Role of immunosuppression in the development of quinolone-resistant Escherichia coli spontaneous bacterial peritonitis and in the mortality of E. coli spontaneous bacterial peritonitis

Primary Peritonitis Secondary to Streptococcus pyogenes in a Young Female Adult-A Case Report and Literature Review

Primary spontaneous bacterial peritonitis (SBP) is a rare cause of acute abdomen in previously healthy patients, even more unusually caused by a group A Streptococcus (GAS) (also known as Streptococcus pyogenes) infection. We report a young, otherwise healthy female who presented with generalized abdominal pain that was initially managed conservatively as gastroenteritis, with a computed tomography (CT) scan showing a ruptured corpus luteal cyst. Upon subsequent readmission with worsened pain and symptoms, a repeat CT scan showed worsened free fluid with signs of peritonitis. A diagnostic laparoscopy confirmed primary peritonitis with an unknown infection source and causative pathology, as the appendix, ovaries and bowels were healthy-looking. Fluid cultures returned positive for GAS Pyogenes, while blood and urine cultures were negative. The discussion reviews the challenges in diagnosis and treatment of GAS primary peritonitis, highlighting the need for clinical suspicion, early diagnosis via laparoscopy or laparotomy and prompt antibiotic therapy as the current standard for treatment.

Evaluation of the health and healthcare system burden due to antimicrobial-resistant Escherichia coli infections in humans: a systematic review and meta-analysis

BACKGROUND

Assessment of the burden of disease due to antimicrobial-resistant Escherichia coli infections facilitates understanding the scale of the problem and potential impacts, and comparison to other diseases, which allows prioritization of research, surveillance, and funding. Using systematic review and meta-analysis methodology, the objectives were to evaluate whether humans with antimicrobial-resistant E. coli infections experience increases in measures of health or healthcare system burden when compared to susceptible E. coli infections.

METHODS

Comprehensive literature searches were performed in four primary and seven grey literature databases. Analytic observational studies of human E. coli infections that assessed the impact of resistance to third/fourth/fifth-generation cephalosporins, resistance to quinolones, and/or multidrug resistance on mortality, treatment failure, length of hospital stay and/or healthcare costs were included. Two researchers independently performed screening, data extraction, and risk of bias assessment. When possible, random effect meta-analyses followed by assessment of the confidence in the cumulative evidence were performed for mortality and length of hospital stay outcomes, and narrative syntheses were performed for treatment failure and healthcare costs.

RESULTS

Literature searches identified 14,759 de-duplicated records and 76 articles were included. Based on 30-day and all-cause mortality meta-analyses, regardless of the type of resistance, there was a significant increase in the odds of dying with resistant E. coli infections compared to susceptible infections. A summary mean difference was not presented for total length of hospital stay meta-analyses due to substantial to considerable heterogeneity. Since small numbers of studies contributed to meta-analyses for bacterium-attributable mortality and post-infection length of hospital stay, the summary results should be considered with caution. Studies contributing results for treatment failure and healthcare costs had considerable variability in definitions and reporting.

CONCLUSIONS

Overall, resistant E. coli infections were associated with significant 30-day and all-cause mortality burden. More research and/or improved reporting are necessary to facilitate quantitative syntheses of bacterium-attributable mortality, length of hospital stay, and hospital costs. Protocol Registration PROSPERO CRD42018111197.

Current Status and Prospects of Spontaneous Peritonitis in Patients with Cirrhosis

Spontaneous bacterial peritonitis (SBP) is a common cirrhotic ascites complication which exacerbates the patient's condition. SBP is caused by gram-negative bacilli and, to a lesser extent, gram-positive cocci. Hospital-acquired infections show higher levels of drug-resistant bacteria. Geographical location influences pathogenic bacteria distribution; therefore, different hospitals in the same country record different bacteria strains. Intestinal changes and a weak immune system in patients with liver cirrhosis lead to bacterial translocation thus causing SBP. Early diagnosis and timely treatment are important in SBP management. When the treatment effect is not effective, other rare pathogens should be explored.

Prevalence and predictors for spontaneous bacterial peritonitis in cirrhotic patients with ascites admitted at medical block in Korle-Bu Teaching Hospital, Ghana

Introduction

Spontaneous bacterial peritonitis (SBP) is one of the most common and life-threatening complications of patients with cirrhotic ascites. Recognition and prompt treatment of this condition is essential to prevent serious morbidity and mortality. This study aimed to determine the prevalence of SBP among in-patients with cirrhotic ascites attending our facility and to determine the clinical and laboratory parameters associated with SBP.

