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Willems P, Djinbachian R, Ditisheim S, Orkut S, Pohl H, Barkun A, Bouin M, Faulques B, von Renteln D. Uptake and barriers for implementation of the resect and discard strategy: an international survey. Endosc Int Open 2020; 8:E684-E692. [PMID: 32355888 PMCID: PMC7165012 DOI: 10.1055/a-1132-5371] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 02/04/2019] [Indexed: 02/06/2023] Open
Abstract
Background and study aims Optical real-time diagnosis (= resect-and-discard strategy) is an alternative to histopathology for diminutive colorectal polyps. However, clinical adoption of this approach seems sparse. We were interested in evaluating potential clinical uptake and barriers for implementation of this approach. Methods We conducted an international survey using the "Google forms" platform. Nine endoscopy societies distributed the survey. Survey questions measured current clinical uptake and barriers for implementing the resect-and-discard strategy , perceived cancer risk associated with diminutive polyps and potential concerns with using CT-colonography as follow-up, as well as non-resection of diminutive polyps. Results Eight hundred and eight endoscopists participated in the survey. 84.2 % (95 % CI 81.6 %-86.7 %) of endoscopists are currently not using the resect-and-discard strategy and 59.9 % (95 % CI 56.5 %-63.2 %) do not believe that the resect-and-discard strategy is feasible for implementation in its current form. European (38.5 %) and Asian (45 %) endoscopists had the highest rates of resect-and-discard practice, while Canadian (13.8 %) and American (5.1 %) endoscopists had some of the lowest implementation rates. 80.3 % (95 % CI 77.5 %-83.0 %) of endoscopists believe that using the resect-and-discard strategy for diminutive polyps will not increase cancer risk. 48.4 % (95 % CI 45.0 %-51.9 %) of endoscopists believe that leaving diminutive polyps in place is associated with increased cancer risk. This proportion was slightly higher (54.7 %; 95 % CI 53.6 %-60.4 %) when asked if current CT-colonography screening practice might increase cancer risks. Conclusion Clinical uptake of resect-and-discard is very low. Most endoscopists believe that resect-and-discard is not feasible for clinical implementation in its current form. The most important barriers for implementation are fear of making an incorrect diagnosis, assigning incorrect surveillance intervals and medico-legal consequences.
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Affiliation(s)
- Philippe Willems
- Division of Internal Medicine, Montreal University Hospital Center (CHUM), Montreal, Canada
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada.
| | - Roupen Djinbachian
- Division of Internal Medicine, Montreal University Hospital Center (CHUM), Montreal, Canada
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada.
| | - Saskia Ditisheim
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada.
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
| | - Sinan Orkut
- Faculty of Medicine, University of Strasbourg, Strasbourg, France
| | - Heiko Pohl
- Department of Veterans Affairs Medical Center, White River Junction, Vermont, and Dartmouth Geisel School of Medicine, Hanover, New Hampshire, United States
| | - Alan Barkun
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Canada
| | - Mickael Bouin
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada.
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
| | - Bernard Faulques
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada.
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
| | - Daniel von Renteln
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada.
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
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Abstract
Background and study aims: In recent years, cold snare polypectomy (CSP) has been recommended as the preferred approach for removal of small and diminutive colorectal polyps. We conducted an international survey among endoscopists to understand the uptake of CSP and changes in polypectomy practice during recent years.Patients and methods: Endoscopists were invited through gastroenterology, colorectal surgery and endoscopy societies to participate in an online survey. The primary outcome was to identify the predominant polypectomy approach used to remove 4‒10 mm colorectal polyps. Secondary outcomes included the uptake of CSP in the past 5 years, current polypectomy practice patterns for 1‒20 mm polyps, practice changes in recent years, and perceived benefits/concerns related to different polypectomy techniques.Results: The survey was distributed internationally by nine societies and completed by 808 endoscopists (response rate 3.7%). CSP was the predominant polypectomy technique for 4‒5 mm polyps (67.0%, 95% CI, 63.7-70.2%) and 6‒10 mm polyps (55.2%, 95% CI, 51.8-58.6%). For 1‒3 mm polyps, cold forceps remained the predominant technique (78.4%, 95% CI, 75.6-81.3%), whereas hot snare polypectomy (HSP) remained the predominant technique for 10‒20 mm polyps (92.5%, 95% CI, 90.7-94.3%). 87.5% (95% CI, 85.2-89.8%) of endoscopists reported an increase in CSP use during the past 5 years.Conclusions: This survey found a substantial increase in CSP use during recent years. CSP has become the predominant polypectomy approach for 4‒10 mm colorectal polyps, while HSP remained the predominant approach for larger (10‒20 mm) polyps. Clinical practice patterns are well aligned with recently issued guideline recommendations.
