Ursodeoxycholic acid use in lactating female patients is associated with clinically negligible concentrations of this bile acid in breast milk

In the literature on the safety of ursodeoxycholic acid (UDCA) during breastfeeding, insufficient data has been reported to date. Thus, the aim of our study was to analyze bile acid (BA) concentrations in breast milk in a cohort of patients, treated with UDCA, and with various cholestatic liver diseases. The study was carried out on a cohort of 20 patients with various cholestatic diseases. All the patients were treated with UDCA (500-1500 mg daily). Concentrations of BA, sampled on day 3 after delivery were analyzed using the GS-MS technique, and then compared to untreated women. Total BA concentrations in the breast milk of the UDCA-treated patients were equal to those of the untreated women controls (3.2 ± 1 vs. 3.2 ± 0.2 µmol/L, respectively). The UDCA concentrations in breast milk remained negligible in UDCA-treated patients (0.69 µmol/L), and in any event did not contribute to the newborn BA pool. No apparent side-effects of the maternal UDCA treatment were observed in any newborn infant, and no deterioration in postnatal development was observed during the routine 1-year follow-ups. Therapeutic administration of UDCA during lactation is safe for breastfed babies since UDCA only gets into breast milk in negligible amounts. UDCA treatment should be allowed and included into the guidelines for the therapy of cholestatic diseases in breastfeeding mothers.

Chronic cholestatic liver diseases - Primary biliary cholangitis and Primary sclerosing cholangitis

Cholestasis is defined as hepatocyte and cholangiocyte bile excretion failure or failure of bile transport to the duodenum. Primary biliary cholangitis (PBC) and primary sclerosing cholangitis as chronic progressive cholestatic diseases are the common reasons of chronic cholestasis. Altogether with cholestatic laboratory picture the pruritus, liver osteodystrophy and fatigue are associated symptoms in both diseases. All associated symptoms and complications are needed to be diagnosed and treated early. In case of liver cirrhosis complicatons of accompanied portal hypertension should be treated and liver transplantation must be considered in all those patients. Diagnosis of PBC is based on cholestatic laboratory features, animitochondrial antibody positivity or typical histological patern. Most patients are asymptomatic in time of diagnosis. First line therapy is ursodeoxycholic acid. In case of first line therapy failure, the prognosis is unfavourable. In this case, second line therapy must be considered. In case of PSC the diagnosis is based on MRCP finding mainly, laboratory test and liver biopsy in some cases. Progressive inflamatory and fibrosing impairment affecting intrahepatic and extrahepatict biliary ducts and strong association with inflamatory bowel disease, especially ulcerative colitis is typical for PSC. Endoscopic therapy with dilatation of dominant structure is crucial. The effect of pharmacotherapy is still being discussed and ursodeoxycholic acid could be used. During follow up patients are in the risk of bacterial cholangitis and malignant tumor development (cholangiogenic and colorectal carcinoma mainly). In PSC patients the severe pruritus and reccurent bacterial cholangitis could be an indication for the liver transplantation.

Bleeding in portal hypertension

Liver cirrhosis is the most common reason of clinically significant portal hypertension in the western countries. Portal vein or hepatic veins thrombosis is less common. Variceal bleeding is the most severe life threatening complication of portal hypertension. Appropriate treatment includes initial general management, fluid replacement and hemosubstitution, antibiotic prophylaxis, vasoactive medication and endoscopic treatment. Transjugular intrahepatic portosystemic shunt (TIPS) is standard option in case of first line treatment failure. Dedicated esophageal metal stent or balloon tamponade could be used as a bridge to the TIPS or in case of TIPS contraindication. Non selective beta-blockers and endoscopic therapy are used in primary and secondary prophylaxis.

Recommended fluid intake and evidence-based medicine

Abundant drinking of fluids at any occasion became popular in wealthy society in last decades. It is referred to asserted beneficial health effects, but rationale of these recommendations is disputed in expert environment as hardly traceable and tenable. Authors of the article analyse theoretical issues as well as empiric literary evidence for the current popular recommendation. They find them unfounded and difficult to be defended and the risks of transitive hypo-hydration overestimated. Moreover, they alert true risks of water poisoning we meet not quite rarely in common practice.

Diagnosis, etiology and management of the Budd-Chiari Syndrome: a bloodcoagulation and hepatological study on the course of the disease treated with TIPS

BACKGROUND

Budd-Chiari Syndrome (BCS) is characterized by obstruction of blood flow in hepatic veins. The aim of the study was to analyze diagnosis, etiology and management of BCS.

METHODS

We analyzed 44 patients (32 females, 12 males, the mean age <35y of age) treated with TIPS. Ascites was found in 35 patients as the most frequent symptom. The median of total follow-up was 52 months. Non-covered (bare) or covered stent was inserted to all patients. Diagnosis of myeloproliferative neoplasm (MPN) was based on WHO criteria. Other inherited or acquired thrombophilia were assessed as well. Therapy of BCS was with regard to the etiology.

RESULTS

The etiology of BCS was identified in 38 cases. Ph- MPN was found as the most common risk factor (50%, N.=22), especially polycythemia vera. JAK2V617F mutation was detected in the most of 22 MPN cases (82.5%). The second most common etiologic factor was inherited thrombophilia (18%, N.=8). In the non-covered (bare) stent group, a primary patency rates 52.9% in 1 year and 20% in 5 years after TIPS (Portasystemic Shunt, Transjugular Intrahepatic) creation. In the covered stent group the 1-year and 5-year primary patency rates were was 80% and 33.3% respectively. The average 5-year re-intervention rate per patient was 1.65 procedures in the bare stent group and 0.67 in the covered stent group. Re-interventions were more frequent in MPN patients. All patients were anticoagulated with heparin at the beginning, switched to vitamin K antagonist. On top of TIPS, anticoagulant and a vigorous therapy of underlying disorder are necessary.

