Complication Of Chronic Liver Disease Research Articles

Role of angiogenic factors/cell adhesion markers in serum of cirrhotic patients with hepatopulmonary syndrome

Hepatopulmonary syndrome is a complication of chronic liver disease resulting in increased morbidity and mortality. It is caused by intrapulmonary vascular dilations and arteriovenous connections with devastating influence on gas exchange. The pathogenesis is not completely understood but evidence mounts for angiogenesis. Aims of this study were to identify angiogenic factors in serum of patients with hepatopulmonary syndrome and to study the possibility to predict its presence by these factors. Multiplex assays were used to measure the concentration of angiogenic factors in patients with (n=30) and without hepatopulmonary syndrome (n=30). Diagnosis was based on the presence of gas exchange abnormality and intrapulmonary vasodilations according to published guidelines. Patients with and without hepatopulmonary syndrome had similar MELD scores (median: 11.2 vs. 11.6; P=0.7), Child-Pugh score (P=0.7) and PaCO2 values (median: 35 vs. 37; P=0.06). PaO2 and P(A-a) O2 gradient were significantly different (respectively median of 80 vs. 86, P=0.02; and 24 vs. 16, P=0.004). Based on area under the curve (AUC) data and P-values, the best predictors were vascular cell adhesion molecule 1 (VCAM1) (AUC=0.932; P<0.001) and intercellular adhesion molecule 3 (ICAM3) (AUC=0.741; P=0.003). Combining these factors results in an AUC of 0.99 (after cross-validation still 0.99). VCAM1 and ICAM3 might be promising biomarkers for predicting hepatopulmonary syndrome. Combining these factors results in an AUC of 0.99 and a negative predictive value of 100%. Determining the concentration of these biomarkers might be a screening method to detect hepatopulmonary syndrome. The use of these biomarkers should be validated in larger groups of patients.

Editorial introductions

Current Opinion in Gastroenterology was launched in 1985. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of gastroenterology is divided into 12 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce one of the Section Editors for this issue. SECTION EDITORS Don RockeyDon RockeyDr Don Rockey completed internship, residency, chief residency, and fellowship at the University of California, San Francisco, USA. He is currently Chairman of the Department of Medicine, the Medical University, Charleston, USA. He has active basic and clinical research interests in liver disease. He has worked on areas ranging from clinical management problems in liver diseases such as portal hypertension, hepatic blood flow, drug induced liver injury and complications of chronic liver disease to basic liver cell and molecular biology. The central theme of his laboratory research revolves around understanding the cell and molecular basis of fibrosis and portal hypertension. His laboratory initially demonstrated that a key player, the hepatic stellate cell, exhibits a contractile phenotype. Further, following liver injury, stellate cells exhibit exaggerated contractility, constrict liver sinusoids, and contribute to increased intrahepatic vascular resistance typical of portal hypertension. He and his laboratory have gone on to explore a number of molecular events important in this disease. Dr Rockey has had highly active clinical interests in multiple aspects of chronic liver disease as well as drug induced liver injury. Dr Rockey and his colleagues have published over 150 peer reviewed scientific papers related to his research and over 100 editorials, reviews, and book chapters. He has served in a number of capacities on behalf of major US Gastroenterology and Liver societies including for the American Gastroenterological Association (AGA) and the American Association for the Study of Liver Disease (AASLD). Among many responsibilities, he has served as Chair of The AGA Research Policy Committee, Chair of the AASLD Training and Workforce committee. He has also been active in the Alliance for Academic Internal Medicine (AAIM) having served as President for the Association of Subspecialty Professors (ASP). He has had a number of editorial responsibilities, including as Associate Editor for Hepatology, Associate Editor for Liver International and has served on various NIH and other study sections, and editorial boards. Gregory J. GoresGregory J. GoresGregory J. Gores, M.D., Reuben R. Eisenberg Endowed Professor of Medicine and Physiology, is Executive Dean for Research at the Mayo Clinic College of Medicine, USA, is a Distinguished Investigator of the Mayo Foundation, and a past chair of the Division of Gastroenterology and Hepatology. A native of North Dakota, he received his undergraduate (Phi Beta Kappa) and M.D. (Alpha Omega Alpha) degrees from the University of North Dakota, USA. He received his training in Internal Medicine and Gastroenterology at Mayo, Rochester, Minnesota, USA. He is a past President of the American Association for the Study of Liver Diseases (AASLD) and the International Liver Cancer Association (ILCA). He has chaired the Hepatobiliary Pathobiology NIH Study Section and is currently a member of the NIDDK Advisory Council. Due to his breadth and depth of interests, he has served as an Associate Editor for Hepatology on two separate terms and once for Gastroenterology. He is the past recipient of a highly prestigious and competitive NIH MERIT Award, currently a Principal Investigator of three NIH R01 grants. He has co-authored more than 500 total publications which have been cited over 25,000 times. His current h-index (number of papers with an identical number of citations) is 92. Well respected as a mentor, he has mentored over 70 post-doctoral research and clinical fellows. His clinical and research contributions include advances in our understanding of hepatobiliary malignancies, liver transplantation and mechanisms of liver cell injury.

