Autologous Peripheral Blood Stem Cell Transplantation Improves Portal Hemodynamics in Patients with Hepatitis B Virus-related Decompensated Cirrhosis

Background:

Chronic hepatitis B virus (HBV) infection may eventually lead to decompensated liver cirrhosis, which is a terminal illness.

Objectives:

The aim of this study was to investigate the therapeutic efficacy of autologous peripheral blood stem cell (APBSC) transplantation to improve portal vein hemodynamics in patients with HBV-related decompensated cirrhosis.

Patients and Methods:

This prospective study included 68 hospitalized patients who were diagnosed with HBV-related decompensated cirrhosis. These patients were divided into two groups: the transplantation group included 33 patients, while the control group included 35. Both groups received conventional medical treatment simultaneously, and APBSC transplantation was performed on the patients in the transplantation group. We evaluated the effects of APBSC transplantation on postoperative liver function using the following indices: total bilirubin, serum prothrombin and albumin, spleen size, and portal vein hemodynamics. Postoperatively, all of the patients were followed up at 24, 36, and 48 weeks.

Results:

The transplantation group had no serious reactions. Compared with the control group, albumin and prothrombin activity in the transplantation group was significantly improved at 24, 36, and 48 weeks after the procedure, and spleen length and portal vein diameter were substantially reduced at 48 weeks. The velocity of peak portal vein blood flow and mean maximum portal vein blood flow were greatly increased in the APBSC transplantation group at 36 and 48 weeks, respectively; however, there was also decreased portal vein diameter, which reduced portal vein pressure in patients with HBV-related decompensated cirrhosis.

Conclusions:

APBSC transplantation greatly benefits HBV-linked decompensated cirrhosis patients and should be recommended in clinical practice.     

Risk Factors for Portal Vein Thrombosis in Patients With Cirrhosis Awaiting Liver Transplantation in Shiraz,Iran

Background:

Portal vein thrombosis is a fairly common and potentially life-threatening complication in patients with liver cirrhosis. The risk factors for portal vein thrombosis in these patients are still not fully understood.

Objectives:

This study aimed to investigate the associations between various risk factors in cirrhotic patients and the development of portal vein thrombosis.

Patients and Methods:

In this case-control study performed at the Shiraz organ transplantation center, Iran, we studied 219 patients (> 18 years old) with liver cirrhosis, who were awaiting liver transplants in our unit, from November 2010 to May 2011. The patients were evaluated by history, physical examination, and laboratory tests, including factor V Leiden, prothrombin gene mutation, Janus Kinase 2 (JAK2) mutation, and serum levels of protein C, protein S, antithrombin III, homocysteine, factor VIII, and anticardiolipin antibodies.

Results:

There was no statistically significant difference in the assessed hypercoagulable states between patients with or without portal vein thrombosis. A history of previous variceal bleeding with subsequent endoscopic treatment in patients with portal vein thrombosis was significantly higher than in those without it (P = 0.013, OR: 2.526, 95% CI: 1.200 - 5.317).

Conclusions:

In our population of cirrhotic patients, treatment of variceal bleeding predisposed the patients to portal vein thrombosis, but hypercoagulable disorders by themselves were not associated with portal vein thrombosis.     

Renal effects of long-term treatment with 5-aminosalicylic acid

BACKGROUND:

A number of case reports link the use of 5-aminosalicylic acid (5-ASA) to interstitial nephritis in patients with inflammatory bowel disease (IBD).

OBJECTIVE:

To investigate whether the long-term use of 5-ASA has harmful effects on renal function in patients with IBD.

METHODS:

A retrospective analysis of 171 consecutive outpatients with Crohn’s disease or ulcerative colitis was conducted. Serum creati-nine levels and body weight were measured before and after treatment to calculate the creatinine clearance (CrCl) rate.

