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Sehgal K, Taylor F, Van Wees M, Li K, De Boo DW, Slater LA. What is the Safe Observation Period for Image-Guided Percutaneous Liver Biopsies? Cardiovasc Intervent Radiol 2024; 47:1327-1334. [PMID: 39078495 DOI: 10.1007/s00270-024-03800-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 06/24/2024] [Indexed: 07/31/2024]
Abstract
PURPOSE Current observation period post-liver biopsy is typically 4 h. This study investigates the safety of reducing the observation period after percutaneous liver biopsy. METHODS Patients who underwent percutaneous liver biopsy between 2017 and 2022 in the Radiology Department of a tertiary centre were included in this retrospective, institutional review board-approved study. Patient demographics, procedure details and complication data were collected from the electronic medical records. Complications were graded according to the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) classification. Conditional survival probabilities were calculated for the 4-h observation period. RESULTS Among 1125 patients, 275 complications were seen; 255 grade 1, 15 grade 2 and five grade 3. Post-procedural pain represented 93% (256) of complications, whereas post-procedural haemorrhage occurred in 17 (6%) patients: 13 were of grade 2 severity requiring prolonged observation, and 4 were of grade 3 severity. Of these grade 3 complications, two required blood transfusion whereas two required embolization. A total of 215 (78%) complications occurred within 1 h, 244 (89%) within 2 h of observation. 16 (94%) of 17 post-procedural haemorrhages occurred within 2 h post-biopsy. If complication-free after 2 h, the probability of experiencing a complication within the next 2 h was 4%. CONCLUSION The majority of complications were identified within 2 h of observation. Complications recognised after this period were largely pain-related, with only one grade 3 complication seen (post-procedural haemorrhage).Our findings suggest 2 h of post-procedural observation may be safe. LEVEL OF EVIDENCE Level 2B, Retrospective Cohort Study.
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Affiliation(s)
- Kunal Sehgal
- Department of Radiology, Monash Medical Centre, Monash Health, 246 Clayton Rd, Melbourne, Clayton, VIC, 3168, Australia.
| | - Fergus Taylor
- Department of Radiology, Monash Medical Centre, Monash Health, 246 Clayton Rd, Melbourne, Clayton, VIC, 3168, Australia
| | - Matthew Van Wees
- Department of Radiology, Monash Medical Centre, Monash Health, 246 Clayton Rd, Melbourne, Clayton, VIC, 3168, Australia
| | - Kenny Li
- Department of Radiology, Monash Medical Centre, Monash Health, 246 Clayton Rd, Melbourne, Clayton, VIC, 3168, Australia
| | - Diederick Willem De Boo
- Department of Radiology, Monash Medical Centre, Monash Health, 246 Clayton Rd, Melbourne, Clayton, VIC, 3168, Australia
- Department of Radiology and Radiological Sciences, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Lee Anne Slater
- Department of Radiology, Monash Medical Centre, Monash Health, 246 Clayton Rd, Melbourne, Clayton, VIC, 3168, Australia
- Department of Radiology and Radiological Sciences, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
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Vo NH, Sari MA, Grimaldi E, Berchmans E, Curry MP, Ahmed M, Siewert B, Brook A, Brook OR. Highest 3-month international normalized ratio (INR): a predictor of bleeding following ultrasound-guided liver biopsy. Eur Radiol 2024; 34:6416-6424. [PMID: 38483589 DOI: 10.1007/s00330-024-10692-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 02/15/2024] [Accepted: 02/20/2024] [Indexed: 09/15/2024]
Abstract