Pulmonary complications in chronic liver disease.

The association of chronic liver disease with respiratory symptoms and hypoxia is well recognized. Over the last century, three pulmonary complications specific to chronic liver disease have been characterized: hepatopulmonary syndrome (HPS), portopulmonary hypertension (POPH), and hepatic hydrothorax (HH). The development of portal hypertension is fundamental in the pathogenesis of each of these disorders. HPS is the most common condition, found in 5%-30% of cirrhosis patients, manifested by abnormal oxygenation due to the development of intrapulmonary vascular dilatations. The presence of HPS increases mortality and impairs quality of life, but is reversible with liver transplantation (LT). POPH is characterized by development of pulmonary arterial hypertension in the setting of portal hypertension, and is present in 5%-10% of cirrhosis patients evaluated for LT. Screening for POPH in cirrhosis patients eligible for LT is critical since severe POPH is a relative contraindication for LT. Patients with moderate POPH, who respond adequately to medical therapy, may benefit from LT, although sufficient controlled data are lacking. HH is a transudative pleural effusion seen in 5%-10% of cirrhosis patients, in the absence of cardiopulmonary disease. Diagnosis of HH should prompt consideration for LT, which is the ultimate treatment for HH. Conservative management includes salt restriction and diuretics, with thoracentesis and transjugular intrahepatic portosystemic shunt (TIPS) as second-line therapeutic options.

Liver damage associated with exposure to aspirin and diazinon in male rats and the ameliorative effect of selenium

PurposeThe widespread use of organophosphorus insecticides (OPIs) consequently leads to the exposure of manufacturing workers, field applicators, the ecosystem, and finally the public to the possible toxic effects of OPIs. In addition, drugs or pharmaceutical products, which are used to cure diseases, are also xenobiotics with both therapeutic/toxic potentials. It is evident from the literature, which is very limited, that drug/insecticide interactions can result in altered response/toxicity, which is of clinical relevance. The aim of the present study was designed to assess the adverse effects of exposure to aspirin and diazinon and their combination on liver of male rats and hepatoprotective potential of selenium (Se). MethodsRats were oral administered with vehicle, acetyl salicylic acid (ASA) at the maximum administration dose (1350mg/personal/day=22.5mg/kg. b.wt.), diazinon (DIA) at 20mg/kg. b.wt. and Se at a dose of 200μg/kg b.wt./day and their combinations for 28 consecutive days. Serum liver biomarkers, e.g. ALT&AST, ALP, ChE, LDH, albumin, total protein were determined as well as histological and histochemical studies. ResultsBody weight was statistically (P≤0.05) decreased, while relative liver weight was statistically (P≤0.05) increased in DIA and ASA+DIA-treated groups. The activities of serum aspartate aminotransferase (AST), alanine transaminase (ALT), alkaline phosphatase (ALP) and lactate dehydrogenase (LDH) were statistically (P≤0.05) increased, while the activity of cholinesterase (ChE) was decreased in rats exposed to DIA, ASA and DIA+ASA. In addition, administration of DIA, ASA and their combination resulted in damage of liver structures and increase in the immunoreactivity of caspase-3 expression in the cytoplasm of the hepatocytes as compared to the control group. Combination therapy with Se significantly (P≤0.05) restored these alterations to within the normal limits and prevents disruptions of liver structures. ConclusionsThe present study indicates that liver enzymes, histopathology and immunoreactivity of caspase-3 would trigger ASA- and DIA-induced liver injury. The severities of such observations were more pronounced in their combined exposure. Combination therapy with Se restored these alterations to within the normal limits and prevents disruptions of liver structures. The data throw light on the problem of simultaneous exposure to OPIs and commonly used drugs especially that are metabolised by CYP450. Accordingly, ASA should be avoided since many of the adverse effects associated with these drugs are similar to the complications of chronic liver disease especially of agricultural workers in developing countries, where the handling of drugs without medical prescription. We suppose that antioxidant supplementation may be beneficial for the people using ASA for longer periods.