RESULTS:

In 171 patients (93 women, 78 men), the mean (± SD) dose of 5-ASA was 3.65±0.85 g/day with a cumulative dose of 11±7.7 kg over an interval of 8.4±5.9 years. Serum creatinine concentrations increased from 76.8 μmol/L to 88.7 μmol/L (n=171; P<0.0001) and the CrCl rate fell significantly from 104.6 mL/min to 93.1 mL/min (n=81; P<0.0001). There was one case of interstitial nephritis reported. Treatment groups included mesalamine (74.3%), sulfasalazine (15.2%) and combination (sulfalsalazine/mesalamine [10.5%]) with treatment durations of 7.2±4.5, 12.3±8.7 and 11.2±6.7 years, respectively. The duration of treatment was the most important covariate for change in CrCl and when analyzed by treatment group, those treated with sulfasazine had a strong correlation (r=−0.54, P=0.0145), while nonsignificant in the mesalamine group (r=0.06, P=0.7017). The decline in CrCl was negatively correlated with the pretreatment CrCl rate (r=−0.34; P=0.0024) and positively correlated with the mean daily dose of 5-ASA (r=0.32; P=0.0034).

CONCLUSION:

The present study is the first to demonstrate a significant dose- and treatment duration-dependant decline in CrCl. The risks need to be further evaluated because 5-ASA is widely used for long-term maintenance therapy in patients with IBD.     

Does transient elastography (FibroScan®) have a role in decision making in hepatocellular carcinoma?

Objectives

Portal hypertension has been reported as a negative prognostic factor and a relative contraindication for liver resection. This study considers a possible role of fibrosis evaluation by transient elastography (FibroScan®) and its correlation with portal hypertension in patients with cirrhosis, and discusses the use of this technique in planning therapeutic options in patients with hepatocellular carcinoma (HCC).

Methods

A total of 77 patients with cirrhosis, 42 (54.5%) of whom had HCC, were enrolled in this study during 2009–2011. The group included 46 (59.7%) men. The mean age of the sample was 65.2 years. The principle aetiology of disease was hepatitis C virus (HCV)-related cirrhosis (66.2%). Liver function was assessed according to Child–Pugh classification. In all patients liver stiffness (LS) was measured using FibroScan®. The presence of portal hypertension was indirectly defined as: (i) oesophageal varices detectable on endoscopy; (ii) splenomegaly (increased diameter of the spleen to ≥12 cm), or (iii) a platelet count of <100 000 platelets/mm³.

Results

Median LS in all patients was 27.9 kPa. Portal hypertension was recorded as present in 37 patients (48.1%) and absent in 40 patients (51.9%). Median LS values in HCC patients with and without portal hypertension were 29.1 kPa and 19.6 kPa, respectively (r = 0.26, P < 0.04). Liver stiffness was used to implement the Barcelona Clinic Liver Cancer algorithm in decisions about treatment.

Conclusions

The evaluation of liver fibrosis by transient elastography may be useful in the follow-up of patients with cirrhosis and a direct correlation with portal hypertension may aid in the evaluation of surgical risk in patients with HCC and in the choice of alternative therapies.     

Portal biliopathy in patients with non-cirrhotic portal hypertension: does the type of surgery affect outcome?

Objectives

After portosystemic anastomoses for biliopathy, some patients continue to suffer biliary obstruction. The effects of splenectomy and devascularization of the abdominal oesophagus and upper stomach are unclear. The aim of the current study was to determine the features of portal biliopathy (PB) in patients with non-cirrhotic portal hypertension, and to investigate outcomes in these patients after surgical procedures.

Methods

A retrospective study of 56 patients who underwent surgery for PB during 1996–2010 was conducted. Data on presenting features, treatment received and outcomes were analysed.

Results

In total, 41 of these patients had extrahepatic portal venous obstruction and 15 had non-cirrhotic portal fibrosis. Forty patients underwent shunt surgery and 16 underwent splenectomy and devascularization. Median bilirubin levels fell from 1.8 mg/dl (range: 0.4–5.9 mg/dl) to 1.0 mg/dl (range: 0.3–5.4 mg/dl) after shunt surgery and from 1.9 mg/dl (range: 0.6–4.0 mg/dl) to 1.2 mg/dl (range: 0.6–5.2 mg/dl) after splenectomy–devascularization. On follow-up, five of 33 patients had persistent jaundice after successful shunt surgery. These patients had a history of multiple endoscopic stentings and three patients had demonstrated a dominant common bile duct stricture preoperatively.