Methods

A cross-sectional study was conducted involving one hundred and three (103) patients admitted at medical block in the Korle-Bu Teaching Hospital (KBTH) with cirrhotic ascites from 25^th March, 2016 to 25^th November, 2016. Demographic and clinical data were collected using a standardized questionnaire. Ascitic fluid culture and cell count were conducted. Positive ascitic fluid culture and/or ascitic polymorphonuclear leukocyte ≥ 250cells/mm³ were diagnostic for SBP.

Results

Of the 103 patients with cirrhotic ascites, the mean age was 43.5 ± 12.2 years. There were fifty eight (58) male patients. The prevalence of SBP was 25.24% (26/103). Majority, 5 (55.6%) of the bacteria isolated from ascitic fluid with SBP was Escherichia coli. Severe ascites and high INR were found to be independent predictors of SBP.

Conclusion

SBP is common among patients with cirrhotic ascites admitted at KBTH. Severe ascites and high INR were highly suggestive of SBP. Diagnostic paracentesis should be done immediately on admission to confirm the diagnosis irrespective of the clinical characteristics as part of baseline investigation.

Follow-up Creatinine Level Is an Important Predictive Factor of In-hospital Mortality in Cirrhotic Patients with Spontaneous Bacterial Peritonitis

BACKGROUND

Spontaneous bacterial peritonitis (SBP) is one of the severe complications of liver cirrhosis. Early detection of high-risk patients is essential for prognostic improvement. The aim of this study is to investigate the predictive factors related to in-hospital mortality in patients with SBP.

METHODS

This was a retrospective study of 233 SBP patients (181 males, 52 females) who were admitted to four tertiary referral hospitals between August 2002 and February 2013. The patients' laboratory and radiologic data were obtained from medical records. The Child-Turcotte-Pugh (CTP) score and model for end-stage liver disease sodium model (MELD-Na) scores were calculated using the laboratory data recorded at the time of the SBP episode.

RESULTS

The causes of liver cirrhosis were hepatitis B (44.6%), alcohol (43.8%), hepatitis C (6.0%), and cryptogenic cirrhosis (5.6%). The mean MELD-Na and CTP scores were 27.1 and 10.7, respectively. Thirty-one of the patients (13.3%) died from SBP in hospital. Multivariate analysis revealed that maximum creatinine level during treatment was a statistically significant factor for in-hospital mortality (P = 0.005). The prognostic accuracy of the maximum creatinine level during treatment was 78.0% (P < 0.001). The optimal cutoff point for the maximum serum creatinine was 2 mg/dL (P < 0.001).

CONCLUSION

The follow-up creatinine level during treatment is an important predictive factor of in-hospital mortality in cirrhotic patients with SBP. Patients with SBP and a serum creatinine level during treatment of ≥ 2.0 mg/dL might have a high risk of in-hospital mortality.

Bacterial infections and hepatic encephalopathy in liver cirrhosis-prophylaxis and treatment

Infections are common among patients with liver cirrhosis. They occur more often in cirrhotic patient groups than in the general population and result in higher mortality. One reason for this phenomenon is bacterial translocation from the intestinal lumen that occurs as a consequence of intestinal bacterial overgrowth, increased permeability and decreased motility. The most common infections in cirrhotic patients are spontaneous bacterial peritonitis and urinary tract infections, followed by pneumonia, skin and soft tissue infections. Intestinal bacterial overgrowth is also responsible for hyperammonemia, which leads to hepatic encephalopathy. All of these complications make this group of patients at high risk for mortality. The role of antibiotics in liver cirrhosis is to treat and in some cases to prevent the development of infectious complications. Based on our current knowledge, antibiotic prophylaxis should be administered to patients with gastrointestinal hemorrhage, low ascitic fluid protein concentration combined with liver or renal failure, and spontaneous bacterial peritonitis as a secondary prophylaxis, as well as after hepatic encephalopathy episodes (also as a secondary prophylaxis). In some cases, the use of non-antibiotic prophylaxis can also be considered. Current knowledge of the treatment of infections allows the choice of a preferred antibiotic for empiric therapy depending on the infection location and whether the source of the disease is nosocomial or community-acquired.