Diffusion Weighted MRI for Hepatic Fibrosis: Impact of b-Value

BackgroundHepatic fibrosis is a typical complication of chronic liver diseases resulting in cirrhosis that remains a major public health problem worldwide. Liver biopsy is currently the gold standard for diagnosing and staging hepatic fibrosis. Percutaneous liver biopsy; however, is an invasive procedure with risks of complications. Therefore, there is need for alternative non-invasive techniques to assess liver fibrosis and chronic liver diseases. In recent years, MRI techniques, including diffusion weighted imaging (DWI), have been developed for in vivo quantification of liver fibrosis.ObjectivesThe purpose of this study is to evaluate the utility of diffusion weighted MRI in the diagnosis and quantification of the degree of hepatic fibrosis and to investigate the influence of b-value.Patients and MethodsTwenty-four patients (13 males, 11 females), with a mean age of 46 years (36-73 years) diagnosed as chronic hepatitis and histopathologically proven liver fibrosis and 22 other patients (8 males, 14 females) with no clinical or biochemical findings of liver disease, with a mean age of 51.2 years (32-75 years) were included in the study. All patients with chronic hepatitis underwent percutaneous liver biopsy by an experienced hepatologist without sonographic guidance. The Knodell histology activity index (HAI) for grading of necroinflammatory changes and Metavir scoring system for staging of the liver fibrosis were used to record the severity of the disease. All patients were examined with a 1.5 Tesla MRI system and the patients underwent diffusion weighted imaging (DWI) with a routine hepatic MRI protocol. Different b-values including 250, 500, 750, and 1000 sec/mm 2 were used to calculate apparent diffusion coefficients.ResultsWe detected decreased apparent diffusion coefficient values in patients with hepatic fibrosis compared to patients without chronic hepatitis and there was a trend toward decrease in hepatic apparent diffusion coefficient values with an increasing degree of fibrosis.ConclusionsOur findings suggest that hepatic apparent diffusion coefficient measurement with a b-value of 750 sec/mm 2 or greater is useful in accurate quantification of liver fibrosis and necroinflammation.

Osteoporosis in primary biliary cirrhosis of the liver.

Osteoporosis is a metabolic bone disease associated with a reduction in bone mass and deterioration of bone architecture, leading to increased fragility and subsequent low-trauma fractures in the vertebral column, hip, forearm and other bones. In literature, metabolic bone diseases such as osteoporosis and osteomalacia have been recognised as a complication of chronic liver disease, although the mechanisms of this association remain unclear. An increasing body of research data indicates a strong relationship between osteoporosis and primary biliary cirrhosis (PBC), which mainly results from early diagnosis of the disease, usually when it is still asymptomatic. The incidence of osteoporosis in PBC ranges from 20% to 44% and increases with the progression of the disease. Similarly, the incidence of bone fractures is high in this group of patients (10–20%). In this article, current knowledge on risk factors, pathogenesis, diagnosis and treatment of osteoporosis in PBC is reviewed.

The Detection of Hepatocellular Carcinoma Using a Prospectively Developed and Validated Model Based on Serological Biomarkers

Hepatocellular carcinoma is a common complication of chronic liver disease (CLD), and is conventionally diagnosed by radiological means. We aimed to build a statistical model that could determine the risk of hepatocellular carcinoma in individual patients with CLD using objective measures, particularly serological tumor markers. A total of 670 patients with either CLD alone or hepatocellular carcinoma were recruited from a single UK center into a case-control study. Sera were collected prospectively and specifically for this study. A logistic regression analysis was used to determine independent factors associated with hepatocellular carcinoma and a model built and assessed in terms of sensitivity, specificity, and proportion of correct diagnoses. The final model involving gender, age, AFP-L3, α fetoprotein (AFP), and des-carboxy-prothrombin ("GALAD") was developed in a "discovery" data set and validated in independent data sets both from the same institution and from an external institution. When optimized for sensitivity and specificity, the model gave values of more than 0.88 irrespective of the disease stage. The presence of hepatocellular carcinoma can be detected in patients with CLD on the basis of a model involving objective clinical and serological factors. It is now necessary to test the model's performance in a prospective manner and in a routine clinical practice setting, to determine if it may replace or, more likely, enhance current radiological approaches. Our data provide evidence that an entirely objective serum biomarker-based model may facilitate the detection and diagnosis of hepatocellular carcinoma and form the basis for a prospective study comparing this approach with the standard radiological approaches.

