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Management and Treatment of Patients With Cirrhosis and Portal Hypertension: Recommendations From the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program

Department of Veterans Affairs Medical Center, West Haven, Connecticut, USA.
The American Journal of Gastroenterology (Impact Factor: 9.21). 06/2009; 104(7):1802-29. DOI: 10.1038/ajg.2009.191
Source: PubMed

ABSTRACT Cirrhosis represents the end stage of any chronic liver disease. Hepatitis C and alcohol are currently the main causes of cirrhosis in the United States. Although initially cirrhosis is compensated, it eventually becomes decompensated, as defined by the presence of ascites, variceal hemorrhage, encephalopathy, and/or jaundice. These management recommendations are divided according to the status, compensated or decompensated, of the cirrhotic patient, with a separate section for the screening, diagnosis, and management of hepatocellular carcinoma (HCC), as this applies to patients with both compensated and decompensated cirrhosis. In the compensated patient, the main objective is to prevent variceal hemorrhage and any practice that could lead to decompensation. In the decompensated patient, acute variceal hemorrhage and spontaneous bacterial peritonitis are severe complications that require hospitalization. Hepatorenal syndrome is also a severe complication of cirrhosis but one that usually occurs in patients who are already in the hospital and, as it represents an extreme of the hemodynamic alterations that lead to ascites formation, it is placed under treatment of ascites. Recent advances in the pathophysiology of the complications of cirrhosis have allowed for a more rational management of cirrhosis and also for the stratification of patients into different risk groups that require different management. These recommendations are based on evidence in the literature, mainly from randomized clinical trials and meta-analyses of these trials. When few or no data exist from well-designed prospective trials, emphasis is given to results from large series and consensus conferences with involvement of recognized experts. A rational management of cirrhosis will result in improvements in quality of life, treatment adherence, and, ultimately, in outcomes.

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    • "However, clinical signs and symptoms are occasionally absent in patients with SBP [11] [12] [13] [14] [15] [16]. Although all cirrhotic patients with ascites are at risk of SBP, the prevalence of SBP among hospitalized patients (10%) is higher than that observed in outpatients (1.5–3.5%) "
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    ABSTRACT: Spontaneous bacterial peritonitis (SBP) is a frequent and severe complication in cirrhotic patients with ascites. Although identifying the pathogen(s) plays a major role in the management of infectious diseases, ascitic fluid cultures often show negative results in patients with clinical signs and symptoms of SBP, and ascitic fluid cell analyses are the gold standard method for diagnosing SBP. SBP is generally diagnosed based on an increased number of polymorphonuclear neutrophils in the ascitic fluid (>250/mm(3)), and the identification of the causal pathogen may not be given consideration. We newly developed an in situ hybridization (ISH) method to provide early and direct evidence of bacterial infection in ascites in patients with SBP. This paper will review the diagnosis of SBP, including our novel approach with ISH method to detect bacterial DNA in SBP ascitic fluid.
    07/2014; 2014:634617. DOI:10.1155/2014/634617
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    • "Paracentesis was performed, and the extracted peritoneal fluid was sent for PMN count and culture study. Patients were initially treated with intravenous cefotaxime, but broad-spectrum antibiotics such as piperacillin–tazobactam or carbapenem were used in patients with septic shock based on hospital guidelines for SBP treatment [16]. Blood sampling for DNI value and culture study was performed prior to administration of antibiotics. "
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    ABSTRACT: Spontaneous bacterial peritonitis (SBP) is a common and life-threatening infection in patients with advanced cirrhosis. The prognostic value of a novel marker, the delta neutrophil index (DNI), was investigated relative to mortality in patients with SBP. Seventy-five patients with SBP were studied from April 2010 to May 2012. DNI at initial diagnosis of SBP was determined and compared with 30-day mortality rates. Of the patients, 87.7% were men, and the median age of all patients was 59.0 yrs. The area under the receiver-operating characteristic (ROC) curve of DNI for 30-day mortality was 0.701 (95% confidence interval [CI], 0.553-0.849; p = 0.009), which was higher than that of C-reactive protein (0.640, 95% CI, 0.494-0.786; p = 0.076) or the model for end-stage liver disease score (0.592, 95% CI, 0.436-0.748; p = 0.235). From the ROC curve, with the sum of sensitivity and specificity, the cutoff value of DNI was determined to be 5.7%. In the high-DNI group (DNI ≥5.7%), septic shock and 30-day mortality were more prevalent compared with the low-DNI group (84.2% vs. 48.2%, p = 0.007; 57.9% vs. 14.3%, p<0.001, respectively). Patients with an elevated DNI had a higher risk of 30-day mortality compared with those with a low DNI (4.225, 95% CI, 1.631-10.949; p = 0.003). A higher DNI at the time of SBP diagnosis is an independent predictor of 30-day mortality in patients with SBP.
    PLoS ONE 01/2014; 9(1):e86884. DOI:10.1371/journal.pone.0086884 · 3.23 Impact Factor
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    • "Cirrhosis of the liver—the only cure for which is liver transplant—is associated with several serious complications, including ascites, spontaneous bacterial peritonitis, variceal bleeding, and hepatic encephalopathy (HE) [1]. Guidelines established by the American Association for the Study of Liver Diseases currently recommend referring patients with cirrhosis for liver transplant when their model for end-stage liver disease (MELD) score is ≥10 and their Child-Turcotte-Pugh (CTP) score is ≥7 or when they experience their first major complication (e.g., HE, ascites, or variceal bleeding) [2]. "
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    ABSTRACT: Patients with cirrhosis commonly experience hepatic encephalopathy (HE), a condition associated with alterations in behavior, cognitive function, consciousness, and neuromuscular function of varying severity. HE occurring before liver transplant can have a substantial negative impact on posttransplant outcomes, and preoperative history of HE may be a predictor of posttransplant neurologic complications. Even with resolution of previous episodes of overt or minimal HE, some patients continue to experience cognitive deficits after transplant. Because HE is one of the most frequent pretransplant complications, improving patient HE status before transplant may improve outcomes. Current pharmacologic therapies for HE, whether for the treatment of minimal or overt HE or for prevention of HE relapse, are primarily directed at reducing cerebral exposure to systemic levels of gut-derived toxins (e.g., ammonia). The current mainstays of HE therapy are nonabsorbable disaccharides and antibiotics. The various impacts of adverse effects (such as diarrhea, abdominal distention, and dehydration) on patient's health and nutritional status should be taken into consideration when deciding the most appropriate HE management strategy in patients awaiting liver transplant. This paper reviews the potential consequences of pretransplant HE on posttransplant outcomes and therapeutic strategies for the pretransplant management of HE.
    11/2013; 2013:952828. DOI:10.1155/2013/952828
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