OBJECTIVES To determine whether international normalized ratio (INR), bilirubin, and creatinine predict bleeding risk following percutaneous liver biopsy. METHODS A total of 870 consecutive patients (age 53 ± 14 years; 53% (459/870) male) undergoing non-targeted, ultrasound-guided, percutaneous liver biopsy at a single tertiary center from 01/2016 to 12/2019 were retrospectively reviewed. Results were analyzed using descriptive statistics and logistic regression models to evaluate the relationship between individual and combined laboratory values, and post-biopsy bleeding risk. Receiver operating characteristic (ROC) curves and area under ROC (AUC) curves were constructed to evaluate predictive ability. RESULTS Post-biopsy bleeding occurred in 2.0% (17/870) of patients, with 0.8% (7/870) requiring intervention. The highest INR within 3 months preceding biopsy demonstrated the best predictive ability for post-biopsy bleeding and was superior to the most recent INR (AUC = 0.79 vs 0.61, p = 0.003). Total bilirubin is an independent predictor of bleeding (AUC = 0.73) and better than the most recent INR (0.61). Multivariate regression analysis of the highest INR and total bilirubin together yielded no improvement in predictive performance compared to INR alone (0.80 vs 0.79). The MELD score calculated using the highest INR (AUC = 0.79) and most recent INR (AUC = 0.74) were similar in their predictive performance. Creatinine is a poor predictor of bleeding (AUC = 0.61). Threshold analyses demonstrate an INR of > 1.8 to have the highest predictive accuracy for bleeding. CONCLUSION The highest INR in 3 months preceding ultrasound-guided percutaneous liver biopsy is associated with, and a better predictor for, post-procedural bleeding than the most recent INR and should be considered in patient risk stratification. CLINICAL RELEVANCE STATEMENT Despite correction of coagulopathic indices, the highest international normalized ratio within the 3 months preceding percutaneous liver biopsy is associated with, and a better predictor for, bleeding and should considered in clinical decision-making and determining biopsy approach. KEY POINTS • Bleeding occurred in 2% of patients following ultrasound-guided liver biopsy, and was non-trivial in 41% of those patients who needed additional intervention and had an associated 23% 30-day mortality rate. • The highest INR within 3 months preceding biopsy (AUC = 0.79) is a better predictor of bleeding than the most recent INR (AUC = 0.61). • The MELD score is associated with post-procedural bleeding, but with variable predictive performance largely driven by its individual laboratory components.
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Affiliation(s)
- Nhi H Vo
- Department of Radiology, Beth Israel Deaconess Medical Center, 1 Deaconess Rd, Boston, MA, 02215, USA
| | - Mehmet A Sari
- Department of Radiology, Beth Israel Deaconess Medical Center, 1 Deaconess Rd, Boston, MA, 02215, USA
| | - Elena Grimaldi
- Department of Radiology, Beth Israel Deaconess Medical Center, 1 Deaconess Rd, Boston, MA, 02215, USA
| | - Emmanuel Berchmans
- Department of Radiology, Beth Israel Deaconess Medical Center, 1 Deaconess Rd, Boston, MA, 02215, USA
| | - Michael P Curry
- Department of Internal Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Muneeb Ahmed
- Department of Radiology, Beth Israel Deaconess Medical Center, 1 Deaconess Rd, Boston, MA, 02215, USA
| | - Bettina Siewert
- Department of Radiology, Beth Israel Deaconess Medical Center, 1 Deaconess Rd, Boston, MA, 02215, USA
| | - Alexander Brook
- Department of Radiology, Beth Israel Deaconess Medical Center, 1 Deaconess Rd, Boston, MA, 02215, USA
| | - Olga R Brook
- Department of Radiology, Beth Israel Deaconess Medical Center, 1 Deaconess Rd, Boston, MA, 02215, USA.
