Potential Utility of Fecal Calprotectin in Discriminating Colorectal Polyps From Other Major Etiologies in Children Presenting With Isolated Hematochezia

BACKGROUND

Colorectal polyps are the most common cause of isolated hematochezia in children, which requires a colonoscopy for diagnosis. We aimed to investigate the potential utility of fecal calprotectin (FC) in assessing colorectal polyps detected by colonoscopy among children presenting with isolated hematochezia.

METHODS

Pediatric patients of the age of < 18 years who had undergone both colonoscopy and FC tests for isolated hematochezia from June 2016 to May 2020 were included in the present multicenter, retrospective, cross-sectional study. Comparative analysis was conducted between major causes of isolated hematochezia and FC cut-offs for discriminating colorectal polyps were explored.

RESULTS

A total 127 patients were included. Thirty-five patients (27.6%) had colorectal polyps, followed by anal fissure (14.2%), ulcerative colitis (UC; 12.6%), and others. A significant difference in FC levels was observed between patients with colorectal polyps (median, 278.7 mg/kg), anal fissures (median, 42.2 mg/kg), and UC (median, 981 mg/kg) (P < 0.001). According to receiver operating characteristic curve analysis, among patients diagnosed with colorectal polyp or anal fissure, the most accurate FC cut-off for discriminating colorectal polyps from anal fissures on colonoscopy was 225 mg/kg (sensitivity, 59.4%; specificity, 94.4%; positive predictive value [PPV], 95.0%; negative predictive value [NPV], 56.7%; area under the curve [AUC], 0.8; 95% confidence interval [CI], 0.678-0.923; P < 0.001), while among patients diagnosed with colorectal polyp or UC, the most accurate FC cut-off for discriminating colorectal polyps from UC on colonoscopy was 879 mg/kg (sensitivity, 81.2%; specificity, 56.2%; PPV, 78.8%; NPV, 60.0%; AUC, 0.687; 95% CI, 0.521-0.852; P < 0.001).

CONCLUSION

FC may assist in assessing the cause of lower gastrointestinal tract bleeding in children who present with isolated hematochezia.

Role of Dietary Habits in the Prevention of Diverticular Disease Complications: A Systematic Review

Recent evidence showed that dietary habits play a role as risk factors for the development of diverticular complications. This systematic review aims to assess the effect of dietary habits in the prevention of diverticula complications (i.e., acute diverticulitis and diverticula bleeding) in patients with diverticula disease. PubMed and Scopus databases were searched up to 19 January 2021, 330 records were identified, and 8 articles met the eligibility criteria and were subjected to data extraction. The quality of the studies was evaluated by the Newcastle-Ottawa quality assessment form. No study meets the criteria for being a high-quality study. A high intake of fiber was associated to a decreased risk of diverticulitis or hospitalization due to diverticular disease, with a protective effect for fruits and cereal fiber, but not for vegetable fiber; whereas, a high red meat consumption and a generally Western dietary pattern were associated with an increased risk of diverticulitis. Alcohol use seemed to be associated to diverticular bleeding, but not to recurrent diverticulitis or diverticular complications. Further high-quality studies are needed to better define these associations. It is mandatory to ascertain the role of dietary habits for the development of recurrent acute diverticulitis and diverticular bleeding.

Perirectal Hematoma and Intra-Abdominal Bleeding after Stapled Hemorrhoidopexy and STARR-A Proposal for a Decision-Making Algorithm