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Affiliation(s)
- Philippe Willems
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada.,Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
| | - Sinan Orkut
- Faculty of Medicine, University of Strasbourg, Strasbourg, France
| | - Saskia Ditisheim
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada.,Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
| | - Heiko Pohl
- Department of Veterans Affairs Medical Center, White River Junction, Hartford, VT, USA.,Dartmouth, Geisel School of Medicine, Hanover, NH, USA
| | - Alan Barkun
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Canada
| | | | - Mickael Bouin
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada.,Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
| | - Daniel von Renteln
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada.,Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
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Cleac’h AL, Villeneuve JP, Sylvestre MP, Huard G, Giard JM, Ditisheim S. Gastric antral vascular ectasia is more frequent in patients with non-alcoholic steatohepatitis-induced cirrhosis. Can Liver J 2019; 2:84-90. [PMID: 35990220 PMCID: PMC9202753 DOI: 10.3138/canlivj.2018-0021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 11/16/2018] [Indexed: 11/24/2023]
Abstract
BACKGROUND Gastric antral vascular ectasia (GAVE) is an uncommon cause of occult gastrointestinal (GI) bleeding. Based on clinical observations, we hypothesized that GAVE was more common in patients with non-alcoholic steatohepatitis (NASH) cirrhosis. METHODS We performed this retrospective study at Centre Hospitalier de l'Université de Montréal (CHUM). We included all cirrhotic patients who had undergone an esophagogastroduodenoscopy (EGD) between 2009 and 2011. GAVE was diagnosed based on a typical endoscopic appearance. NASH cirrhosis was diagnosed in patients with a metabolic syndrome after excluding other causes of liver disease. GAVE was considered symptomatic if it required treatment. RESULTS We included 855 cirrhotic patients in the study. The median age was 58 (range 19-88) years. The etiology of cirrhosis was as follows: NASH in 18% (n = 154), autoimmune diseases in 15.1% (n = 129), hepatitis B virus (HBV) in 6.3% (n = 54), hepatitis C virus (HCV) in 19.4% (n = 166), alcohol in 25.7% (n = 220), alcohol plus HCV in 7.8% (n = 67), cryptogenic in 2.8% (n = 24), and other etiologies in 4.8% (n = 41). GAVE was more frequently observed among patients with NASH cirrhosis than in cirrhosis of other etiologies (29.2% vs. 9.4%, respectively; p < 0.001). In multivariate analysis, NASH was strongly associated with GAVE with an odds ratio (OR) of 3.73 (95% CI 2.36 to 5.90, p < 0.001), and the association was stronger with symptomatic GAVE (OR 5.77, 95% CI 2.93 to 11.38). CONCLUSIONS NASH cirrhosis is a major risk factor for GAVE and symptomatic GAVE.
