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.

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.

Vascular disorders of the liver.

This guideline has been approved by the American Association for the Study of Liver Diseases (AASLD) and represents the position of the association.

Use of over-the-counter analgesics is not associated with acute decompensation in patients with cirrhosis.

Background & Aims: Over-the-counter analgesics have been proposed to lead to decompensation of compensated cirrhosis or to further decompensation of an already decompensated patient. We performed a prospective, case-control study to investigate the effects of analgesics on acute hepatic decompensation.

Methods: Data from consecutive cirrhotic patients hospitalized at 2 tertiary care hospitals for decompensation of cirrhosis (cases, n = 91) were compared with that from consecutive patients with compensated cirrhosis that were followed in the liver clinic (n = 153) and with randomly selected noncirrhotic patients concurrently hospitalized with the cases (n = 89).

Hepatic venous pressure gradient predicts development of hepatocellular carcinoma independently of severity of cirrhosis.

Background/aims: A total of 213 patients with compensated cirrhosis, portal hypertension and no varices were included in a trial evaluating beta-blockers in preventing varices. Predictors of the development of hepatocellular carcinoma (HCC), including hepatic venous pressure gradient (HVPG) were analyzed.

Methods: Baseline laboratory tests, ultrasound and HVPG measurements were performed.

Incidence, prevalence, and clinical significance of abnormal hematologic indices in compensated cirrhosis.

Background & Aims: Patients with cirrhosis develop abnormal hematologic indices (HI) from multiple factors, including hypersplenism. We aimed to analyze the sequence of events and determine whether abnormal HI has prognostic significance.

Methods: We analyzed a database of 213 subjects with compensated cirrhosis without esophageal varices.

Prognostic indicators in hepatocellular carcinoma: a systematic review of 72 studies.

Background: Although there are many studies of the predictors of death in hepatocellular carcinoma (HCC), most combine patients with and without cirrhosis and many combine those with compensated and decompensated cirrhosis.

Objective: To perform a systematic review of the literature evaluating the predictors of death in patients with cirrhosis and HCC and to evaluate whether the predictors differ between patients with compensated and decompensated cirrhosis.

Inclusion Criteria: (i) publication in English, (ii) adult patients, (c) >80% of the patients had cirrhosis, (iv) follow-up >6 months and (v) multivariable analysis.

Psychosocial issues in hepatitis C: a qualitative analysis.

Background: Despite demonstrated prevalence of psychosocial problems among hepatitis C (HCV) patients, little is known about how these problems develop, why they are sustained, and how clinical providers can effectively intervene.

Objective: The authors used a qualitative approach to investigate the nature of psychosocial issues in HCV.

Method: Focus groups were conducted with HCV patients.

Acute kidney injury in cirrhosis.

Unlabelled: Acute renal failure (ARF), recently renamed acute kidney injury (AKI), is a relatively frequent problem, occurring in approximately 20% of hospitalized patients with cirrhosis. Although serum creatinine may underestimate the degree of renal dysfunction in cirrhosis, measures to diagnose and treat AKI should be made in patients in whom serum creatinine rises abruptly by 0.3 mg/dL or more (>/=26.

Prediction of clinical outcomes in primary biliary cirrhosis by serum enhanced liver fibrosis assay.

Unlabelled: Primary biliary cirrhosis (PBC) is sometimes diagnosed based on a positive antimitochondrial antibody in the appropriate clinical setting without a liver biopsy. Although a liver biopsy can assess the extent of liver fibrosis and provide prognostic information, serum fibrosis markers avoid biopsy complications and sampling error and provide results as a continuous variable, which may be more precise than categorical histological stages. The current study was undertaken to evaluate serum fibrosis markers as predictors of clinical progression in a large cohort of PBC patients.

Hepatic vascular malformations in hereditary hemorrhagic telangiectasia.

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant vascular disorder that can involve the liver diffusely in the form of vascular malformations ranging from small telangiectases to discrete arteriovenous malformations. Anatomically, three different patterns of abnormal vascular communications can occur in liver: portal vein to hepatic vein (portovenous), hepatic artery to hepatic vein (arteriovenous) and hepatic artery to portal vein (arterioportal), with the most common being arteriovenous. Only 5 to 8% of patients with these vascular malformations are symptomatic.

Probiotics and liver disease.

Modulation of intestinal flora through the use of probiotics is an emerging therapeutic strategy in the management of chronic liver diseases. This article focuses on the pathophysiologic basis for using probiotics in liver disease and reviews the existing literature on the subject. The role of probiotics is examined in the following areas: a) prevention of infection, b) the hyperdynamic circulatory state of cirrhosis, c) hepatic encephalopathy, d) liver function, and e) nonalcoholic fatty liver disease.