Background and Objectives: The present study aims to assess the effectiveness and current evidence of the treatment of perirectal bleeding after stapled haemorrhoidopexy. Materials and methods: A systematic literature review was performed that combined the published and the obtained original data after a search of PubMed, Web of Science, and SCOPUS. Results: The present systematic review includes 16 articles with 37 patients. Twelve papers report perirectal and six report intra-abdominal bleeding. Stapled hemorrhoidopexy (SH) was performed in 57% of cases (3 PPH 01 and 15 PPH 03), stapled transanal rectal resection (STARR) in 13%, and for 30% information was not available. The median age was 49 years (±11.43). The sign and symptoms of perirectal bleeding were abdominal pain (43%), pelvic discomfort without rectal bleeding (36%), urinary retention (14%), and external rectal bleeding (21%). The median time to bleeding was 1 day (±1.53 postoperative days), with median hemoglobin at diagnosis 8.8 ± 1.04 g/dL. Unstable hemodynamic was reported in 19%. Computed tomography scan (CT) was the first examination in 77%. Only two cases underwent the abdominal US, but subsequently, a CT scan was also conducted. Non-operative management was performed in 38% (n = 14) with selective arteriography and percutaneous angioembolization in two cases. A surgical treatment was performed in 23 cases - transabdominal surgery (3 colostomies, 1 Hartmann' procedure, 1 low anterior resection of the rectum, 1 bilateral ligation of internal iliac artery and 1 ligation of vessels located at the rectal wall), transanal surgery (n = 13), a perineal incision in one, and CT-guided paracoccygeal drainage in one. Conclusions: Because of the rarity and lack of experience, no uniform tactic for the treatment of perirectal hematomas exists in the literature. We propose an algorithm similar to the approach in pelvic trauma, based on two main pillars -hemodynamic stability and the finding of contrast CT.

Effect of acute upper gastrointestinal bleeding manifestations at admission on the in-hospital outcomes of liver cirrhosis: hematemesis versus melena without hematemesis

OBJECTIVES

Patients with acute upper gastrointestinal bleeding (AUGIB) often manifest as hematemesis and melena. Theoretically, hematemesis will carry worse outcomes of AUGIB. However, there is little real-world evidence. We aimed to compare the outcomes of hematemesis versus no hematemesis as a clinical manifestation of AUGIB at admission in cirrhotic patients.

METHODS

All cirrhotic patients with AUGIB who were consecutively admitted to our hospital from January 2010 to June 2014 were considered in this retrospective study. Patients were divided into hematemesis with or without melena and melena alone without hematemesis at admission. A 1:1 propensity score matching analysis was performed. Subgroup analyses were performed based on systemic hemodynamics (stable and unstable) and Child-Pugh class (A and B+C). Sensitivity analyses were conducted in patients with moderate and severe esophageal varices confirmed on endoscopy. Primary outcomes included five-day rebleeding and in-hospital death.

RESULTS

Overall, 793 patients were included. Patients with hematemesis at admission had significantly higher five-day rebleeding rate (17.4 versus 10.1%, P = 0.004) and in-hospital mortality (7.9 versus 2.4%, P = 0.001) than those without hematemesis. In the propensity score matching analyses, 358 patients were included with similar Child-Pugh score (P = 0.227) and MELD score (P = 0.881) between the two groups; five-day rebleeding rate (19.0 versus 10.6%, P = 0.026) and in-hospital mortality (8.4 versus 2.8%, P = 0.021) remained significantly higher in patients with hematemesis. In the subgroup and sensitivity analyses, the statistical results were also similar.

CONCLUSIONS

Hematemesis at admission indicates worse outcomes of cirrhotic patients with AUGIB, which is useful for the risk stratification of AUGIB.

Development and Validation of CAGIB Score for Evaluating the Prognosis of Cirrhosis with Acute Gastrointestinal Bleeding: A Retrospective Multicenter Study

INTRODUCTION

Acute gastrointestinal bleeding (GIB) is a major cause of death in liver cirrhosis. This multicenter study aims to develop and validate a novel and easy-to-access model for predicting the prognosis of patients with cirrhosis and acute GIB.

METHODS

Patients with cirrhosis and acute GIB were enrolled and randomly divided into the training (n = 865) and validation (n = 817) cohorts. In the training cohort, the independent predictors for in-hospital death were identified by logistic regression analyses, and then a new prognostic model (i.e., CAGIB score) was established. Area under curve (AUC) of CAGIB score was calculated by receiver operating characteristic curve analysis and compared with Child-Pugh, model for end-stage liver disease (MELD), MELD-Na, and neutrophil-lymphocyte ratio (NLR) scores.

