Life-threatening Complication Of Cirrhosis Research Articles

Treatment-Related Cost Analysis of Terlipressin for Adults with Hepatorenal Syndrome with Rapid Reduction in Kidney Function.

Hepatorenal syndrome (HRS), a special form of acute kidney failure, is a rare, acute, life-threatening complication of cirrhosis and has a very poor prognosis. Terlipressin (TERLIVAZ®) is the first and only pharmacological treatment approved by Food and Drug Administration (September 2022) to improve kidney functionfor adults with HRS with rapid reduction in kidney function. We constructed a decision analytic economic model to estimate the cost per complete response/HRS reversal of terlipressin+albumin from a United States hospital perspective. A decision analytic model was developed to estimate the HRS treatment-related cost per response over an HRS hospitalization (assuming 14days). Patients can experience either HRS reversal (complete response) or no HRS reversal (partial/no response) upon receipt of treatment. The efficacy, safety, and treatment duration data were from published head-to-head randomized international trials. Total treatment cost comprised drug acquisition and treatment-related costs (intensive care unit [ICU], dialysis [intermittent or continuous], pulse oximetry monitoring for terlipressin, and adverse events) sourced from the published literature. Cost per response, defined as the total treatment cost per HRS reversal was estimated for each treatment. The number needed to treat (NNT), defined as the number of patients treated to achieve HRS reversal in 1 additional patient, was estimated. Cost per response of terlipressin+albumin was lower than midodrine and octreotide+albumin (M&O) (US$85,315 vs. $467,794) and norepinephrine+albumin ($81,614 vs. $139,324). NNT for HRS reversal was 2 patients with terlipressin+albumin vs. M&O+albumin and 4 patients with terlipressin+albumin vs. norepinephrine+albumin, respectively. The analysis shows that terlipressin is a cost-effective treatment due to its higher efficacy and administration in the non-ICU setting. Terlipressin is a value-based treatment option for appropriate adults with HRS with rapid reduction in kidney function.

Diagnostic Accuracy of Portal Vein Flow Velocity for Esophageal Varices in Cirrhotic Patients.

Background Variceal bleeding is a life-threatening complication of cirrhosis. Traditionally, endoscopy has been utilized as a preferred modality for the detection and grading of esophageal varices. However, endoscopy is an invasive procedure and may not be readily available in resource-limited settings. To overcome this limitation, various non-invasive tests, including Doppler ultrasonography (DUS) with portal vein (PV) velocity measurement, have been investigated to predict the presence of esophageal varices (EV). This study aimed to evaluate the potential utility of portal vein flow velocity (PVFV) as a non-invasive alternative to endoscopic screening for predicting the presence of esophageal varices among cirrhotic patients. Methodology This validation cross-sectional study was carried out at the Department of Gastroenterology and Hepatology, Pakistan Kidney and Liver Institute & Research Centre (PKLI&RC), Lahore, Pakistan from June 8, 2022, to March 8, 2023. Cirrhotic patients were enrolled based on clinical, laboratory, and radiological assessments. Doppler ultrasonography was performed to measure portal vein flow velocity along other relevant indices. Subsequently, all patients underwent endoscopic evaluation to screen and grade the esophageal varices. Univariate and multivariate logistic regression analyses were performed to identify significant clinical predictors of EV based on the results of the independent sample t-tests or Mann-Whitney U tests. Receiver operating characteristic (ROC) curves were employed to determine the optimal cut-off value for portal vein flow velocity (PVFV). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy were calculated based on the identified cut-off value. A p-value ≤ 0.05 was considered statistically significant. Results A cohort of 137 cirrhotic patients was enrolled. The study population consisted of 92 males (67.2%) and 45 females (32.8%). Endoscopic screening confirmed the presence of esophageal varices in 81 patients (59.91%). A multivariate analysis revealed that aspartate aminotransferase to platelet ratio index (APRI) (p=0.008) and portal vein flow velocity (p=0.001) were significant factors associated with esophageal varices and were used for receiver operating characteristic (ROC) analysis. The area under the curve (AUC) for PVFV was 0.981, and for APRI, it was 0.711. At a cut-off value of 18 cm/sec for PVFV, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy for esophageal varices were found to be 93.83%, 92.86%, 95%, 91.23%, and 93.43%, respectively. Conclusion Measurement of portal vein flow velocity using Doppler ultrasonography (DUS) is a reliable screening method for predicting the presence of esophageal varices (EV) in patients with liver cirrhosis. DUS offers several advantages, including its non-invasive nature, cost-effectiveness, and widespread availability, making it a recommended approach due to its high diagnostic accuracy.

