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Query: UMLS:C0023890 (cirrhosis)
 42,195 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Cirrhosis can be the end stage of any chronic liver disease. At the time of diagnosis of cirrhosis varices are present in about 60% of decompensated and 30% of compensated patients. The risk factors for the first episode of variceal bleeding in cirrhotic patients are the severity of liver dysfunction, large size of varices and the presence of endoscopic red colour signs but only one-third of patients who have variceal haemorrhage have the above risk factors. Recent interest has been directed at identifying haemodynamic factors that may reflect the pathophysiological changes which lead to variceal bleeding, e.g. it has been confirmed that no bleeding occurs if HVPG falls below 12 mmHg and also a hypothesis has been put forward in which bacterial infection is considered a trigger for bleeding. Pharmacological treatment with beta-blockers is safe, effective and is the standard long-term treatment for the prevention of recurrence of variceal bleeding. Combination of beta-blockers with isosorbide-5-mononitrate needs further testing in randomized controlled trials. The use of haemodynamic targets for reduction in HVPG response needs further study, and surrogate markers of pressure response need evaluation. If endoscopic treatment is chosen, variceal ligation is the modality of choice. The combination of simultaneous variceal ligation and sclerotherapy does not offer any benefit. However, the use of additional sclerotherapy for the complete eradication of small varices after variceal ligation needs to be evaluated. The results of current prospective randomized controlled trials comparing variceal ligation with pharmacological treatment are awaited with great interest. Finally, the use of transjugular intrahepatic portosystemic shunt (TIPS) for the secondary prevention of variceal bleeding is not substantiated by current data, as survival is not improved and because of its worse cost-benefit profile compared to other treatments. In contrast, there still is a role for the selective surgical shunts in the modern management of portal hypertension. The ideal patients should be well compensated cirrhotics, who have had troublesome bleeding - either who have failed at least one other modality of therapy (drugs or ligation), have bled from gastric varices despite medical or endoscopic therapy, or live far from suitable medical services. Recently, ligation has been compared to beta-blockers for primary prophylaxis but so far there is no good evidence to recommend banding for primary prophylaxis, if beta-blockers can be given.
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PMID:Variceal bleeding and portal hypertensive gastropathy. 1120 18

Complications of liver cirrhosis are increasingly frequent in elderly patients due to increased life expectancy and better management of cirrhotic patients. However, the influence of this condition on the evolution of variceal bleeding has not been well established. The aim of the present study was to determine the characteristics of esophagogastric variceal bleeding in elderly patients and the possible influence of advanced age on hemorrhage-related mortality. We analyzed 321 episodes of variceal bleeding in 227 cirrhotic patients. One hundred and thirteen (35.2%) episodes occurred in patients older than 65 years. No differences were found among patients older or younger than this age in terms of bleeding characteristics or Child-Pugh score. Patients older than 65 years more frequently presented serious associated diseases, hepatocellular carcinoma and hepatic encephalopathy during the episode (52.7% vs. 14%, p < 0.001; 19.7% vs. 8.7%, p = 0.01 and 17.4% vs. 10%, p = 0.09 respectively). Although hemorrhage-related mortality was higher in elderly patients (23.2% vs. 13.5%, p = 0.04), only the Child-Pugh score, definitive hemostasis, hepatocellular carcinoma and the development of encephalopathy or bacterial infection were independent predictive factors of mortality. A considerable proportion of the patients with esophagogastric variceal bleeding were older than 65 years. Advanced age does not independently influence mortality due to variceal bleeding.
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PMID:[Predictive factors of the mortality of digestive hemorrhage caused by esophageal varices in elderly patients]. 1124 89

A significant proportion of patients with cirrhosis can demonstrate elevated serum C-reactive protein (CRP) values which are not stimulated by bacterial infection. This may limit the clinical application of CRP determination in patients with cirrhosis. Therefore, we designed this prospective study to clarify whether serum CRP value could be used as an indicator of bacterial infection in patients with cirrhosis or not. A total of 129 sessions of admission (bacterial infection 46, bacterial infection and gastrointestinal hemorrhage 5, gastrointestinal hemorrhage 24, other causes 54) from 94 patients with cirrhosis were studied. Serum CRP value was determined on admission. The normal range of CRP value was < 6 micrograms/ml. The serum CRP values obtained on admission ranged from 3 to 232 micrograms/ml in patients with bacterial infection, 17 to 178 micrograms/ml in patients with bacterial infection and hemorrhage, < 1 to 44 micrograms/ml in patients with gastrointestinal hemorrhage, and < 1 to 54 micrograms/ml in patients with other causes of admission. Using the normal upper limit of CRP value as a cut-off value did not differentiate those patients with from those without bacterial infection. However, using the CRP value of 20 micrograms/ml which was obtained from receiver-operating characteristic curves could differentiate between two groups of patients (sensitivity 80.39%, specificity 80.77%, accuracy 80.62%). In conclusion, serum CRP determination can be used in the detection of bacterial infection in patients with cirrhosis. However, a new cut-off value should be applied.
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PMID:Clinical application of serum C-reactive protein measurement in the detection of bacterial infection in patients with liver cirrhosis. 1214 26