RESULTS

In the training cohort, hepatocellular carcinoma (HCC), diabetes, total bilirubin (TBIL), albumin (ALB), alanine aminotransferase (ALT), and serum creatinine (Scr) were independent predictors of in-hospital death. CAGIB score = diabetes (yes = 1, no = 0) × 1.040 + HCC (yes = 1, no = 0) × 0.974 + TBIL (μmol/L) × 0.005 - ALB (g/L) × 0.091 + ALT (U/L) × 0.001 + Scr (μmol/L) × 0.012 - 3.964. In the training cohort, the AUC of CAGIB score for predicting in-hospital death was 0.829 (95% CI 0.801-0.854, P < 0.0001), which was higher than that of Child-Pugh (0.762, 95% CI 0.732-0.791), MELD (0.778, 95% CI 0.748-0.806), MELD-Na (0.765, 95% CI 0.735-0.793), and NLR (0.587, 95% CI 0.553-0.620) scores. In the validation cohort, the AUC of CAGIB score (0.714, 95% CI 0.682-0.746, P = 0.0006) remained higher than that of Child-Pugh (0.693, 95% CI 0.659-0.725), MELD (0.662, 95% CI 0.627-0.695), MELD-Na (0.660, 95% CI 0.626-0.694), and NLR (0.538, 95% CI 0.503-0.574) scores.

CONCLUSION

CAGIB score has a good predictive performance for prognosis of patients with cirrhosis and acute GIB.

Novel Model to Predict Gastrointestinal Bleeding During Left Ventricular Assist Device Support

BACKGROUND

Gastrointestinal bleeding (GIB) is a leading cause of morbidity during continuous-flow left ventricular assist device (CF-LVAD) support. GIB risk assessment could have important implications for candidate selection, informed consent, and postimplant therapeutic strategies. The aim of the study is to derive and validate a predictive model of GIB in CF-LVAD patients.

METHODS AND RESULTS

CF-LVAD recipients at the Utah Transplantation Affiliated Hospitals program between 2004 and 2017 were included. GIB associated with a decrease in hemoglobin ≥2 g/dL was the primary end point. A weighted score comprising preimplant variables independently associated with GIB was derived and internally validated. A total of 351 patients (median age, 59 years; 82% male) were included. After a median of 196 days, GIB occurred in 120 (34%) patients. Independent predictors of GIB included age >54 years, history of previous bleeding, coronary artery disease, chronic kidney disease, severe right ventricular dysfunction, mean pulmonary artery pressure <18 mm Hg, and fasting glucose >107 mg/dL. A weighted score termed Utah bleeding risk score, effectively stratified patients based on their probability of GIB: low (0-1 points) 4.8%, intermediate (2-4) 39.8%, and high risk (5-9) 83.8%. Discrimination was good in the development sample (c-index: 0.83) and after internal bootstrap validation (c-index: 0.74).

CONCLUSIONS

The novel Utah bleeding risk score is a simple tool that can provide personalized GIB risk estimates in CF-LVAD patients. This scoring system may assist clinicians and investigators in designing tailored risk-based strategies aimed at reducing the burden posed by GIB in the individual CF-LVAD patient and healthcare systems.

Efficacy of a novel endoscopically deliverable muco-adhesive hemostatic powder in an acute gastric bleeding porcine model

This study investigated the effectiveness of new hemostatic adhesive powder (UI-EWD) in a swine mode of acute gastric bleeding. Gastric ulcer bleeding was induced endoscopically at two locations in each of eight heparinized mini-pigs. UI-EWD and saline were sprayed endoscopically in the experimental (n = 5) and control groups (n = 3), respectively. The hemostatic effect and hydrogel persistence on ulcers were periodically evaluated endoscopically. Initial hemostasis was achieved successfully in all lesions in the experimental group. Follow-up endoscopy showed minor delayed bleeding in 10% at 6 hours in the experimental group, whereas re-bleeding was observed in 50% at 6 hours in the control group. UI-EWD gel persisted at 90%, 80%, and 50% of ulcer bases at 6, 18, and 42 hours post-application, respectively. This study suggests that muco-adhesive UI-EWD may be effective in the endoscopic treatment of active ulcer bleeding.