Risk stratification based on acute-on-chronic liver failure in cirrhotic patients hospitalized for acute variceal bleeding

Background and aimsAcute variceal bleeding (AVB) is a life-threatening complication of cirrhosis. Acute-on-chronic liver failure (ACLF) is a syndrome characterized by acute decompensation of cirrhosis, multiple organ failures and high short-term mortality. This study aimed to evaluate the role of ACLF in the risk stratification of cirrhotic patients with AVB.MethodsProspective data of 335 cirrhotic patients hospitalized for AVB were retrospectively extracted from Medical Information Mart for Intensive Care (MIMIC)-IV database. ACLF was defined by European Association for the Study of Liver-Chronic Liver Failure Consortium and diagnosed/graded with chronic liver failure-organ failure (CLIF-OF) score. Cox-proportional hazards regression analysis was performed to identify the risk factors for 6-week morality in AVB patients. Discrimination and calibration of prognostic scores were evaluated by plotting the receiver operating characteristics (ROC) curve and calibration curve, respectively. Overall performance was assessed by calculating the Brier score and R2 value.ResultsA total of 181 (54.0%) patients were diagnosed with ACLF (grade 1: 18.2%, grade 2: 33.7%, grade 3: 48.1%) at admission. The 6-week mortality in patients with ACLF was significantly higher than that in patients without ACLF (43.6% vs. 8.4%, P < 0.001) and increased in line with the severity of ACLF (22.5%, 34.2% and 63.8% for ACLF grade 1, 2 and 3, P < 0.001). In multivariate analysis, presence of ACLF remained as an independent risk factor for 6-week mortality after adjusting for confounding factors (HR = 2.12, P = 0.03). The discrimination, calibration and overall performance of CLIF-C ACLF and CLIF-C AD were superior to the traditional prognostic scores (CTP, MELD and MELD-Na) in the prediction of 6-week mortality of patients with and without ACLF, respectively.ConclusionThe prognosis of cirrhotic patients with AVB is poor when accompanied by ACLF. ACLF at admission is an independent predictor for the 6-week mortality in cirrhotic patients with AVB. CLIF-C ACLF and CLIF-C AD are the best prognostic scores in AVB patients with and without ACLF, respectively, and can be used for the risk stratification of these two distinct entities.

A novel prognostic model for predicting the risk of first variceal hemorrhage in patients with HBV-related cirrhosis.

Variceal hemorrhage (VH) is a life-threatening complication of cirrhosis. An accurate VH risk evaluation is critical to determine appropriate prevention strategies. We aimed to develop an individualized prediction model to predict the risk of first VH in hepatitis B virus (HBV)-related cirrhotic patients. A nomogram was developed based on a retrospective analysis of 527 consecutive HBV-related cirrhotic patients with gastroesophageal varices (GEVs). The nomogram evaluation was performed using the area under the receiver operating characteristic curve (AUC), concordance index (C-index), calibration plot, and decision curve analysis (DCA). The results were verified using an external cohort (n = 187). We developed a nomogram based on clinical and endoscopic features, including the size of varices, red wale marks, ascites, spleen thickness, γ-glutamyltransferase, and hematocrit. The C-index of the nomogram in the derivation and validation cohort was 0.806 and 0.820, respectively, and the calibration plot fitted well. Compared with those of the North Italian Endoscopic Club (NIEC) and revised NIEC indexes, the AUC (derivation cohort: 0.822 vs. 0.653 vs. 0.713; validation cohort: 0.846 vs. 0.685 vs. 0.747) and DCA curves of this nomogram were better. Further, based on the risk scores, patients were classified into low-, medium-, and high-risk groups, and significant differences were noted in VH incidence among the three risk groups (P <0.001 for each cohort). An effective individualized nomogram to predict the risk of first VH in HBV-related GEV patients was established, which can assist clinicians in developing more appropriate prevention strategies.

External validation of Chronic Liver Failure-Consortium Acute Decompensation score in the risk stratification of cirrhotic patients hospitalized with acute variceal bleeding.