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Affiliation(s)
- Aline Le Cleac’h
- Division of Hepatology, Department of Medicine, Centre Hospitalier de l’Université de Montréal, Montréal, Québec
| | - Jean-Pierre Villeneuve
- Division of Hepatology, Department of Medicine, Centre Hospitalier de l’Université de Montréal, Montréal, Québec
| | - Marie-Pierre Sylvestre
- Department of Social and Preventive Medicine, Université de Montréal & Centre de recherche du Centre Hospitalier de l’Université de Montréal, Montréal, Québec
| | - Geneviève Huard
- Division of Hepatology, Department of Medicine, Centre Hospitalier de l’Université de Montréal, Montréal, Québec
| | - Jeanne-Marie Giard
- Division of Hepatology, Department of Medicine, Centre Hospitalier de l’Université de Montréal, Montréal, Québec
| | - Saskia Ditisheim
- Division of Hepatology, Department of Medicine, Centre Hospitalier de l’Université de Montréal, Montréal, Québec
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Willems P, Orkut S, Ditisheim S, Bouin M, Faulques B, Pohl H, von Renteln D. A239 CLINICAL MANAGEMENT OF COLORECTAL POLYPS: RESULTS OF AN INTERNATIONAL SURVEY. J Can Assoc Gastroenterol 2019. [DOI: 10.1093/jcag/gwz006.238] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- P Willems
- University of Montreal, Montréal, QC, Canada
| | - S Orkut
- University of Strasbourg, Strasbourg, France
| | - S Ditisheim
- University of Montreal, Montréal, QC, Canada
| | - M Bouin
- University of Montreal, Montréal, QC, Canada
| | - B Faulques
- University of Montreal, Montréal, QC, Canada
| | - H Pohl
- Dartmouth-Hichcock Medical Center, Lebanon, NH
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Girardin M, Bertolini D, Ditisheim S, Frossard JL, Giostra E, Goossens N, Morard I, Nguyen-Tang T, Spahr L, Vonlaufen A, Hadengue A, Dumonceau JM. Use of glasgow-blatchford bleeding score reduces hospital stay duration and costs for patients with low-risk upper GI bleeding. Endosc Int Open 2014; 2:E74-9. [PMID: 26135264 PMCID: PMC4423275 DOI: 10.1055/s-0034-1365542] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Accepted: 01/23/2014] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Upper gastrointestinal (UGI) bleeding is a frequent cause of hospitalization. Its severity may be assessed before endoscopy using the Glasgow-Blatchford Bleeding Score (GBS), a score validated to identify patients requiring clinical intervention. The aim of this study was to assess whether the GBS was effective for shortening hospital stay and reducing costs in patients with an UGI bleeding predicted at low risk of requiring clinical intervention. PATIENTS AND METHODS Consecutive outpatients presenting with UGI bleeding at our hospital were prospectively included. In the observational study phase, UGI endoscopy was performed in all patients according to routine clinical practice. In the interventional study phase, patients with a GBS of 0 were discharged with an appointment for an outpatient UGI endoscopy. All patients had follow-up at 7 and 30 days. Need for clinical intervention was defined as performance of endoscopic hemostasis, blood transfusion or surgery. Results Two-hundred and eight patients were included, 104 in each study phase; complete follow-up was obtained in 201 patients. GBS varied from 0 to 18, with 15 (14 %) and 11 (11 %) patients having a GBS of 0 in the observational and interventional study phase, respectively. For patients with a GBS of 0, hospital stay was shorter (6 versus 19 h, P < 0.01), and costs were lower (845 EUR versus 1272 EUR, P = 0.002) in the interventional versus the observational study phase. For patients with a GBS > 0, hospital stay duration did not significantly differ between study phases (189 versus 207 h, P = 0.726). No adverse event was observed in the patients sent home with a GBS of 0 during the interventional study phase. Conclusions Implementing the GBS as a tool for triage of hospital outpatients who present with UGI bleeding allowed us to identify those who could safely be discharged for ambulatory management. Implementing this change in the hospital strategy significantly shortened hospital stay and decreased management costs.