C-reactive Protein Can Predict Patients with Cirrhosis at a High Risk of Early Mortality after Acute Esophageal Variceal Bleeding

Objective The aim of this study was to identify patients with a high risk of early mortality after acute esophageal variceal bleeding by measuring the C-reactive protein (CRP) level. Methods We retrospectively evaluated 154 consecutive cirrhotic patients admitted with acute esophageal variceal bleeding. Differences between categorical variables were assessed by the chi-square test. Continuous variables were compared using the Mann-Whitney U-test. Multivariate logistic regression analyses consisting of clinical laboratory parameters were performed to identify risk factors associated with the 6-week mortality. The discriminative ability and the best cut-off value were assessed by a receiver-operating characteristic (ROC) curve analysis. Results Child-Pugh C patients showed a significantly higher 6-week mortality than Child-Pugh A or B patients (38% vs. 6%, p<0.0001). The 6-week mortality in Child-Pugh C patients was associated with the age (p<0.0001), etiology of cirrhosis (p=0.003), hepatocellular carcinoma (p=0.0003), portal vein thrombosis (p=0.005), baseline creatinine (p=0.0001), albumin (p=0.001), white blood cell count (p=0.038), baseline CRP [p=0.0004; area under the ROC (AUROC)=0.765; optimum cut-off value at 1.30 mg/dL] and bacterial infection (p=0.019). We determined that CRP ≥1.30 mg/dL was an independent predictor for 6-week mortality in Child-Pugh C patients [odds ratio (OR)=8.789; 95% confidence interval (CI): 2.080-47.496; p=0.003], along with a creatinine level of 0.71 mg/dL (OR=17.628; 95% CI: 2.349-384.426; p=0.004) (73% mortality if CRP ≥1.30 mg/dL vs. 19% if CRP<1.30 mg/dL, p<0.0001). Conclusion In Child-Pugh C patients with esophageal variceal bleeding, a baseline CRP ≥1.30 mg/dL can help identify patients with an increased risk of mortality.

Sepsis as an important risk factor for gastrointestinal bleeding in acute coronary syndrome patients: Two case reports

RATIONALE

Sepsis is a common stressor that may decrease microcirculation in the gastrointestinal tract in patients and increase the gastrointestinal bleeding risk of stress-related mucosal disease. However, the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines) bleeding risk score, recommended by authoritative guidelines for acute coronary syndrome (ACS), does not include sepsis as a bleeding risk factor.

PATIENT CONCERNS

The 2 cases were about ACS with hemorrhagic complications. The first patient was an 88-year-old man with hypertension, gallstones, hepatic cysts, and chest pain; the second one was a 79-year-old man with chest pain and hypertension. These 2 ACS patients had no bleeding on admission; however, both patients suffered apparent gastrointestinal bleeding immediately after the development of sepsis or severe sepsis.

DIAGNOSES

Both patients were diagnosed as ACS with sepsis.

INTERVENTIONS

The first ACS patient had no use of proton pump inhibitors (PPIs) for prophylaxis prior to the diagnosis of sepsis. The second one was administered PPIs at standard oral doses.

OUTCOMES

The first patient suffered from gastrointestinal bleeding immediately after the onset of sepsis. And oral PPIs failed to prevent upper gastrointestinal bleeding for the second patient, when severe sepsis developed. However, the second patient's gastrointestinal hemorrhage gradually stopped immediately after high doses of PPIs were administered intravenously, rather than orally. When sepsis developed again, the second patient also had no recurrent gastrointestinal bleeding under the protection of PPIs at standard oral doses.

LESSONS

Our report suggests that sepsis may be an important bleeding risk factor for ACS patients, and the reasonable use of PPIs to prevent gastrointestinal bleeding could be vital for ACS patients complicated with sepsis.

Small bowel capsule endoscopy revealing neuromuscular and vascular hamartoma of the jejunum: A case report

RATIONALE

Digestive hemorrhage is a life-threatening and represents for both clinicians and patient a challenger problematic condition with the urgencies to discover the origin for correct the cause and safe the life of patient.

PATIENT CONCERNS

We report the case of a 58 -year-old man with extremely rare hamartomatous neurovascular lesion. Following recurrent episode of intestinal hemorrhage the patient underwent small bowel capsule endoscopy.

DIAGNOSES

Diagnosed with small intestine neoplasia.

INTERVENTIONS

The patient underwent curative small bowel resection. Histologic diagnosis was neuromuscular and vascular hamartoma (NMVH). In the small intestine, neoplastic lesions are very rare (2%) and mostly malformative while the more frequent cause of cryptic digestive hemorrhage remains angiodysplasia (50%) . The preexisting NMVH was exacerbated by the use of non-steroidal anti-inflammatory drugs, causing hemorrhage due to diffuse ulceration.

OUTCOMES

The patient stay healthy after treatment.