Conclusions

Portal biliopathy was reversed in 38 of 43 patients by either portosystemic shunting or splenectomy–devascularization. In five patients, direct biliary decompressive procedures were required because of shunt blockage or a non-reversible biliary stricture.     

Is There any Difference Between the Glomerular Filtration Rate of Patients With Chronic Hepatitis B and C and Patients With Cirrhosis?

Background

Renal dysfunction is a major determinant of the Model of End-stage Liver Disease (MELD) score. The implementation of the MELD score has shifted allocation of livers to patients with renal dysfunction.

Objectives

The aim of our study was the assessment of estimated Glomerular Filtration Rate (eGFR) by the Modification of Diet in Renal Disease 4 (MDRD4) method in patients with HBV chronic hepatitis, HCV chronic hepatitis, and cirrhosis (CH) caused by these viruses to detect any differences in renal function among these diseases.

Patients and Methods

We performed a cross-sectional analysis of all consecutive patients with HBV chronic hepatitis, HCV chronic hepatitis, and cirrhosis caused by these viruses hospitalized during a 4 year period in the Gastroenterology and Hepatology department of the Emergency County Hospital Timisoara, Romania. The eGFR was assessed by the MDRD4 method. Statistical analysis (unpaired t-test, ANOVA, Chi Square test) was performed using OpenEpi 2.3.1.

Results

HBV chronic hepatitis, HCV chronic hepatitis, and cirrhosis secondary to these viruses were associated with a reduction of the GFR. The eGFR was higher in patients with HBV chronic hepatitis than in patients with HCV chronic hepatitis (P &lt; 0.001). Patients with cirrhosis secondary to HBV infection had a higher eGFR than patients with cirrhosis secondary to HCV (P = 0.01). The eGFR of patients with HCV chronic hepatitis was higher than the eGFR of patients with cirrhosis due to this virus (P &lt; 0.001).

Conclusions

Functional renal impairment in diseases caused by HCV was more important than in diseases caused by HBV. The eGFR was statistically lower in cirrhosis secondary to HCV than in HCV chronic hepatitis.     

Effect of a diet with unrestricted sodium on ascites in patients with hepatic cirrhosis

Background/Aims

There has been debate on whether a sodium-restricted diet (SRD) should be used in cirrhotic patients with ascites in China in recent years. The purpose of this study was to compare the effect of sodium-restricted and unrestricted diets on plasma renin activity (PRA), renal blood flow (RBF) and ascites in patients with liver cirrhosis.

Methods

Two hundred cirrhotic patients with ascites were randomly divided into two groups (98 cases in the sodium-unrestricted diet [SUD] group and 102 cases in the SRD group); 95 patients (96.94%) in the SUD group and 97 patients (95.1%) in the SRD group had post-hepatitis B cirrhosis.

Results

Blood sodium and RBF were higher in SUD group than in SRD group (p<0.001), while PRA were significantly lower in SUD group than the SRD group 10 days after treatment (p<0.001). Renal impairment caused by low blood sodium was higher in SRD group than in SUD group (p<0.01). Ascites disappeared in higher proportion of patients in SUD group than in SRD group (p<0.001).

Conclusions

SUD can increase the level of blood sodium and RBF, and be beneficial to diuresis and ascite reduction and disappearance.     

Safety and efficacy of preoperative right portal vein embolization in patients at risk for postoperative liver failure following major right hepatectomy

Background

Right portal vein embolization (RPVE) has been utilized with or without segment IV (RPVE + IV) prior to hepatectomy to induce hypertrophy and prevent liver insufficiency in patients with a predicted future liver remnant (FLR) of ≤30% or cirrhosis.