Acute variceal bleeding (AVB) is a serious life-threatening complication of cirrhosis. This study aimed to validate the predictive value of Chronic Liver Failure-Consortium Acute Decompensation score (CLIF-C ADs) in the risk stratification of cirrhotic patients hospitalized with AVB. A total of 235 cirrhotic patients with AVB and without acute-on-chronic liver failure (ACLF) were retrospectively enrolled. The discrimination, calibration, overall performance and clinical utility of CLIF-C AD were evaluated and compared with traditional prognostic scores. The area under the receiver operating characteristics curve of CLIF-C AD was significantly or numerically higher than that of Child-Turcotte-Pugh (CTP) (0.871 vs. 0.737, P = 0.03), Model for End-stage Liver Disease (MELD) (0.871 vs. 0.757, P = 0.1) and MELD-Sodium (MELD-Na) (0.871 vs. 0.822, P = 0.45). The calibration of CLIF-C AD was excellent and superior to that of CTP, MELD and MELD-Na. The brier score/ R2 value for CLIF-C AD, CTP, MELD and MELD-Na were 0.045/0.278, 0.051/0.090, 0.050/0.123 and 0.046/0.207, respectively, suggesting a superior overall performance of CLIF-C AD to traditional scores. In decision curve analysis, the standardized net benefit of CLIF-C AD was higher to that of traditional scores. Patients with CLIF-C ADs ≤48, 49-59 and ≥60 were, respectively, stratified into low, moderate and high-risk groups (6-week mortality: 2.7% vs. 12.5% vs. 37.5%, P < 0.001). The prediction performance and clinical utility of CLIF-C AD for 6-week mortality in cirrhotic patients with AVB and without ACLF are excellent and superior to traditional prognostic scores. The new risk stratification with CLIF-C ADs may be useful in guiding rational management of AVB.

Alfapump® implantable device in management of refractory ascites: An update.

Refractory ascites (RA) is a frequent and life-threatening complication of cirrhosis. In selected patients with RA, transjugular intrahepatic portosystemic shunt (TIPS) placement and liver transplantation (LT) are currently considered the best therapeutic alternatives to repeated large volume paracentesis. In patients with a contraindication to TIPS or LT, the alfapump® system (Sequana Medical, Ghent, Belgium) has been developed to reduce the need for iterative paracentesis, and consequently to improve the quality of life and nutritional status. We report here recent data on technical progress made since the first implantation, the efficacy and tolerance of the device, the position of the pump in the therapeutic arsenal for refractory ascites, and the grey areas that remain to be clarified regarding the optimal selection of patients who are potential candidates for this treatment.

EE329 Early Albumin Infusion in Cirrhotic Patients with Spontaneous Bacterial Peritonitis (SBP) Is Associated with Reductions in Total Hospitalization Costs: A Cross-Sectional Study

SBP is a common, life-threatening complication of cirrhosis that imposes a substantial and growing healthcare cost burden. Treatment guidelines from the American Association for the Study of Liver Diseases recommend albumin administration in conjunction with antibiotics for SBP management due to albumin’s demonstrated clinical efficacy and safety. We examined the relationship between albumin infusion timing and total hospitalization cost among cirrhotic inpatients who developed SBP during hospitalization.

Prognostic Nomograms for Hospital Survival and Transplant-Free Survival of Patients with Hepatorenal Syndrome: A Retrospective Cohort Study.

Hepatorenal syndrome (HRS) is a life-threatening complication of cirrhosis with a poor prognosis. To develop novel and effective nomograms which could numerically predict both the hospital survival and transplant-free survival of HRS, we retrospectively enrolled a cohort of 149 patients. A backward stepwise method based on the smallest Akaike information criterion value was applied to select the covariates to be included in the Cox proportional hazards models. The Harrell C-index, area under the receiver operating characteristic curve (AUC), Brier score, and Kaplan–Meier curves with the log-rank test were used to assess nomograms. The bootstrapping method with 1000 resamples was performed for internal validation. The nomogram predicting hospital survival included prothrombin activity, HRS clinical pattern, Child–Pugh class, and baseline serum creatinine. The C-index was 0.72 (95% confidence interval (CI), 0.65–0.78), and the adjusted C-index was 0.72 (95% CI, 0.66–0.79). The nomogram predicting transplant-free survival included sex, prothrombin activity, HRS clinical pattern, model for end-stage liver disease–Na score, and peak serum creatinine. The C-index of the nomogram was 0.74 (95% CI, 0.69–0.79), and the adjusted C-index was 0.74 (95% CI, 0.68–0.79). The AUC and Brier score at 15, 30, and 45 days calculated from the hospital survival nomogram and those at 6, 12, and 18 months calculated from the transplant-free survival nomogram revealed good predictive ability. The two models can be used to identify patients at high risk of HRS and promote early intervention treatment.