Increasing frequency of gram-positive cocci and gram-negative multidrug-resistant bacteria in spontaneous bacterial peritonitis

BACKGROUND

Spontaneous bacterial peritonitis (SBP) is historically caused by Gram-negative bacteria (GNB) almost exclusively Enterobacteriaceae. Recently, an increasing rate of infections with Gram-positive cocci (GPC) and multidrug-resistant (MDR) microorganisms was demonstrated.

AIMS

To assess possible recent changes of the bacteria causing SBP in cirrhotic patients.

METHODS

We retrospectively recorded 47 cases (66% males) during a 4-year-period (2008-2011).

RESULTS

Twenty-eight (60%) patients had healthcare-associated infections while 15 (32%) received prophylactic quinolone treatment. GPC were found to be the most frequent cause (55%). The most prevalent organisms in a descending order were Streptococcus spp (n = 10), Enterococcus spp (n = 9), Escherichia coli (n = 8), Klebsiella pneumonia (n = 5), methicillin-sensitive Staphylococcus aureus (n = 4) and coagulase-negative Staphylococcus spp (n = 3). Nine of the isolated bacteria (19%) were MDR, including carbapenemase-producing K. pneumonia (n = 4), followed by extended-spectrum beta-lactamase-producing E. coli (n = 3) and Pseudomonas aeruginosa (n = 2). MDR bacteria were more frequently isolated in healthcare-associated than in community-acquired infections (100% vs 50%, P = 0.006), in patients receiving long-term quinolone prophylaxis (67% vs 24%, P = 0.013) and in those with advanced liver disease as suggested by higher MELD score (28 vs 19, P = 0.012). More infections with GNB than GPC were healthcare-associated (81% vs 42%, P = 0.007). Third-generation cephalosporin resistance was observed in 49% and quinolone resistance in 47%.

CONCLUSIONS

GPC were the most frequent bacteria in culture-positive SBP and a variety of drug-resistant microorganisms have emerged. As a result of high rates of resistance in currently recommended therapy and prophylaxis, the choice of optimal antibiotic therapy is vital in the individual patient.

Diagnosis and management of bacterial infections in decompensated cirrhosis

Bacterial infections are one of the most frequent complications in cirrhosis and result in high mortality rates. Patients with cirrhosis have altered and impaired immunity, which favours bacterial translocation. Episodes of infections are more frequent in patients with decompensated cirrhosis than those with compensated liver disease. The most common and life-threatening infection in cirrhosis is spontaneous bacterial peritonitis followed by urinary tract infections, pneumonia, endocarditis and skin and soft-tissue infections. Patients with decompensated cirrhosis have increased risk of developing sepsis, multiple organ failure and death. Risk factors associated with the development of infections are severe liver failure, variceal bleeding, low ascitic protein level and prior episodes of spontaneous bacterial peritonitis (SBP). The prognosis of these patients is closely related to a prompt and accurate diagnosis. An appropriate treatment decreases the mortality rates. Preventive strategies are the mainstay of the management of these patients. Empirical antibiotics should be started immediately following the diagnosis of SBP and the first-line antibiotic treatment is third-generation cephalosporins. However, the efficacy of currently recommended empirical antibiotic therapy is very low in nosocomial infections including SBP, compared to community-acquired episodes. This may be associated with the emergence of infections caused by Enterococcus faecium and extended-spectrum β-lactamase-producing Enterobacteriaceae, which are resistant to the first line antimicrobial agents used for treatment. The emergence of resistant bacteria, underlines the need to restrict the use of prophylactic antibiotics to patients with the greatest risk of infections. Nosocomial infections should be treated with wide spectrum antibiotics. Further studies of early diagnosis, prevention and treatment are needed to improve the outcomes in patients with decompensated cirrhosis.

Management of bacterial infections in cirrhosis

Bacterial infections are very frequent in advanced cirrhosis and become the first cause of death of these patients. Despite numerous experimental data and significant advances in the understanding of the pathogenesis of sepsis in cirrhosis, the outcome remains poor. Classical diagnostic parameters such as C-reactive protein and SIRS criteria have less diagnostic capacity in the cirrhotic population, often delaying the diagnosis and the management of bacterial infection. Prompt and appropriate empirical antibiotic treatment of infection and early resuscitation of patients with severe sepsis or septic shock are essential in determining patient's outcome. A strategy of careful restriction of prophylactic antibiotics to the high-risk populations could reduce the spread of multidrug resistant bacteria. This review is focused on the currently recommended diagnostic, therapeutic and prophylactic strategies for bacterial infections in the cirrhotic population.