Methods

Records of patients who underwent RPVE during 2006–2010 were retrospectively reviewed. Patient demographics, operative outcomes and complications were analysed. Computed tomography-based volumetrics were performed to determine FLR volume and degree of hypertrophy. Patients were stratified by segment IV embolization. Short-term outcomes following RPVE and liver resection are reported.

Results

A total of 23 patients were identified. Ten patients underwent RPVE and 13 underwent RPVE + IV. The RPVE procedure resulted in a 38% increase in FLR volume. Liver volumes, hypertrophy rates and outcomes were similar in both groups. Rates of operative complications in the RPVE and RPVE + IV groups were similar at 50% and 54%, respectively, and most complications were minor. Complication rates as a result of embolization were 30% in the RPVE group and 31% in the RPVE + IV group. One patient underwent modified operative resection as a result of a complication of RPVE.

Conclusions

Right portal vein embolization (±segment IV) is a safe and effective modality to increase FLR volume. Post-embolization complications and short-term outcomes after resection are acceptable and are similar in both RPVE and RPVE + IV.     

Prognostic Significance of p53, mTOR,c-Met,IGF-1R,and HSP70 Overexpression after the Resection of Hepatocellular Carcinoma

Background/Aims

The current study examines the expression of molecular biomarkers in hepatocellular carcinoma (HCC) and whether these findings correlate with the clinicopathologic features of the disease and patient survival.

Methods

We analyzed the immunohistochemical expression of p53, mammalian target of rapamycin (mTOR), c-Met, and insulin-like growth factor 1 receptor (IGF-1R) heat shock protein 70 (HSP70) with the clinicopathologic features of 83 HCCs.

Results

p53 expression was higher in the male patients with undifferentiated histological tumor grades, cirrhosis, and portal vein invasion. High 48 c-Met expression correlated with cirrhosis, and high mTOR expression correlated with the tumor grade and cirrhosis. High IGF-1R expression correlated with the tumor grade and cirrhosis. A multivariate analysis identified a significant relationship between the high expression of p53, tumor grade, and portal vein invasion. In addition, a high expression of mTOR was related to tumor grade and cirrhosis, and a high expression of HSP70 was related to portal vein invasion in a multivariate analysis. The Kaplan-Meier survival curve for patients with high versus low Edmondson grades and p53 expression was statistically significant.

Conclusions

p53, mTOR, and IGF-1R expression correlated with the Edmondson tumor grade in a univariate analysis, while p53 and mTOR correlated with the Edmondson tumor grade in a multivariate analysis. In addition, the tumor grade was found to predict survival. p53 was primarily related to the clinicopathologic features compared to other markers, and it is a poor prognostic factor of survival.     

Low Serum Hepatitis B Surface Antigen Level Predicts Compensated Cirrhosis Caused by Chronic Hepatitis B in HBeAg Positive Patients in East China

Backgrounds:

Serum hepatitis B surface antigen (HBsAg) levels are associated with fibrosis in patients with chronic hepatitis B (CHB) infection.

Objectives:

The aim of our study was to evaluate serum HBsAg level as a biomarker for compensated cirrhosis in hepatitis B e antigen (HBeAg) positive CHB patients.

Patients and Methods:

Two-hundred and one HBeAg-positive Chinese CHB patients with or without cirrhosis were enrolled in this retrospective study. Cirrhosis was diagnosed based on liver biopsy. Furthermore, patients with decompensated cirrhosis were excluded. A statistical analysis was performed regarding the association between serum HBsAg level and compensated cirrhosis.

Results:

Patients with compensated cirrhosis had a significantly lower mean serum HBsAg level compared to those without cirrhosis (3.27 Log₁₀ IU/mL VS 4.17 Log₁₀ IU/mL, P < 0.001). Furthermore, examining the correlation with compensated cirrhosis revealed that lower level of serum HBsAg was a significant factor in multivariate analysis. The area under the receiver operating characteristics curve of serum HBsAg was 0.856 for compensated cirrhosis. A positive predictive value of 66.2% and negative predictive value of 90.7% were obtained with a cut-off value of < 3.60 Log₁₀ IU/mL (4000 IU/mL) of serum HBsAg. Moreover, the rate of compensated cirrhosis increased to 75.0% after combining with APRI > 2.