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Wang L, Hu YF, Yang AY, Du ZX, Liu HL, Zhu P, Li LQ, Zhong YD, Xu ZY, Wang SS, Yang YF. Development and validation of a noninvasive prediction model of autoimmune hepatitis in patients with liver diseases. Scand J Gastroenterol 2024; 59:62-69. [PMID: 37649307 DOI: 10.1080/00365521.2023.2249571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 08/08/2023] [Accepted: 08/14/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND AND AIMS There is no golden standard for the diagnosis of autoimmune hepatitis which still dependent on liver biopsy currently. So, we developed a noninvasive prediction model to help optimize the diagnosis of autoimmune hepatitis. METHODS From January 2017 to December 2019, 1739 patients who had undergone liver biopsy were seen in the second hospital of Nanjing, of which 128 were here for consultation. Clinical, laboratory, and histologic data were obtained retrospectively. Multivariable logistic regression analysis was employed to create a nomogram model that predicting the risk of autoimmune hepatitis. Internal and external validation was both performed to evaluate the model. RESULTS A total of 1288 patients with liver biopsy were enrolled (1184 from the second hospital of Nanjing, the remaining 104 from other centers). After the univariate and multivariate logistic regression analysis, nine variables including ALT, IgG, ALP/AST, ALB, ANA, AMA, HBsAg, age, and gender were selected to establish the noninvasive prediction model. The nomogram model exhibits good prediction in diagnosing autoimmune hepatitis with AUROC of 0.967 (95% CI: 0.776-0.891) in internal validation and 0.835 (95% CI: 0.752-0.919) in external validation. CONCLUSIONS ALT, IgG, ALP/AST, ALB, ANA, AMA, HBsAg, age, and gender are predictive factors for the diagnosis of autoimmune hepatitis in patients with unexplained liver diseases. The predictive nomogram model built by the nine predictors achieved good prediction for diagnosing autoimmune hepatitis.
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Affiliation(s)
- Li Wang
- Nanjing University of Chinese Medicine, Nanjing, China
- The Second Hospital of Nanjing, Teaching Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Yi-Fan Hu
- Nanjing University of Chinese Medicine, Nanjing, China
| | - An-Yin Yang
- Nanjing University of Chinese Medicine, Nanjing, China
| | - Zhi-Xiang Du
- Nanjing University of Chinese Medicine, Nanjing, China
| | | | - Ping Zhu
- Nanjing University of Chinese Medicine, Nanjing, China
| | - Li-Qiu Li
- Nanjing University of Chinese Medicine, Nanjing, China
| | - Yan-Dan Zhong
- The Second Hospital of Nanjing, Teaching Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | | | | | - Yong-Feng Yang
- Nanjing University of Chinese Medicine, Nanjing, China
- The Second Hospital of Nanjing, Teaching Hospital of Nanjing University of Chinese Medicine, Nanjing, China
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Vetter M, Kremer AE, Agaimy A, Pfeifer L, Neurath MF, Siebler J, Zopf S. How Much Liver Tissue Is Required for Sufficient Histological Staging in Patients with Primary Biliary Cholangitis? Digestion 2021; 102:428-436. [PMID: 32492681 DOI: 10.1159/000507392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 03/22/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Histological alterations in primary biliary cholangitis (PBC) are heterogeneously distributed throughout the liver. Thus, the quality of histological staging is probably dependent on the available amount of liver tissue. The goals of this study were to test this hypothesis and to define biopsy conditions for obtaining sufficient tissue. METHODS In this retrospective analysis, we investigated 34 patient cases who fulfilled the criteria of the European Association for the Study of the Liver (EASL) for PBC and underwent a mini-laparoscopic liver biopsy between 2011 and 2018 using 16 or 18G needles. For histological assessment of fibrosis, we used the Ishak score, and the amount of tissue was measured by the number of portal fields. Histological staging was compared with the macroscopic mini-laparoscopic fibrosis score (MLFS), and non-invasive liver stiffness measurements using acoustic radiation force impulse (ARFI) imaging and the FIB-4 score. RESULTS Biopsy was successful in 33 of 34 patients (97%). Fibrosis assessment by MLFS and ARFI correlated strongly with each other (r = 0.7088, p = 0.000017). However, the correlation of both methods with the histological staging was weaker (MLFS vs. histology: r = 0.4231, p = 0.0142; ARFI vs. histology: r = 0.3564, p = 0.0577). The correlation of ARFI and MLFS with the histological staging was better in the subgroup of biopsies with at least 10 portal fields (= SG≥10PF) (MLFS vs. histology: r = 0.6369, p = 0.006; ARFI vs. histology: r = 0.7538, p = 0.0012). FIB-4 correlated weakly with the histological staging, which was statistically not significant (all samples: r = 0.2693, p = 0.1296; SG≥10PF: r = 0.2244, p = 0.3866). The number of portal fields correlated well with the length of the samples (r = 0.6436, p = 0.00012). The probability to attain at least 10 portal fields depended on the needle diameter and number of samples (1 × 16G or 18G [n = 10]: 30.0%; 2 × 18G [n = 15]: 53.3%; 2 × 16G [n = 5]: 100%; p = 0.0414). CONCLUSION ARFI and MLFS are probably well suited for the assessment of liver fibrosis in patients with PBC. A minimum of 10 portal fields could improve the histological assessment in PBC and can probably be achieved by obtaining two 16G biopsies.