LESSONS

This is an hemorrhagic lesion with macroscopic "neoplastic" patterns due to abnormal mixing of normal indigenous tissue components. It poses a diagnostic challenge for clinicians and pathologists, but diagnosis is facilitated by capsule endoscopy and surgical treatment should provide definitive resolution.

Glasgow Blatchford Score and risk stratifications in acute upper gastrointestinal bleed: can we extend this to 2 for urgent outpatient management?

Upper gastrointestinal (GI) bleeds are a common presentation to emergency departments in the UK. The Glasgow Blatchford score (GBS) predicts the outcome of patients at presentation. Current UK and European guidelines recommend outpatient management for a GBS of 0. In the current study, our aim was to assess whether extending the GBS allows for early discharge while maintaining patient safety. We also analysed whether pathologies could be missed by discharging patients too early. Data were retrospectively collected on patients admitted with symptoms of an upper GI bleed between 1 October 2013 and 10 June 2016. The GBS was calculated and gastroscopy reports were obtained for each patient. In total, 399 patients were identified, 63 of whom required therapy. The negative predictive value (NPV) for excluding the need for endoscopic intervention with a GBS score up to 1 was 100%. Extending the score to 2 and 3 reduced the NPV to 98.53% and 98.77%, respectively. The NPV of GBS in excluding any diagnosis at 0 was 43.55%. Two patients died as a result of GI bleeding, with a GBS score of 3. Therefore, we can conclude that, for non-variceal bleeds, the GBS can be extended to 2 for safe outpatient management, thereby reducing the number of bed days and pressure for urgent endoscopies.

Association between Alcohol Consumption and Diverticulosis and Diverticular Bleeding: A Systematic Review and Meta-analysis

There have been conflicting reports on the association of alcohol use and diverticular disease. We aimed to determine the odds of developing diverticular disease and diverticular bleeding in patients who consumed alcohol on a regular basis compared with those who did not. MEDLINE and PUBMED were searched up until February 2017 on observational trials, which investigated the effect of alcohol use on two outcomes of diverticular disease: diverticulosis and diverticular bleeding. Quantitative estimates (odds ratios [OR] and confidence intervals [CI]) from included studies were pooled by using a random-effects model. Heterogeneity across studies was assessed by the I² statistic. In 6 studies including 53,644 subjects and 6 studies including 3,404 subjects, alcohol consumption on a regular basis was not associated with either diverticulosis (OR=1.99; 95% CI 0.99-4.03, I²=99%) or diverticular bleeding (OR=1.39; 95% CI 0.84-2.32, I²=45%) compared to subjects who did not consume alcohol on a regular basis, respectively. Increased odds of diverticulosis or diverticular bleeding among individuals who consume alcohol on a regular basis were not observed in these meta-analyses.

Ectopic variceal bleeding due to portosystemic shunt via dilated mesenteric veins and a varicous left ovarian vein : case report and literature review of ectopic varices

Ectopic varices are dilated portosystemic venous collaterals located outside of the gastro-esophageal region. Whereas they are common endoscopic findings in patients with portal hypertension, ectopic variceal bleeding is rather rare and accounts for only 1 to 5 % of all variceal bleedings. The rectum and the duodenum are the most common sites for ectopic varices, but they can be present along the whole intestinal tract and neighborhood. At present, there is no consensus well established on diagnostic workup for ectopic variceal bleeding and their therapeutic strategies. Further investigation of large series or randomized-controlled trials is needed because nowadays most of the data available are based on case reports. We report here an unusual case of an ectopic variceal bleeding, presented as an acute small intestine bleeding, due to a portosystemic shunt via dilated mesenteric veins and a varicous left ovarian vein in a patient with alcoholic cirrhosis. The involvement of an ovarian vein in ectopic variceal bleeding is rarely described.

Endoscopic ultrasonography predicts early esophageal variceal bleeding in liver cirrhosis: A case report

RATIONALE

Bleeding esophageal and gastric varices constitute a serious complication in liver cirrhosis. Previous studies have shown that endoscopic ultrasonography (EUS) can be used to predict early esophageal variceal bleeding in liver cirrhosis.

PATIENT CONCERNS

We report a case of a 46-year-old man with hepatitis B liver cirrhosis (CTP score, 5; Child-Pugh class, A) who was admitted to our hospital due to a decreased appetite lasting 1 week.

