors for gastric injury such as alcohol, aspirin and traditional NSAIDs is critical. The role of Helicobacter pylori colonization of the gastric mucosa in PHG is not clear. Careful and critical interpretation of human and experimental data can be helpful to establish a rationale for the medical management of this important condition.

Efficacy of Helicobacter pylori eradication therapy in chronic liver disease

BACKGROUND/AIMS

Peptic ulcers occur more commonly in patients with liver cirrhosis (LC). Helicobacter pylori is recognized as the most important etiology in the pathogenesis of peptic ulcers. We investigated the efficacy of proton pump inhibitor (PPI)-based triple therapy in patients with chronic liver disease and peptic ulcer.

PATIENTS AND METHODS

One hundred sixty-three patients with LC or chronic hepatitis (CH) with a peptic ulcer and proven H. pylori infection were included. The combination of PPI, amoxicillin (1.0 g), and clarithromycin (500 mg), each given twice daily, was administered for 1 or 2 weeks. The eradication of H. pylori was determined by the rapid urease test, histology, or the 13C-urea breath test at least 4 weeks after completing the treatment.

RESULTS

The eradication rate of H. pylori was similar between the LC and CH groups; 82.6% and 88.1%, respectively. In addition, there were no significant differences in eradication rates between the patients with Child-Pugh class A and Child-Pugh class B/C disease. The side effects in each group were generally mild. Only the serum ALT levels showed a significant correlation with the success of H. pylori eradication in both the LC and CH groups.

CONCLUSION

The PPI-based triple therapy achieves high eradication rates for H. pylori infection, in patients with chronic liver disease, without significant side effects.

Avoiding pitfalls: what an endoscopist should know in liver transplantation--part 1

Cirrhosis is associated with global homodynamic changes, but the majority of the complications are usually manifested through the gastrointestinal tract. Therefore, Gastrointestinal Endoscopy has become an important tool in the multidisciplinary approach in the management of these patients. With the ever growing number of cirrhotic patients requiring pre-transplant endoscopic management, it is imperative that the community endoscopists are well aware of the pathologies that can be potentially noted on Gastrointestinal Endoscopy. Their timely management is also considered to have the utmost importance in being able to stabilize the patient until their transfer to a Liver Transplant Center. The aim of this manuscript is to give a comprehensive update and review of various endoscopic findings that a non-transplant endoscopist will encounter in the pre-transplant setting.

Upper and lower gastrointestinal diseases in liver transplant candidates

BACKGROUND

The incidence and risk factors of gastrointestinal diseases in pre-liver transplant population are still a matter of debate. In a retrospective analysis, we addressed two questions: (1) Are there any lesions that occur at a higher prevalence than in the general population, and (2) are there patient characteristics that could predict their presence?

MATERIALS AND METHODS

All asymptomatic patients that successfully entered the waiting list of liver transplantation were recorded. We also compared results with those obtained from a control group of non-cirrhotic patients undergoing screening for colorectal cancer. Main outcome measures were the incidence and description of upper/lower gastrointestinal findings after screening endoscopic examination.

RESULTS

We retrospectively evaluated from April 2004 to July 2007 a total of 80 liver transplant candidates. The most frequent pathologies were esophageal varices (71.2% of subjects), portal hypertensive gastropathy (51.2%), hemorrhoids (22.5%), and colonic polyps (18.7%). Comparison with 80 non-cirrhotic patients matched for age and sex demonstrated an increased frequency in the cirrhotic group of ulcerative colitis (6.2 vs 0%; p = 0.02) and portal hypertensive colopathy (12.5 vs 0%; p = 0.001) in non-cirrhotic of diverticulosis (10 vs 25%; p = 0.01) and hemorrhoids (22.5 vs 40%; p = 0.02). The univariate analysis showed no significant correlation between colonic polyps and patients' variables, except a mild correlation with age not confirmed at the multivariate analysis.

CONCLUSIONS

The incidence of some benign gastrointestinal pathologies in liver transplant candidates is different from the asymptomatic population but not that of colorectal cancer or colonic polyps.

Consequences of living-donor liver transplantation for upper gastrointestinal lesions: high incidence of reflux esophagitis

There is little information available regarding the consequences of living-donor liver transplantation (LDLT) for upper gastrointestinal lesions. We retrospectively compared the pre- and posttransplant incidences of noninfectious reflux esophagitis, portal hypertensive gastropathy (PHG), esophageal varix, gastroduodenal ulcer, Helicobacter pylori infection, and abnormal gastroesophageal valve in 29 adult patients (16 males, 13 females) who underwent LDLT for end-stage liver disease. Here we present four findings from this study. First, the posttransplant incidence of noninfectious esophagitis was significantly higher than the pretransplant incidence (27.6% vs. 3.4%; P < 0.001), irrespective of postoperative use of standard-dose H2RA. Second, PHG and esophageal varix, which were noted in 65.5% and 96.6% of pretransplant recipients, respectively, spontaneously resolved postoperatively in all cases. Third, H. pylori infection, which was observed in 50.0% of preoperative recipients, decreased to 5.6% postoperatively, although no significant difference was observed between the pre- and the posttransplant incidences of gastroduodenal ulcer (6.9% vs. 6.9%). Finally, the incidence of abnormal gastroesophageal valve did not change following LDLT (34.5% vs. 34.5%). In conclusion, this study suggests that noninfectious reflux esophagitis occurs more frequently following LDLT. Although the disease is the results of a very complex interaction of various factors, spontaneous resolution of PHG and serendipitous H. pylori eradication might have contributed to increased incidence of postoperative esophagitis, possibly through gastric acid hypersecretion. In contrast, morphological change of the gastroesophageal valve was not considered to be the cause of this disease. Because this study was a retrospective analysis of a small population of LDLT recipients, prospective randomized controlled studies of a sufficient number of cases are required to substantiate these conclusions.