Predictive Value of the Model of End-Stage Liver Disease in Cirrhotic Patients with and without Spontaneous Bacterial Peritonitis

Objective. We aimed to assess the predictive value of the model of end-stage liver disease (MELD) in hospitalized cirrhotic patients with and without spontaneous bacterial peritonitis (SBP) and fatal outcome. Methods. A cross-sectional study included 256 consecutive patients (199 men and 57 women) diagnosed with cirrhosis and ascites who were hospitalized at the University Hospital Center in Tirana from January 2008 to December 2009. SBP was defined as a neutrophil count of ≥250 cells/mm³ in ascitic fluid. MELD score was based on laboratory parameters determined by UNOS Internet site MELD calculator. Results. In multivariable-adjusted logistic regression models controlling for age, sex, diabetes, and etiology, there was evidence of a positive association of SBP with MELD score: the odds ratio (OR) for SBP for one unit increment of MELD score was 1.06 (95% Cl = 1.02–1.09). MELD score was significantly higher in fatal cases than nonfatal patients (mean age-adjusted score was 32.7 versus 18.4 overall; 34.8 versus 18.0 in SBP patients, and 32.0 versus 18.5 in non-SBP patients; all P < 0.001). Conclusions. In this Albanian sample of hospitalized cirrhotic patients, MELD score was confirmed as a significant predictor of both SBP and fatal outcome.

Renal dysfunction is the most important independent predictor of mortality in cirrhotic patients with spontaneous bacterial peritonitis

BACKGROUND & AIMS

Spontaneous bacterial peritonitis (SBP) is the most common infection among patients with cirrhosis. To improve stratification of patient care, we performed a systematic review to identify the most robust predictors of mortality in cirrhotic patients with SBP.

METHODS

We reviewed prognostic studies (English language only) of adult patients with SBP, defined as a polymorphonuclear ascitic fluid cell count of 250 cells/mm(3) or more, with or without positive results from culture of ascitic fluid. We reviewed only studies that performed survival and multivariate analyses and reported in-hospital or mortalities within 30 days.

RESULTS

Of 2008 available references, 18 were included in the study (median, 115 patients per trial). The median age of patients was 56 years (68% male). The most common predictors of death were renal dysfunction, lack of SBP resolution, immunosuppressive factors, and hospital-acquired SBP. Sensitivity analysis using the 12 best-quality studies identified renal dysfunction and levels of blood urea nitrogen and creatinine as the most important variables. The mortality rate among patients with renal dysfunction was 67%, compared with only 11% of patients who maintained normal renal function.

CONCLUSIONS

Renal dysfunction is the main prognostic factor for cirrhotic patients with SBP, followed by the MELD score. Further studies are needed to determine whether these factors identified retain prognostic value in high-risk patients who receive albumin. Risk stratification might be used to select additional treatments, such as early vasoconstrictor therapy, for the highest-risk group.

Infections in patients with cirrhosis increase mortality four-fold and should be used in determining prognosis

BACKGROUND & AIMS

A staged prognostic model of cirrhosis based on varices, ascites, and bleeding has been proposed. We analyzed data on infections in patients with cirrhosis to determine whether it is also a prognostic factor.

METHODS

Studies were identified by MEDLINE, EMBASE, COCHRANE, and ISI Web of Science searches (1978-2009); search terms included sepsis, infection, mortality, and cirrhosis. Studies (n = 178) reporting more than 10 patients and mortality data were evaluated (225 cohorts, 11,987 patients). Mortality after 1, 3, and 12 months was compared with severity, site, microbial cause of infection, etiology of cirrhosis, and publication year. Pooled odds ratio of death was compared for infected versus noninfected groups (18 cohorts, 2317 patients).

RESULTS

Overall median mortality of infected patients was 38%: 30.3% at 1 month and 63% at 12 months. Pooled odds ratio for death of infected versus noninfected patients was 3.75 (95% confidence interval, 2.12-4.23). In 101 studies that reported spontaneous bacterial peritonitis (7062 patients), the median mortality was 43.7%: 31.5% at 1 month and 66.2% at 12 months. In 30 studies that reported bacteremia (1437 patients), the median mortality rate was 42.2%. Mortality before 2000 was 47.7% and after 2000 was 32.3% (P = .023); mortality was reduced only at 30 days after spontaneous bacterial peritonitis (49% vs 31.5%; P = .005).

CONCLUSIONS

In patients with cirrhosis, infections increase mortality 4-fold; 30% of patients die within 1 month after infection and another 30% die by 1 year. Prospective studies with prolonged follow-up evaluation and to evaluate preventative strategies are needed.