DIAGNOSIS

He was initially diagnosed with decompensated hepatitis B cirrhosis; an abdominal computed tomography (CT) scan indicated a diagnosis of liver cirrhosis and portal hypertension (PHT).

INTERVENTIONS

Common endoscopic examination showed no evidence of gastroesophageal varices; EUS revealed distinct varices of the esophageal and gastric veins. Six months after discharge, the patient was rehospitalized because of upper gastrointestinal bleeding. Endoscopic ligation was implemented as well as esophageal varices loop ligature (EVL).

OUTCOMES

Six months later, EUS showed obvious collateral and perforator veins.

LESSONS

We should strongly recommend that patients with liver cirrhosis undergo EUS in addition to a routine endoscopic examination. EUS can play an important role in evaluating the risk for bleeding in PHT and can be used to assess the efficacy of EVL.

Seasonal variation in occurrence of ischemic colitis: a retrospective study

Objectives We aimed to identify the clinical characteristics of ischemic colitis (IC) and to investigate the occurrence of seasonal variation. Methods From January 2008 to December 2014, 368 had IC as the reason for their admission. A total of 364 patients were enrolled in this study. We investigated patient characteristics and seasonal variations in incidence. Results The mean age (±standard deviation) of patients with IC at diagnosis was 66.8 (±16.9) years. Most patients had abdominal pain (341 cases), hematochezia (337 cases), and diarrhea (199 cases) as their chief complaints. The clinical courses of the disease were classified as transient (294 cases), stricture (17 cases), gangrenous (2 cases), and indeterminate types (51 cases). Although IC tended to occur less frequently in winter, the seasonal difference was not significant. Conclusion There is currently no evidence for seasonal variation in hospital admissions for IC.

Upper gastrointestinal ectopic variceal bleeding treated with various endoscopic modalities: Case reports and literature review

RATIONALE

Ectopic variceal bleeding is a rare (2-5%) but fatal gastrointestinal bleed in patients with portal hypertension. Patients with ectopic variceal bleeding manifest melena, hematochezia, or hematemesis, which require urgent managements. Definitive therapeutic modalities of ectopic varices are not yet standardized because of low incidence. Various therapeutic modalities have been applied on the basis of the experiences of experts or availability of facilities, with varying results.

PATIENT CONCERNS

We have encountered eight cases of gastrointestinal ectopic variceal bleeding in five patients in the last five years.

DIAGNOSES

All patients were diagnosed with liver cirrhosis presenting melena or hematemesis.

INTERVENTIONS

All patients were treated with various endoscopic modalities (endoscopic variceal obturation [EVO] with cyanoacrylate in five cases, endoscopic variceal band ligation (EVL) in two cases, hemoclipping in one case).

OUTCOMES

Satisfactory hemostasis was achieved without radiologic interventions in all cases. EVO and EVL each caused one case of portal biliopathy, and EVL induced ulcer bleeding in one case.

LESSONS

EVO generally accomplished better results of variceal obturations than EVL or hemoclipping, without serious adverse events. EVO may be an effective modality for control of ectopic variceal bleeding without radiologic intervention or surgery.

The Approach to Occult Gastrointestinal Bleed

Occult gastrointestinal bleeding is not visible and may present with a positive fecal occult blood test or iron deficiency anemia. Obscure bleeding can be overt or occult, with no source identified despite an appropriate diagnostic workup. A stepwise approach to this evaluation after negative upper and lower endoscopy has been shown to be cost effective. This includes repeat endoscopies if warranted, followed by video capsule endoscopy (VCE) if no obstruction is present. If the VCE is positive then specific endoscopic intervention may be possible. If negative, patients may undergo either repeat testing or watchful waiting with iron supplements.

Relationship Between Patients With or Without a History of Esophageal Varices Bleeding and the Changes in Hemodynamics During Inferior Vena Cava Clamping in Living Donor Liver Transplantation

BACKGROUND

Whether the history of esophageal variceal bleeding (EVB) can be used clinically to predict the tolerability or hemodynamic instability during clamping of the inferior vena cava (IVC) and portal vein in liver transplantation is unknown and, therefore, needs to be elucidated.

