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

Portal-systemic shunting of all types has failed to improve long-term survival in patients with bleeding esophageal varices and carries a high morbidity and prohibitive mortality in the emergency setting. Direct esophageal approaches are receiving renewed attention. Sclerotherapy promises to be the simplest, safest, and most effective treatment for acute bleeding. Rebleeding is frequent with this technique unless all the varices are subsequently obliterated. Even then, rebleeding may be a recurring hazard, albeit with reduced frequency and increasing interval. For the nonalcoholic patient with a significant life expectancy or in the young patient with cirrhosis, this can be a significant factor. Simple esophageal resection-transection using stapling devices is a rapidly accomplished, simple, and effective operative approach if combined with coronary vein ligation. This procedure deserves a trial earlier in such patients and in those who are failures of repeated sclerotherapy. Extensive esophagogastric devascularization preserving the paraesophageal veins--the Sugiura procedure--is a more extensive undertaking that is probably unnecessary for most and too dangerous for some. At present, it should be reserved for failures of other techniques. It shows promise of long-term effectiveness if performed safely on only certain patients.
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PMID:Esophageal procedures to control bleeding from varices. 635

Splenomegaly, ascites, and anatomy of intra- and extrahepatic portal vessels can reliably be detected by ultrasound in case of portal hypertension. The increased diameter of the portal vein and its roots is a not sufficient sensitive and specific finding in portal hypertension. However a marked variation of diameter at the superior mesenteric vein during in- and expiration is nearly exclusive. With the help of colour flow imaging or duplex sonography additional finding of blood flow in the portal system can be detected noninvasively and continuously. Quantitative blood-flow measurement in routine examinations is unnecessary and reserved to special questions. Reverse flow or significantly decreased blood flow velocity or the detection of portocaval collaterals are reliable findings in portal hypertension. In addition thrombosis of portal vessels and its hemodynamic consequences can be seen. Because underlying diseases e.g. liver cirrhosis or tumours are diagnosed in the same procedure ultrasound techniques are used in first line when portal hypertension is suspected. The findings are complementary to endoscopy of upper g.i.tract and lead on the one hand to a well-aimed use of CT scanning or x-ray splenoportography, and--on the other hand--make them dispensable in a low of cases.
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PMID:[Portal hypertension--current status of ultrasound diagnosis]. 766 26

The course of pregnancy in three patients with portal hypertension is described. The cause of portal hypertension was cirrhosis in one and portal vein obstruction in two (one of these had previous shunt surgery). The patient with cirrhosis had an episode of encephalopathy at week 27, the rest of the patients had an uneventful pregnancy. All three had preterm vaginal deliveries at week 33, 31 and 37 of pregnancy. The clinical features of pregnancy in women with portal hypertension was reviewed in the literature. There is agreement that the risk of preterm delivery increases and pregnancy does not influence maternal prognosis. Vaginal delivery can be anticipated in most women and cesarean section is reserved for obstetric indications. Pregnancy in these women should be managed in tertiary care centers with close collaboration between perinatologists, internists and surgeons.
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PMID:[Pregnancy and portal hypertension]. 827 39

In general, chemotherapy does not play an essential role in hepatocellular carcinoma (HCC) because of the low sensitivity to antitumor agents in cancer cells. Additionally, the vast majority of patients with HCC have chronic liver disease, notably cirrhosis, so it is virtually impossible to administer a large amount of antitumor agents. In fact, chemotherapy plays an important part in multimodal treatment for HCC. Whenever chemotherapy is used for patients in the advanced stage, it should be aimed to improve prognosis without impairment of their quality of life. Regarding prognostic factors of chemotherapy for unresectable patients, both reserved hepatic function and tumor advancement are important. Intra-arterial infusion chemotherapy using MMC, ADM, CDDP and/or 5-FU via hepatic artery is appropriately used to improve the therapeutic efficacy. The response rate by one shot injection seems to be approximately 10-20% in general. Although it is not clear which medicine and means of administration are most effective, oral administration is used as a subsidiary treatment for HCC in general. In order to enhance the efficacy of antitumor agents, various drug delivery systems including selective enhancement of tumor blood flow with angiotensin II and drug carriers such as Lipiodol have been applied. Recently, totally implantable arterial access devices have been used for intermittent intra-arterial infusion chemotherapy. It seems to make life easier for the treated patients. Further trials are planned to develop new modes of chemotherapy such as overcoming multidrug resistance by calcium antagonists.
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PMID:[The present status of chemotherapy for hepatocellular carcinoma]. 838 60