After the Cure: Management of HCV After Achievement of SVR

Co-infection with HIV and HCV is associated with accelerated progression of liver disease and increased complications compared with HCV infection alone. Treatment of HCV and achievement of a sustained virologic response (SVR) can improve outcomes in these patients. Even after clearance of the hepatitis C virus, however, patients remain at risk, albeit diminished, for the complications of chronic liver disease. As such, longitudinal monitoring of treated patients remains important for clinicians caring for this population. This article summarizes the benefits and persistent risks after attaining SVR. It reviews the natural history of fibrosis and addresses the monitoring and management of progressive liver disease.

Multiple Ways to Manage Portal Thrombosis During Liver Transplantation: Surgical Techniques and Outcomes

BackgroundPortal vein thrombosis (PVT) is a well-recognized complication of chronic liver disease with a prevalence ranging from 1% to 16%. Materials and MethodsWe performed a retrospective review of 447 consecutive patients who underwent liver transplantation (OLT) between October 2000 and December 2011 comparing 51 recipients with PVT (study group) with 399 without PVT (control group). The aim of this study was to determine the impact of pre-existent PVT on the surgical procedure, to identify specific preventable perioperative complications, and based on our studies and other works, to determine whether this group of patients are acceptable candidates for OLT. ResultsAmong the 51 patients with PVT, 44 showed partial and 7 complete thrombosis. In 47 cases, we performed a thromboendovenectomy. There were six anastomoses at the confluence of the superior mesenteric vein (SMV) and one, with a venous graft interposition. In four complete thrombosis recipients we performed an extra-anatomic by pass between the main trunk of the SMV and the donor portal vein. Compared with the control group, regarding preoperative characteristics, PVT patients were older at the time of transplantation (P = .001) and had a higher use of TIPS (P = .02). The operative characteristics showed a longer warm ischemia time in the PVT group (46.9 ± 22.5 vs 39.3 ± 15 min; P = .004). There were significant differences in postoperative evaluations, nor in the complication rates. Overall survivals at 10 years were similar: 61.7% versus 65.3%; (P = .9). ConclusionAlthough PVT was associated with greater operative complexity, it had no influence on postoperative complications or overall survival.

Letter to the editor concerning “hepatic myelopathy with spastic paraparesis: report of two cases and review of the literature” by S. Ben Amor et al. (Eur Spine J. 2013, Jun 1)

To the Editor, We read with great interest the article by Ben Amor et al. [1] published in the European Spine Journal entitled “Hepatic myelopathy with spastic paraparesis: report of two cases and review of the literature”. The authors state in their paper that there is no special diagnostic tool for hepatic myelopathy (HM), and that the diagnosis has to be established on clinical grounds after exclusion of other possible entities. However, in our opinion, there is a noticeable omission in this important article. Our previous study [2] revealed that motor evoked potentials (MEP) elicited by transcranial magnetic stimulation (TMS) may be very helpful in the diagnosis of this rare complication of chronic liver diseases that is usually associated with a portosystemic shunt and likely to be overlooked. The authors demonstrated that central motor conduction studies by means of TMS are sensitive, accurate and easily applicable methods for detecting even a subclinical damage of the corticospinal tract. The threshold for corticospinal electrophysiological abnormalities was below that for clinical and/or radiological changes. Spinal cord involvement was evident even at the preclinical stage and became more overt as the disease progressed. Most of the examined patients did not have clinical symptoms and presented only physiological subclinical abnormalities. MEP studies may thus disclose an impairment of the corticospinal pathways even before HM is clinically manifest and enable an early diagnosis of HM. Since, liver transplantation (the first therapeutic option) should be performed before spinal cord damage becomes irreversible [3–5], the diagnosis of HM must be established as early as possible to enhance the chance of a complete recovery of the spinal cord. Therefore, we believe that such an important examination, which is at present widely and easily performed in the most neurophysiology laboratories, cannot be neglected. We found important to highlight that, especially in a review article on HM, this important diagnostic tool should be included and discussed.

AB1022 Osteoporosis is associated with chronic liver disease

BackgroundBone manifestations are well-known extra hepatic complication of chronic liver disease. The prevalence of osteoporosis among patients with chronic liver diseases ranges from 10% to 60%.Objectivesthe aim of this study...