CONCLUSION

BCS is a serious and life-threatening disorder in MPD is a major cause of morbidity and mortality. Therapy requires a multidisciplinary approach. Insertion of TIPS dedicated covered stent is a very effective treatment in cases resistant to conservative approach with lower dysfunction rate and the number of re-interventions.

[Survival of patients after TIPS in the University Hospital Hradec Kralove]

AIM

To analyze survival of patients after TIPS (transjugular intrahepatic portosystemic shunt).

PATIENT SAMPLE AND METHODOLOGY

Between September 1992 and August 2010, TIPS was created in 848 patients of the University Hospital Hradec Kralove. These patients were divided into groups. Survival was analyzed using Kaplan-Meier survival curves. Differences between groups were evaluated using log-rank test.

RESULTS

Ten percent of patients do not survive one month after TIPS, 40% of patients survive 5 years and 20% of patients survive 10 years. There were statistically significant differences between groups divided according to Child-Pugh classification (A vs B p = 0.0053; B vs. C p < 0.0001), indication for surgery [prevention of bleeding recurrence differed from refractory ascites (p = 0.0001) and the indication to stop acute bleeding (p = 0.026)]; aetiology of the liver disease [patients with alcoholic cirrhosis differed from patients with Budd-Chiari syndrome (p < 0.0001) and from patients with chronic viral hepatitis (p = 0.024)].

CONCLUSION

Survival of patients after TIPS is influenced by Child-Pugh score, indication and aetiology of the liver disease.

[Diabetes mellitus and the liver cirrhosis]

Patients with liver cirrhosis have increased risk of diabetes mellitus development, especially when the underlying disease is hereditary hemochromatosis, autoimmune hepatitis, non-alcoholic steatohepatitis or chronic hepatitis C. Patients with associated diabetes according to liver cirrhosis complications have worse prognosis and the therapy is influenced by both diseases. The authors bring short review of particular diseases, diagnosis and treatment strategy.

[Steatosis and steatohepatitis in diabetic patient]

Nonalcoholic fatty liver disease (NAFLD) is an increasingly recognized condition of excess fat deposition within the liver. NAFLD includes a spectrum of liver pathology ranging from bland hepatic steatosis to steatohepatitis and cirrhosis. Nonalcoholic steatohepatitis (NASH) is an inflammatory and fibrosing condition of the liver thought to be an intermediate stage of NAFLD that may progress to endstage liver disease, liver-related death and hepatocellular carcinoma. Nonalcoholic steatohepatitis (NASH) is a common liver disease that is characterized histologically by hepatic steatosis, lobular inflammation, and hepatocellular ballooning, it can progress to cirrhosis in up to 15% of patients. There is currently no therapy that is of proven benefit for nonalcoholic steatohepatitis. The disease is closely associated with insulin resistance and features of the metabolic syndrome such as obesity (increased waist circumference), hypertriglyceridemia, and type 2 diabetes. The pathologic criteria are now well established and the diagnosis can only be made once the absence or limited use of alcohol is confirmed. In addition to insulin resistance, oxidative stress has been implicated as a key factor contributing to hepatic injury in patients with nonalcoholic steatohepatitis. Thus, both insulin resistance and oxidative stress are attractive targets for therapy in patients with this disease. Several pilot studies have provided evidence that insulin sensitizers such as thiazolidinediones and antioxidants such as vitamin E improve clinical and histologic features of nonalcoholic steatohepatitis. The medical evidence of a benefit, however, is limited, because these studies had small samples and were performed at single centers. Moreover, a recent multicenter trial showed a reduction in hepatic steatosis but no improvement in markers of cell injury after a year of rosiglitazone therapy. The value of these remains uncertain. Until now the best trial was done by Sanyal, who studied 240 patients divided into 3 groups (pioglitazone versus vitamin E versus placebo)--multicenter, randomized, double-blind clinical trial in non-diabetics.

TIPS creation in patients with persistent left superior vena cava

Transjugular intrahepatic portosystemic shunt is a minimally invasive endovascular procedure that has played an important role in the treatment of acute or repeated variceal bleeding or refractory ascites. The standard venous access route for this procedure is the right jugular vein. Sometimes it is better to use the left jugular vein because of lower probability of life threatening complication or technical failure. In this case reports the authors have described their experience with TIPS creation in two patients with persistent left and absent right superior vena cava and recommend using the left jugular vein as an access route in this rare anatomical variant.

[Metabolic syndrome and the liver (NAFLD/NASH)]

Metabolic syndrome (MS) is one of the most prevalent disease states in the so-called developed countries and is closely associated with the incidence of cardiovascular as well as other diseases. Predominant sign is the abdominal type of obesity with increased visceral fat mass and the associated insulin resistance. Glucose metabolism disorder, dyslipidemia and arterial hypertension are other important attributes. Metabolic syndrome is also closely associated with the liver steatosis, mostly benign and reversible liver disease. Nevertheless, uncomplicated steatosis may, under certain conditions, progress to inflammation and the disease may, through the stage of NASH (nonalcoholic steatohepatitis) and liver fibrosis, result in liver cirrhosis and hepatocellular carcinoma. Anglo-Saxon literature uses the term NAFLD (non-alcoholic fatty liver disease) to refer to these various stages ofthe liver disease (uncomplicated liver steatosis, steatohepatitis, fibrosis and cirrhosis). While simple steatosis is not dangerous for the patient, NASH is the sign of developing cirrhosis. Etiopathogenesis of NASH features identical characteristics as etiopathogenesis of insulin resistance and metabolic syndrome. Even though liver biopsy remains the gold standard in the diagnosis, new diagnostic approaches are emerging that could be useful in distinguishing simple steatosis from NASH. Therapy includes lifestyle changes, insulin resistance-reducing medication (also useful in the treatment of type 2 diabetes) with a range of other agents under development. In the meantime, randomized double-blind placebo-controlled studies with histological proof of the results are still lacking. A range of unresolved issues remains with regards to etiopathogenesis as well as diagnosis and treatment of NAFLD and NASH.

