Hepatocellular carcinoma in a non‐cirrhotic liver with a tumor thrombus

Young adults with HCC tend to have a poor prognosis because of advanced disease despite preserved liver function. Screening and early diagnosis for HCC are needed for young adults to demonstrate an improved prognosis, especially in HBsAg positive patients.     

Community-acquired bacterial meningitis in cirrhotic patients.

The Hospital Universitari de Bellvitge (Barcelona, Spain) records all cases of bacterial meningitis in a 120-variable database. The characteristics of bacterial meningitis in cirrhotic patients are not well-known, and all cases of community-acquired bacterial meningitis occurring in cirrhotic patients were therefore identified. During 1977-2002, there were 602 episodes of community-acquired bacterial meningitis in adults, of which 29 (4.8%) occurred in cirrhotic patients. Compared to non-cirrhotic patients, there were significant differences in: duration of disease for >4 days at the time of diagnosis; absence of nuchal rigidity; certain aetiologies, e.g., Escherichia coli and Listeria monocytogenes; renal and liver function impairment; relapse of fever; and incidence of relapse and mortality. Overall, bacterial meningitis in cirrhotic patients was associated with a high mortality rate and a large number of complications. A high index of suspicion is necessary because of the frequent absence of meningeal signs. In addition to the classic meningeal pathogens, other aetiologies, including E. coli and L. monocytogenes, should be considered when prescribing empirical therapy.     

Partial nodular transformation in a cirrhotic liver

We present a case of partial nodular transformation (PNT) of the liver in a 57-year-old man with a history of heavy drinking. On computed tomography, a low-density mass, measuring 3 cm in diameter, and associated with portal flow defect was visualized. Based on this finding and on the findings of other imaging studies, hepatic resection was performed because of suspected hepatocellular carcinoma. Pathology examination of the excised specimen showed small portal tracts in the lesion. The findings for the rest of the liver were suggestive of mild liver cirrhosis. While PNT is similar to nodular regenerative hyperplasia (NRH), in NRH there is diffuse nodular transformation of the whole liver, whereas in PNT only the area adjacent to the porta hepatis is affected. The portal flow defect in PNT may be the result of attenuation of the portal tracts in the lesion. This case is of interest because there was only one PNT lesion, rather than multiple lesions, and because it occurred in a cirrhotic liver, thus giving rise to the suspicion of hepatocellular carcinoma. PNT is a benign disorder, thus it is essential to establish a definitive diagnosis by imaging and ultrasound-guided histological biopsy to prevent unnecessary hepatic resection.     

Acute kidney injury and hepatorenal syndrome in cirrhosis

Cirrhosis is the eighth leading cause of “years of lost life” in the United States and accounts for approximately 1% to 2% of all deaths in Europe. Patients with cirrhosis have a high risk of developing acute kidney injury. The clinical characteristics of hepatorenal syndrome (HRS) are similar to prerenal uremia, but the condition does not respond to volume expansion. HRS type 1 is rapidly progressive whereas HRS type 2 has a slower course often associated with refractory ascites. A number of factors can precipitate HRS such as infections, alcoholic hepatitis, and bleeding. The monitoring, prevention, early detection, and treatment of HRS are essential. This paper reviews the value of early evaluation of renal function based on two new sets of diagnostic criteria. Interventions for HRS type 1 include terlipressin combined with albumin. In HRS type 2, transjugular intrahepatic portosystemic shunt (TIPS) should be considered. For both types of HRS patients should be evaluated for liver transplantation.     

Simultaneous partial splenectomy during liver transplantation for advanced cirrhosis patients combined with severe splenomegaly and hypersplenism