Pharmacokinetics of omeprazole after intravenous and oral administration to rats with liver cirrhosis induced by dimethylnitrosamine

The aim of this study is to report the pharmacokinetics of omeprazole after intravenous (20 mg/kg) and oral (40 mg/kg) administration to rats with liver cirrhosis induced by dimethylnitrosamine (cirrhotic rats) with respect to CYP isozyme changes. The expressions of CYP1A2 and 3A1 decreased in cirrhotic rats and omeprazole is reported to be mainly metabolized via CYP1A1/2, 2D1, and 3A1/2 in male Sprague-Dawley rats. Hence, the pharmacokinetics of omeprazole could be changed in cirrhotic rats. After intravenous administration to cirrhotic rats, the AUC (1180 microg min/ml versus 474 microg min/ml) and CL(NR) (17.4 ml/min/kg versus 42.3 ml/min/kg) of omeprazole were significantly greater and slower, respectively, than the controls. This could be due to decrease in the expressions of CYP1A2 and 3A1 in cirrhotic rats. The significantly slower CL(NR) could be supported by significantly slower in vitro CL(int) for the disappearance of omeprazole from hepatic microsomal study (0.102 ml/min/mg protein versus 0.144 ml/min/mg protein) and slower hepatic blood flow rate in cirrhotic rats. After oral administration to cirrhotic rats, the AUC difference was considerably greater (451% versus 149%) than that after intravenous administration, possibly due to decrease in intestinal first-pass effect of omeprazole in addition to decrease in hepatic metabolism of omeprazole in cirrhotic rats.

Association between Helicobacter pylori infection and cirrhosis in patients with chronic hepatitis C virus

We evaluated, employing a logistic regression model, the association between Helicobacter pylori infection and cirrhosis in a cohort of 106 patients (57 males; mean age, 52.9 years; range, 20-78 years) with chronic hepatitis C virus (HCV) from Rosario, Argentina. HCV was confirmed by ELISA and PCR. H. pylori status was determined by ELISA. Of the 106 patients evaluated, 47 (44.3%) had cirrhosis. A total of 70.2% (33/47) of cirrhotic patients and 47.5% (28/59) of noncirrhotic patients were H. pylori-positive. In univariate analyses, cirrhosis was associated with age (P = 0.016) and H. pylori-positive status (P = 0.019) but not with gender (P = 0.28) or length of infection (P = 0.35). In multivariate analysis, H. pylori infection (P = 0.037; OR = 2.42; 95% CI = 1.06-5.53) and age (P = 0.033; OR = 1.04; 95% CI = 1.00-1.07) of patients remained significant and independently associated with cirrhosis. In conclusion, our results demonstrate an association between H. pylori infection and cirrhosis in patients with hepatitis C virus.

Mucosal abnormalities of the small bowel in patients with cirrhosis and portal hypertension: a capsule endoscopy study

BACKGROUND

The frequency of small-bowel mucosal changes in patients with portal hypertension is not known. The objective of the study is to better define the mucosal abnormalities of portal hypertensive enteropathy (PHE) and to determine whether these findings are associated with the severity of liver disease, esophageal varices, portal gastropathy, portal colonopathy, or other clinical characteristics.

METHODS

We compared the medical records of 37 patients with cirrhosis and portal hypertension with 34 control patients who underwent capsule endoscopy over a 3-year period.

RESULTS

Mucosal changes were found to be significantly more common in the cirrhotic patients than in the control patients (67.5% vs. 0, p < 0.001). The lesions included telangiectasias or angiodysplastic-like lesions in 9 (24.3%) patients, red spots in 23 (62.2%), and varices in 3 (8.1%). Active bleeding was seen during endoscopic examinations in 4 (10.8%) patients. A comparison of patients with and those without PHE showed that grade 2+ or larger esophageal varices, portal gastropathy, portal colonopathy, and Child-Pugh class C cirrhosis were all significantly associated with PHE. There were no differences between these two groups of patients with regard to the etiology of cirrhosis, gender, or history of esophageal variceal bleeding.

CONCLUSIONS

Mucosal abnormalities in portal jejunopathy include edema, erythema, and vascular lesions findings. A standardized grading system to classify the endoscopic appearance and the severity of portal enteropathy is proposed. The clinical import of these changes remains to be explained.

Diagnosis of portal hypertensive gastropathy

Portal hypertensive gastropathy is a relatively recently described entity that is an important cause of bleeding in portal hypertension. This article focuses on the endoscopic diagnosis of portal hypertensive gastropathy, including a review of different proposed scoring systems, and briefly examines the epidemiology, pathogenesis, and treatment of portal hypertensive gastropathy.