Echocardiography for the detection of portopulmonary hypertension in liver transplant candidates: An analysis of cutoff values

Portopulmonary hypertension (POPH), a complication of chronic liver disease, may be a contraindication to liver transplantation (LT) because of the elevated risk of peritransplant and posttransplant morbidity and mortality. Because POPH is frequently asymptomatic, screening with echocardiography is recommended. The only reliable technique, however, for diagnosing POPH is right heart catheterization (RHC). The aims of this study were to evaluate the current estimated systolic pulmonary artery pressure (sPAP) cutoff value of 30 mm Hg and to determine a better cutoff value. One hundred fifty-two patients underwent pretransplant echocardiography between January 2005 and December 2010. These echocardiographic results were compared with pulmonary artery pressures measured during the pretransplant workup or at the beginning of the transplantation procedure (both by catheterization). With a cutoff value of 30 mm Hg, 74 of the 152 patients met the criteria for POPH on echocardiography, although the diagnosis was confirmed in only 7 patients during catheterization; this resulted in a specificity of 54%. It would have been more accurate to use a cutoff value of 38 mm Hg, which had a maximal specificity of 82% and, at the same time, guaranteed a sensitivity and negative predictive value of 100%. With the incorporation of the presence or absence of right ventricular dilatation, the specificity even increased to 93% for this new cutoff value. In conclusion, the prevalence of POPH was 4.6% among LT candidates in this study. We can recommend that LT candidates with an sPAP > 38 mm Hg should be referred for RHC. With the cutoff value increased from 30 to 38 mm Hg, the number of patients undergoing invasive RHC during their evaluation could be safely reduced.

Оцінка ефективності корекції запальних та фібротичних процесів у хворих на хронічний вірусний гепатит С

Високий рівень захворюваності, погіршення якості життя хворих, зростання смертності від ускладнень хронічних захворювань печінки обумовлюють соціально значиму медичну проблему. Пошук механізмів гальмування процесів фіброгенезу є одним із актуальних напрямів.У роботі вивчено вплив базової терапії (препаратів урсодезоксихолевої кислоти, есенціальних фосфоліпідів, пентоксифіліну, аргініну гідрохлориду) і поєднання базової терапії з автоцитокінами на показники функціональної активності печінки, ендогенної інтоксикації, процесів фіброгенезу. Обстежено 42 хворих на хронічний вірусний гепатит С.Застосування базової терапії та автоцитокінів мало більш вагомий позитивний вплив на прояви цитолізу, холестазу, обмін глікопротеїнових комплексів позаклітинного матриксу, детоксикаційну функцію печінки та ендотоксемію, про- і антифіброгенні фактори.

Assessing portal hypertension in liver diseases

Portal hypertension is a common complication of chronic liver diseases and is responsible for most clinical consequences of cirrhosis, which represent the more frequent causes of death and liver transplantation in these patients. This review is aimed at clarifying the state-of-the art assessment of portal hypertension and at discussing recent developments in this field. Particular attention is paid to new noninvasive techniques that will be soon available for potential routine use.

Liver Fibrosis – Mouse Models and Relevance in Human Liver Diseases

Liver fibrosis, the excessive accumulation of extracellular matrix (ECM) in the liver, develops as a long-term consequence of chronic liver injury, and significantly contributes to the mortal complications of chronic liver disease. Different cell types contribute to the hepatic wound healing response. Hepatic stellate cells (HSC) are the main fibrogenic cell in the liver. Upon liver injury, HSCs transdifferentiate into myofibroblasts and contribute to ECM deposition in the liver. Small animal models have provided insight into the activation process of HSCs and the complex interplay of the different cell types involved in liver fibrogenesis. Animal models not only allow one to identify relevant profibrogenic pathways, but also to test the contribution of these pathways to liver disease in preclinical settings. In this review, mouse models of toxic, cholestatic, apoptotic, acoholic, viral and metabolic liver fibrosis will be discussed, with a particular emphasis on the underlying pathophysiology, relevance to human liver disease and drug development.

