Thirty-day postoperative mortality after hysterectomy in women with liver cirrhosis: a Danish population-based cohort study

BACKGROUND: Women with liver cirrhosis have a higher incidence of hysterectomy than the general population, generally because of abnormal bleeding. They may also have an increased risk of postoperative mortality and morbidity. METHODS: In the nationwide Danish National Patients Register (NPR) we identified all women diagnosed with liver cirrhosis from 1977 to 1993. From this cohort we selected all women undergoing hysterectomy. A random sample of women without liver cirrhosis undergoing hysterectomy was selected as controls. Outcome was defined as mortality within the first 30 days after discharge. Logistic regression analysis was used to estimate the association between liver cirrhosis and 30-day postoperative mortality, adjusted for age, comorbidity, and type of admission. RESULTS: Out of 8539 women with liver cirrhosis 105 underwent hysterectomy. We found a 30-day postoperative mortality of 7.6% (95% confidence interval (CI) 2.5-12.7%) and 0.6% (95% CI 0.5-0.7%) in women with and without liver cirrhosis, respectively. The crude odds ratio was 14 (95% CI 6.5-29) and the adjusted odds ratio was 11 (95% CI 4.8-24) for 30-day postoperative mortality in women with liver cirrhosis compared with non-cirrhotic controls. CONCLUSION: Hysterectomy in women with liver cirrhosis is associated with an 11-fold increased risk of death within the first 30 days after discharge.     

Gastroduodenal ulcer perforation in the patient with cirrhosis.

This retrospective study was done to stress the particular features of perforation of the gastroduodenal ulcer in patients with cirrhosis. From 1979 to 1987, 135 patients were operated upon for perforation of the gastroduodenal ulcer: clinical, biologic and roentgenographic data of 22 patients with cirrhosis were compared with 112 patients without cirrhosis. In the 22 patients with cirrhosis, three gastrectomies and 19 simple closures with omental patch were performed. Clinical ascites was present in 16 of 22 patients with cirrhosis. Acute abdominal pain and leukocytosis were less frequent in patients with cirrhosis (p less than 0.05), whereas associated bleeding in the upper part of the gastrointestinal (GI) tract was more frequent (p less than 0.05). In patients with cirrhosis, abnormal plasma creatinine level and associated upper GI bleeding were more frequent in patients with ascites (p less than 0.05); on the other hand, acute abdominal pain and rebound tenderness were less frequent (p less than 0.05). The incidence of pneumoperitoneum was higher in patients with cirrhosis. Surgical treatment was significantly delayed in patients with cirrhosis and ascites. Ulcers were larger in patients with cirrhosis and ascites than without (p less than 0.001). Over-all morbidity and mortality rates in patients with cirrhosis were 77.3 and 50.0 per cent, respectively. Mortality and morbidity were significantly higher in patients with ascites than without (62.5 versus 16.6 and 100 versus zero per cent, respectively), in patients with prothrombin times of less than 50 per cent and with plasma creatinine levels more than 110 micromolars.     

Cryptococcus neoformans peritonitis in two patients with liver cirrhosis.

Cryptococcus neoformans is an important pathogen in immunocompromised patients. We report 2 cases of spontaneous C. neoformans peritonitis in patients with liver cirrhosis, a condition not previously reported in Taiwan. Patient 1, a 59-year-old man with alcoholic liver cirrhosis, had primary C. neoformans peritonitis with fungemia. The patient recovered completely after prolonged fluconazole therapy without relapse. Patient 2, a 51-year-old woman with liver cirrhosis due to Budd-Chiari syndrome, had C. neoformans isolated from ascites, cerebrospinal fluid, and blood culture. In spite of adequate antifungal treatment, the patient died of fulminant sepsis. Information about the interaction and relation between liver cirrhosis and cryptococcal peritonitis is rare in the literature. The experience of these cases may help facilitate the diagnosis and treatment of cryptococcal peritonitis.     

Successful pregnancy in a woman with secondary biliary cirrhosis with portal hypertension from recurrent pyogenic cholangitis. A case report.

BACKGROUND: Pregnancy in women with secondary biliary cirrhosis due to recurrent pyogenic cholangitis is extremely rare. Little information is available on the effect of pregnancy on the disease and vice versa. CASE: A patient who had secondary biliary cirrhosis due to recurrent pyogenic cholangitis complicated by splenomegaly and portal hypertension had a successful pregnancy. Although she had a history of esophageal variceal bleeding before this pregnancy, there was no such bleeding during pregnancy. She had an uneventful antenatal course except that her liver enzyme level fluctuated slightly. The serum bilirubin level increased during the third trimester of pregnancy but returned to the prepregnant level after delivery. CONCLUSION: Termination of pregnancy may not be the only option for management. The management protocol for patients with primary biliary cirrhosis complicating pregnancy, which includes regular fetal surveillance and monitoring of maternal liver function, should be considered for pregnant women with secondary biliary cirrhosis.     