Hiatal hernia and Barrett's oesophagus impact on symptoms occurrence and complications

The aim of the study was to evaluate the influence of sliding hiatal hernia over the Barrett's oesophagus, including symptoms rate and complications.

METHODS

A total of 520 (4.6%) cases of Barrett's oesophagus were found out of 18.276 upper gastrointestinal endoscopies, performed in 11.276 patients at a single tertiary centre in a period from 1994 to 2004.

RESULTS

Sliding hiatal hernia was found in 58% of patients with Barrett's oesophagus, more frequently in men (60%). The association between hernia and some complications of Barrett's oesophagus was significant (94% of Barrett's ulcer, 77% of low-grade dysplasia with p < 0.01). However, there was no significant association with adenocarcinoma (54%; p > 0.05). The other complications of Barrett's oesophagus (i.e. bleeding, stenosis, high-grade dysplasia) were identified in small number (less than 10), so they were not evaluated statistically. Association between the presence of hiatal hernia and occurrence of symptoms (reflux symptoms, dysphagia, odynophagia, dyspeptic and other symptoms) was significant with p < 0.01.

CONCLUSIONS

Our study suggests that sliding hiatal hernia may play a significant role as a pathophysiologic factor in Barrett's oesophagus. Complications rate of Barrett's oesophagus were not equally frequent in particular cases with hiatal hernia. The occurrence of symptoms is getting more pronounced in those with sliding hiatal hernia.

[Diagnosis and treatment of chronic hepatitis B. Recommendations of the Czech Hepatology Society of the J. E. Purkinje Medical Society and the Society of Infectious Medicine of the J.E. Purkinje Medical Society]

Chronic hepatitis B is one of the world's most common infectious diseases. In the Czech Republic it has a prevalence of 0.56%. Antiviral therapy for chronic hepatitis B demonstrably increases quality of life and where indication criteria are met and standard therapeutic procedures are followed, it is clearly cheaper than treatment for the complications of advanced cirrhosis of the liver or hepatocellular carcinoma. At the time of issuing of this recommendation, 4 medicines were classified for the treatment of chronic hepatitis B in the Czech Republic--pegylated interferon (IFN) alpha-2a, conventional IFN alpha, lamivudine (LAM) and adefovir dipivoxil (ADV). In a number of other developed states, entecavir (ETV) and telbivudine (LdT) have also been approved for treatment. The most effective treatment available at present is pegylated IFN alpha-2a, which should be the medication of first choice for initial treatment of hepatitis B, HBeAg positive and negative forms, provided that there are no contraindications for IFN alpha treatment. Conventional (standard, classical) IFN alpha can also be used, though clinical studies have shown it to be less effective than pegylated IFN alpha-2a. The main advantage of interferon compared to other commercially available medications is its relatively shorter and more clearly defined treatment period, the high probability of permanent suppression of virus replication and seroconversion of HBeAg/anti-HBe (in HBeAg positive forms of the illness) and the non-creation of mutant strains of HBV resistant to IFN in the course of treatment. If there are contraindications for IFN alpha (pegylated or conventional) or it is ineffective or poorly tolerated, ADV, ETV, LAM or LdT can be used. LAM and LdT treatments are often accompanied by the appearance of mutant strains of HBV, that are resistant to lamivudine or LdT and therefore they are not preferred.

The efficacy of terlipressin in comparison with albumin in the prevention of circulatory changes after the paracentesis of tense ascites--a randomized multicentric study

BACKGROUND/AIMS

Postparacentesis circulatory dysfunction is the most severe complication of ascites paracentesis. The aim of our study was to compare the standard treatment with the administration of a vasoconstrictor terlipressin.

METHODOLOGY

Forty-nine patients treated by paracentesis due to tense ascites were randomized for the treatment with albumin (8g/L of removed ascites) or terlipressin (1 mg every four hours for 48 hours). The blood pressure, heart rate, diuresis, electrocardiograph, standard biochemical and hematological parameters, sodium, potassium and nitrogen urinary excretion, aldosterone and renin activity in the blood plasma were monitored for a period of 72 hours.

RESULTS

In any parameter of hemodynamic changes, no statistically significant difference was demonstrated between randomized groups, in particular measurements as well as in the development in the course of the first three days after the intervention. The result suggests similar efficacy of the circulatory dysfunction prevention after the paracentesis in both treatment procedures. In both groups, on the first three days, there was a tendency to improve hemodynamics reflected by the renin-angiotensin-aldosteron system activity. In the terlipressin group, this tendency approached statistically significant levels.

CONCLUSIONS

The administration of terlipressin in a dose of 1 mg every fourth hour performed for a period of 48 hours was as effective as intravenous albumin in preventing hemodynamic changes in patients with tense ascites treated by paracentesis. The treatment was well tolerated.

[The impact of secondary insertion of ePTFE-coated stent on sustainable TIPS patency]

OBJECTIVE

Retrospective evaluation of the effect of secondary insertion of ePTFE-coated stent in the treatment of TIPS dysfunction versus other current options (simple angioplasty, insertion of additional non-coated stent). PATIENT SET AND METHODOLOGY: From the beginning of 2000 to the end of 2004, there were 121 interventions for TIPS dysfunction performed in our centre in which a non-coated stent was used to make up the shunt at the time of intervention. Depending on the type of intervention, the patient set was divided in 4 groups: simple angioplasty (52 cases, 43%), insertion of non-coated stent (35 cases, 28.9%), insertion of non-dedicated ePTFE-coated stent (15 cases, 12.4%), and insertion of dedicated ePTFE-coated stent (19 cases, 15.7%). All patients were monitored on a regular basis after the intervention for shunt patency with the use of clinical examination and Doppler ultrasonography, or also portal venography. Primary shunt patency after the intervention was evaluated in all four groups by Kaplan-Meier analysis. The primary shunt patency results after the intervention were compared with the use Cox F text and logrank test.