Identifying early indicators of secondary peritonitis in critically ill patients with cirrhosis

Ascitic fluid infection (AFI) is a life-threatening complication of cirrhosis. We aimed to identify early indicators of secondary peritonitis (SP), which requires emergency surgery, and to describe the outcomes of SP and spontaneous bacterial/fungal peritonitis (SBFP). Adults with cirrhosis and AFI admitted to 16 university or university-affiliated ICUs in France between 2002 and 2017 were studied retrospectively. Cases were identified by searching the hospital databases for relevant ICD-10 codes and hospital charts for AFI. Logistic multivariate regression was performed to identify factors associated with SP. Secondary outcomes were short- and long-term mortality and survivors’ functional outcomes. Of 178 included patients (137 men and 41 women; mean age, 58 ± 11 years), 21 (11.8%) had SP, confirmed by surgery in 16 cases and by abdominal computed tomography in 5 cases. Time to diagnosis exceeded 24 h in 7/21 patients with SP. By multivariate analysis, factors independently associated with SP were ascitic leukocyte count > 10,000/mm3 (OR 3.70; 95%CI 1.38–9.85; P = 0.009) and absence of laboratory signs of decompensated cirrhosis (OR 4.53; 95%CI 1.30–15.68; P = 0.017). The 1-year mortality rates in patients with SBFP and SP were 81.0% and 77.5%, respectively (Log-rank test, P = 0.92). Patients with SP vs. SBFP had no differences in 1-year functional outcomes. This multicenter retrospective study identified two indicators of SP as opposed to SBFP in patients with cirrhosis. Using these indicators may help to provide early surgical treatment.

Comparison of the serum fibrinogen level and International Normalized Ratio in the assessment of the risk of gastrointestinal bleeding in decompensated cirrhosis

Introduction: Gastrointestinal (GI) bleeding is the most life-threatening complication of cirrhosis and it's predicting is crucial for the management of cirrhotic patients. The present study aimed to assess the relationship between INR and plasma fibrinogen level and the risk of GI bleeding using in cirrhotic patients. Methods: In the present cross-sectional study, seventy-eight cirrhotic patients were enrolled. We assessed demographic, biochemical, hematologic parameters in all patients. Underlying diseases and the etiology of cirrhosis were documented. The Child-Pugh and the Model for End-stage Liver Disease (MELD) scores were used to assess the severity of liver cirrhosis. The history of bleeding episodes within 6 months before inclusion were recorded. A blood sample was drowned and fibrinogen and prothrombin time (PT) were measured and INR was calculated. Results: The patients' mean age was 51.23±15.08 years and 40 (51.3%) were male. About 17 patients (%21.7) had a history of GI bleeding within 6 months before the study. The significant difference was observed between the two groups who experienced bleeding and who did not regarding the fibrinogen level (P &lt; 0.05). The fibrinogen level was a better predictive marker of bleeding in cirrhotic patients (AUC: 0.87). According to the results of predictive tests, the fibrinogen level had a sensitivity of (77%) and specificity of (%94) in the prediction of bleeding with the cut-off value of 182.5. Conclusion: The results of the present study showed that the fibrinogen level is a better predictor of bleeding in cirrhotic patients compared with INR.

Spontaneous Bacterial Peritonitis and Secondary Bacterial Peritonitis—a Comprehensive Review