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Affiliation(s)
- Marc Girardin
- Division of Gastroenterology and Hepatology, Geneva University Hospital, Geneva, Switzerland,Corresponding author Marc Girardin, MD 4 Gabrielle-Perret Gentil Street1211 Geneva 14Switzerland
| | - David Bertolini
- Division of Gastroenterology and Hepatology, Geneva University Hospital, Geneva, Switzerland
| | - Saskia Ditisheim
- Division of Gastroenterology and Hepatology, Geneva University Hospital, Geneva, Switzerland
| | - Jean-Louis Frossard
- Division of Gastroenterology and Hepatology, Geneva University Hospital, Geneva, Switzerland
| | - Emiliano Giostra
- Division of Gastroenterology and Hepatology, Geneva University Hospital, Geneva, Switzerland
| | - Nicolas Goossens
- Division of Gastroenterology and Hepatology, Geneva University Hospital, Geneva, Switzerland
| | - Isabelle Morard
- Division of Gastroenterology and Hepatology, Geneva University Hospital, Geneva, Switzerland
| | - Thai Nguyen-Tang
- Division of Gastroenterology and Hepatology, Geneva University Hospital, Geneva, Switzerland
| | - Laurent Spahr
- Division of Gastroenterology and Hepatology, Geneva University Hospital, Geneva, Switzerland
| | - Alain Vonlaufen
- Division of Gastroenterology and Hepatology, Geneva University Hospital, Geneva, Switzerland
| | - Antoine Hadengue
- Division of Gastroenterology and Hepatology, Geneva University Hospital, Geneva, Switzerland
| | - Jean-Marc Dumonceau
- Division of Gastroenterology and Hepatology, Geneva University Hospital, Geneva, Switzerland
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Ditisheim S, Goossens N, Spahr L, Hadengue A. [Coagulation and cirrhosis: new insight]. Rev Med Suisse 2012; 8:1652-1656. [PMID: 22988724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The liver plays a key role in coagulation as all clotting factors except for factor VIII are synthetized by hepatocytes. In cirrhotic patients, there is a decrease of clotting factors and a thrombocytopenia. Those parameters usually modify routine coagulation tests and may suggest that cirrhotic patients are at a higher risk of bleeding. However, studies have shown that these patients are rather at risk for thrombosis. The reason is a concomitant decrease of coagulation inhibitors factors that is not detected in routine laboratory coagulation tests. The coagulation system in cirrhotic patient is a balance of pro and anti-coagulants. This balance may be affected by co-factors such as renal failure or infection. Artificial correction of laboratory values by transfusion of blood products may be rather deleterious (e.g. volume overload, TRALI).
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Affiliation(s)
- S Ditisheim
- Service de gastroentérologie et hépatologie, Département des spécialités de médecine, HUG, Genève.
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Goossens N, Ditisheim S, Lanthier N, Spahr L, Hadengue A. [Alcoholic steatohepatitis: what's new in 2012?]. Rev Med Suisse 2012; 8:1646-1651. [PMID: 22988723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Alcoholic liver disease is a spectrum of lesions, of which the most severe is alcoholic steatohepatitis (ASH). Recent European guidelines define alcoholic hepatitis as a clinical syndrome: the recent onset of jaundice and/or ascites in a patient with ongoing alcohol misuse. Next to infection, the most frequent aetiology is ASH, a histological diagnosis. In case of severe ASH, as defined by prognostic scores, a biopsy is needed to confirm the diagnosis. Non-severe forms of ASH may improve with interruption of alcohol abuse only; however survival of severe forms of ASH is improved by the association of corticosteroids and N-acetylcysteine. In case of uncontrolled infection, pentoxifylline may be administered. The Lille score, measured at the 7th day of corticosteroid therapy, measures response to therapy and guides the total duration of treatment.
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Affiliation(s)
- N Goossens
- Service de gastroentérologie et hépatologie, Département des spécialités, HUG, Genève.