In cirrhotic patients who develop hepatocellular carcinoma the only hope of prolonged survival is surgery. A review of the literature was carried out in order to determine precisely the indications for surgical treatment and the choice between liver resection and transplantation. With a low post-operative mortality rate, the survival rate 3 years after liver resection is almost 50 percent. The most favourable cases are tumours smaller than 5 cm, uninodular and well encapsulated, but intrahepatic recurrences are almost constant at 5 years. Liver transplantation does not improve the long-term survival. Its best indications are the same as those of liver resection. Because of graft scarcity and rapid tumoral progress in patients on the waiting list, liver transplantation must be reserved for unstable cirrhosis. In the other situations, liver resection must be considered in priority.
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PMID:[Hepatocellular carcinoma on cirrhosis. Resection or transplantation]. 838 6

Liver cirrhosis is associated with malnutrition in 10 to 90% of cases, following different authors. This prompted us to compare our previous studies with recent literature data in order to review this topic from a practical standpoint. Several pathophysiological factors are blamed for this state and mainly protein and lipid-restricted diets from among these. Some lean and fat body mass indices predictive of malnutrition are proposed taking into account the influence of liver disease in their evaluation. Nitrogen balance derangements and liposoluble vitamins and carotenoids plasma decrease are highlighted as sensitive nutritional parameters. After a brief review of amino acid, glucose and lipid metabolic derangements, some nutritional guidelines are provided by distinguishing oral selective supports from the parenteral nutrition. The latter, being reserved to moderate-severe encephalopathy or to hemorrhagic conditions, is proposed following an algorithm which takes into account different nutritional principles as a function of the severity of the clinical condition. During the first period (24-48 hrs) parenteral fluids, electrolytes, dextrose and whole blood or derivatives (when necessary) are provided; lactulose or lactitol via nasogastric tube, or by enema, are started as well. During the following 48-72 hrs branched-chain amino acids alone or enriched solutions are added taking into account an optimum calorie/nitrogen ratio. Finally, vegetable lipids, vitamins and oligoelements can be added if intravenous nutrition must be maintained, with a view of warranting the most complete nutritional approach to these severely malnourished patients.
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PMID:[Nutrition and malnutrition in hepatic cirrhosis]. 851 55

Low serum albumin levels are common in patients with cirrhosis and liver failure. Decreased synthesis is the main but not the only mechanism leading to decreased serum levels. The consequences of low albumin concentrations are a decreased plasma colloid osmotic pressure and a decreased binding of liposoluble xenobiotics and endogenous substances. Besides the fluid accumulation in pleura and peritoneum, the complications directly related to low serum albumin levels have been only poorly assessed. An increase in serum albumin levels (by a few g.L-1) for a few days can be achieved by the infusion of large amounts of human albumin (approximately 120 g over 3 days). The efficacy of this treatment has been only tested in association with large paracentesis: albumin infusion, which induces volume expansion, reduced the incidence of hyponatremia and functional renal failure. No significant effect on ascites production rate or survival has been observed. Similar results were achieved through polygelin or dextran-70 infusions. No well-conducted controlled study on the value of albumin infusion in other circumstances apart from cirrhotic patients is available. In conclusion, albumin infusion should be reserved to the treatment of hyponatraemia or functional renal failure complicating cirrhosis with severe liver failure and marked hypoalbuminaemia, when the infusion of colloids failed to correct these anomalies.
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PMID:[Indications and role of albumin, plasma volume expansion excluded, in the preoperative or postoperative management of portal hypertension]. 888 92