RESULTS

The intervention was successful in 120 cases (the overall technical success rate of all interventions was 99.2%). The primary shunt patency was 49.7 % after 12 months and 25.3 % after 24 months following sole angioplasty intervention; 74.9% after 12 and 64.9% after 24 months following intervention involving the insertion of non-coated stent; 75.2 % after 12 months and 64.5% after 24 months following intervention involving the insertion of non-dedicated ePTFE-coated stent, and 88.1% after 12 months and 80.8% after 24 months following intervention involving the insertion of a dedicated ePTFE-coated stent. A statistically significant improvement in shunt patency was obtained in the group of interventions involving the insertion of dedicated ePTFE-coated stent and in the group of interventions involving the insertion of non-coated stent as compared with the group of interventions involving sole angioplasty (p < 0.01).

CONCLUSION

From among all the currently used methods of therapeutic intervention for TIPS dysfunction, the best, the best subsequent TIPS patency was obtained after intervention involving insertion of dedicated ePTFE-coated stent.

[Dysfunction of transjugular intrahepatic portosystemic shunt (TIPS) and applicable solutions]

A synoptic article providing a comprehensive view of TIPS dysfunction. The article covers current terminology, definition, etiology, pathogenesis, diagnostics, therapy and prevention of TIPS dysfunction.

[MELD score in prediction of early mortality in patients suffering refractory ascites treated by TIPS]

Transjugular Intrahepatic Portosystemic Shunt (TIPS) is now well established in the treatment of complications of symptomatic portal hypertension such as acute or recurrent variceal bleeding, refractory ascites and Budd-Chiari syndrome. In some patients with refractory ascites who belong to group C according to Child-Pugh classification (score around 12), the indication of the procedure could be very questionable and early mortality is quite high. However, in some cases, the subgroup of such risky patients can profit from TIPS. Child-Pugh classification is used for the stratification of the patients routinely. During the last decade other scoring systems occured to bring a better prognostic value. MELD (Model for End stage Liver Disease) score, based only on laboratory values is one of them. Comparison of these two scoring systems in patients treated by TIPS in previous trials brought certain discrepancy, but MELD score seems to be better in predicting early mortality. The aim of our study was to determine retrospectively the predictive accuracy of MELD score for the early mortality in comparison to Child-Pugh score in patients treated for refractory ascites by TIPS.

METHODS

We evaluated 110 patients (mean age 55 years) with liver cirrhosis (61% of patients with alcoholic etiology), who underwent TIPS for refractory ascites in our center from September 1992 to December 2003. MELD and Child-Pugh score was calculated and then compared between groups with early (one month), three month and one year mortality, and those who survived over this period (one, three and twelve months), comparing MELD and Child-Pugh score (ROC analysis and Student's T test were used).

RESULTS

Mean follow up was 23 months. Average MELD score in the whole group was (16). In patients, who died within one month the score before TIPS was 21, three months 20 and 18 one year. Comparing MELD score between subgroups and then Child-Pugh score, only for MELD score there was a statistically significant difference (p < 0.05) in one month. Using ROC (AUC) analysis, discriminant power of MELD score was superior to Child-Pugh score for one (0.73 vs 0.63) and three month (0.73 vs 0.67) mortality. The discriminant power for one year mortality was low in both scores.

CONCLUSION

MELD scoring system is a better tool to predict the risk of early mortality in patients with refractory ascites treated by TIPS than Child-Pugh classification. The discriminant power was low in both scores in one year horizon.

[Diagnostics and therapy of hepatorenal syndrome. Recommendations of of the working group on portal hypertension of the Czech Hepatology Society and the J. E. Purkinje Czech Medical Society]

Hepatorenal syndrome is a functional renal failure in patients with advanced cirrhosis and portal hypertension or acute liver failure. It is caused by extreme vasoconstriction in renal arterial bed. Type I HRS presents as an acute renal failure, while type II HRS is chronic alteration of renal function in patients with refractory ascites. Prognosis of HRS is very poor with survival reaching several weeks in patients with HRS type I. Causal treatment is liver transplantation, other treatment options include use of splanchnic vasoconstrictors (terlipressin) together with plasmaexpansion (albumin) and TIPS. It is important to exclude nephrotoxic medication (non-steroid anti inflammatory drugs, aminoglycosides) and properly treat all infective complications in prevention of HRS.

[The diagnostics and therapy of hepatic encephalopathy. Recommendations of of the working group on portal hypertension in the Czech Hepatology Society and the J. E. Purkinje Czech Medical Society]

Hepatic encephalopathy (HE) is a set of reversible neuropsychic features which occur in connection with hepatic cirrhosis or acute hepatic failure. We distinguish manifest HE (with clinical symptoms) and minimal FE (normal clinical finding, abnormal psychometric or neurophysiologic exam). The diagnosis is clinical or laboratory one. From the auxiliary examinations in common practice the number connection test is sufficient.

THERAPY

Presence of hepatic encephalopathy should lead to the consideration of the possibility to solve basic disease by hepatic transplantation. Conservative therapy lies in 1. Basic disease elimination, 2. Measures lowering the ammonia level in blood--optimalization of protein intake, administration of indigestible disaccharides (lactulose, lactitol) and fill sterilisation by antibiotics (Rifaxin, Metronidazol), ornitine-aspartate administration, 3. Influencing the changes in amino acid metabolism (administration of branched chain amino acids--BCAA). Prognosis depends on the advancement of the disease, after hepatic transplantation the clinical symptoms of HE are mostly fully reversible.