PATIENTS AND METHODS

A total of 50 anesthesia charts of patients who underwent living donor liver transplantation were reviewed, analyzed and compared retrospectively. Patients without a history of EVB were classified as group 1 and patients with a history of EVB were classified as group 2. The numbers of patients with a decrease in cardiac index (CI) of ≥20%, ≥30%, or ≥40% from their preclamping values after IVC clamping were compared with a χ(2), and a P value of .05 was regarded as statistically significant.

RESULTS

The measured hemodynamic parameters before and 5 minutes after clamping of the IVC and portal vein were all significantly different in comparison with the patient's preclamping values. The incidence of a decrease in CI of ≥20%, ≥30%, or ≥40% 5 minutes after clamping of the IVC and portal vein were not significantly different between groups.

CONCLUSIONS

Clamping of the portal vein and IVC without performing veno-venous bypass in living donor liver transplantation had a significant negative impact on CI in both groups due to the drastic reduction in the venous return. Statistical analysis revealed that a history of EVB affects hemodynamics in a manner similar to that in patients without history of EVB during IVC clamping.

Natural history of definitive diverticular hemorrhage based on stigmata of recent hemorrhage and colonoscopic Doppler blood flow monitoring for risk stratification and definitive hemostasis

BACKGROUND AND AIMS

Few prospective reports describe the short-term natural history of colon diverticular hemorrhage based on stigmata of recent hemorrhage, and none include blood flow detection for risk stratification or as a guide to definitive hemostasis. Our purposes were to report the 30-day natural history of definitive diverticular hemorrhage based on stigmata and to describe Doppler probe blood flow detection as a guide to definitive hemostasis.

METHODS

Different cohorts of patients with severe diverticular bleeding and stigmata on urgent colonoscopy are reported. For 30-day natural history, patients were treated medically. If severe rebleeding occurred, they had surgical or angiographic treatment. We report natural history with major stigmata (active bleeding, visible vessel, or adherent clot) and no stigmata or flat spots after clots were washed away. We also report Doppler probe detection of arterial blood flow underneath stigmata before and after hemostasis in a recent cohort.

RESULTS

For natural history, patients with major stigmata treated medically had 65.8% (25/38) rebleeding rates, and 44.7% (17/38) had intervention for hemostasis. Patients with spots or clean bases had no rebleeding. A Doppler probe detected arterial blood flow in 92% of major stigmata--none after hemostasis--and there was no rebleeding.

CONCLUSIONS

(1) Patients with major stigmata treated medically had high rates of rebleeding and intervention for hemostasis. (2) Patients with clean diverticula or only flat spots had no rebleeding. (3) High rates of arterial blood flow were detected under major stigmata with a Doppler probe, but with obliteration by hemostasis no rebleeding occurred.

[THE TREATMENT TACTICS IN GASTROINTESTINAL ULCER HEMORRHAGE]

Experience of the patients treatment, suffering gastrointestinal ulcer hemorrhage, in Municipal Centre, dealing with such cases, was summarized. There was established, that conduction of endoscopic monitoring is indicated in all patients, suffering gastrointestinal ulcer hemorrhage for early diagnosis of the hemorrhage recurrence signs and conduction of prophylactic measures. Introduction of local endoscopic hemostasis, еndoscopic monitoring in complex of conservative therapy have permitted to reduce the operative interventions conduction rate in 2,5 times.

[VENOUS ECTASIA OF GASTRIC ANTRUM]

Gastric antral vascular ectasia (GAVE) is an uncommon but often severe cause of upper gastrointestinal bleeding. GAVE may be asymptomatic or accompanied by clinical anemia or overt gastrointestinal bleeding. The diagnosis is mainly based on pathognomonic endoscopic pattern, defined as «watermelon stomach», located in antrum. Autoimmune disorders aye co-existing in about 60% of patients with GAVE, chirrosis in about 30%, and cardiac or renal failure in 10%.The "golden standarden" treatment of GAVE is endoscopic argon plasma coagulation (APC). There is poor information about diagnostics and treatment of GAVE in the domestic literature. The analysis of the presented materials shows that correct diagnostics takes much time and the choice of the optimum optimal treatment strategy encounters difficulty. Our experience with diagnostics and therapy of GAVE is based on the treatment of 4 patients. The diagnosis of GAVE was established within the period from 5 months to 1.5 years after onset of the disease. In two cases, GAVE was asymptomatic. Two patients with severe anemia completed endoscopic treatment; in one case, APC was supplemented by laser coagulation and bipolar coagulation. The implementation of laser coagulation caused some technical difficulties. Treatment of both patients was successful. Endoscopy pivotal for diagnosis of GAVE is the main method of its treatment. Due to the large number of diagnostic errors and the importance of correct diagnosis of GAVE, it is necessary to pay attention to this issue in training programs for endoscopists.