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Ditisheim S, Giostra E, Burkhard PR, Goossens N, Mentha G, Hadengue A, Spahr L. A capillary blood ammonia bedside test following glutamine load to improve the diagnosis of hepatic encephalopathy in cirrhosis. BMC Gastroenterol 2011; 11:134. [PMID: 22151412 PMCID: PMC3253684 DOI: 10.1186/1471-230x-11-134] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Accepted: 12/08/2011] [Indexed: 12/29/2022] Open
Abstract
Background Hepatic encephalopathy (HE) is a frequent and severe complication of cirrhosis. A single determination of ammonia in venous blood correlates poorly with neurological symptoms. Thus, a better biological marker is needed. Aim To make a diagnosis of HE, we explored the value of ammonia in capillary blood, an equivalent to arterial blood, measured at bedside following an oral glutamine challenge. Methods We included 57 patients (age 56 yrs; M/F: 37/20) with cirrhosis (alcoholic = 42; MELD score 13.8 [7-29], esophageal varices = 38) and previous episodes of HE (n = 19), but without neurological deficits at time of examination, and 13 healthy controls (age 54 yrs). After psychometric tests and capillary (ear lobe) blood ammonia measurements, 20 gr of glutamine was administered orally. Tests were repeated at 60 minutes (+ blood ammonia at 30'). Minimal HE was diagnosed if values were > 1.5 SD in at least 2 psychometric tests. Follow-up lasted 12 months. Results The test was well tolerated (nausea = 1; dizziness = 1). Patients showed higher values of capillary blood ammonia over time as compared to controls (0'-30'-60 minutes: 75, 117, 169 versus 52, 59, 78 umol/L, p < 0.05). At baseline, 25 patients (44%) had minimal HE, while 38 patients (67%) met the criteria for HE at 60 minutes (chi2: p < 0.01). For the diagnosis of minimal HE, using the ROC curve analysis, baseline capillary blood ammonia showed an AUC of 0.541 (CI: 0.38-0.7, p = 0.6), while at 60 minutes the AUC was 0.727 (CI: 0.58-0.87, p < 0.006). During follow-up, 18 patients (31%) developed clinical episodes of HE. At multivariate analysis, the MELD score (1.12 [1.018-1.236]), previous episodes of HE (3.2[1.069-9.58]), but not capillary blood ammonia, were independent predictors of event. Conclusions In patients with cirrhosis and normal neurological examination, bedside determination of ammonia in capillary blood following oral glutamine load is well tolerated and achieves a better diagnostic performance for minimal HE than basal capillary ammonia levels. However, capillary blood ammonia is a poor predictor of development of clinically overt HE.
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Affiliation(s)
- Saskia Ditisheim
- Gastroenterology and Hepatology, University Hospitals and Faculty of Medicine, 4, Rue Gabrielle Perret-Gentil, 1211 Geneva, Switzerland
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Ditisheim S, Girardin M, Dumonceau JM, Hadengue A, Frossard JL. Primary aortodigestive fistula: a rare and potentially lethal cause of gastrointestinal hemorrhage. Case Rep Gastroenterol 2011; 5:428-32. [PMID: 21960944 PMCID: PMC3180658 DOI: 10.1159/000329881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Primary aortodigestive fistulas (PAFs) are a rare cause of gastrointestinal bleeding, with an incidence of 0.04-0.07% in autopsy series. The diagnosis of PAF is difficult and should be considered in patients with gastrointestinal hemorrhage of obscure origin. Because of its high mortality rate, clinical recognition of prodromal symptoms for early diagnosis is crucial for effective treatment. We report on the case of a 79-year-old patient with a PAF who was admitted for hematochezia and melena. The PAF was suspected during upper gastrointestinal endoscopy and confirmed by CT angiography.
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Affiliation(s)
- Saskia Ditisheim
- Department of Gastroenterology and Hepatology, University Hospital of Geneva, Geneva, Switzerland
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Ditisheim S, Spahr L. [Hepatic encephalopathy in patients with cirrhosis: new aspects and practical recommendations]. Rev Med Suisse 2010; 6:1667-1671. [PMID: 20939401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Hepatic encephalopathy in patients with cirrhosis may present under various clinical aspects, although minimal and episodic forms are the most frequent in clinical practice. Except for the typical alteration of the level of consciousness, other clinical presentations may exist that require additional diagnostic tests and exclusion of other causes. Management of hepatic encephalopathy includes the eviction of the precipitating factor and prevention of recurrence. Medical therapy is mostly directed at the gut as the main source of neurotoxins, but drugs that aimed at correcting liver and brain alterations demonstrate some efficacy. Liver transplantation should be discussed in the presence of persistent symptoms despite optimal medical therapy.
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Affiliation(s)
- Saskia Ditisheim
- Service de gastro-entérologie et d'hépatologie, Département de médecine interne HUG, 1211 Genève 14.
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