Disturbances in blood capillary exchange of fluid, macromolecules, and cells across intact and abnormal microvessels and deranged lymphatic transport are integral, interacting components in disorders of tissue swelling. Lymphedema or low-output failure of the lymph circulation is often indolent for many years before lymphatic insufficiency (failure) and tissue swelling emerge and persist. Superimposed occult or overt infection (lymphangitis) are probably major contributors to progressive limb deformity (elephantiasis). Long-standing lymphedema is characterized by trapping in the skin and subcutaneous tissue of fluid, extravasated plasma proteins, and other macromolecules: impaired immune cell trafficking; abnormal processing of autologous and foreign antigens; heightened susceptibility to superimposed infection; local immunodysregulation; defective lymphatic (lymphangion) propulsion from an imbalance of mediators regulating vasomotion; soft-tissue overgrowth; scarring and hypertrophy; and exuberant angiogenesis occasionally culminating in vascular tumors (Fig. 8). In contrast to the blood circulation, where flow depends primarily on the propulsive force of the myocardium, lymph propulsion depends predominately on intrinsic truncal contraction, a phylogenetic vestige of amphibian lymph hearts. Whereas venous "plasma" flows rapidly (2-3 l/min) against low vascular resistance, lymph flows slowly (1-2 ml/min) against high vascular resistance. On occasion, impaired transport of intestinal lymph may be associated with reflux and accumulation and leakage of intestinal chyle in a swollen leg. Although the term "lymphedema" is usually reserved for extremity swelling, the pathogenesis of a wide variety of visceral disorders also may be traceable to defective tissue fluid and macromolecular circulation and impaired cell trafficking of lymphocytes and macrophages. Thus, lymph stasis, with impaired tissue fluid flow, underlies or complicates an indolent subclinical course with a long latent period and sporadic episodes of lymphangitis, which culminates in intense scarring. Examples are pulmonary fibrosis (e.g., pneumoconiosis), regional enteritis, retroperitoneal fibrosis, and perhaps chronic pancreatitis and cirrhosis of the liver. Transdifferentiation and ultimately transformation of endothelial and other vascular accessory cells during lymph stasis also may be pivotal to a wide range of dysplastic and neoplastic vascular disorders, including Stewart-Treves angiosarcoma, AIDS-associated Kaposi's sarcoma, and lymphangitic metastatic carcinomatosis. Lymphscintigraphy has now replaced conventional lymphography as the procedure of choice to corroborate the diagnosis of peripheral lymphedema, whereas MR imaging using paramagnetic and superparamagnetic contrast agents has the potential to yield huge dividends in furthering understanding of a variety of enigmatic edematous states, including lymphedema. Not only are better explanations and insights into swelling disorders likely to be forthcoming, but, equally important, these new, safe, noninvasive imaging techniques can and should be used to monitor the evolution and document the efficacy of commonly advocated operations and nonoperative remedies for defective lymph transport and function.
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PMID:Disorders of lymph flow. 941 70

The therapy of portal hypertension depends to a significant extent on its clinical manifestation. In cases of acute haemorrhage from oesophageal varices in patients with portal hypertension, the objective of the therapy is to stop the haemorrhage (endoscopically, or by compression by means of a balloon probe) and to decrease the pressure and the reflux within the portal vascular bed. Urgent sclerotisation under the simultanous pharmacologic decrease of portal hypertension is successful in 93-95%. There is an alternative procedure residing in introducing a balloon probe for several hours and subsequent repeated sclerotisation until a complete eradication of varices is achieved regarding the prevention of haemorrhage exacerbation. Urgent surgical solution is on the basis of the results of various investigated studies reserved for patients in whom endoscopic sclerotisation was not successful. Indication of surgical therapy must be also deliberated in candidates for liver transplantation, regarding the possible consequent technical problems after some types of interventions. Endoscopic sclerotisation of oesophageal varices is also an appropriate preparation for transplantation of the liver in patients with liver cirrhosis included into the transplantation programme. TIPS is a perspective new method in the therapy of portal hypertension of both, non-bleeding varices, as well as in other indications. It is also a certain intermediating link in therapy in some patients with liver cirrhosis on the waiting list of candidates for liver transplantation. Pharmacotherapy is a significant part of the portal hypertension therapy. It is appropriate to combine the endoscopic treatment with pharmacotherapy of portal hypertension in both, cases of acute haemorrhage, as well as in the prevention of haemorrhage exacerbation. In cases of acute haemorrhage, the combination of glypressin with nitroglycerin is justified, as well as the therapy by somatostatin. The prevention of haemorrhage exacerbations uses a whole series of vasoactive substances, especially nitrates, beta-blockers and ACE inhibitors. The prevention of the first bleeding includes the prophylactic therapy (endoscopic, pharmacologic, or surgical) recommended only in a selected group of patients under high risk of bleeding. The possible perspective option will reside especially in the combined pharmacological therapy, the fact of which will have to be proven in the future. (Fig. 1, Ref. 25.)
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PMID:[Treatment of portal hypertension]. 958 83

Many treatments are able to eradicate or slow the progression of hepatocellular carcinoma in cirrhosis. All are described in this issue of Annales de Chirurgie. These various alternative mean that treatment can be adapted to different clinical situations determined by the patient's general state, the size of the liver tumour, its extrahepatic dissemination and the functional quality of the underlying liver parenchyma. Liver hepatic transplantation, offers a good chance of cure, provided it is reserved for patients in good general condition with a small hepatocellular carcinoma confined to the liver. This situation is increasingly frequent.
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PMID:[Treatments for hepatocellular carcinoma in cirrhosis : practical aspects]. 975 7


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