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Affiliation(s)
- Marcel Vetter
- Department of Medicine 1, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Andreas E Kremer
- Department of Medicine 1, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Abbas Agaimy
- Institute of Pathology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Lukas Pfeifer
- Department of Medicine 1, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Markus F Neurath
- Department of Medicine 1, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Jürgen Siebler
- Department of Medicine 1, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Steffen Zopf
- Department of Medicine 1, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany, .,Department of Medicine 2, Klinikum Fürth, Fürth, Germany,
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Johnson KD, Laoveeravat P, Yee EU, Perisetti A, Thandassery RB, Tharian B. Endoscopic ultrasound guided liver biopsy: Recent evidence. World J Gastrointest Endosc 2020; 12:83-97. [PMID: 32218888 PMCID: PMC7085945 DOI: 10.4253/wjge.v12.i3.83] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 12/26/2019] [Accepted: 03/01/2020] [Indexed: 02/06/2023] Open
Abstract
Liver biopsy (LB) is an essential tool in diagnosing, evaluating and managing various diseases of the liver. As such, histopathological results are critical as they establish or aid in diagnosis, provide information on prognosis, and guide the appropriate selection of medical therapy for patients. Indications for LB include evaluation of persistent elevation of liver chemistries of unclear etiology, diagnosis of chronic liver diseases such as Wilson's disease, autoimmune hepatitis, small duct primary sclerosing cholangitis, work up of fever of unknown origin, amyloidosis and more. Traditionally, methods of acquiring liver tissue have included percutaneous LB (PCLB), transjugular LB (TJLB) or biopsy taken surgically via laparotomy or laparoscopy. However, traditional methods of LB may be inferior to newer methods. Additionally, PCLB and TJLB carry higher risks of adverse events and complications. More recently, endoscopic ultrasound guided LB (EUS-LB) has evolved as an alternative method of tissue sampling that has proven to be safe and effective, with limited adverse events. Compared to PC and TJ routes, EUS-LB may also have a greater diagnostic yield of tissue, be superior for a targeted approach of focal lesions, provide higher quality images and allow for greater patient comfort. These advantages have contributed to the increased use of EUS-LB as a technique for obtaining liver tissue. Herein, we provide a review of the recent evidence of EUS-LB for liver disease.
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Affiliation(s)
- Kemmian D Johnson
- Department of Internal Medicine, Louisiana State University Health Sciences Center, New Orleans, LA 70112, United States
| | - Passisd Laoveeravat
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, United States
| | - Eric U Yee
- Department of Pathology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
| | - Abhilash Perisetti
- Department of Internal Medicine, Division of Gastroenterology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
| | - Ragesh Babu Thandassery
- Department of Internal Medicine, Division of Gastroenterology, Central Arkansas Veterans Health Care System, Little Rock, AR 72205, United States
| | - Benjamin Tharian
- Department of Internal Medicine, Division of Gastroenterology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
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Bihari C, Patil A, Sarin SK. Adequate platelet counts in cirrhosis for laboratory-based optimum platelet functions. Clin Res Hepatol Gastroenterol 2018; 42:e89-e91. [PMID: 29615328 DOI: 10.1016/j.clinre.2018.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 03/13/2018] [Indexed: 02/04/2023]
Affiliation(s)
- Chhagan Bihari
- Department of Hematology and Pathology, Institute of Liver and Biliary Sciences, New Delhi, India.