Conclusions:

In HBeAg positive CHB patients, low serum HBsAg level is a useful predictor of compensated cirrhosis.     

Pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: a French multicentre prospective evaluation of resection margins in 150 evaluable specimens

Objectives

This study aimed to determine the impact of a standardized pathological protocol on resection margin status after pancreaticoduodenectomy (PD) for ductal adenocarcinoma.

Methods

A total of 150 patients operated during 2008–2010 were included in a prospective multicentre study using a ‘quality protocol’. Multicolour inking by the surgeon identified three resection margins: the portal vein–superior mesenteric vein margin (PV-SMVm) or mesenterico–portal vein groove; the superior mesenteric artery margin (SMAm), and the posterior margin. Resection margins were stratified by 0.5-mm increments (range: 0–2.0 mm). Pancreatic neck, bile duct and intestinal margins were also analysed. Correlations between histopathological factors and survival in the 0-mm resection margin group were analysed.

Results

Thirty-six patients (24%) had a PV-SMV resection (PV-SMVR). An analysis of resections categorized according to margin distances of 0 mm, <1.0 mm, <1.5 mm and <2.0 mm confirmed R1 resections in 35 (23%), 91 (61%), 94 (63%) and 107 (71%) patients, respectively. The most frequently invaded resection margin was the PV-SMVm (35% of all patients) and PV-SMVR was the only factor correlated with a higher risk for at least one 0-mm positive resection margin on multivariate analysis (P < 0.001). Two-year progression-free survival (PFS) and median PFS time in patients with R0 and R1 resections (at 0 mm), respectively, were 42.0% and 26.5%, and 19.5 months and 10.5 months, respectively (P = 0.02). A positive PV-SMVm and SMAm had significant impact on PFS, whereas a positive posterior margin had no impact.

Conclusions

Pancreaticoduodenectomy requiring PV-SMVR was associated with a higher risk for R1 resection. The standardization of histopathological analysis has a clinically relevant impact on PFS data.     

Feasibility of the Glissonian approach during right hepatectomy

Objective

The Glissonian approach during hepatectomy is a selective vascular clamping procedure associated with low rates of technical failure and complications. The aim of the present study was to assess the feasibility of a right Glissonian approach in relation to portal vein anatomy.

Methods

This was a prospective study conducted over a 12-month period, which included 32 patients for whom preoperative three-dimensional reconstruction using contrast-enhanced computed tomography in the portal venous phase and portography for right portal vein embolization were available, and in whom a right Glissonian approach was applied during right hepatectomy. Preoperative imaging data were correlated with intraoperative Doppler ultrasound findings (considered as the reference dataset). Causes of failures and complications specifically related to the Glissonian approach were identified.

Results

Right hepatectomy was performed for colorectal liver metastases (n = 25), hepatocellular carcinoma on cirrhosis (n = 6) and intrahepatic cholangiocarcinoma (n = 1). The Glissonian approach was effective in 24 (75%) patients. In the remaining eight (25%) patients, failure was caused by incomplete clamping (n = 2) or clamping of the left portal pedicle (n = 6). The portal anatomy was aberrant in six patients with failure, showing portal trifurcation (n = 1), right portal trifurcation (n = 1) and a common trunk between the right anterior and left portal branch (n = 4). An angle of less than 50 ° between the portal vein and left portal branch was reported in association with extended clamping to the left portal branch (selectivity = 72%, specificity = 71%). Intraoperative bleeding and biliary fistula occurred in two patients with non-normal portal anatomy.

Conclusions

The right Glissonian approach was effective in 75% of patients. Failure of the procedure (including the extension of clamping to the left pedicle) mostly occurred in patients with portal vein variations, which can be accurately assessed using a combination of preoperative imaging and intraoperative Doppler ultrasound.     