Malnutrition is a risk factor in cirrhotic patients undergoing surgery

Cirrhotic patients may become candidates for elective and emergency surgery. This may be due to conditions requiring operations such as cholecystectomy, herniotomy, or gastrointestinal malignancies, more common in cirrhotics when compared with the general population, or to complications of the liver disease such as resectable hepatocellular carcinomas or surgical portosystemic shunts to treat portal hypertension. It has been estimated that 10% of cirrhotics undergo at least one operative procedure during the final 2 y of their lives. Many studies have documented a high risk of morbidity and mortality associated with surgical procedures in these patients, and several factors influencing the postoperative outcome have been identified. Malnutrition, which is frequently encountered in cirrhotic patients, has been shown to have an important impact on the surgical risk. A poor nutrition status also has been associated with a higher risk of complications and mortality in patients undergoing liver transplantation. Few data are available concerning the perioperative nutrition support in surgical cirrhotic patients. The results of these studies are sometimes encouraging in reporting that the nutrition therapy may improve the clinical outcome in cirrhotic patients undergoing general surgery and/or liver transplantation. The limited number of patients and their heterogeneity, however, do not allow definitive conclusions, and more research on this issue is needed.

Helicobacter pylori is a risk factor for peptic ulcer disease in cirrhotic patients. A meta-analysis

BACKGROUND

Peptic ulcer disease is highly prevalent in cirrhosis, and ulcer complications are a major cause of morbidity in these patients. Helicobacter pylori infection is considered the chief aetiological factor of ulcer disease. However, in cirrhotic patients the role of H. pylori in the pathogenesis of peptic ulcer remains uncertain.

AIM

To evaluate the evidence of the pathogenic role of H. pylori infection in peptic ulcer disease in patients with cirrhosis.

MATERIALS AND METHODS

An extensive MEDLINE search of the literature was performed. Studies reporting the prevalence of H. pylori infection in cirrhotic patients with and without ulcers were selected. Meta-analysis was conducted using RevMan 4.0.3. Pooled odds ratios were calculated for each comparison, using a fixed model analysis.

RESULTS

The search identified seven studies with a total of 976 patients with cirrhosis (275 cases with ulcer disease and 701 controls). The prevalence of H. pylori infection in patients with peptic ulcer disease was higher than in those without. The pooled odds ratio was 2.70 (95% CI, 1.91-3.82). H. pylori infection was associated more or less equally with duodenal and gastric ulcers.

CONCLUSION

H. pylori infection increases the risk of peptic ulcer disease in patients with cirrhosis.

Mucosal abnormalities of the colon in patients with portal hypertension: an endoscopic study

BACKGROUND

Controversy still exists regarding colonic mucosal abnormalities in patients with portal hypertension (portal colopathy). The aims of this study were to better define portal colopathy and to identify risk factors for these colonic mucosal abnormalities.

METHODS

We reviewed the medical records of 437 patients with cirrhosis and portal hypertension and 224 with irritable bowel syndrome (control patients) who underwent colonoscopy over a 6-year period.

RESULTS

Individuals with portal hypertension were significantly more likely than control patients to have colitis-like abnormalities (38% vs. 3%, p < 0.001) and vascular lesions (13% vs. 3%, p < 0.001). In the multivariate model, portal hypertensive gastropathy (odds ratio 5.64: 95% CI [3.39, 9.41]; p < 0.001), 2+ or larger esophageal varices (odds ratio 4.76: 95% CI [2. 78, 8.15]; p < 0.001), and Child-Pugh class C cirrhosis (odds ratio 2.64: 95% CI [1.40, 4.97]; p = 0.003) were independently associated with an increased risk of having portal colopathy, whereas the use of beta-blockers independently decreased the risk of having these findings (odds ratio 0.23: 95% CI [0.13, 0.40]; p < 0.001). Mucosal biopsies of the colon in patients with colitis-like abnormalities revealed a mild, nonspecific inflammatory infiltrate with edema and vascular ectasias in the majority of cases.

CONCLUSIONS

Mucosal abnormalities in portal colopathy include edema, erythema, granularity, friability, and vascular lesions, findings that may be confused with colitis. A standardized grading system to classify the endoscopic appearance and severity of portal colopathy should be adopted.

Does quantitative serologic testing for Helicobacter pylori predict peptic ulcer disease in cirrhosis?

BACKGROUND

Helicobacter Pylori is strongly associated with peptic ulcer disease. A correlation between high IgG serum antibody concentrations and a clinical diagnosis has been reported. It has been recognized that peptic ulcer disease occurs with increased frequency in cirrhosis. In this study, we attempted to establish a relation between the magnitude of serum IgG antibody to H pylori and the endoscopic diagnoses in H pylori-infected cirrhotic patients.

METHODS

All cirrhotic patients who had undergone esophagogastroduodenoscopy with a positive H pylori IgG serology and who did not receive anti-H pylori treatment or take medications noxious to the gastroduodenal mucosa were included in the study. H pylori IgG serology was determined by an enzyme-linked immunosorbent assay with values of greater than 50 units/mL being seropositive. The functional reserve of cirrhosis was classified by modified Pugh-Child criteria.