| | - Anupama Patil
- Department of Hematology and Pathology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shiv K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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Veronese LR, Miller M, Spearman WC. Thromboelastography in mild, chronic liver disease: challenging conventional coagulation tests preceding liver biopsy. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2018. [DOI: 10.1080/22201181.2018.1510234] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- LR Veronese
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - M Miller
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - WC Spearman
- Division of Hepatology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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Affiliation(s)
- Stephen Caldwell
- Department of Medicine, Division of GI/Hepatology, University of Virginia Medical Center, Charlottesville, Virginia, USA
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Abstract
Determining practice parameters for interventional procedures is challenging due to many factors including unreliable laboratory tests to measure bleeding risk, variable usage of standardized terminology for adverse events, poorly defined standards for administration of blood products, and the growing numbers of anticoagulant and antiplatelet medications. We aim to address these and other issues faced by radiologists performing invasive procedures through a review of available literature, and experiential guidance from three academic medical centers. We discuss the significant limitations with respect to using prothrombin-time and international normalized ratio to measure bleeding risk, especially in patients with synthetic defects due to liver function. Factors affecting platelet function including the impact of uremia; recent advances in laboratory testing, including platelet function testing; and thromboelastography are also discussed. A review of the existing literature of fresh-frozen plasma replacement therapy is included. The literature regarding comorbidities affecting coagulation including malignancy, liver failure, and uremia are also reviewed. Finally, the authors present a set of recommendations for laboratory thresholds, corrective transfusions, as well as withholding and restarting medications.
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Abstract
Liver disease is characterized by changes in all phases of hemostasis. These hemostatic alterations were long considered to predispose patients with liver disease towards a bleeding tendency, as they are associated with prolonged conventional coagulation tests. However, these patients may also suffer from thrombotic complications, and we now know that the hemostatic system in patient with liver disease is, in fact, in a rebalanced state. In this review we discuss the concept of rebalanced hemostasis and its implications for clinical management of patients with liver disease. For instance, there is no evidence that the use of prophylactic blood product transfusion prior to invasive procedures reduces bleeding risk. Clinicians should also be aware of the possibility of thrombosis occurring in patients with a liver disease, and regular thrombosis prophylaxis should not be withheld in these patients.
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Affiliation(s)
- Wilma Potze
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Centre Groningen, BA44, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
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Muciño-Bermejo J, Carrillo-Esper R, Méndez-Sánchez N, Uribe M. Thrombosis and hemorrhage in the critically ill cirrhotic patients: five years retrospective prevalence study. Ann Hepatol 2015; 14:93-98. [PMID: 25536646 DOI: 10.1016/s1665-2681(19)30805-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
BACKGROUND Cirrhotic patients present a complex interaction between deficient synthetic liver function, hemodynamic abnormalities and superimposed conditions that alter coagulation system. This alters both coagulation and fibrinolytic processes,increasing bleeding and thrombosis risks. Particularly, critically ill cirrhotic patients represent a diagnostic challenge since they have multiple comorbidities making the thrombotic and bleeding risks unpredictable. The prevalence of bleeding and thrombosis in this subset of patients remains poorly described. The main aim of this article is to describe the prevalence of thrombotic and hemorrhagic complications in cirrhotic patients admitted between 2007 and 2012 at Médica Sur Clinic and Foundation ICU. MATERIAL AND METHODS We performed a five years retrospective study including every cirrhotic patient admitted to ICU between January 2007 and December 2012. RESULTS The incidence of hemorrhage was 48.5%, the overall incidence of thrombotic complications was 13.66%. Variceal bleeding was the most prevalent hemorrhagic event and portal vein thrombosis the most common thrombotic event. Factors associated with presenting a bleeding episode included kidney injury, infection an thrombosis. Factors associated with increased thrombotic risk included ascitis,infection and bleeding. CONCLUSION Critically ill cirrhotic patients have an high risk for both thrombotic and bleeding episodes. The association between the presence of bleeding and thrombotic events was statistically significant.