[Diagnostics and treatment of hepatocellular carcinoma. Recommendations of the Portal Hypertension Working Group of the Czech Hepatology Society and the J.E. Purkinje Czech Medical Society ]

Hepatocellular carcionma (HCC) is almost exclusively associated with liver cirrhosis as a significant HCC risk marker in advanced countries. Applicable therapy depends on early diagnosis, and risk patients should be screened for the presence of HCC on a regular basis. Liver ultrasound and determination of alpha-fetoprotein serum levels (AFP) are the screening methods used. Spiral CT is the most often used method for HCC staging. Non-invasive methods may under certain circumstances replace aimed biopsy. There are 3 basic curative therapies for the early stage of HCC: liver transplantation, surgical resection and different methods of local destruction of tumour (i.e., ethanolisation, thermoablation, etc.). Patients at medium stage of HCC may profit from chemoembolisation. Current available systemic chemotherapy is ineffective. Patients with advanced HCC are treated symptomatically. Patient survival prognosis after the application of one of the above treatment methods may be similar with that for HCC free cirrhosis patients, however, prognosis for advanced HCC patients is bad, with survival period from one to nine months.

[Budd-Chiari syndrome and TIPS--twelve years' experience]

BACKGROUND

Massive thrombosis of hepatic veins is clinically the most serious type of Budd-Chiari syndrome (BCS). Ischemic impairment is the basic problem in case of acute or fulminate course of BCS. Restitution of blood drainage within the liver is a key therapeutic approach in such situation. In chronic course of the disease, symptoms of portal hypertension as ascites, G1 bleeding or hepatorenal syndrome are more common. The portosystemic shunt leads both to blood outflow restitution and to the decrease of portal hypertension. TIPS is a promising method due to minimal perioperative risk for the patient in critical situation and also due to its easiness of use. The aim of our study was to determine the clinical outcome in patients with BCS treated by TIPS in a retrospective analysis.

METHODS AND RESULTS

During 12 years 23 patients with intraparenchymal thrombotic occlusion of hepatic veins were treated using TIPS, 17% were children, only 4 patients (17%) were men, the median age was 33.3 years (range 13 to 75 years). One third of the procedures was performed as urgent. In 2/3 of patients thrombosis developed in relation to myeloproliferative syndrome, in nearly 1/3 the origin of thrombosis was not detected. In 2 patients a defect of coagulation was revealed. In the first 11 patients the bare stent was used, the consecutive 12 patients received the ePTFE covered stent (stentgraft). Six patients died during follow-up: I due to fulminate liver failure, 2 due to liver failure caused by acute shunt occlusion, 1 due to the progression of the underlying hematooncological disease; the reason of death in 2 patients was not known. One patient was treated by OLTx during follow-up. The 17 surviving patients are in good condition with good shunt function although they need anticoagulant therapy and intermittent reinterventions. The average period between revisions was 2-3 years, 2 patients had no revision of TIPS for 4 years. The use of ePTFE covered stents had no effect on the number of early occlusions (approx. 18%), the occurrence of late stenoses and occlusions was substantially decreased (p=0.04, log-rank test).

CONCLUSIONS

Standing on this experience we consider TIPS, in accordance with literature data, an advantageous therapeutic approach in Budd-Chiari syndrome caused by massive liver vein thrombosis. If the follow up treatment is rigorous, the TIPS usually ensures the necessary perfusion and the function of the liver So it may spare the patients of objectionable liver transplantation.

[Congenital dyserythropoietic anemia--type II (CDA-II) in 3 siblings with long-term follow up and iron overload]

The diagnosis of congenital dyserythropioetic anemia-type II (CDA-II) was established in 1974 in three siblings aged 20, 18 and 5 years, respectively. Liver biopsy performed in two elder siblings on admission revealed liver siderosis. Anemia showing haemolytic component with destruction of erythrocytes in the spleen was corrected after splenectomy. Increased number of erythrocytes showing "the double membrane phenomenon" was found in the peripheral blood after splenectomy. All three siblings developed cholecystolithiasis with choledocholithiasis and obstructive jaundice in two of them. Two patients at the age of 49 and 34 years (the third died in an accident at the age of 40 years) developed 29 years after the diagnosis of CDA-II had been established signs of iron overload with transferin saturation 99%, serum ferritin 1450.4 microg/l and 1131.7 microg/l respectively, and hepatic iron concentration (dry weight) 14,843 microg/g and 15,415 microg/g (norm 70-1400 microg/g) respectively. No mutations of HFE gene (C282Y and H63D) were found. Liver biopsy showed heavy accumulation of hemosiderin in hepatocytes and reticuloendothelial cells. The structure of the liver tissue was not changed, only mild fibrosis in portal area was present in the older patient. Because of iron overload therapy with phlebotomy once monthly (400 ml) has been started in both patients. In peripheral blood films excess of Pappenheimer bodies was found.

[The Budd-Chiari syndrome in a patient with primary thrombocythemia treated with interferon alfa and transjugular portosystemic shunt]

The case report of a young female patient with personal history of primary thrombocythaemia, treated with interferon alpha, admitted to our medical department for severe abdominal pain, hepatomegaly, ascites and alteration of hepatic function is presented. Magnetic resonance imaging showed the picture typical for Budd-Chiari syndrome caused by external obstruction of the intrahepatal portion of inferior vena cava. The cause of the syndrome remains uncertain, possibility of the haematogenic infiltration of the liver or venal thrombosis within primary or secondary (interferon-induced) antiphospholipid syndrome is discussed. Liver biopsy could elucidate the exact cause, but it was not performed for technical problems.

[Intravascular brachytherapy in the prevention of vascular restenosis]

Vascular restenoses currently represent a major problem in the treatment of vascular stenoses. One of new approaches in the prevention of restenoses is intravascular brachytherapy. Intravascular brachytherapy uses local irradiation of the stenotic vessel segment by ionizing radiation with the aim of prevention of restenosis. This is a new rapidly developing multidisciplinary approach based on collaboration of specialties of intervention radiology, intervention cardiology, angiology, nephrology and radiation oncology. This review examines current options of intravascular brachytherapy as well as results of clinical trials evaluating the efficacy of intravascular brachytherapy in the different anatomical regions. Intravascular brachytherapy may substantially reduce the rate of restenoses. However, intravascular brachytherapy should be currently used only in the setting of clinical trials. Optimal method of irradiation of the stenotic segment of the vessel is still to be defined.