Acute haemorrhage from the upper gastrointestinal tract is a frequent and serious complication which affects 20-60% patients with cirrhosis of the liver and portal hypertension. It is assumed that bacterial infections can be the direct cause of haemorrhage but accurate data on the influence of infection on the development and course of haemorrhage are lacking. Acute haemorrhage as a result of portal hypertension has a very high mortality, 30-50%, and an early relapse of haemorrhage occurs in as many as 40% of these patients. Most recent meta-analyses indicate that bacterial infection is an independent prognostic factor in failure of haemostasis and has a significant impact on the mortality of these patients. The authors examined for the presence of bacterial infection (blood, urine, throat, ascites) 25 patients with cirrhosis of the liver and acute haemorrhage as a result of portal hypertension and compared the results with a group of 25 patients with cirrhosis of the liver and portal hypertension without acute haemorrhage. According to the results in patients with acute haemorrhage due to portal hypertension there is a significantly higher incidence of bacterial infections than in patients with cirrhosis of the liver and portal hypertension without acute haemorrhage. The results confirm the necessity to administer antibiotic prophylaxis to cirrhotic patients with varicose bleeding, not only to patients with symptoms and evidence of infection but also in their absence. Antibiotic prophylaxis extends the survival period of these patients.
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PMID:[Bacterial infections in patients with acute hemorrhage due to portal hypertension--personal experience]. 1279 46

Alterations in immunological defense in the gut may lead to the bacterial infection that is frequently associated with cirrhosis of the liver. The aim of this study was to investigate the changes in distribution and function of intestinal intraepithelial lymphocytes (IELs) in relation to intestinal barrier dysfunction in experimental cirrhosis. Cirrhosis was induced in mice by treatment with carbon tetrachloride (CCl4) intraperitoneally with 5% alcohol in drinking water for 12 weeks. Bacterial translocation was assessed in mesenteric lymph nodes (MLNs) by the transport of fluorescence-labeled latex beads and by bacteriological cultures. The lymphocyte subpopulation was compared in three groups (cirrhosis, alcohol alone and controls). IFN-gamma production from isolated IELs was determined by ELISA after stimulation with anti-CD3 or IL-12/IL-18. The total number of IELs significantly increased in the cirrhosis and alcohol groups. There was a preferential increase in TCRgammadelta+CD8+ population in the alcohol group, but no change in cirrhosis. Bacterial translocation was negative in the control group, and a small number was noted in the alcohol group, whereas it was significantly noted in the cirrhosis group. Although the number of IEL was significantly increased in the cirrhosis group, their proliferative response was decreased, and IFN-gamma production from each IEL was markedly diminished in either stimulation by anti-CD3 or IL-12/IL-18. These changes were more remarkable in the cirrhosis group than in the alcohol group. In conclusion, bacterial translocation due to intestinal barrier dysfunction in cirrhosis may be closely correlated with the alteration of the immune function in IELs.
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PMID:Alteration of intestinal intraepithelial lymphocytes and increased bacterial translocation in a murine model of cirrhosis. 1461 1

Acute bleeding from upper part of gastrointestinal tract is a frequent and serious complication affecting 20 to 60% of patients with liver cirrhosis and portal hypertension. It is associated with a high death rate of 30 to 50% and a frequent relapse of bleeding occurs in up to 40% of these patients. The most recent meta-analyses have shown that bacterial infection is an independent factor in the failure of blood hemostasis and significantly influenced mortality in these patients. The authors investigated 25 patients with acute bleeding from the upper part of gastrointestinal tract due to portal hypertension in patients with liver cirrhosis. Irrespective of the proved bacterial infection the patients were given antibiotic prophylaxis. In 13 patients the authors administered norfloxacin orally and 12 patients were treated intravenously with ampicilin/sulbactam. The prophylaxis of the bleeding cirrhotic patients by norfloxacin (orally) resulted in a statistically significant prevention of early relapse as compared with the therapy by ampicilin/sulbactam (intravenously). The death rate reached 40% in spite of the antibiotic prophylaxis. There was no significant difference in the death rate between the two groups with different treatments.
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PMID:[Antibiotic prophylaxis in patients with acute hemorrhage due to portal hypertension--personal experience]. 1468 54