Infective endocarditis in patients with liver cirrhosis.

BACKGROUND AND PURPOSE: Infective endocarditis complicating liver cirrhosis is infrequently reported. This study evaluated the clinical features of infective endocarditis in Taiwanese patients with liver cirrhosis. METHODS: All cases of infective endocarditis occurring in patients with liver cirrhosis from December 1995 to December 2002 were included in this study. Data were collected by retrospective chart review. RESULTS: Twenty six patients (18 males, 8 females) with median age 6 years (range, 43 to 87) were included. The etiology of liver cirrhosis was hepatitis virus infection in 20 patients. There were 7 nosocomial infections. Bacterial pathogens were identified in 25 patients, with Staphylococcus aureus (n = 8), viridans streptococci (n = 4), Streptococcus sanguis (n = 2), Pseudomonas aeruginosa (n = 2), and Enterococcus faecalis (n = 2) the most common isolates. The hospital mortality rate was 27%. Patients with in-hospital death were more likely to have a history of uremia, staphylococcal infection, nosocomial infection and less likely to have aortic valve infection. CONCLUSIONS: The prognosis of patients with infective endocarditis and liver cirrhosis was poor. Infection with Staphylococcus species was a dominant cause and methicillin resistance was common.     

Therapeutic effect of ursodeoxycholic acid on early-stage primary biliary cirrhosis.

Primary biliary cirrhosis is a rare chronic liver disease in Taiwan, which eventually causes mortality. As yet, no safe and effective treatment has been found. To investigate the safety and therapeutic efficacy of recently introduced ursodeoxycholic acid (UDCA) in the treatment of primary biliary cirrhosis, an uncontrolled trial was conducted in 6 patients in the early stages (I-II) and 5 patients in the late stages (III-IV). Five patients in stage I and one patient in stage II were treated with 10-15 mg/kg/day UDCA for a mean administration period of 13 +/- 9 months. Levels of laboratory tests including serum alkaline phosphatase (ALP), alanine aminotransferase (ALT) and aspartate aminotransferase (AST) improved significantly within one month and were sustained at the new lower levels for the period of observation. The symptoms of one patient with pruritus were reduced after long-term therapy. No major side effects were found during the treatment period. In contrast to early-stage patients, patients with late-stage primary biliary cirrhosis who received UDCA therapy for a mean duration of 25 +/- 5 months showed no beneficial effects either clinically or biochemically. From these preliminary results, UDCA appears to be safe and effective in the treatment of early-stage primary biliary cirrhosis, although further controlled clinical trials in conjunction with histological follow-up are mandatory to evaluate the critical role of UDCA in primary biliary cirrhosis.     

Decompensated cirrhosis and pregnancy: a case report

The association of decompensated cirrhosis and pregnancy is rare. Portal hypertension exposure to gastrointestinal bleeding from a ruptured esophageal varix may at any time complicate the course of the disease. We report the case of a 24-year-old patient who delivered at 35 weeks/four days of gestation with decompensated cirrhosis secondary to viral hepatitis B; icterus, oedema, and ascites were present. The postpartum course was uneventful despite the biological disorder of coagulation.     

Pregnancy and primary biliary cirrhosis

Pregnancy is rarely encountered in patients with primary biliary cirrhosis. Ten pregnancies in nine patients have been reported in the literature. All five pregnancies that continued beyond the 31st week had increasing jaundice during late pregnancy. We describe a case of primary biliary cirrhosis with symptomatic onset at age 19, pregnancy a year later, with subsequent resolution of jaundice and pruritus. This course is different than most described by others.     

Pregnancy in liver cirrhosis and/or portal hypertension.

Clinical features of pregnancy in women with liver cirrhosis and/or portal hypertension have been reviewed. Termination of pregnancy is seldom indicated in a woman with compensated cirrhosis or a young woman with extrahepatic venous obstruction. However, the risk of spontaneous abortion is increased in cirrhotic women without shunt even if there is no deterioration of liver function. The risk of bleeding from esophageal varices or deterioration of liver function is usually unpredictable. Shunt surgery can be done with relatively little effect on both the mother and the fetus if conservative measurements fail to control the hematemesis. Vaginal delivery can be anticipated in most women, and cesarean section should be preserved for obstetric indications. The risk of postpartum hemorrhage is greatly increased, particularly in patients with previous shunt surgery. Perinatal loss is high because of the increased rate of premature delivery and stillbirth. Maternal prognosis is grave in women with cirrhosis.     

