Management of portal hypertension

Hepatorenal Syndrome: Diagnosis and Treatment - newsreel

Hepatorenal syndrome (HRS) is defined as renal failure that occurs in the presence of severe acute or chronic liver disease in the absence of underlying renal pathology. Due to the functional nature of the disease and the absence of specific diagnostic markers, HRS diagnosis is determined based on positive criteria associated with excluding other causes of renal failure in patients with liver cirrhosis and ascites. Differentiation from other types of acute or chronic renal disease is extremely difficult and therapeutic options are limited, prophylactic behavior is most appropriate in patients with severe hepatic disease and risk factors for the installation of hepatorenal syndrome. Highlighting all precipitating factors of acute renal insufficiency and therapeutic modalities in order to minimize adverse events is an important step in improving the follow-up of the patients with liver cirrhosis. The prognosis is reserved especially for type 1 HRS. Liver transplantation is the best option for patients without contraindications. The therapies introduced in recent years, such as vasoconstrictor drugs or transjugular intrahepatic portosystemic shunt are effective methods in the renal function improvement.

Critical care management of patients before liver transplantation

The critical care management of patients before liver transplantation is aimed at optimizing hepatic and extrahepatic organ function before the transplant operation, with a goal to favorably influence perioperative and postoperative graft and patient outcomes. Critical illness in liver disease can present in the context of acute liver failure or acute on chronic liver failure. The differing pathophysiologic processes underlying these 2 types of liver failure necessitate specific approaches to their intensive care management. In their extreme presentations, both types of liver failure present as multiorgan system failure; and therefore, the critical care management of these entities requires a systematic multiorgan system approach to address hepatic and extrahepatic organ dysfunction. This review provides a multiorgan system-based description of critical care management of acute liver failure and acute on chronic liver failure before liver transplantation.

The evaluation of liver dysfunction: when to suspect portal hypertension

Portal hypertension, as a result of cirrhosis or other cause of liver dysfunction, is a life-threatening disease process. The risk of bleeding varices is high. Treatment options have much better outcomes when administered early on. The role of the PA in treating portal hypertension centers on recognizing the complications and understanding the medical management of those problems. Familiarity with the available treatment options can facilitate initiation of the most appropriate therapy for each patient. The best plan of action is to stabilize the patient and refer him or her to a tertiary center with clinicians who have experience in managing this uncommon problem.

Management of Cirrhosis and Associated Complications

Liver cirrhosis is the encapsulation or replacement of injured tissue by collagen, resulting in end-stage liver disease and portal hypertension. The consequences of cirrhosis are impaired hepatocyte function, increase intrahepatic circulatory resistance, portal hypertension, and the development of hepatocellular carcinoma. Complications include encephalopathy, coagulopathy, varices, ascites, spontaneous bacterial peritonitis, epatorenal syndrome, and hepatopulmonary syndrome. Managing patients with acute or chronic liver failure is challenging, and liver failure may have profound effects on other organ systems. Most therapies are directed at managing the complications and bridging patients to liver transplantation. The clinician must be aware of the pathologic presentations and the appropriate management, including pharmacologic and nonpharmacologic therapies, goals and end points of therapy, and monitoring of therapy. This review focuses on the management of the complications directly associated with liver dysfunction (encephalopathy and coagulopathy) and portal hypertension (varices, ascites, spontaneous bacterial peritonitis, hepatorenal syndrome, hepatopulmonary syndrome).

Usefulness of the immunological rapid urease test for detection of Helicobacter pylori in patients who are reluctant to undergo endoscopic biopsies

Cardiovascular diseases and liver cirrhosis are in the list of Helicobacter pylori-related extragastric diseases. Patients with cirrhosis and cardiovascular diseases under the control of aspirin have increased risk of gastrointestinal bleeding. The immunological rapid urease test (IRUT) provides a rapid and safe diagnostic test for H. pylori using gastric mucus collected at endoscopy. We investigated its usefulness in 93 patients with these extragastric diseases including 46 with H. pylori infection assessed by urea breath test and serology. Twenty H. pylori-infected patients received eradication therapy and the IRUT was assessed to evaluate the efficacy of bacterial eradication. The sensitivity, specificity, and positive and negative predictive values for IRUT were 96%, 90%, 90%, and 96%, respectively. The results of IRUT completely agreed with those of urea breath test following anti-H. pylori therapy. The IRUT has acceptable diagnostic performance in such cohorts reluctant to undergo endoscopic biopsies due to the risk of bleeding.

Portal hypertensive enteropathy

The available data on the use of VCE in patients who have cirrhosis and portal hypertension are inadequate to reach a firm conclusion about the usefulness of this diagnostic tool in this patient population. In fact, only retrospective case series exist, in which the characteristics of the patients are heterogeneous in terms of severity of liver disease and of portal hypertension, etiology of cirrhosis, and indication for VCE. In addition, the controls included in the studies are heterogeneous or poorly described. In spite of this, it appears that in patients with portal hypertension, the small bowel frequently shows mucosal abnormalities. Such abnormalities appear to be particularly frequent in patients who have severe portal hypertension and in those with low hemoglobin levels. The clinical significance of these findings remains undefined, however, especially in view of the fact that small bowel lesions also have been found in about 10% of patients with arthritis not taking nonsteroidal anti-inflammatory drugs and in 13.8% of healthy subjects [41,42]. Therefore,large prospective studies are needed to evaluate the prevalence and clinical significance of small bowel mucosal changes in patients who have cirrhosis. Such studies should compare patients who have cirrhosis with healthy subjects. A comparison between cirrhotic patients with a history of intestinal bleeding and bleeding patients without cirrhosis also would be interesting.

Interventional procedures involving portal vein circulation: a review

Rapid development of diagnostic radiological methods during recent decades has been followed by development of new interventional procedures involving portal circulation. The majority of these interventions were developed for treatment of patients with symptoms secondary to portal hypertension (PH). Interventions involving portal vein circulation have an established position in the treatment of PH and other diseases, and further development of these methods can be expected.

Treatment of alcoholic liver disease

Alcoholic liver disease (ALD) remains a major cause of morbidity and mortality worldwide. For example, the Veterans Administration Cooperative Studies reported that patients with cirrhosis and superimposed alcoholic hepatitis had a 4-year mortality of >60% (worse than many common cancers such as breast and prostate). The cornerstone for therapy for ALD is lifestyle modification, including drinking cessation and treatment of decompensation, if appropriate. Nutrition intervention has been shown to play a positive role on both an in-patient and out-patient basis. Corticosteroids are effective in selected patients with alcoholic hepatitis, and treatment with pentoxifylline appears to be a promising anti-inflammatory therapy. Recent studies have indicated anti-TNFalpha therapy, at least for alcoholic hepatitis. Some complementary and alternative medicinal agents, such as milk thistle and S-adenosylmethionine, may be effective in alcoholic cirrhosis. Treatment of the complications of ALD can improve the quality of life and, in some cases, decrease short-term mortality.