BACKGROUND The most effective treatment for advanced cirrhosis and portal hypertension is liver transplantation(LT).However,splenomegaly and hypersplenism can persist even after LT in patients with massive splenomegaly.AIM To examine the feasibility of performing partial splenectomy during LT in patients with advanced cirrhosis combined with severe splenomegaly and hypersplenism.METHODS Between October 2015 and February 2019,762 orthotopic LTs were performed for patients with end-stage liver diseases in Tianjin First Center Hospital.Eighty-four cases had advanced cirrhosis combined with severe splenomegaly and hypersplenism.Among these patients,41 received partial splenectomy during LT(PSLT group),and 43 received only LT(LT group).Patient characteristics,intraoperative parameters,and postoperative outcomes were retrospectively analyzed and compared between the two groups.RESULTS The incidence of postoperative hypersplenism(2/41,4.8%)and recurrent ascites(1/41,2.4%)in the PSLT group was significantly lower than that in the LT group(22/43,51.2%;8/43,18.6%,respectively).Seventeen patients(17/43,39.5%)in the LT group required two-stage splenic embolization,and further splenectomy was required in 6 of them.The operation time and intraoperative blood loss in the PSLT group(8.6±1.3 h;640.8±347.3 mL)were relatively increased compared with the LT group(6.8±0.9 h;349.4±116.1 mL).The incidence of postoperative bleeding,pulmonary infection,thrombosis and splenic arterial steal syndrome in the PSLT group was not different to that in the LT group,respectively.CONCLUSION Simultaneous PSLT is an effective treatment and should be performed in patients with advanced cirrhosis combined with severe splenomegaly and hypersplenism to prevent postoperative persistent hypersplenism.     

芫花散贴脐治疗肝硬变腹水50例

目的:观察芫花散贴脐治疗肝硬变腹水的临床疗效。方法:将100例肝硬变并腹水患者随机分为两组各50例。两组均给予支链氨基酸、还原型谷胱甘肽注射液静脉滴注,针对血浆白蛋白28 g·L-1者,静脉补充人血白蛋白至正常,以30 d为1个疗程。对照组给予呋塞米40 mg·d-1+螺内酯100 mg·d-1口服利尿,治疗组应用芫花散贴敷于脐处。结果:对照组显效23例,有效15例,无效12例,有效率为76.0%,治疗组显效20例,有效26例,无效4例,有效率为88.0%,两组有效率比较差异有统计学意义(P0.05)。结论:芫花散穴位贴敷治疗肝硬变腹水临床疗效显著,未见明显不良反应。     

Arterial pressure profile in patients with cirrhosis: Fourier analysis of arterial pulse in relation to pressure level,stroke volume,and severity of disease: On the reduction of afterload in the hyperdynamic syndrome

Abstract

Objective. Patients with cirrhosis have cardiovascular dysfunction and altered mechanical properties of large and small arteries. This study was undertaken in order to analyze the arterial pressure curve in relation to mean arterial pressure level, stroke volume, and severity of liver disease. Materials and methods. Forty-one patients with cirrhosis (Child–Turcotte classes A/B/C = 13/15/13) were studied during a hemodynamic investigation of portal hypertension. Fifteen patients without liver disease served as controls. We applied fast Fourier analysis to quantify the pressure components of the arterial curve, the harmonic Fourier coefficients (HFC). Results. Mean arterial pressure was significantly reduced (91 vs. 98 mmHg, p < 0.001) and stroke volume was significantly increased (94 vs. 78 ml, p < 0.001) in patients with cirrhosis versus controls. The HFC were significantly lower in patients with cirrhosis than in controls (–15 to –24%, p < 0.002), except for the fourth HFC, which was significantly increased (+28%, p < 0.02). In contrast to controls, which showed a highly significant effect of the level of arterial pressure on their HFC (p < 0.001), patients with cirrhosis did not show pressure or stroke volume dependence on their HFC, indicating an overall compliant and slow reflective arterial vascular bed. The initial rise in pulse pressure (dP/dt) was inversely related to the Child–Turcotte score (p < 0.05), and the HFC were borderline significantly related to this score (p = 0.07). Conclusions. The arterial pulsation in cirrhosis is qualitatively changed with reduced pulse reflections, which may protect against manifest cardiac failure in patients with advanced cirrhosis.     

Role of laparoscopic subtotal cholecystectomy in the treatment of complicated cholecystitis

Introduction It is well known that laparoscopic cholecystectomy (LC) allows for shorter hospital stay and operative time, faster operative rehabilitation, and reduced wound complications compared with conventional open cholecystectomy. These advantages have been extensively published, and LC has become the "gold standard" in treating benign gallbladder diseases. When LC began in the early 1990s, acute cholecystitis and cirrhosis were considered comparative contraindications.[1-3] Growing ex…