Spontaneous bacterial peritonitis (SBP) and secondary bacterial peritonitis are life-threatening complications of cirrhosis if not recognized immediately and managed appropriately. SBP occurs in ~ 3.5 to 10% of patients with cirrhosis and ascites, whereas secondary bacterial peritonitis occurs in 5%. Prompt recognition of SBP variants is vital for tailoring therapy to decrease mortality rate from 90 to 20%. Our objective is to provide an update on the recent publications to elucidate the variants of SBP and provide a management algorithm for the potentially life-threatening complications of cirrhosis. The general guidelines for the management of spontaneous bacterial peritonitis are mostly unchanged, but there are newer data regarding trends in bacteriology and pathogens and newer prophylactic strategies. Spontaneous fungal peritonitis, spontaneous bacterial empyema, and secondary bacterial peritonitis can be clinically challenging if not diagnosed promptly. Nutrition is an under-recognized but important aspect of the management of ascites and SBP prevention. Emerging options for the management of diuretic refractory ascites and infection management are discussed in detail. Early diagnosis and treatment of SBP and secondary bacterial peritonitis are usually associated with good outcomes, but mortality remains as high as 40%. There is a higher risk of other decompensating cirrhotic events after the initial episode of SBP or secondary bacterial peritonitis that portends poor prognosis. The emphasis should be to identify the precipitating cause and focus on the modifiable risk factors to improve outcomes and survival. Newer strategies for SBP prophylaxis and ascites management appear promising until liver transplantation. Personalized approach is crucial to improve the morbidity, quality of life, and mortality in every patient with decompensated cirrhosis.

A clinical risk prediction model to identify patients with hepatorenal syndrome at hospital admission.

Hepatorenal syndrome (HRS) is a life-threatening complication of cirrhosis and early detection of evolving HRS may provide opportunities for early intervention. We developed a HRS risk model to assist early recognition of inpatient HRS. We analysed a retrospective cohort of patients hospitalised from among 122 medical centres in the US Department of Veterans Affairs between 1 January 2005 and 31 December 2013. We included cirrhotic patients whohad Kidney Disease Improving Global Outcomescriteria based acute kidney injury on admission. We developed a logistic regression risk prediction model to detect HRS on admission using 10 variables. We calculated 95% confidence intervals on the model building dataset and, subsequently, calculated performance on a 1000 sample holdout test set. We report model performance with area under the curve (AUC) for discrimination and several calibration measures. The cohort included 19 368 patients comprising 32 047 inpatient admissions. The event rate for hospitalised HRS was 2810/31 047 (9.1%) and 79/1000 (7.9%) in the model building and validation datasets, respectively. The variable selection procedure designed a parsimonious model involving ten predictor variables. Final model performance in the validation dataset had an AUC of 0.87, Brier score of 0.05, slope of 1.10 and intercept of 0.04. We developed a probabilistic risk model to diagnose HRS within 24hours of hospital admission using routine clinical variables in the largest ever published HRS cohort.The performance was excellent and this model may help identify high-risk patients for HRS and promote early intervention.

Constipation and upper gastrointestinal bleed: Leading precipitating factors of hepatic encephalopathy in Indian cirrhotic patients

Abstract Background Liver cirrhosis and its complications pose major health problems. In India, commonest causes of cirrhosis are alcohol abuse and viral hepatitis. Hepatic encephalopathy (HE) is a life-threatening complication of cirrhosis. This study aimed to determine clinical, etiological and laboratory profile of chronic liver disease patients presenting with HE. Methods Cross-sectional study was conducted in Institute of Internal Medicine at Madras Medical College, Chennai. Seventy-five diagnosed cases of chronic liver disease presenting with hepatic encephalopathy were enrolled. Hepatic encephalopathy was clinically graded according to West Haven grading. Results Middle aged group males comprised the largest affected group (30–50 year). Alcohol abuse was most common etiological factor. Jaundice (78%) was most common presenting complaint. Most common precipitating factors were constipation (54%) and upper gastrointestinal (GI) bleeding (45%). Thrombocytopenia was present in 78% cases while 16% cases presented with coagulopathy. The mean serum AST, ALT, bilirubin, ALP and albumin level were 90 U/l, 68.4 U/l, 9.66 mg/dl, 124.2U/l and 2.9 g m/dl, respectively. Mean serum urea and creatinine level were 43.22 mg/dl and 1.39 mg/dl respectively. Conclusion In the specific study group, alcohol-related chronic liver disease was the commonest, with constipation and upper gastrointestinal bleeding being the leading precipitating factors for hepatic encephalopathy.