Spontaneous bacterial peritonitis: a severe complication of liver cirrhosis

This report presents a survey of current knowledge concerning one of the relatively frequent and severe complications of liver cirrhosis and associated ascites-spontaneous bacterial peritonitis. Epidemiology, aetiology, pathogenesis, clinical manifestation, diagnosis and present possibilities of treatment are discussed.

Spontaneous bacterial peritonitis: A severe complication of liver cirrhosis

This report presents a survey of current knowledge concerning one of the relatively frequent and severe complications of liver cirrhosis and associated ascites-spontaneous bacterial peritonitis. Epidemiology, aetiology, pathogenesis, clinical manifestation, diagnosis and present possibilities of treatment are discussed.

Genetic background of Escherichia coli isolates from patients with spontaneous bacterial peritonitis: relationship with host factors and prognosis

Spontaneous bacterial peritonitis (SBP) is a severe complication in patients with cirrhosis and ascites. It is predominantly caused by Escherichia coli. The phylogenetic group and virulence genotype of E. coli isolates causing SBP were investigated, and the association of these characteristics with host factors and prognosis was examined. Seventy-six episodes of E. coli SBP that occurred over a 9-year period were studied. The phylogenetic group of the isolates and the presence of 36 virulence factor genes were investigated. The influence of bacterial and host factors on in-hospital mortality was assessed by multiple logistic regression. Phylogenetic groups A, B1, B2 and D were found in 26%, 4%, 46% and 24% of the isolates, respectively. Virulence factor genes were more frequent in B2 isolates than in non-B2 isolates (mean virulence score 15.4 vs. 7.3, p <10(-4)). Ciprofloxacin resistance was significantly associated with non-B2 groups and a low virulence score. Host factors independently associated with a shift from B2 to non-B2 isolates were norfloxacin prophylaxis (OR 13.01, p 0.0213) and prothrombin ratio (OR 1.04 for a 10% decrease, p 0.0211). The model for end-stage liver disease (MELD) score (OR 1.83, p 0.0007) and hospital-acquired SBP (OR 4.13, p 0.0247) were independent predictors of in-hospital mortality. In contrast, outcome was not influenced by the phylogenetic group or the virulence profile. These findings indicate that the characteristics of E. coli isolates causing SBP vary with the severity of liver disease and with fluoroquinolone prophylaxis. Host factors are more important than bacterial factors in predicting in-hospital mortality.

Role of host and bacterial virulence factors in Escherichia coli spontaneous bacterial peritonitis

OBJECTIVES

Host factors and bacterial virulence determinants may play a role in Escherichia coli (E. coli) spontaneous bacterial peritonitis. We evaluated the importance of these factors in the emergence of fluoroquinolone-resistant strains and outcome in cirrhotic patients with E. coli spontaneous bacterial peritonitis.

METHODS

E. coli spontaneous bacterial peritonitis was detected in a 2-year period in three tertiary hospitals. Clinical and bacteriological data were obtained. Phylogenetic group and 15 virulence genes of E. coli strains were analyzed by polymerase gene reaction and compared with 50 isolates from pyelonephritis patients.

RESULTS

Forty-seven E. coli spontaneous bacterial peritonitis patients were identified, 18 (38%) were fluoroquinolone-resistant, a 12% increase compared with our earlier series from 1997 to 2002. Fluoroquinolone resistance was associated with norfloxacin prophylaxis, increased resistance to trimethoprim-sulfamethoxazole and cefotaxime, and less bacterial virulence, as demonstrated by a higher prevalence of 'nonpathogenic' phylogenetic groups A+B1 (56 vs. 28%; P=0.04) and lower virulence scores in fluoroquinolone-resistant E. coli compared with fluoroquinolone-susceptible E. coli. E. coli strains from cirrhotic patients belonged more frequently to 'nonpathogenic' phylogenetic groups A+B1, had fewer virulence factors and higher rates of fluoroquinolone resistance than isolates from pyelonephytis patients. Immunosuppression was independently associated with in-hospital and 3-month mortality. Bacterial virulence factors were unrelated to mortality.

CONCLUSION

Fluoroquinolone-resistant E. coli spontaneous bacterial peritonitis prevalence is increasing because of norfloxacin prophylaxis. Strains from peritonitis are less virulent than strains from pyelonephritis because of a higher prevalence of A+B1 phylogeny and quinolone resistance. Mortality is related to immunosuppression, but not to bacterial virulence factors.