RESULTS

One hundred four seropositive cirrhotic patients were recruited. The serum IgG titers ranged from 51 to 1200 units/mL with a peak frequency at 50 to 99 units/mL (35. 6%). Statistical analysis did not reveal any relation between the quantitative H pylori IgG values and the endoscopic diagnoses, which included gastric ulcers, duodenal ulcers, gastroduodenal erosions, and normal findings.

CONCLUSIONS

In cirrhosis, the magnitude of H pylori IgG serology cannot be used to predict the presence or absence of peptic ulcer disease.

Prevalence of upper and lower gastrointestinal tract findings in liver transplant candidates undergoing screening endoscopic evaluation

OBJECTIVE

The incidence of esophageal and gastric varices and portal hypertensive gastropathy (PHG) has been well studied in cirrhotic patients. Because little is known of the prevalence of other upper and lower gastrointestinal tract pathology in pre-liver transplant candidates, we retrospectively studied the prevalence of and factors associated with these findings.

METHODS

One hundred and twenty pre-liver transplant candidates underwent esophagogastroduodenoscopy to evaluate for varices, and 71 of them also underwent flexible sigmoidoscopy to screen for colorectal carcinoma. The association of upper and lower GI tract pathology with Child-Pugh Class, etiology of cirrhosis, and signs of portal hypertension, including presence and size of esophageal varices, presence of gastric varices, PHG, ascites, and splenomegaly, was analyzed using univariate and multivariate analysis.

RESULTS

Etiology of cirrhosis among 87 men and 33 women (mean age, 52 yr) included 25% hepatitis C, 27% hepatitis C/alcohol, 15% alcohol, 10% primary sclerosing cholangitis/primary biliary cirrhosis, 9% cryptogenic, 8% metabolic, and 6% hepatitis B. Prevalence of Child-Pugh Classes A, B, and C were 34%, 49%, and 17%, respectively; 73% of patients had esophageal varices (23% were large), 62% PHG (23% were severe), and 16% gastric varices. Excluding varices and PHG, endoscopic findings in the upper GI tract (n = 120) included: 13% esophagitis/ulcers, 7.5% gastritis, 8% duodenitis, 2% Barrett's esophagus, 3% duodenal ulcers, and 2% gastric ulcers. Findings in the lower gastrointestinal tract (n = 71) included 21% adenomatous polyps, 21% internal hemorrhoids, 15% diverticulosis, 7% rectal varices, 3% colopathy, and 3% vascular ectasias. Univariate analysis revealed that there was a significant association between rectal varices and severe PHG (p < 0.05). This association was not maintained when multivariate analysis was performed.

CONCLUSIONS

Among all the findings, only rectal varices and colopathy were of higher prevalence in the pre-liver transplant population than that reported for the general population. No significant associations were found between these gastrointestinal tract lesions and patient characteristics.

Epidemiology of peptic ulcer disease in cirrhotic patients: role of Helicobacter pylori infection

OBJECTIVE

The aim of this study was to investigate the clinical and epidemiological factors associated with the appearance of peptic ulcer in patients with cirrhosis and, in particular, the role of Helicobacter pylori infection.

METHODS

A total of 201 of 220 consecutive patients included in a prospective study that aimed to evaluate the effect of dietary intervention on cirrhotic complications and survival underwent upper gastrointestinal endoscopy. At entry, an epidemiological and clinical questionnaire was completed and the presence of peptic ulcer disease or esophageal varices at endoscopy was prospectively collected. Sera were obtained and stored at -70 degrees C until analyzed, being tested afterward for Helicobacter pylori antibodies using a commercial ELISA kit.

RESULTS

Eleven of 201 patients had borderline anti-Helicobacter pylori IgG titers and were excluded from further analysis. In the remaining 190 patients, point prevalence of peptic ulcer was 10.5% and lifetime prevalence 24.7%. Multivariate analysis selected male sex (OR 2.3; 95%CI 1.09-4.89) and Helicobacter pylori seropositivity (OR: 1.7, 95%CI 1.02-2.81) as the variables independently related to peptic ulcer disease.

CONCLUSIONS

Male sex and seropositivity for Helicobacter pylori are the major risk factors for peptic ulcer in cirrhosis.

Correlation between serum-ascites albumin concentration gradient and endoscopic parameters of portal hypertension

OBJECTIVE

We sought to determine the correlation between the level of serum-ascites albumin concentration gradient (SAAG) and the complications of portal hypertension (PHTN), manifested by the presence and grade of esophageal varices (EV).

METHODS

Our study included 31 patients with ascites, demonstrated by ultrasonography, who had measurement of the SAAG. All had upper gastrointestinal endoscopy with assessment of the presence and size of EV. High SAAG was considered to be present when the SAAG was > or = 1.1 g/dl and Low SAAG when it measured < 1.1 g/dl.