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Affiliation(s)
- Jimena Muciño-Bermejo
- Intensive Care Unit, Liver Unit, Medica Sur Clinic & Foundation, Mexico City, Mexico
| | - Raúl Carrillo-Esper
- Intensive Care Unit, Liver Unit, Medica Sur Clinic & Foundation, Mexico City, Mexico
| | - Nahum Méndez-Sánchez
- Intensive Care Unit, Liver Unit, Medica Sur Clinic & Foundation, Mexico City, Mexico
| | - Misael Uribe
- Liver Unit, Medica Sur Clinic & Foundation, Mexico City, Mexico
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Northup PG, Caldwell SH. Coagulation in liver disease: a guide for the clinician. Clin Gastroenterol Hepatol 2013; 11:1064-74. [PMID: 23506859 DOI: 10.1016/j.cgh.2013.02.026] [Citation(s) in RCA: 174] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Revised: 02/18/2013] [Accepted: 02/20/2013] [Indexed: 02/06/2023]
Abstract
The human hemostasis system is complex and poorly understood after decades of intense scientific study. Despite multiple defects in routine coagulation laboratory studies in patients with chronic liver disease, there is growing evidence that these patients are effectively "rebalanced" with regard to procoagulant and anticoagulant activity and that most of these patients remain in a tenuous but balanced state of hemostasis. A major difficulty in the assessment of these patients is that there are no established laboratory tests that accurately reflect the changes in both the procoagulant and anticoagulant systems; therefore, routine laboratory testing is misleading to the clinician and may prompt inappropriate or risky therapies with little real benefit to the patient. The international normalized ratio is an example of this type of misleading test. Although the international normalized ratio is inextricably linked to prognosis and severity of protein synthetic dysfunction in acute and chronic liver disease, it is a very poor marker for bleeding risk and should not be used in isolation for this purpose. Coagulation disorders are critical in the management of frequent clinical scenarios such as esophageal variceal bleeding, invasive and percutaneous procedures, portal vein thrombosis, venous thromboembolism, and acute liver failure. This article summarizes the pathophysiology of hemostasis in liver disease, describes the strengths and weaknesses of various laboratory tests in assessment of these patients, and outlines the optimal management of hemostasis for some common clinical scenarios. Further research is needed for proper understanding of hemostasis in liver disease to optimally and safely manage these complex patients.
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Affiliation(s)
- Patrick G Northup
- Division of Gastroenterology and Hepatology, Center for the Study of Coagulation in Liver Disease, University of Virginia, Charlottesville, Virginia, USA.
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Abstract
The clotting process is a dynamic array of multiple processes which can be described in four phases: platelet plug initiation and formation, clotting process propagation by the coagulation cascade, clotting termination by antithrombotic mechanisms and clot removal by fibrinolysis. The liver plays a central role in each of these phases of clotting process, as it synthesizes the majority of coagulation factors and proteins involved in fibrinolysis as well as thrombopoeitin, which is responsible for platelet production from megakaryocytes. Many pathological processes associated with cirrhosis, such as portal hypertension and endothelial dysfunction, as well as co-morbid conditions, may also alter the coagulation process. Consequently, patients with liver disease have a disturbed balance of procoagulant and anti-coagulant factors which deviates from the normal coagulation cascade. This situation poses an additional problem in the diagnostic and therapeutic approach to this group of patients, since traditional coagulation test may not be reliable for assessing bleeding or thrombotic risk and traditional transfusional strategies may not be applicable in cirrhotic patients. In this article, we review the pathophysiological bases of coagulation abnormalities, in cirrhotic patients, the diagnostic therapeutic strategies to be followed and its impact on the clinical outcome in the cirrhotic patient.