Relationship between immunosuppression and intensive care unit-acquired multidrug-resistant bacteria: a case-control study

OBJECTIVE

To determine the relationship between immunosuppression and intensive care unit (ICU)-acquired multidrug-resistant (MDR) bacteria.

DESIGN

Retrospective case-control study based on prospectively collected data.

SETTING

A 30-bed medical and surgical ICU.

PATIENTS

All patients hospitalized >48 hrs in the ICU were eligible during a 2-yr period.

INTERVENTIONS

Immunosuppression was defined as active solid or hematologic malignancy, leucopenia, or chronic immunosuppressive treatment. MDR bacteria were defined as methicillin-resistant Staphylococcus aureus, ceftazidime- or imipenem-resistant Pseudomonas aeruginosa, Acinetobacter baumannii, Stenotrophomonas maltophilia, and extending spectrum beta-lactamase producing Gram-negative bacilli. MDR bacteria screening (nasal, anal, and axilla swabs and tracheal aspirate in intubated patients) was performed at ICU admission and weekly. Only MDR bacteria isolated >48 hrs after ICU admission were taken into account; duplicates were excluded. Isolation measures were applied in all patients at ICU admission, in patients with MDR bacteria, and in patients with immunosuppression. Immunosuppressed patients (cases) were matched (1:1) with immunocompetent patients (controls) according to all the following criteria: age +/-5 yrs, Simplified Acute Physiology Score II +/-5, duration of ICU stay +/-3 days, and category of admission (medical/surgical). Risk factors for ICU-acquired MDR bacteria were determined using univariate and multivariate analyses.

MEASUREMENTS AND MAIN RESULTS

Of 1,065 eligible patients, nine patients were excluded for absence of MDR bacteria screening at ICU admission. One hundred thirty-three (12%) patients were immunosuppressed, and 128 (96%) of them were successfully matched. Mean time between ICU admission and first ICU-acquired MDR bacteria was 12 +/- 9 days. Incidence of MDR bacteria was significantly higher in cases than in controls (22 vs. 12 MDR bacteria/1000 ICU days, p = .004). However, immunosuppression was not independently associated with ICU-acquired MDR bacteria.Multivariate analysis identified prior antibiotic treatment and antibiotic treatment in the ICU as risk factors for ICU-acquired MDR bacteria (odds ratio [95% confidence interval] = 1.9 [1-3.6], p = .003; 11 [1.4-83], p = .02; respectively).

CONCLUSIONS

Immunosuppression is not independently associated with ICU-acquired MDR bacteria. However, infection control measures used in our ICU may have influenced this result.

Gut flora and bacterial translocation in chronic liver disease

Increasing evidence suggests that derangement of gut flora is of substantial clinical relevance to patients with cirrhosis. Intestinal bacterial overgrowth and increased bacterial translocation of gut flora from the intestinal lumen, in particular, predispose to an increased potential for bacterial infection in this group. Recent studies suggest that, in addition to their role in the pathogenesis of overt infective episodes and the clinical consequences of sepsis, gut flora contributes to the pro-inflammatory state of cirrhosis even in the absence of overt infection. Furthermore, manipulation of gut flora to augment the intestinal content of lactic acid-type bacteria at the expense of other gut flora species with more pathogenic potential may favourably influence liver function in cirrhotic patients. Here we review current concepts of the various inter-relationships between gut flora, bacterial translocation, bacterial infection, pro-inflammatory cytokine production and liver function in this group.

Portal hypertension

PURPOSE OF REVIEW

This review discusses the advances in the pathophysiology, diagnosis, and management of the complications of portal hypertension that have occurred in the past year.

RECENT FINDINGS

The specific topics reviewed are the pathophysiology of portal hypertension (including recent findings regarding intrahepatic vascular resistance and splanchnic vasodilatation) and experimental methods used to act on the mechanisms that lead to portal hypertension, as well as recent advances in the diagnosis and management of the complications of portal hypertension.

SUMMARY

The specific complications discussed in this review are varices and variceal bleeding (primary prophylaxis, treatment of the acute episode, and secondary prophylaxis), portal hypertensive gastropathy, ascites, hepatorenal syndrome, spontaneous bacterial peritonitis, the cardiopulmonary complications of portal hypertension (hepatopulmonary syndrome, portopulmonary hypertension, cardiac dysfunction), and hepatic encephalopathy.