RESULTS

We found that 25 of 31 (80.6%) patients had High SAAG and six of 31 (19.4%) had Low SAAG. Esophageal varices were present in 17 of 25 (68%) patients with High SAAG and in none of six (0%) patients with Low SAAG (p = 0.028). In patients with alcoholic liver disease (ALD), 14 of 14 (100%) had EV. Otherwise, in patients with nonALD, only three of 11 (27.3%) had EV (p < 0.05). The presence of EV was associated with the Child-Pugh Score (p = 0.039). Among patients with High SAAG, EV were present in four of 10 (40%) with SAAG values of 1.10-1.49 g/dl; in four of 6 (66.7%) with SAAG values of 1.50-1.99 g/dl; and in nine of nine (100%) with SAAG values of > or =2.0 g/dl (p = 0.049). The size of the EV had no association with the level of SAAG in patients with High SAAG (p = 0.788), with a Pearson correlation coefficient of R = 0.54 (p = 0.005). Using the Receiver-Operating-Characteristic Curve a SAAG value of > or =1.435 +/- 0.015 g/dl was an accurate indicator of the presence of EV (cutoff point for the higher predictive value: positive = 87.5% and negative = 66.7%).

CONCLUSIONS

In patients with ascites the presence of EV is associated only with patients with High SAAG. The presence of EV in patients with ascites and High SAAG is directly related to the degree of SAAG. The size of the EV in patients with ascites and High SAAG is not associated with the degree of SAAG. A SAAG value of > or =1.435 +/- 0.015 g/dl is a useful means to predict the presence of EV in patients with ascites. Finally, in patients with ascites, EV were more prevalent in those with ALD.

Portal-hypertensive gastropathy

In the present article we describe updated information concerning the clinical feature of portal-hypertensive gastropathy (PHG), which is characterized by mucosal and submucosal vascular dilatation without inflammation. Although this lesion represents non-variceal bleeding, there is a wide variation of its prevalence. Portal pressure and some humoral factors may play important roles in its pathogenesis. Gastric acid secretory activity is reduced, whereas the gastric mucosal barrier is impaired. With regard to gastric mucosal haemodynamics, whether 'overflow' (i.e. active congestion) or 'stasis' (i.e. passive congestion) cause gastric mucosal hyperaemia is not known. A severe lesion is a potential source of bleeding, while mild lesions are of little clinical significance and endoscopic variceal obliteration aggravates PHG in some patients. In the treatment of PHG, pharmacological (e.g. propranolol), surgical (e.g. portosystemic shunt) and radiological (e.g. transjugular intrahepatic portosystemic shunt) procedures may be useful in preventing bleeding from PHG.

Gastric mucosal blood flow and hepatic perfusion index in patients with portal hypertensive gastropathy

Endoscopic laser Doppler velocimetry is a simple non-invasive method to measure gastric mucosal blood flow. The present study is an attempt to determine a correlation, if any, between gastric mucosal blood flow and the hepatic perfusion index in patients with portal hypertensive gastropathy and their relationship to the severity of liver disease. Thirty patients with portal hypertensive gastropathy due to cirrhosis of the liver (eight class A, 13 class B, nine class C, according to Child-Pugh Classification) and six normal subjects were recruited into the study. In all subjects, the gastric mucosal blood flow and venous vasomotor reflex response was measured at two sites: the lesser and greater curvature, using endoscopic laser Doppler velocimetry. The hepatic perfusion index was measured using dynamic liver scintigraphy. The hepatic perfusion index (ratio of arterial/portal venous perfusion) in normal subjects and patients with portal hypertensive gastropathy belonging to Child-Pugh class A, B and C were 0.36 +/- 0.02, 0.53 +/- 0.08, 0.62 +/- 0.14 and 1.04 +/- 0.28, respectively. The gastric mucosal blood flow was similar in Child's A, B and C cases, while the venous vasomotor reflex response was reduced according to the Child-Pugh score (Child's A 37.4 +/- 5.4%, normal control 62.3 +/- 10.9%, Child's B 38.3 +/- 18.2%, Child's C 22.5 +/- 15.2%) and was statistically significant. The gastric mucosal blood flow and hepatic perfusion index are inversely correlated. The hepatic perfusion index altered with grading of cirrhotic change. This study confirms that the severity of portal hypertensive gastropathy is correlated with Child-Pugh score.

Transjugular intrahepatic portosystemic shunt for bleeding angiodysplasia-like lesions in portal-hypertensive colopathy

Portal-hypertensive colopathy has attracted interest in recent years because such lesions can cause life-threatening hemorrhage. In contrast to upper gastrointestinal bleeding from varices, there is no established therapy for bleeding from angiodysplasia-like lesions. This case report describes the first successful use of transjugular intrahepatic portosystemic shunt (TIPS) for long-term control of bleeding from angiodysplasia-like colonic lesions in a patient with cirrhosis caused by chronic hepatitis B infection. During an 18-month course after TIPS, angiodysplasia-like lesions disappeared without any further evidence of recurrent hematochezia. TIPS may be helpful as second-line treatment in patients with recurrent portal-hypertensive bleeding from colonic angiodysplasia-like lesions who do not tolerate or are unresponsive to treatment with beta-adrenergic blockers.