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Tannapfel A, Dienes HP, Lohse AW. The indications for liver biopsy. DEUTSCHES ARZTEBLATT INTERNATIONAL 2012; 109:477-83. [PMID: 22833761 DOI: 10.3238/arztebl.2012.0477] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2011] [Accepted: 03/20/2012] [Indexed: 12/18/2022]
Abstract
BACKGROUND Despite improvements in serological and radiological techniques, liver biopsy remains the most reliable way to diagnose diffuse hepatic disease and hepatic nodules. The indications for this invasive technique must be weighed against the small, but not negligible, risk of a complication. METHODS The indications for liver biopsy are summarized on the basis of a selective review of the literature, including the published recommendations and position statements of specialty societies in Germany and abroad. The conclusions are supplemented with an evaluation of the authors' own experience. RESULTS The success of liver biopsy depends not only on the selection of the puncture method and on due attention to the relative and absolute contraindications, but also on the experience of the person carrying out the procedure. For patients with hepatitis of various etiologies, liver biopsy is used not only to establish the cause of the disorder, but also to assess the degree of inflammatory activity (grading) and the extent of fibrosis (staging). CONCLUSION Liver biopsy enables the reliable diagnosis of hepatic lesions and is an important aid to treatment planning and prognostication.
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Ferro D, Angelico F, Caldwell SH, Violi F. Bleeding and thrombosis in cirrhotic patients: what really matters? Dig Liver Dis 2012; 44:275-279. [PMID: 22119620 DOI: 10.1016/j.dld.2011.10.016] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Revised: 10/13/2011] [Accepted: 10/20/2011] [Indexed: 12/11/2022]
Abstract
Bleeding complications, particularly in the gastro-intestinal tract, may complicate the clinical course of liver cirrhosis. Coexistence of abnormal global tests exploring the platelet and clotting systems generated the hypothesis that cirrhotic patients have "coagulopathy" predisposing to bleeding complications. Using more sophisticated laboratory methods this hypothesis has been partly confuted as cirrhotic patients actually disclose an ongoing prothrombotic state in the portal and systemic circulation that could predispose to thrombosis. Recent data of the literature support this hypothesis as portal vein thrombosis and peripheral thrombosis are frequent features of cirrhosis. We reviewed the literature data to assess the prevalence of bleeding and thrombotic complication in cirrhosis and the role of clotting activation in precipitating them. Whilst it appears scarcely relevant the interplay between the so called "coagulopathy" and bleeding, the interplay between clotting activation and thrombosis seems to be relevant but needs more accurate investigation in larger study populations.