Pregnancy in primary biliary cirrhosis.

A 34-year-old multigravid woman with symptomatic primary biliary cirrhosis (PBC) of the liver had a successful pregnancy. A healthy baby was born prematurely at 36 weeks of gestation. Six months prior to the conception of this pregnancy, stage III PBC had been diagnosed. Portal hypertension and liver cirrhosis had not developed. It is uncommon for pregnancy to occur in the presence of PBC. In the case presented, the outcome of pregnancy was good and the liver function had not been significantly affected by the pregnancy.     

Sex steroids in women with liver cirrhosis

Eighteen women with hepatic cirrhosis were examined for plasma levels of testosterone, estrone, estradiol, progesterone and sex hormone binding globulin. For eight who were amenorrheic, with advanced liver cirrhosis and ascites, the reduction of testosterone and rise in estrone and sex hormone binding globulin concentrations were significant. Plasma extradiol and progesterone were lower than normal levels, but the differences were not statistically significant. The other ten patients were menstruating (mostly irregularly), and their hormonal levels were assessed in different states of their cycles. All of them did not ovulate, had low levels of plasma progesterone and also showed consistent estrone concentration excess relative to estradiol and significant lowering of testosterone and elevation of sex hormone binding globulin. These findings are compared with previous reports on males with liver cirrhosis.     

Functioning hepatic cell mass and the hyperdynamic state in cirrhosis

Seventeen patients with advanced hepatic cirrhosis underwent cardiopulmonary assessment by means of Swan-Ganz catheters combined with indocyanine green clearance studies to measure functioning hepatic cell mass. The indocyanine green clearance test was found to have a statistically significant linear correlation with such indicators of the hyperdynamic circulatory state as cardiac index and total peripheral resistance. Results from these studies also showed that the hyperdynamic state in cirrhosis is associated with limited oxygen consumption as compared with a control series of patients. Of the 14 patients who required operations, eight survived and six died. The mean indocyanine green clearance was a statistically significant predictor of death.     

Outcomes of pregnancies complicated by liver cirrhosis,portal hypertension,or esophageal varices

Objective: To evaluate pregnancy outcomes in women with liver cirrhosis, portal hypertension, or esophageal varices.

Study design: We analyzed a retrospective cohort of 2?284?218 pregnancies in 2005–2009 recorded in the California Birth Registry database. Utilizing ICD-9 codes we analyzed the following outcomes for liver cirrhosis, portal hypertension, or esophageal varices in pregnancy: preeclampsia (PET), preterm delivery (PTD; <37 weeks), cesarean section, low birth weight (LBW; <2500?g), small for gestational age (SGA; <10th percentile), neonatal death (NND), and postpartum hemorrhage (PPH).

Results: Cirrhosis in pregnancy conferred an increased risk of PET, PTD, CS in multiparous women, LBW, and NND. Portal hypertension in pregnancy was associated with PTD, LBW, NND, and PPH. Non-bleeding esophageal varices in pregnancy were not associated with the outcomes assessed in a statistically significant manner. One case of bleeding esophageal varices was observed, resulting in PTD with a LBW infant. There were three cases of concomitant portal hypertension or concomitant esophageal varices with cirrhosis in pregnancy.

Conclusion: Pregnancy in women with concomitant liver cirrhosis, portal hypertension, or esophageal varices can be successful. However, pregnancy outcomes are worse and may warrant closer antenatal monitoring and patient counseling. Cirrhosis in pregnancy with concomitant portal hypertension or esophageal varices is rare.     

Fatal Klebsiella pneumoniae meningitis and emphysematous brain abscess after endoscopic variceal ligation in a patient with liver cirrhosis and diabetes mellitus.

Procedure-related bacterial infections may complicate esophageal variceal ligation in cirrhosis patients. Here, we report a 58-year-old man with underlying diabetes and liver cirrhosis who developed Klebsiella pneumoniae meningitis and brain abscess with gas formation in brain parenchyma and ventricles after this procedure. Despite administration of appropriate antimicrobial therapy, he became comatose on the 3rd day of acute illness and died on the 4th day of hospitalization. This case highlights the indication for antimicrobial prophylaxis in cirrhotic patients with gastrointestinal bleeding, and the need for early and heightened awareness of central nervous system infections in cirrhotic patients with hepatic encephalopathy.     

Survival after distal splenorenal shunt.