[Effect of transjugular portosystemic shunt on insulin resistance]

Patients with cirrhosis of the liver suffer from hyperinsulinaemia and a certain degree of insulin resistance. More frequently than in the rest of the population they have diabetes. Transjugular intrahepatic portosystemic shunts (TIPS) as a therapeutic method in complications of portal hypertension lead to rapid haemodynamic changes in the liver. The objective of the submitted work was to assess whether TIPS has an impact on insulinaemia and whether it influences insulin resistance in patients with cirrhosis of the liver.

GROUP AND METHODS

The authors evaluated a group of 22 patients with cirrhosis of the liver (10 diabetics and 12 subjects without diabetes) indicated for TIPS. They investigated the insulin and C-peptide concentration in blood obtained by catheterization from the hepatic and portal vein before and after TIPS and in the peripheral blood before TIPS, 1 hour, 1 day, 1 week and 1 month after TIPS. The insulin resistance was examined by the method of the hyperinsulin euglycaemic clamp (HEC) before TIPS, 1 day, 1 week, and 1 month after TIPS. The levels of C-peptide and insulin were assessed by the IRMA method. The blood sugar level in HEC was measured by means of a Hemocue apparatus. The results were evaluated by the non-parametric Wilcoxon test for two dependent samples.

RESULTS

Both groups (diabetics and non-diabetics) were comparable as to age, sex, etiology of liver cirrhosis and indication for TIPS. After introduction of TIPS a change of insulin clearance occurred (p = 0.01) and a change of the insulin level in the hepatic vein immediately after TIPS (p = 0.02). Insulin clearance before TIPS was 37-90% (median 54%) and after TIPS it declined to 0-79% (median 38%) (p = 0.01). Already 1 hour after the operation the authors observed a rise of the insulin level in peripheral blood as compared with baseline values (p = 0.002). Statistically significant hyperinsulinaemia persisted one month after TIPS (p = 0.005). Values of C-peptide did not change significantly in time, neither in the hepatic vein nor in the peripheral blood. On examination of IR no statistically significant changes occurred after TIPS. On evaluation of different groups of diabetics and non-diabetics the IR was more marked in patients with DM (mean M = 1.7 mg/kg/min.) than in patients without DM (3.7 mg/kg/min.) (p = 0.03). The authors did not record significant changes of IR in time in different groups. Compensation of DM was not influenced by TIPS. The fasting blood sugar levels before TIPS and 1 month after TIPS were comparable.

CONCLUSION

After TIPS a rise of the insulin level in peripheral blood occurred due to the reduced insulin clearance in the liver. Despite hyperinsulinaemia which persisted for one month after the operation, the insulin resistance did not deteriorate. Compensation of diabetes was not affected by TIPS.

[Double blind randomized multicentre study of a seven-day eradication regime of Helicobacter pylori by omeprazole, clarithromycin and ornidazole vs. omeprazole, clarithromycin and metronidazole]

Effective eradication regimes of Helicobacter pylori infections are nowadays based on administration of a substance with a strong suppressive effect on production of gastric HCl combined with two antibiotics. As suppressor of gastric HCl production unequivocally some drug from the group of proton pump blockers is used. As to antibiotics, in first line therapy the following are recommended: clarithromycin, amoxicillin, metronidazole. A problem in the eradication therapy of Helicobacter pylori infection in recent years is the increasing resistance to clarithromycin and apparently also metronidazole. In the Czech Republic the resistance to clarithromycin in relation to Helicobacter pylori is stabilized at a level lower than 3.0 %. Resistance to metronidazole was reported in 1992 within the range of 24 % - 26 %, however in 2001 it was already 36.0 %. Therefore the question arises whether it is possible under our conditions to check the increasing metronidazole resistance by a drug which by its spectrum of action resembles metronidazole while it differs from it as to its chemical structure. This is the reason why the authors implemented a trial where metronidazole was replaced by tinodazole (Avrazor, Léciva Co.). The results revealed that in the group treated with tinidazole eradication was achieved after 7-day administration of ornidazole in 93.0 %, in the group where part of the eradication regime was metronidazole eradication was 82.6 %. The tolerance of both drugs was very good. The authors recommend to include the pattern omeprazole 2 x 20 mg, clarithromycin 2 x 500 mg and tinidazole 2 x 500 mg among first line therapeutic regimes.

[Principles of conservative treatment of severe acute pancreatitis]

The main principles of conservative treatment of severe acute pancreatitis include early diagnosis of the disease, diagnosis of its severe form and assessment of the etiology of pancreatitis, replacement of fluids, adjustment of the milieu intérieur, administration of antibiotics in patients with confirmed necroses, in particular if they exceed 25 - 30%, early endoscpic treatment of pancreatitis with a biliary etiology, adequate nutrition, prevention and treatment of complications. The diagnosis of pancreatitis is based on clinical examination, biochemical evidence of elevated amylase and lipase concentrations and on the imaging of the pancreas. In the severe form necroses of the pancreas are present or other local complications and/or organ dysfunction. As regards assessment of the etiology rapid diagnosis of biliary pancreatitis is fundamental as it leads to therapeutic consequences. Fluid replacement should not be discontinued even during transport and diagnostic procedures. Infection remains the main cause of mortality in patients who got over the hypovolaemic stage of pancreatitis. Antibiotics are therefore indicated in all patients with necroses or biliary infection. Systemic complications include renal failure, pulmonary failure, coagulopathy, cardiac and hepatic failure--frequently manifested as combined multiple organ dysfunction. Local complications such as pseudocysts, abscesses, compression conditioned stenoses of the bile ducts or haemorrhage from impaired visceral arteries are treated as a rule in an interdisciplinary manner with preference of less invasive procedures. Clinical deterioration of patients in particular the development of multiple organ failure in patients with extensive infiltrates and necroses is caused in the great majority of cases by infection of necroses and is an indication for early, usually surgical intervention.