Aflatoxins, Hepatitis and Hepatocellular Carcinoma: A Special Focus on Turkey’s Current Status

Aflatoxins, Hepatitis and Hepatocellular Carcinoma: A Special Focus on Turkey’s Current Status Mycotoxins are food contaminants produced as secondary metabolites by different kinds of fungi. The major groups of mycotoxins are aflatoxins (AFs), ochratoxins, patulin and fusarium toxins. Aflatoxin B1 (AFB1) is classified as carcinogenic to humans (Group I) by The International Agency for Research on Cancer. The principle target organ of AFB1 is liver. AFB1 causes hotspot mutation of p53 gene at third base of codon 249, and takes the form of G…>T transversions. Besides, both hepatits B virus (HBV) and hepatits C virus (HCV) infections were suggested to be responsible HCC. HCC is the most frequent primary liver cancer and the most severe complication of chronic liver disease. The annual number of new cases worldwide represents more than 5% of human cancers and is the third leading cause of cancer-related deaths. One or more causative agents can be identified in most HCC cases. AFB1 exposure with viral hepatitis is suggested to lead to HCC. This review will focus on AFB1, viral hepatitis, their synergistic and additive effects and the measures that should be taken to prevent HCC stemming from AFB1 exposure with viral hepatitis.

Distribution of Liver Disease in Bangladesh: A Cross-country Study.

ABSTRACTIntroduction ‘Hepatology’, as an independent discipline of medical science, has recently been established in Bangladesh. The aim of this study was to formulate the distribution of pattern of liver diseases in this country.Materials and methods In this retrospective study, data regarding patients of liver diseases from the seven different administrative divisions of Bangladesh between January 2012 and 2013 were compiled.Results The study included 59,227 patients (age ranged 15-95 years). Majority of the patients were males (67.9%). Although all patients appeared at the department of hepatology, 13.2% were diagnosed with liver diseases, but a vast majority of patients (77.35%) were suffering from nonulcer dyspepsia or irritable bowel syndrome. Patients with liver diseases were mostly suffering from chronic liver diseases (CLDs) (37 -69%). Complication of CLD, like hepatic encephalopathy, was less frequent in regions with better healthcare system. Nonviral infections, like liver abscess and biliary ascarisis, were not uncommon. Acute hepatitis was another very common entity and contributed to approximately 20% cases.Conclusion This study provides insight about heterogeneous distribution pattern of liver diseases in different regions of Bangladesh.How to cite this article: Rahman S, Ahmed MF, Alam MJ, Debnath CR, Hoque MI, Hussain MM, Shamsul Kabir AKM, Karim MF, Khondokar FA, Mahtab MA, Masud MG, Mollick MKU, Moben AL, Noor-E-Alam SM, Podder PK, Raha AK, Rahim MA, Rashid MHO, Zaki KMJ, Akbar SMF. Distribution of Liver Disease in Bangladesh: A Cross-country Study. Euroasian J Hepato-Gastroenterol 2014;4(1):25-30.

Dual (Mixed and Bland) Thrombus in Inferior Vena Cava: A Rare Presentation of Hepatocellular Carcinoma

Budd-Chiari syndrome (BCS) is defined as hepatic venous outflow obstruction at any level from the small hepatic veins to the junction of the inferior vena cava (IVC) and the right atrium. Hepatocellular carcinoma (HCC) is the complication of chronic liver disease and it usually presents as decompensation of the known chronic liver disease. HCC rarely present as BCS. Here, we present a rare case of HCC presenting first time with BCS with involvement of hepatic veins and dual thrombus in the IVC.

Rifaximin may have a dramatic effect on hepatic encephalopathy

With a steadily increasing healthcare burden, all physicians must be aware of methods to manage the complications of chronic liver disease, including hepatic encephalopathy. Approved by the Food and Drug Administration in the USA and several European countries as a treatment for recurrent hepatic encephalopathy an increasing number of patients are now receiving rifaximin for this condition. This ‘lesson of the month’ highlights the dramatic effect that rifaximin may have on hepatic encephalopathy.

Breath biomarkers of liver cirrhosis

The diagnosis of asymptomatic cirrhosis in patients with liver disease is of importance to start screening for complications in due time. Liver biopsy is neither sensitive nor practical enough to be used as a frequent follow-up test in patients with chronic liver disease. The volatile organic compounds present in exhaled breath offer the possibility of exploring internal physiologic and pathologic process in a non invasive way. This study examined whether a specific pattern of biomarkers can be found in breath samples of patients with cirrhosis. To this aim samples of alveolar breath from patients with cirrhosis and healthy volunteers were analyzed using gas chromatography–mass spectrometry. When linear discriminant analysis was used to search for a model(s)/pattern of compounds characteristic for liver cirrhosis, 24 models of 8 independent compounds could distinguish between the groups. The sensitivity and specificity (between 82% and 88%, and 96% and 100%, respectively) of the models suggest that a specific pattern of breath biomarkers can be found in patients with cirrhosis, which may allow detecting this complication of chronic liver disease in an early stage.