Colonic disease in cirrhotic patients with portal hypertension: an endoscopic and clinical evaluation

Fifty cirrhotic patients with portal hypertension but without colonic or systemic disease underwent lower gastrointestinal endoscopy in order to investigate the effects, if any, of portal hypertension on the colon. Fifty patients without liver or systemic disease, examined by colonoscopy because of irritable bowel syndrome in the same period served as controls. Rectosigmoid varices were observed in 34% of the cirrhotic patients and 2% of the controls. Hemorrhoids were observed in 70% of the cirrhotic patients and 48% of the controls. Multiple vascular-appearing lesions were found in 16% of the cirrhotic patients and 6% of the controls. Nonspecific inflammatory changes were noted in 10% of the cirrhotic patients and 4% of the controls. Simultaneous presence, in the same patient, of rectosigmoid varices, hemorrhoids, multiple vascular-appearing lesions, and nonspecific inflammatory changes, was observed in only five (10%) of the cirrhotic patients. We found polyps in 12% of the cirrhotic patients and 14% of the controls, and a malignant tumor in 4% of the cirrhotic patients. The patients with normal colonoscopic findings were 8% of the cirrhotic patients and 36% of the controls. All patients and controls were followed up for 1 year; there was no gastrointestinal hemorrhage among controls, whereas 34% of the cirrhotic patients had an upper gastrointestinal hemorrhage (88% from esophageal varices, 12% from the stomach) and 4% had a lower gastrointestinal hemorrhage (one from rectosigmoid varices and one from nonspecific inflammatory lesions). Colonic lesions were significantly more frequent in the cirrhotic patients (92%) than in the control group (64%); however, such lesions did not seem specific to the disease and were not statistically correlated with the degree of esophageal varices by Child's grading, the etiology of cirrhosis, or the bleeding risk from the lower gastrointestinal tract.

Portal Hypertensive gastropathy

The term portal hypertensive gastropathy (PHG) defines a wide spectrum of diffuse macroscopic lesions that appear in the gastric mucosa of patients with portal hypertension. Histologically, these lesions correspond to dilated vessels in the mucosa and submucosa in the absence of erosions or inflammation. Endoscopically, the lesions are classified as mild when mosaic pattern or superficial reddening are present, and severe when gastric mucosa appear with diffuse cherry red spots. Mild lesions are highly prevalent (65-90%), whereas severe lesions are present in only 10-25% of cirrhotic patients. The pathogenesis of PHG is not well known, but both venous congestion related with raised portal pressure and increased gastric blood flow seem to be crucial factors for its development. Variceal sclerosis may contribute to the development or aggravation of the lesions. Bleeding is the unique clinical manifestation of PHG, and occurs only in those patients with severe lesions. During a 5-year follow-up, the risk of overt bleeding or chronic bleeding, which induces anaemia, is 60 % and 90%, respectively, for patients with severe PHG. Propranolol is the only pharmacological treatment that has been proven useful in preventing bleeding from PHG. Porto-systemic shunts and liver transplantation are also effective.

Endosonographic evaluation of the rectum in children with extrahepatic portal venous obstruction

Rectal endoscopic ultrasonography (REUS) was performed using an Olympus EU-M3 ultrasound fiberscope in 25 children with extrahepatic portal venous obstruction (median age of 8, range 3-16 years) and in eight control subjects (median age of 8, range 6-13). Rectal varices (tortuous or nodular distended veins seen beneath the mucosa) and portal hypertensive rectopathy were diagnosed endoscopically. At rectal endosonography, rectal varices were seen as rounded, oval, or longitudinal echo-free structures in the submucosa. Perirectal veins outside the rectal wall were also seen in REUS. Portal hypertensive rectopathy was endoscopically observed in nine (36%) patients. Rectal varices were detected by endoscopy in nine (36%) and by endosonographic examination in 19 (76%) patients with extrahepatic portal venous obstruction. The number (2, range 0-10) and size (3, range 0-4.5 mm) of submucosal veins seen on endosonography in patients were greater than in controls (0, range 0-1, and 0, range 0-2 mm; p < 0.001 for both). The size of perirectal veins was greater in patients than in controls (3.5, range 3-5 mm versus 2.5, range 2-3 mm; p < 0.001). Communicating veins between the submucosal and perirectal veins were seen in nine (36%) patients. Rectal endoscopic ultrasonography was superior to endoscopy in detecting the presence of rectal varices (76% versus 35%, p < 0.005). Our study suggests that endosonography is useful in detecting changes in the rectal and perirectal vasculature in patients with extrahepatic portal venous obstruction.

Prevalence of gastric ulcer in cirrhotic patients and its relation to portal hypertension

The prevalence of gastric ulcer and its relationship to the severity of cirrhosis and degree of portal hypertension was evaluated in 245 cirrhotic patients, and compared with 245 age- and sex-matched healthy subjects. Portal and systemic haemodynamic studies were performed in cirrhotic patients. The prevalence of gastric ulcer in cirrhotic patients was 20.8%, which was significantly higher than the 4.0% found in healthy controls. Using a multivariate logistic regression model, the hepatic venous pressure gradient was found to be the only predictor of the prevalence of gastric ulcer in cirrhotic patients to present with gastric ulcer. The hepatic venous pressure gradient was significantly higher in cirrhotic patients with gastric ulcer than in those without (17.3 +/- 4.4 vs 15.5 +/- 5.0 mmHg, P = 0.01). Other variables, including sex, smoking, cardiac output and severity or aetiology of cirrhosis did not show significant differences between the two patient groups. The prevalence of gastric ulcer in cirrhotic patients whose hepatic venous pressure gradient was below 12 mmHg (4.5%) was similar to that observed in the healthy controls (4.0%). However, when the hepatic venous pressure gradient was > 12 mmHg, the prevalence of gastric ulcer (24.4%) was significantly higher than that in control subjects. However, the incidence of gastric ulcer was not related to the degree of portal hypertension. In conclusion, the prevalence of gastric ulcer in cirrhotic patients was found to be significantly higher than in the age- and sex-matched healthy subjects. Portal hypertension with a hepatic venous pressure gradient > 12 mmHg may be an important factor contributing to the increased prevalence of gastric ulcer observed in patients with liver cirrhosis.