Portal vein resection using the no-touch technique with a hepatectomy for hilar cholangiocarcinoma

Objectives

To assess the safety and feasibility and discuss the oncological impact of a portal vein resection using the no-touch technique with a hepatectomy for locally advanced hilar cholangiocarcinoma.

Patients and Methods

From 2005 to March 2009, 49 patients with hilar cholangiocarcinoma underwent a major right-sided hepatectomy with curative intent. Portal vein resection was performed using the no-touch technique in 36 patients (PVR group) but the portal vein was not resected in the other 13 patients (NR group). Peri-operative data and histological findings were compared between the two groups. Moreover, tumour recurrence and survival rates after surgery were calculated and compared for each group.

Results

Although the tumours of the patients in the PVR group were more locally advanced, the residual tumour status and tumour recurrence rate were similar and there was no significant difference in long-term survival between the two groups: 5-year survival rates in the PVR and NR groups were 59% and 51%, respectively (P = 0.353). In-hospital mortality was encountered in 2 of the 49 patients.

Conclusion

A portal vein resection using the no-touch technique with a right-sided hepatectomy had a positive impact on survival and is feasible in terms of long-term outcomes with acceptable mortality.     

Cirrhosis is not a contraindication to laparoscopic cholecystectomy: results and practical recommendations

Background

Gallstones appear more frequently in patients with cirrhosis and open cholecystectomy in this patient population is associated with higher morbidity and mortality. The aim of the present study was to evaluate experience with laparoscopic cholecystectomy in patients with cirrhosis and to provide recommendations for management.

Methods

Retrospective review of laparoscopic cholecystectomy in patients with cirrhosis from March 1999 to May 2008 was performed. Peri-operative characteristics and subgroup analysis were performed in patients with Child–Pugh''s classes A, B and C cirrhosis.

Results

A total of 68 patients were reviewed in this study. In all, 69% of the patients were Child''s class A. The most common indication for cholecystectomy was chronic/symptomatic cholelithiasis (68%). Compared with patients with Child''s class B and C, laparoscopic cholecystectomy in patients with Child''s class A was associated with significantly decreased operative time (P= 0.01), blood loss (P= 0.001), conversion to open cholecystectomy (P= 0.001) and length of hospital stay (P= 0.001).

Conclusions

Laparoscopic cholecystectomy in patients with cirrhosis is feasible with no mortality and low morbidity, especially in patients with Child''s class A cirrhosis.     

Granulocyte Colony Stimulating Factor Adjuvant Role on the Immunological Response to Hepatitis B Vaccine in Patients With Cirrhosis: A Double Blind Randomized Placebo Controlled Trial

Background:

Patients with liver cirrhosis have usually poor antibody response to hepatitis B virus (HBV) vaccination.

Objectives:

This study aimed to investigate the effect of granulocyte colony stimulating factor (G-CSF) on increasing antibody titers, after HBV vaccination, in patients with liver cirrhosis waiting for transplantation.

Patients and Methods:

From 56 patients with cirrhosis, 28 patients were allocated to receive double dose HBV vaccine (40 μgr) plus G-CSF and 28 patients were allocated to receive double dose HBV vaccine (40 μgr) plus placebo. Injections were performed on weeks 0, 4 and 8 and the blood samples were obtained one month after each vaccination session.

Results:

There was no statistically significant difference between anti-HBV antibody titers in patients receiving double dose HBV vaccination plus G-CSF and patients receiving double dose HBV vaccination plus placebo, after first, second or third vaccination rounds (P > 0.05). Although the adjuvant G-CSF injection did not cause significant increased antibody titers in our patients compared to the placebo group, the increase in antibody titers following vaccination, happened faster in this group, compared to the placebo group.

Conclusions:

The present study showed that G-CSF is not superior to placebo in production of protective antibody titers after HBV vaccination but could result in a more rapid antibody response, compared to the placebo.     

The Risk of Cellulitis in Cirrhotic Patients: A Nationwide Population-Based Study in Taiwan

Background/Aims

Cellulitis is a common infectious disease. However, the risk of cellulitis in cirrhotic patients is not well established, and whether liver cirrhosis is a risk factor for cellulitis remains unknown. This study evaluated the relationship between cellulitis and liver cirrhosis.