TIPS creation in a patient with situs inversus totalis

We describe the successful creation of a transjugular intrahepatic portosystemic shunt (TIPS) in a patient with complete situs inversus using a simple modification of the standard TIPS technique.

[Rifaximin in the treatment of hepatic encephalopathy]

Hepatic encephalopathy is a frequent and serious complication of liver cirrhosis. Usually it is treated by non-absorbable disaccharides or antibiotics and its treatment is often difficult and associated with undesirable effects. The objective of our investigation was to evaluate the safety and effectiveness of a new antibiotic used in this indication--rifaximine. With rifaximine, 400 mg three times per day, a total of 25 patients were treated for a 10-day period. Significant improvement of the manifestations of encephalopathy occurred (evaluated by the grade of encephalopathy, test of combining numerals, the degree of flapping tremor and the arterial ammonia level). None of the patients developed undesirable effects. Rifaximine seems an effective, safe drug for hepatic encephalopathy.

[Hepatic encephalopathy after TIPS--retrospective study]

Hepatic encephalopathy (HE) is the main neuropsychiatric complication in cirrhosis of the liver. It develops slowly, begins by alteration of sleep and proceeds via flapping tremor to sopor, coma. Among known factors which promote its development are age, high dietary protein intake, haemorrhage into the GIT and the use of sedatives. Transjugular portosystemic anastomosis (TIPS) as a therapeutic method in complications of portal hypertension is associated with a higher incidence of HE. The objective of the work was to assess by retrospective investigations of patients with cirrhosis of the liver after TIPS the incidence of clinically significant HE and identify risk factors for the development of HE.

MATERIAL AND METHODS

The group comprised 256 patients with cirrhosis of the liver after TIPS. This number included 59 diabetic and 197 non-diabetic patients, 7 patients suffered from chronic renal insufficiency and were in a regular dialyzation programme. The presence of HE was evaluated clinically.

RESULTS

HE was found in 51% patients above 60 years of age, vs. 27% in younger patients (p = 0.002). The authors did not observe a difference in the incidence of HE in relation to sex, stage of cirrhosis, diameter of the stent nor the drop of the portosystemic gradient. In diabetic patients HE developed in 45.8% (27 of 59), as compared with 30% (59 of 197) in non-diabetic patients (p = 0.02). Multivariance analysis revealed however that the group of diabetic patients had a higher average age and thus the incidence of HE was statistically significantly conditioned by age and not by the presence of diabetes.

CONCLUSION

The risk group for HE in our patients were those above 60 years of age and patients with another than ethylic etiology of liver cirrhosis. There was no direct relationship between the development of HE and other investigated parameters. Although there was no difference in the incidence of HE in relation to the diameter of the inserted stent or portosystemic gradient and its reduction, in case of unsuccessful conservative treatment with lactulose and diet, HE can be resolved by narrowing of the shunt by insertion of a reducing stent.

Value of Doppler sonography in revealing transjugular intrahepatic portosystemic shunt malfunction: a 5-year experience in 216 patients

OBJECTIVE

The purpose of the study was to evaluate the long-term clinical efficacy of Doppler sonography in revealing failure of transjugular intrahepatic portosystemic shunts (TIPS).

SUBJECTS AND METHODS

During a 5-year period, 1192 Doppler examinations were performed in 216 patients with TIPS. No regular follow-up shunt venography was performed. Doppler examinations were retrospectively compared with the results of shunt revisions. Sonograms with negative findings were compared with the patients' clinical status so that the number of false-negative sonographic findings leading to an episode of shunt failure (recurrence of gastrointestinal bleeding or ascites) could be ascertained. Sonographic parameters assessed included diameter, velocity, flow volume, and congestion index of the portal vein; and shunt velocities.

RESULTS

Doppler sonography revealed shunt occlusion in 25 of 26 angiographically proven cases (sensitivity, 96%). The combination of velocity criteria (peak intrashunt velocity > or =250 cm/sec, maximum velocity in the portal third of the shunt < or =50 cm/sec, or maximum portal vein velocity less than or equal to two thirds of the baseline value) revealed shunt stenosis in 103 of 110 cases (sensitivity, 94%). Doppler sonography missed a significant shunt stenosis that led to an episode of gastrointestinal bleeding or ascites recurrence in only seven cases. The congestion index of the portal vein showed significant differences between patent and malfunctioning shunts (p < 0.001).

CONCLUSION

Doppler sonography is an effective primary imaging method for long-term follow-up of patients with TIPS.

Endovascular brachytherapy of transjugular intrahepatic portosystemic shunt

PURPOSE

To evaluate the technical feasibility and efficacy of endovascular brachytherapy with Iridium-192 in the prevention of restenosis caused by neointimal hyperplasia of transjugular intrahepatic portosystemic shunt (TIPS).

MATERIALS AND METHODS

The endovascular brachytherapy with high dose rate automatic afterloading system was performed in six patients with recurrent of stenosis of TIPS. We used a single dose fraction of 12 Gy delivered at 3 millimeter (mm) from the source axis to the stenotic vessel segment in five patients with spiral Z-stent, and 15 Gy at 5 mm in one patient with Wallstent.

RESULTS

Follow-up time ranged from 148 to 639 days. In one patient, restenosis occurred in the treated vessel segment, diagnosed 71 days after endovascular brachytherapy by doppler ultrasound. All other patients were, during the follow-up time, without restenosis in the irradiated vessel segment. Radiation-associated side effects were not observed.