These data support the conclusions that the distal splenorenal shunt is attended by the highest post-shunt survival as yet reported for patients with non-alcoholic cirrhosis, portal hypertension and bleeding varices; the procedure is safe, and in this series, the mortality has been nil for 66 consecutive operations. An analysis of the causes of death suggests that continued alcohol abuse plays an important part in the late mortality among those in the post-shunt alcoholic cirrhosis group.     

Endoscopic mucosal resection with a cap-fitted endoscope for early gastric carcinoma with focal submucosal invasion in a patient with decompensated liver cirrhosis.

Prognosis for patients with early gastric cancer who undergo gastric resection is far better than that for patients with advanced disease. However, patients with advanced liver cirrhosis may not be suitable for general anesthesia and major surgery. We used a less invasive endoscopic mucosal resection (EMR) with a cap-fitted endoscope to resect an early gastric cancer in a 58-year-old male with decompensated liver cirrhosis. Although postoperative pathology revealed that the tumor had focal invasion to the submucosa, the patient had an uneventful course and was well during 4 years' follow-up. This method may be effective for the treatment of early gastric cancer with focal submucosal invasion when patients are not suitable for major surgery.     

Elevated level of CA 125 antigen in women in reproductive age without neoplastic diseases in pelvis minor

Behaviour of CA 125 antigen in women in reproductive age without neoplastic diseases in pelvis minor was presented. The study material was divided into 4 groups: 29 women with endometriosis, 16 women with inflammation of pelvis minor, 7 women with cirrhosis, developmental malformation of reproductive organs and pregnancy, 8 women of middle gynaecological age 6.75 had endometriosis. It has been revealed that the inflammatory state of the uterine adnexa and the appendix as well as cirrhosis, developmental malformation of reproductive organs may evolve with elevated level of CA 125 marker. It has also been shown that endometriosis in pelvis minor may be expressed by a raised level of CA 125 marker.     

Two successive pregnancies after ursodeoxycholic acid therapy in a previously infertile woman with antimitochondrial antibody-negative primary biliary cirrhosis

OBJECTIVE: To describe the benefit of ursodeoxycholic acid (UDCA) for the initiation and completion of a successful pregnancy in a previously infertile woman with primary biliary cirrhosis. DESIGN: Case report. SETTING: A university hospital with relevant departments. PATIENT(S): A 29-year-old woman with primary biliary cirrhosis and failure to conceive for 6 years. INTERVENTION(S): Establishment of diagnosis with a liver biopsy, pretreatment of patient with UDCA before conception, and continuation of UDCA after first trimester until term. UDCA was used in the second pregnancy again after the first trimester. MAIN OUTCOME MEASURE(S): Achievement of a safe conception and full-term pregnancy. RESULT(S): Two consecutive successful pregnancies, a healthy 3,250-g male infant and a healthy 3,000-g female infant. The second conception occurred in a period without the use of UDCA, implicating a latent beneficial effect of either UDCA or the previous pregnancy via some possible immune mechanism. CONCLUSION(S): Ursodeoxycholic acid could help achieve conception in infertile women with primary biliary cirrhosis. The use of UDCA after the first trimester is shown to be safe in two consecutive pregnancies. Although it cannot be conclusive, the unintentional use of UDCA in the first 20 days after conception did not result in any teratogenicity in the first child.     

Hepatic resection in patients with cirrhosis and hepatocellular carcinoma.

Hepatic resection can be performed safely in carefully selected patients with cirrhosis. To minimize morbidity and mortality, it is essential to reliably estimate functional hepatic reserve and the extent of tumor before resection is performed. Child's classification is a reliable predictor of long term survival, but a more sensitive measure of hepatic function is needed to predict early morbidity and mortality. Child's classification can also be used to stratify patients and exclude those at high risk from hepatic resection. Promising predictors of operative mortality focus on the mitochondrial function of hepatocytes and include cytochrome a (+a3) contents and the redox tolerance index. Patients with advanced cirrhosis are not candidates for extensive hepatic resection and require careful evaluation before consideration for any hepatic resection. In patients with well-compensated cirrhosis and unifocal tumors, the procedure of choice is an anatomic resection of the tumor. If tumor size and location allows, a segmentectomy offers the best outcome, minimizing postoperative liver dysfunction while offering a long term outcome not dissimilar to a major liver resection. In highly selected patients with incidental tumors, a central tumor and perhaps in patients with multifocal hepatocellular carcinoma, hepatic transplantation may be of benefit. By using the appropriate predictors of hepatic function, refined surgical techniques and optimal postoperative care, a mortality rate of less than 10 per cent is achievable in cirrhotic patients with hepatocellular carcinoma who require resection.