Methods

The National Health Insurance Database, which was derived from the Taiwan National Health Insurance program, was used to identify patients. The study group consisted of 39,966 patients with liver cirrhosis, and the comparison group consisted of 39,701 randomly selected age- and sex-matched patients.

Results

During the 3-year follow-up period, 2,674 (6.7%) patients with liver cirrhosis developed cellulitis, and 1,587 (4.0%) patients without liver cirrhosis developed cellulitis (p<0.001). Following a Cox''s regression analysis adjusted for age, sex, and underlying medical disorders, the cirrhotic patients demonstrated a greater risk for the occurrence of cellulitis than the non-cirrhotic patients during the 3-year period (hazard ratio [HR], 1.66; 95% confidence interval [CI], 1.55 to 1.77; p<0.001). Additionally, cirrhotic patients with complications also had a greater risk for the occurrence of cellulitis than those patients without complications (HR, 1.23; 95% CI, 1.14 to 1.33; p<0.001).

Conclusions

We conclude that cirrhotic patients have a greater risk of cellulitis than non-cirrhotic patients.     

Clinical Characteristics of Patients with Hepatocellular Carcinoma in a Middle Eastern Population

Background

Hepatocellular carcinoma (HCC) is one of the leading causes of death in Saudi male patients. Local clinical and demographic data of this disease are scarce.

Objectives

We sought to describe the clinical characteristics and outcomes of patients from two tertiary care centers in Saudi Arabia.

Patients and Methods

Data were collected for all patients diagnosed to have hepatocellular carcinoma between June 2003 and July 2008 who had been registered in a special research database (the Saudi Observatory Liver Disease Registry (SOLID)). Data were extracted from SOLID for clinical, biochemical, radiologic parameters and outcome.

Results

Data was available for 363 patients, the mean age of diagnosis was 66 years, 74% of patients were males, and Hepatitis C was the underlying cause of liver disease in 48%, while Hepatitis B in 29%. Most of the patients were diagnosed at an advanced stage, 53 % of patients had a CLIP score of 4 to 6 (advanced stage), 55% had large multi-nodular tumors and 16% had vascular invasion or extra-hepatic spread at the time of diagnosis. Most of the patients had decompensated cirrhosis; with child-pogh score B in 44% and C in 26% with presence of portal hypertension in 55%. Forty eight percent died during the study period. Predictors of poor survival in the univariate analysis were; presence of portal vein thrombosis (P = 0.03), portal hypertension (P < 0.0001), presence of ascites (P = 0.022), hepatic encephalopathy (P < 0.0001), advanced child-pough score (P < 0.0001), bilirubin > 22 (P < 0.0001) and INR > 1.2 (P = 0.02). On multivariate analysis, only the presence of portal hypertension, bilirubin > 22 and severe hepatic encephalopathy were significant with adjusted hazard ratio of 1.6 (95% CI; 1.04-2.47), 1.76 (95% CI; 1.12-2.8), and 3.18 (95% CI; 1.42-7.14) respectively.

Conclusions

The data from this cohort indicates that most of patients diagnosed with HCC present at late tumor and liver disease stages, when prognosis is usually dismal. Regular cancer surveillance in cirrhotic patients might change the outcomes. Further studies with results of treatment outcomes in this community are needed.     

Idiopathic Colonic Varices: Case Report and Review of Literature

Introduction:

Colonic varices represent a very rare entity, either an incidental finding at colonoscopy or discovered due to its complication, the lower gastrointestinal bleeding. The most common cause of colonic varices is portal hypertension associated with liver disease or secondary to pancreatic conditions, like chronic pancreatitis or malignancies. The incidence of colonic varices is very low, even in liver cirrhosis where the patients frequently develop varices in the upper gastrointestinal tract, but surprisingly uncommon present with varices localized in the colon.