Frequency of peptic ulcers in patients with portal hypertension

To find the frequency of peptic ulceration in portal hypertension, 137 patients with portal hypertension were studied retrospectively. Patients with hepatocellular carcinoma, other malignancies or underlying severe systemic disease were excluded and the remaining 114 patients were included in the study. There were 81 males (mean age 49.1 +/- 13.7 years) and 33 females (mean age 52.9 +/- 10 years). Portal hypertension was secondary to viral liver disease in 75%. Fifty-seven patients had no evidence of peptic ulcers (group I) and another 57 patients (group II) had peptic ulcers diagnosed during upper gastrointestinal endoscopy. There was no significant difference between the two groups regarding age, sex, Child-Pugh score or variceal size. Duodenal ulcers were found in 24% while gastric ulcers were found in 4.4%; other endoscopic findings included erosive gastritis and duodenitis in 21% and 18.4% respectively. Twelve percent of the patients from group II developed bleeding from the ulcers and the majority of bleeding ulcers responded to conservative treatment. The study concludes that the frequency of peptic ulcers in patients with portal hypertension is high. Bleeding peptic ulcers respond to conservative treatment.

Peptic ulcer and its course in cirrhosis: an endoscopic and clinical prospective study

The epidemiological and clinical characteristics of peptic ulcer were studied in 324 of 368 consecutive patients with cirrhosis of the liver during a mean period of 1.2 (+/- 0.61) years. Peptic ulcer prevalence rates in patients with cirrhosis were as follows: point prevalence 11.7%, period prevalence 15.1%, and life-time prevalence 24.2%. The annual incidence rate observed in 140 patients with cirrhosis undergoing endoscopic follow up was 4.3%. Ulcers were asymptomatic in more than 70% of patients. The peptic ulcer complication rate at entry was 20% in the whole group and 40% in those who had not a previous diagnosis of peptic ulcer when admitted to the study. Peptic ulcer was more frequent among HBsAg+ cirrhotics (p = 0.05). Patients with more severely decompensated cirrhosis also had a higher frequency of asymptomatic ulcers (p = 0.04), gastric ulcers (p = 0.01) and asymptomatic gastric ulcers (p = 0.005). After diagnosis, during endoscopic follow up, gastric ulcer in patients with cirrhosis tended to heal slowly and recurred with higher frequency than in controls without cirrhosis (p = 0.04). Seventy-nine per cent of peptic ulcer recurrences were asymptomatic in patients with cirrhosis. There were no complications during the follow-up period: this could be due to the regular timing of endoscopy, which permitted early detection and treatment of the recurrences, thus preventing further complications.

Peptic ulcer in hepatic cirrhosis and renal failure

The prevalence of peptic ulcer in cirrhotic patients is similar to that reported for the general population. Although gastric acid outputs ar normal or lower in cirrhotic subjects compared with non-cirrhotics, the frequency of non-response to histamine H2-receptor antagonists is higher. Peptic ulcer disease in the cirrhotic seems to pursue a more virulent course compared with that in the non-cirrhotic subject. Peptic ulcer prevalences in patients dying of uraemia or in uraemic patients on maintenance dialysis treatment are comparable with those in the general population. However, the frequency of peptic ulcer, especially complicated ulcer, is increased following renal transplantation. Ulcer complications in this context are associated with a high mortality rate. Pre-transplant risk factors for subsequent development of peptic ulcer remain to be identified and the value of histamine H2-receptor antagonists in prophylaxis is as yet unproven.

Endoscopic ultrasonographic evaluation of the rectum in cirrhotic portal hypertension

Rectal endoscopic ultrasonography was performed using an ultrasound fiberscope in 20 patients with cirrhotic portal hypertension (6 alcoholic patients, 4 patients with hepatitis B surface antigen positive, and 10 cryptogenic patients) and in 10 patients with irritable bowel syndrome as controls. Rectal varices were diagnosed endoscopically when either tortuous or saccular distended veins were seen beneath the mucosa. At rectal endoscopic ultrasonography rectal varices were seen as rounded or oval echo-free structures in the submucosa. Rectal endoscopic ultrasonography also showed perirectal veins outside the rectal wall. Rectal varices were detected by endoscopy in 9 patients and by rectal endoscopic ultrasonography in 17 patients. Rectal endoscopic ultrasonography also detected submucosal veins in 3 of 10 controls. The number and size of submucosal veins seen on rectal endoscopic ultrasonography in patients with portal hypertension were greater than in controls (p < 0.01 for both number and size). The size of perirectal veins was greater in patients than in controls (p < 0.05), although their number was no different (p = NS). A perforating vein communicating between a submucosal and perirectal vein was seen in only one patient. Rectal wall thickness was not different in patients and controls (p = NS). Rectal endoscopic ultrasonography was superior to endoscopy in detecting the presence (85% versus 45%, p < 0.01), and number (p < 0.01) of rectal varices. Our study suggests that rectal endoscopic ultrasonography is useful in detecting changes in rectal and perirectal vasculature in patients with cirrhotic portal hypertension.