Screening and Surveillance of Varices in Patients With Cirrhosis

Gastro-esophageal varices (GEV) and variceal hemorrhage (VH) are clinical milestones in the natural history of cirrhosis, as they are closely related to the severity of portal hypertension and define specific stages in disease progression. Variceal hemorrhage is a life-threatening complication of cirrhosis and is one of the clinical complications that defines cirrhosis decompensation. The goal of screening and surveillance of varices is to identify patients with GEV at a high risk of bleeding, so that prevention strategies can be implemented. There have been significant updates in the management of GEV over the last years, particularly in the use of non-invasive methods to assess the degree of portal hypertension and the likelihood of having GEV. This paper is focused on esophageal varices with or without extension along the lesser curvature (type 1 or GOV1), as special considerations are required for the management of cardiofundal varices (GOV2 - esophageal varices extending into the fundus, or IGV1 - isolated gastric varices in the fundus) or isolated gastric varices type 2 (IGV2 – gastric varices elsewhere in the stomach, not in the fundus).

Incidence, predictors and outcomes of acute-on-chronic liver failure in outpatients with cirrhosis

Acute-on-chronic liver failure (ACLF) is the most life-threatening complication of cirrhosis. Prevalence and outcomes of ACLF have recently been described in hospitalized patients with cirrhosis. However, no data is currently available on the prevalence and the risk factors of ACLF in outpatients with cirrhosis. The aim of this study was to evaluate incidence, predictors and outcomes of ACLF in a large cohort of outpatients with cirrhosis. A total of 466 patients with cirrhosis consecutively evaluated in the outpatient clinic of a tertiary hospital were included and followed up until death and/or liver transplantation for a mean of 45±44months. Data on development of hepatic and extrahepatic organ failures were collected during this period. ACLF was defined and graded according to the EASL-CLIF Consortium definition. During the follow-up, 118 patients (25%) developed ACLF: 57 grade-1, 33 grade-2 and 28 grade-3. The probability of developing ACLF was 14%, 29%, and 41% at 1year, 5years, and 10years, respectively. In the multivariate analysis, baseline mean arterial pressure (hazard ratio [HR] 0.96; p=0.012), ascites (HR 2.53; p=0.019), model of end-stage liver disease score (HR 1.26; p<0.001) and baseline hemoglobin (HR 0.07; p=0.012) were found to be independent predictors of the development of ACLF at one year. As expected, ACLF was associated with a poor prognosis, with a 3-month probability of transplant-free survival of 56%. Outpatients with cirrhosis have a high risk of developing ACLF. The degree of liver failure and circulatory dysfunction are associated with the development of ACLF, as well as low values of hemoglobin. These simple variables may help to identify patients at a high risk of developing ACLF and to plan a program of close surveillance and prevention in these patients. There is a need to identify predictors of acute-on-chronic liver failure (ACLF) in patients with cirrhosis in order to identify patients at high risk of developing ACLF and to plan strategies of prevention. In this study, we identified four simple predictors of ACLF: model of end-stage liver disease (MELD) score, ascites, mean arterial pressure and hemoglobin. These variables may help to identify patients with cirrhosis, at a high risk of developing ACLF, that are candidates for new strategies of surveillance and prevention. Anemia is a potential new target for treating these patients.

Correlation Between Esophageal Varices and Lok Score as a Non-invasive Parameter in Liver Cirrhosis Patients

Background: Bleeding from gastro-esophageal varices is the most serious and life-threatening complication of cirrhosis. Endoscopic surveillance of esophageal varices in cirrhotic patients is expensive and uncomfortable for the patients. Therefore, there is a particular need for non-invasive predictors for esophageal varices. The aim of the present study was to evaluate association of esophageal varices and Lok Score as non-invasive parameter in liver cirrhosis patients.Method: This is a cross-sectional study of patients admitted at the Adam Malik hospital Medan between September to December 2014 with a diagnosis of cirrhosis based on clinical, biochemical, ultrasound, and gastroscopy. Lok Score was calculated for all patients, tabulated and analyzed.Results: Among 76 patients with esophageal varices, 55.3% was due to hepatitis B virus (HBV). The majority of patients were Child C with only 13,2% being Child Pugh class A. Majority of the population had F2 esophageal varices (42,1%), F1 (32,9%), and F3 (25%). There is significance difference between Lok Score and grading of esophageal varices, Lok score is higher in Large esophageal varices compared with small esophageal varises (0.92 ± 0.14 vs. 0.70 ± 0.29; p = 0.001). Lok Score cut-off value of 0,9141 was highly predictive in the diagnosis large esophageal varices with a sensitivity of 74.5%, specificity of 72%, positive predictive value of 84%, negative predictive value 58%, and accuracy was 73.7%.Conclusion: Lok Score was significantly associated with esophageal varices. Lok score is a good non-invasive predictor of large esophageal varices in cirrhotic patients.