CONCLUSIONS

Endovascular brachytherapy of TIPS is technically feasible and may be done as a part of the percutaneous revision of the shunt. This pilot study may be the largest experience of treating TIPS restenosis in humans to date. For definitive conclusions, a lot of studies are needed.

[Transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of symptomatic portal hypertension]

BACKGROUND

A transjugular intrahepatic portosystemic shunt (TIPS) is the creation of a percutaneous portosystemic anastomosis which is used as an alternative method of surgical portosystemic shunts and endoscopic treatment in the therapy of complications of portal hypertension. The objective of the present work was to summarize experience with TIPS in 100 patients.

METHODS AND RESULTS

In 1992-1995 the authors treated 100 patients with symptomatic portal hypertension by TIPS. To create the shunt in 84% patients a spiral Z stent was used, in the remainder a Wallstent. In 86% patients the indication for TIPS was haemorrhage associated with portal hypertension and in 14% refractory ascites. TIPS was implemented in 98% patients. The pressure in the portal vela was not reduced on average to 58% of the original value. Haemorrhage was not stopped in one of 7 patients. Haemorrhage from varices reappeared in 7% patients indicated on account of repeated haemorrhage and was always associated with the finding of chronic stenosis of the shunt. The mortality in conjunction with the procedure was 4%, the mortality within 30 days after operation was 8%. Uncontrollable encephalopathy developed in 3% of the patients. Primary patency of the shunt created by the spiral Z stent was 85% after 6 months, after 12 months 72% and thus does not differ from primary patency when Wallstents are used, as reported in the literature.

CONCLUSIONS

TIPS is an effective method to reduce the pressure in the portal vein in portal hypertension. The main limiting factor of the method is stenosis of the shunt due to hyperplasia of the neointima. Stenoses of the shunt can be effectively dilated by percutaneous balloon angioplasty.

Advanced electrophysiological diagnostics of hepatic and portosystemic encephalopathy

In 28 patients with liver cirrhosis, pre- and post-TIPS (transjugular intrahepatic porta-caval shunt), pattern-reversal visual evoked potentials (PREPs) and motion-onset visual evoked potentials (M-VEPs) examinations, EEG spectral analysis and Number Connection Test were performed. The M-VEPs (representing an activity of the magnocellular system of the visual pathway and reactions of the mediotemporal associate visual area) displayed the highest sensitivity (latencies delay) for detection of subclinical hepatic encephalopathy. The PREPs (originating in the primary visual cortex -area striata) were not significantly changed in comparison with a group of age matched controls. The EEG frequency spectrum exhibited significant slowing of the dominant frequency which was more pronounced in the post-TIPS examination. Combined analysis of the M-VEPs latency and EEG dominant frequency seem to be a recommendable method for early detection and objective classification of subclinical hepatic or portosystemic encephalopathy.

Pharmacokinetic parameters of verapamil and its active metabolite norverapamil in patients with hepatopathy

Verapamil (CAS 52-53-9) is a calcium channel blocker with a vasodilatatory effect. Because of its significant first-pass effect, verapamil might be advantageous in the treatment of portal hypertension. It does not produce any excessive systemic effects, provided the doses are suitably adjusted. A decision was made to examine the pharmacokinetic parameters, independent of compartmental analysis of verapamil and its active metabolite norverapamil, in patients with portal hypertension. Their biological half-lives of the terminal phase were significantly prolonged as compared with the control group. However, no statistically significant differences were found in the values of tmax and Cmax. The calculated pharmacokinetic parameters of norverapamil were not significantly different from those of verapamil, except for the tmax of norverapamil, which was significantly longer in patients suffering from portal hypertension as compared with verapamil. The ratio of areas under the plasma concentration-time curve (AUC) of verapamil and norverapamil was comparable in both groups of patients. No relationship between the changes in the pharmacokinetic parameters and the extent of hepatic insufficiency was observed.

A study of the inhibition of adrenaline-induced vasoconstriction in the isolated perfused liver of rabbit

We have studied the action of a series of vasoactive and antispasmodic agents on the intrahepatic vasoconstriction induced by adrenaline in the isolated perfused liver of rabbits. The arterial and portal venous resistance, oxygen consumption, liver weight and bile flow were investigated. The drugs used were as follows: nonspecific alpha-adrenergic antagonists (DH-ergocristine, dibenamine, phenoxybenzamine), vasodilators with a direct miscellaneous action (theophylline, papaverine, dipyridamole, glucagon, Aiu-cor by Instituto Gentilli, Italy [inosine, ATP, IPI, UTP]) and antispasmodics (piperylone, tropenziline, noraminophenazone). Adrenaline increased arterial and portal venous resistance followed by a diminution of oxygen consumption, liver weight and bile flow. alpha-Adrenergic antagonists inhibited the effects of adrenaline on portal venous resistance and oxygen consumption and especially the effects on hepatic arterial resistance. The most potent agent was phenoxybenzamine. In contrast to alpha-adrenoceptor blockade, the effects of other vasoactive agents were without a sustained influence on hepatic arterial resistance (excepting those of glucagon and dipyridamole). Some of them were effective as antagonists on responses in the portal venous bed (papaverine, Aiu-cor). Moreover, there were drugs exerting an enhancement of the vasoconstrictor responses of hepatic artery to low concentrations of adrenaline with no effect on the portal venous bed (piperylone, tropenziline). Theophylline and noraminophenazone exerted no effect either on the arterial or portal venous bed. No vasodilator agent antagonized the changes of the bile flow after adrenaline administration.

[Treatment of pyogenic liver abscesses using percutaneous transparietal drainage]

Authors present their own experience with the method of external transparietal drainage of pyogenic hepatic abscesses. It is both effective and available method with minimum complications if performed in time. Mortality rate is much lower than in surgical drainage. Percutaneous drainage of hepatic abscesses depends on the possibility of their diagnostics by means of ultrasonography or computer tomography and access to special instruments.