Reduced gastric mucosal blood flow in patients with portal-hypertensive gastropathy

Although congestive gastric mucosal circulation has been suggested in patients with portal-hypertensive gastropathy, whether it is due to "active" (overflow) or "passive" (stasis) congestion is not known. To answer this question, we assessed regional gastric mucosal blood flow with laser Doppler flowmetry in 57 patients with portal hypertension and 30 controls. Twelve patients had portal-hypertensive gastropathy of the antrum: in eight it was mild and in four it was severe. Portal-hypertensive gastropathy of the corpus was seen in 32 patients: it was mild in 24 and severe in 8. Thus prevalence of portal-hypertensive gastropathy was higher in the corpus than in the antrum (p < 0.01). In the antrum, gastric mucosal blood flow was significantly lower (p < 0.05) in patients with severe portal-hypertensive gastropathy (0.54 +/- 0.27 V) than in controls (1.12 +/- 0.44 V), whereas the values in patients without portal-hypertensive gastropathy (0.90 +/- 0.35 V) and with mild portal-hypertensive gastropathy (0.91 +/- 0.31 V) were not significantly different from the values in controls (p < 0.05 on one-way analysis of variance). In the corpus, gastric mucosal blood flow was significantly lower in patients with mild (0.75 +/- 0.25 V) or severe portal-hypertensive gastropathy (0.42 +/- 0.22 V) than in controls (1.16 +/- 0.37 V) (p < 0.01 and p < 0.01, respectively) whereas the value in patients without portal-hypertensive gastropathy (0.99 +/- 0.37 V) was not significantly different from values in controls (p < 0.01 on one-way analysis of variance).(ABSTRACT TRUNCATED AT 250 WORDS)

Peptic ulcer surgery in patients with liver cirrhosis

OBJECTIVE

This study identified risk factors of surgical treatment for gastroduodenal ulcer disease in patients with liver cirrhosis.

SUMMARY BACKGROUND DATA

Liver cirrhosis is frequently associated with complicated peptic ulcer disease. Surgery in liver cirrhotics has a high mortality and morbidity especially when abdominal operations are performed.

METHODS

Sixty-nine patients undergoing surgery for gastroduodenal ulcer disease between 1972 and 1991 were studied, retrospectively.

RESULTS

Ninety percent of patients required emergency surgery for bleeding ulcer (n = 45) or perforation (n = 17). Mortality was 29% for elective patients (n = 7), 35% for patients with perforation and 64% for patients with bleeding. Overall mortality of 69 patients was 54%. Only 15 of 69 patients (22%) had an uncomplicated postoperative course. Postoperative bleeding, septic complications, and renal failure were the most frequent postoperative complications. Bleeding and multiple organ failure were the leading causes of death in 70% of patients. A univariate analysis determined preoperative hemoglobin < 12 g/L (p < 0.05), systolic blood pressure < 100 mm Hg (p < 0.025), prothrombin time < 60% (p < 0.05) and the presence of portal hypertension (p < 0.01) as prognostic factors. No significant correlation with survival could be established for excretory liver function (serum bilirubin) and partial thromboplastin time.

CONCLUSIONS

To improve treatment results it is recommended (1) to substitute blood products (particularly coagulation factors) early and in sufficient quantities, (2) to diligently search for and to treat septic foci and administer antibiotics in a nonrestrictive manner, and (3) to restrict the operative procedure to the treatment required for control of the ulcer complication.

Portal colopathy: prospective study of colonoscopy in patients with portal hypertension

Twenty patients with portal hypertension related to a variety of causes prospectively underwent colonoscopy for hematochezia (n = 10), hemoccult positive stool and anemia (n = 9), or polyp found with screening flexible sigmoidoscopy (n = 2) (includes 1 patient with anemia/heme-positive stool). Twelve patients (60%) had previously undergone a course of sclerotherapy, and 10 (50%) had endoscopic evidence of congestive gastropathy. Colonoscopic findings included mucosal abnormalities resembling multiple vascular ectasias in 14 (70%), 4 of whom also had endoscopic features suggesting a mild, chronic colitis. Neither signs of chronic liver disease nor stigmata suggestive of more severe portal hypertension correlated with the colonoscopic findings. Two patients required heater probe therapy for actively oozing lesions resembling vascular ectasias and an additional two patients sclerotherapy for bleeding midrectal varices. Although likely an overestimate of the frequency, this study suggests that portal colopathy can occur in portal hypertension. Vascular ectasialike lesions in such settings may be associated with acute as well as chronic gastrointestinal bleeding and may require pharmacological, directed endoscopic, or portal decompressive therapy. Additional studies are required to determine not only the pathophysiology but also the true frequency of this entity.