Incidence, predictors and outcomes of acute on chronic liver failure in outpatients with cirrhosis

Background and aims: Acute-on-chronic liver failure (ACLF) is the most life-threatening complication of cirrhosis. Prevalence and outcomes of ACLF have been recently described in hospitalized patients with cirrhosis. However, no data is currently available on the prevalence and the risk factors of ACLF in outpatients with cirrhosis. The aim of this study was to evaluate incidence, predictors and outcome of ACLF in a large cohort of outpatients with cirrhosis.

Prevalence and predictors of spontaneous bacterial peritonitis: does low zinc level play any role?

IntroductionSpontaneous bacterial peritonitis (SBP) is a frequent and life-threatening complication of cirrhosis. Several large studies have identified additional risk factors for the development of SBP. Zinc deficiency has been found to be frequent in cirrhotic patients.Aim of the workThe aim of the present study was to evaluate the frequency, possible risk factors and the role of zinc in the development of first-time and recurrent SBP.MethodologyA total of 176 cirrhotic ascetic patients admitted to the Hepatology Department in Sohag University Hospital were enroled in the study. SBP peritonitis was diagnosed through history-taking and through examination and laboratory investigations, including ascetic fluid study and the detection of serum zinc level.ResultsOf the 176 cirrhotic patients, SBP was diagnosed in 54 (31%); in total, 40 patients (23%) had single and 14 (8%) had recurrent episodes of SBP. Out of the 23 studied clinical and laboratory variables, we found that the prolonged use of proton pump inhibitor (PPI) (P = 0.001), lower prothrombin concentration (P = 0.03), ascetic protein level less than or equal to 1 g/dl (P < 0.0001) and zinc deficiency (P = 0.001) were independent risk factors for the development of SBP in cirrhotic patients; using multivariate analysis, only low protein in ascites less than or equal to 1 and low zinc status were predictors of SBP.ConclusionIn our study, the frequency of SBP was 31%; overall, 23% of the patients had first-episode and 8% had recurrent SBP. The use of PPI, low platelet count, ascetic protein content and zinc deficiency were the predictors for the development of SBP; only low protein in ascites less than or equal to 1 and low zinc status were independent predictors of SBP.

Combination of non-endoscopic parameters as predictors of large esophageal varices.

Bleeding from gastroesophageal varices is a life-threatening complication of cirrhosis. Prophylactic therapy for large varices considerably reduces such bleeding. Current guidelines recommend upper GI endoscopy as the gold standard for detecting high-grade varices. However, in peripheral centers, this is often unfeasible or inaccessible thus requiring non-endoscopic predictors of large oesophageal varices. This prospective study involved 100 newly diagnosed cirrhosis patients without any history of variceal bleeding. Demographic, clinical, bio-chemical and ultrasonographic parameters were recorded. Esophageal varices were classified endoscopically as small and large. Multivariate logistic regression was performed to identify predictors of variceal size and presence. Cut-offs of significant indicators were determined by ROC analysis. 69% patients had small and 31% had large varices. Univariate analysis revealed significant differences between the grade of spleen, blood parameters, platelet count, international normalized ratio, serum albumin, spleen size, portal vein diameter (PVD) and platelet count to spleen diameter ratio in the two groups. Multivariate analysis revealed that INR [OR: 2.432(95% CI: 1.192 - 4.958)], splenomegaly at USG [OR: 2.138 (95% CI: 0.662 - 6.911)] and PVD [OR: 1.318 (95% CI: 0.937 - 1.853)] were the most significant predictors for large varices. Multivariate prediction of large varices based on a combination of non-endoscopic parameters can be utilized in place of single parameter based predictions.

Outcomes of TIPS for Treatment of Gastroesophageal Variceal Hemorrhage.

Variceal hemorrhage is a life-threatening complication of cirrhosis that requires a multidisciplinary approach to management. The transjugular intrahepatic portosystemic shunt (TIPS) procedure is a minimally invasive image-guided intervention used for secondary prevention of bleeding and as salvage therapy in acute hemorrhage. This review focuses on the role of TIPS in the setting of variceal hemorrhage, with emphasis on the pathophysiology and conventional management of variceal hemorrhage, current and emerging indications for TIPS creation, TIPS clinical outcomes, and the role of adjuvant embolotherapy.