Case Presentation:

We report a case of idiopathic colonic varices, diagnosed at a routine colonoscopy performed for nespecific abdominal disturbances in a female patient without liver disease or pancreatic conditions responsible for portal hypertension development.

Conclusions:

The development of colonic varices in the absence of a certain trigger represents a major issue for practitioners due to its major complication, lower gastrointestinal bleeding.     

Laparoscopic cholecystectomy is the preferred approach in cirrhosis: a nationwide,population-based study

Background/aim

To assess the impact of open versus laparoscopic surgery in cirrhotic patients undergoing a cholecystectomy using the Nationwide Inpatient Sample (NIS).

Methods

All patients with cirrhosis who underwent a cholecystectomy (open or laparoscopic) between 2003 and 2006 were queried from the NIS. Associated complications including infection, transfusion, reoperation, liver failure and mortality were determined.

Results

A total of 3240 patients with cirrhosis underwent a cholecystectomy: 383 patients underwent an open cholecystectomy (OC) whereas 2857 patients underwent a laparoscopic cholecystectomy (LC), which included 412 patients converted (LCC) from a LC to an OC. Post-operative infection was higher in OC as opposed to a laparoscopic cholecystectomy (TLC) or LCC (3.5% versus 0.7% versus 0.2%, P < 0.0001). The need for a blood transfusion was significantly higher in the OC and LCC groups as compared with the TLC group (19.2% versus 14.4% versus 6.2%, P < 0.0001). Reoperation was more frequent after OC or LCC versus TLC (1.5% versus 2.5% versus 0.8%, P = 0.007). In-hospital mortality was higher after OC as compared with TLC and LCC (8.3% versus 1.3% versus 1.4%, P < 0.0001).

Conclusion

Patients with cirrhosis have increased in-hospital morbidity and mortality after an open as opposed to a laparoscopic or conversion to an open cholecystectomy. LC should be the preferred initial approach in cirrhotic patients.     

The Factors Affecting Bone Density in Cirrhosis

Background:

Bone loss is common in cirrhosis. However, the prevalence of osteopenia and osteoporosis has been heterogeneous in different reports. Reduction in bone formation with or without increase in bone resorption appears to be responsible for bone loss in these patients.

Objectives:

We aimed to investigate bone loss in patients with cirrhosis at different anatomical sites and key factors that might affect it.

Patients and Methods:

In this cross-sectional study, 97 patients with cirrhosis who were referred to Razi Hospital, Rasht, Iran, from 2008 to 2010, were studied. Cirrhosis was diagnosed using biopsy and/or clinical and paraclinical findings. Bone mineral densitometry was done in L2 through L4 lumbar spine (LS) and femoral neck (FN), using dual-energy X-ray absorptiometry (DEXA) (QDR 1000, Hologic DEXA Inc, Waltham, Massachusetts, the United States). Statistical analysis was performed using SPSS 18. A P value < 0.05 was considered statistically significant.

Results:

A total of 97 patients with cirrhosis (55.7% male) and the mean age of 51 ± 13 years and median body mass index (BMI) of 22.7 kg/m² were recruited over a two-year period. Etiologies of cirrhosis were hepatitis C (40.2%), hepatitis B (26.8%), cryptogenic (21.6%), and other causes (11.4%). Child A, B, and C, were seen in 16.5%, 47.4%, and 36.1% of patients, respectively. The DEXA results were abnormal in 78.4% of our participants (osteopenia, 45.4%; osteoporosis, 33%). BMI and calculated glomerular filtration rate (GFRc) had moderate positive and Child score had moderate negative significant correlation with T score in both anatomical sites. There was no significant association between abnormal DEXA and the causes of cirrhosis. The univariate analysis showed that the risk of abnormal results in DEXA was significantly higher in those with low BMI, current smoking, higher Child score, and low GFRc; however, in multivariate analysis, the abnormal results were more frequent in those with lower vitamin D, higher Child score, and less GFRc.

Conclusions:

Abnormal DEXA was highly prevalent among patients with cirrhosis. The risk of this finding was increased by lower vitamin D levels, advanced disease, and impaired renal function.