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Affiliation(s)
- Domenico Ferro
- Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Rome, Italy
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Stavropoulos SN, Im GY, Jlayer Z, Harris MD, Pitea TC, Turi GK, Malet PF, Friedel DM, Grendell JH. High yield of same-session EUS-guided liver biopsy by 19-gauge FNA needle in patients undergoing EUS to exclude biliary obstruction. Gastrointest Endosc 2012; 75:310-8. [PMID: 22248599 DOI: 10.1016/j.gie.2011.09.043] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2011] [Accepted: 09/21/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND EUS-guided liver biopsy by Trucut yields variable specimen adequacy at high cost, limiting its utility. A modified EUS-guided technique with reliable adequacy could be a viable alternative to standard techniques in cost-effective clinical settings. OBJECTIVE To describe our experience with EUS-guided liver biopsy by 19-gauge FNA, non-Trucut, needle in a cost-effective setting: patients with abnormal liver test results of unclear etiology referred for EUS to exclude biliary obstruction in whom an unrevealing EUS would have prompted a next-step liver biopsy by the referring physician. DESIGN Prospective case series. SETTING Tertiary-care teaching hospital. PATIENTS Consecutive patients with abnormal liver tests referred for EUS. INTERVENTIONS EUS-guided liver biopsy by 19-gauge FNA needle (non-Trucut). MAIN OUTCOME MEASUREMENTS Diagnostic yield, specimen adequacy, and complications. An adequate specimen was defined as a length of 15 mm or longer and 6 or more complete portal tracts (CPTs). RESULTS Between July 2008 and July 2011, 22 of 31 consecutive patients meeting inclusion criteria underwent unrevealing EUS with same-session EUS-guided liver biopsy by 19-gauge FNA needle. A median of 2 FNA passes (range 1-3) yielded a median specimen length of 36.9 mm (range 2-184.6 mm) with a median of 9 CPTs (range 1-73 CPTs). EUS-guided liver biopsies yielded a histologic diagnosis and adequate specimens in 20 of 22 patients (91%). Expanded experience led to improved specimen adequacy. There were no complications. LIMITATION Small study size. CONCLUSIONS EUS-guided liver biopsy by using a 19-gauge FNA needle appears to be feasible and safe and provides excellent diagnostic yield and specimen adequacy.
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Affiliation(s)
- Stavros N Stavropoulos
- Department of Gastroenterology, Hepatology and Nutrition, Winthrop-University Hospital, Mineola, New York, USA
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Zheng X, Jiang T, Wu H, Zhu D, Wang L, Qi R, Li M, Ling C. Hepatic iron stores are increased as assessed by magnetic resonance imaging in a Chinese population with altered glucose homeostasis. Am J Clin Nutr 2011; 94:1012-9. [PMID: 21880847 DOI: 10.3945/ajcn.111.015743] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Emerging scientific evidence has disclosed a correlation between iron metabolism and type 2 diabetes (T2D). OBJECTIVE The objective of this study was to test the hypothesis that body iron stores are higher in a Chinese population with altered glucose homeostasis. DESIGN Serum iron, ferritin, and soluble transferrin receptor concentrations were measured in 298 subjects, including 70 subjects with normal glucose tolerance (NGT group), 60 subjects with prediabetes (prediabetes group), and 168 subjects with T2D (T2D group). Hepatic iron stores in 88 subjects were assessed by using a magnetic resonance imaging (MRI) T2* gradient-recalled-echo technique. A general linear model ANOVA was performed for comparisons between groups after adjustment for age and BMI. Stepwise multiple linear regression analysis was used to identify factors associated with the MRI-estimated hepatic iron concentration (M-HIC). RESULTS Mean (±SD) M-HIC and R2* values in the prediabetes and T2D groups were significantly higher than in the NGT group (M-HIC: 40.6 ± 8.6 and 39.3 ± 10.7 μmol/g compared with 27.8 ± 9.1 μmol/g; R2* values: 47.9 ± 11.9 and 47.3 ± 11.5 s(-1) compared with 34.9 ± 7.0 s(-1); all P < 0.01). No significant difference was shown in M-HIC and R2* values between prediabetes and T2D groups. The M-HIC independently contributed to 43.3% of the glycated hemoglobin variance after adjustment for main clinical indexes (P < 0.001). The proportions of subjects with mild hepatic iron overload in the NGT, prediabetes, and T2D groups were 12.5%, 70.6%, and 63.6%, respectively. CONCLUSIONS To our knowledge, our findings provide novel evidence to support the hypothesis of a mild iron overload in patients with prediabetes and T2D. A cohort study concerned with the effect of the attenuation of excess iron on glucose metabolism in a prediabetic population is warranted.
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Affiliation(s)
- Xuan Zheng
- Clinical Nutrition Department, Division of Traditional Chinese Medicine, Second Military Medical University, Shanghai, China
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