Recommendations for probiotic use--2008.

Recommendations for the clinical use of probiotics were published after a Yale University Workshop in 2005. A similar workshop was held in 2007, and the recommendations were updated and extended into other areas. The recommendations are graded into an "A," "B," "C" or no category based on the expert's opinion and review by the workshop participants.

A randomized, prospective, double-blind, placebo-controlled trial of terlipressin for type 1 hepatorenal syndrome.

Background & Aims: Hepatorenal syndrome (HRS) type 1 is a progressive functional renal failure in subjects with advanced liver disease. The aim of this study was to evaluate the efficacy and safety of terlipressin, a systemic arterial vasoconstrictor, for cirrhosis type 1 HRS.

Methods: A prospective, randomized, double-blind, placebo-controlled clinical trial of terlipressin was performed.

Bacterial infections, sepsis, and multiorgan failure in cirrhosis.

Bacterial infections are an important complication of cirrhosis, particularly in hospitalized patients. In this article we review the prevalence, risk factors, and pathogenesis of bacterial infections in cirrhosis, focusing on the mechanisms of bacterial translocation such as impaired immunity and bacterial overgrowth, as well as maneuvers that may inhibit bacterial translocation and could be used not only to prevent infections but also to ameliorate the hyperdynamic circulatory state of cirrhosis. We also review the clinical features and management of the most common infection in cirrhosis, spontaneous bacterial peritonitis (SBP), specifically the evidence behind the therapy of acute SBP, the role of albumin, and the role of antibiotics in the prophylaxis of high-risk patients.

Treatment of gastropathy and gastric antral vascular ectasia in patients with portal hypertension.

Portal hypertensive gastropathy (PHG) and gastric antral vascular ectasia (GAVE) are two distinct gastric mucosal lesions that may cause acute and/or chronic upper gastrointestinal hemorrhage in patients with cirrhosis. Whereas PHG is associated with portal hypertension, GAVE may present in patients without portal hypertension or liver disease. Diagnosis is made upon visualization of the characteristic lesions with upper gastrointestinal endoscopy, although the differential may be difficult at times.

Platelet count is not a predictor of the presence or development of gastroesophageal varices in cirrhosis.

Unlabelled: Current guidelines recommend esophagogastroduodenoscopy (EGD) in patients with cirrhosis to screen for gastroesophageal varices (GEV). Thrombocytopenia has been proposed as a noninvasive test to predict the presence of GEV. There is no agreement regarding a specific platelet count (PLT) that can reliably predict GEV.

Preventing the development of varices in cirrhosis.

Gastroesophageal varices are a direct consequence of portal hypertension. Nonselective beta-adrenergic blockers decrease portal pressure and are effective in preventing variceal hemorrhage. However, a large multicenter placebo-controlled trial demonstrates that nonselective beta-adrenergic blockers are not effective in preventing the development of varices and are associated with a significant rate of adverse events.

A pilot project examining the predicted preferences of patients and physicians in the primary prophylaxis of variceal hemorrhage.

Unlabelled: Endoscopic variceal ligation (EVL) and nonselective beta-blockers (hereafter just called beta-blockers) are both effective for primary prophylaxis for variceal hemorrhage; however, the route of administration and side effects of these treatments are distinct. The objective of this study was to examine predicted preferences of patients and physicians for the primary prevention of variceal hemorrhage. Untreated patients with newly diagnosed esophageal varices and practicing gastroenterologists were enrolled in this study.

Hepatic venous pressure gradient predicts clinical decompensation in patients with compensated cirrhosis.

Background And Aims: Our aim was to identify predictors of clinical decompensation (defined as the development of ascites, variceal hemorrhage [VH], or hepatic encephalopathy [HE]) in patients with compensated cirrhosis and with portal hypertension as determined by the hepatic venous pressure gradient (HVPG).

Methods: We analyzed 213 patients with compensated cirrhosis and portal hypertension but without varices included in a trial evaluating the use of beta-blockers in preventing varices. All had baseline laboratory tests and HVPG.

Differences between Caucasian, African American, and Hispanic patients with primary biliary cirrhosis in the United States.

Unlabelled: Primary biliary cirrhosis (PBC) is an uncommon chronic cholestatic liver disease that primarily afflicts young and middle-aged Caucasian women; there are limited data on the clinical presentation and disease severity among non-Caucasian patients with this disease. The goal of this study was to examine differences in the severity of liver disease between Caucasian and non-Caucasian patients with PBC screened for enrollment in a large national multicenter clinical trial. Demographic features, symptoms, physical findings, and laboratory tests obtained during screening were examined in 535 patients with PBC with respect to ethnicity, gender, and antimitochondrial antibody (AMA) status; 73 of 535 (13.