Patients with liver cirrhosis have an impaired function of reticuloendothelial system; moreover they exhibit several defects of cellular and humoral immunity. These deficiencies enhance their susceptibility to bacterial infections. The prognosis is better if the infection is detected as early as possible and treated adequately. Except in cases of septicemia, empirical monotherapy is effective. Broad-spectrum beta-lactam antibiotics have proved efficient for the treatment of severe infections; a limitation of third-generation cephalosporins is their ineffectiveness against Enterococci; the acylureidopenicillins may be a good choice since they are active against Enterococci and most enteric, pulmonary and urinary pathogens, including Escherichia coli and Streptococcus pneumoniae which are the pathogens most frequently isolated from cirrhotic patients with severe infection. Similarly, the combination of a beta-lactamase inhibitor with a penicillin may offer an adequate antibacterial spectrum. Piperacillin, like other beta-lactam antibiotics, can induce leukopenia in patients with cirrhosis; the more severe the hepatic dysfunction, the greater the risk; a reduction in dosages is necessary. Meropenem monotherapy is effective and safe for the initial therapeutic regimen of bacterial infection. The fluoroquinolones may be useful for the treatment of infections in liver cirrhosis; however, the marginal activity against S. pneumoniae is a drawback. Oral long-term fluoroquinolone administration is utilized for the prevention of spontaneous bacterial peritonitis recurrence; selective intestinal decontamination with fluoroquinolones is useful in preventing bacterial infections in cirrhosis with gastrointestinal hemorrhage. Given the high risk of nephrotoxicity due to aminoglycosides in liver cirrhosis, these antibiotics should be used only in cases of severe infection with septicemia, in which beta-lactam-aminoglycoside combination is indicated for rapid bactericidal effect and enhanced killing afforded by synergism. Perhaps a short course (no more than 3 days) and a once-daily schedule of administration would minimize the risk of aminoglycoside-induced nephrotoxicity.
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PMID:[The choice of antibiotic therapy for bacterial infections in patients with cirrhosis of the liver]. 1496 93

Incidence of bacterial infections in hospitalised patients with liver disease is high. Due to a liver dysfunction immune reactivity is significantly impaired and bacterial infections are more frequent. Also incidence of nosocomial infections is higher in patients with liver disease compared to patients hospitalised for other conditions. To make a differential diagnosis of infectious and non-infectious aetiology of an inflammation is very difficult. Characteristic laboratory tests for bacterial infection include test of a number of leucocytes in peripheral blood, differential count of leucocytes, erythrocyte sedimentation, procalcitonin, C-reactive protein, tumor necrosis factor alpha, interleukin-1, interleukin-6, interleukin-8, and complement fragment C3a. Clinically the most significant are C-reactive protein test and procalcitonin test. Procalcitonin is a protein, a calcitonin precursor, which is in healthy individuals produced by cells of thyroid gland. A half-life of procalcitonin in serum is 20-24 hours which makes it suitable for daily monitoring and enables to control a course of treatment and to distinguish bacterial infection from other types of inflammations. Procalcitonin levels rise in bacterial, parasite, and yeast infections. Elevated procalcitonin levels appear only in inflammations of an infectious etiology with systemic signs. In patients with liver cirrhosis bacterial infections are more frequent. They usually include spontaneous bacterial peritonitis, infection of the respiratory system, urinary infections, and bacteremia. A timely proof of a bacterial infection and an appropriate and effective antibiotic therapy lead to an improvement of the general state of a patient and to his/her better prognosis. Procalcitonin determination is appropriate for diagnosing infections and control of treatment.
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PMID:[Procalcitonin as an indicator of infection in patients with liver cirrhosis]. 1507 92

Hepatic encephalopathy (HE) is a major sign of severe liver disease and the impact of associated bacterial infections should be better evaluated. A retrospective cohort of 333 patients with cirrhosis and HE was analyzed in three periods of time, from 1984 to 1998. Variance analysis, Wilcoxon, Chi-square and Fisher's exact tests were used for statistical comparisons. Prevalence of bacterial infections decreased along the time (p = 0.0029). Spontaneous Bacterial Peritonitis -SBP- (37%) and urinary tract infection (30%) were the more frequent types of bacterial infections. Early death was significantly higher in HE with infection (46,47%) and the calculated RR was 2.047. Prognosis was worse in septicemia (79%) and respiratory tract infection (50%) and better in urinary tract infection (27%). SBP lethality was reduced from 70% to 38% (p = 0.062). In conclusion, lower prevalence of bacterial infections, in severe liver disease, was achieved in the last decade, but short-term prognosis remains bad, varying according to the type of bacterial infection.
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PMID:Bacterial infections associated with hepatic encephalopathy: prevalence and outcome. 1509 5

It has been reported that phagocytic function of neutrophils is impaired in cirrhotic patients. We examined the effects of oral supplementation of branched-chain amino acids (BCAA) on phagocytic function of neutrophils in peripheral blood of patients with decompensated cirrhosis. Five patients with decompensated cirrhosis received 12g of BCAA daily for 3 months. Phagocytic function of neutrophils and NK activities of lymphocytes in peripheral blood as well as serum albumin levels and Fisher's ratios were determined before and at 1 and 3 months of BCAA supplementation. Phagocytic function of neutrophils was significantly improved by 3-month BCAA oral supplementation. NK activity of lymphocytes was improved in four of five patients at 3 months of BCAA supplementation, although the changes were not statistically different. In conclusion, BCAA supplementation improved phagocytic function of neutrophils in cirrhotic patients. BCAA supplementation may reduce the risk of bacterial infection in patients with decompensated liver cirrhosis.
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PMID:Phagocytic function of neutrophils of patients with decompensated liver cirrhosis is restored by oral supplementation of branched-chain amino acids. 1528 12


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