Predictive factors of mortality within 30 days in patients with nonvariceal upper gastrointestinal bleeding

BACKGROUND/AIMS

Nonvariceal upper gastrointestinal bleeding (NVUGIB) is a common medical emergency that can be life threatening. This study evaluated predictive factors of 30-day mortality in patients with this condition.

METHODS

A prospective observational study was conducted at a single hospital between April 2010 and November 2012, and 336 patients with symptoms and signs of gastrointestinal bleeding were consecutively enrolled. Clinical characteristics and endoscopic findings were reviewed to identify potential factors associated with 30-day mortality.

RESULTS

Overall, 184 patients were included in the study (men, 79.3%; mean age, 59.81 years), and 16 patients died within 30 days (8.7%). Multivariate analyses revealed that comorbidity of diabetes mellitus (DM) or metastatic malignancy, age ≥ 65 years, and hypotension (systolic pressure < 90 mmHg) during hospitalization were significant predictive factors of 30-day mortality.

CONCLUSIONS

Comorbidity of DM or metastatic malignancy, age ≥ 65 years, and hemodynamic instability during hospitalization were predictors of 30-day mortality in patients with NVUGIB. These results will help guide the management of patients with this condition.

[CLINICAL CHARACTERISTICS OF PATIENTS WITH ARTERIAL HYPERTENSION ASSOCIATED WITH PEPTIC DUODENAL ULCER AFTER ACUTE GASTROINTESTINAL BLEEDING]

Objective of the investigation was to examine clinical characteristics of peptic duodenal ulcer (DU) associated with arterial hypertension (АH) after acute gastrointestinal bleeding (AGB). The study included 25 patients with AH associated with DU, 45 patients with AH in AGB, 63 patients with AGB without AH, 48 patients with AH without AGB and 69 patients with DU without AH. If AH joins the existing DU, it increases the intensity of pain and dyspeptic syndromes. If DU joins AH, on the other hand, the clinical picture of ulcer disease was unclear. The largest concentration of Helicobacter pylori antibodies was found in patients with AH in AGB. Hypertensive crises were detected more often in combination of AH and DU.

Dextran sulfate sodium-induced acute colitis impairs dermal lymphatic function in mice

AIM: To investigate whether dermal lymphatic function and architecture are systemically altered in dextran sulfate sodium (DSS)-induced acute colitis.

METHODS: Balb/c mice were administered 4% DSS in lieu of drinking water ad libitum for 7 d and monitored to assess disease activity including body weight, diarrhea severity, and fecal bleeding. Control mice received standard drinking water with no DSS. Changes in mesenteric lymphatics were assessed following oral administration of a fluorescently-labelled fatty acid analogue, while dermal lymphatic function and architecture was longitudinally characterized using dynamic near-infrared fluorescence (NIRF) imaging following intradermal injection of indocyanine green (ICG) at the base of the tail or to the dorsal aspect of the left paw prior to, 4, and 7 d after DSS administration. We also measured dye clearance rate after injection of Alexa680-bovine serum albumin (BSA). NIRF imaging data was analyzed to reveal lymphatic contractile activity after selecting fixed regions of interest (ROIs) of the same size in fluorescent lymphatic vessels on fluorescence images. The averaged fluorescence intensity within the ROI of each fluorescence image was plotted as a function of imaging time and the lymphatic contraction frequency was computed by assessing the number of fluorescent pulses arriving at a ROI.

RESULTS: Mice treated with DSS developed acute inflammation with clinical symptoms of loss of body weight, loose feces/watery diarrhea, and fecal blood, all of which were aggravated as disease progressed to 7 d. Histological examination of colons of DSS-treated mice confirmed acute inflammation, characterized by segmental to complete loss of colonic mucosa with an associated chronic inflammatory cell infiltrate that extended into the deeper layers of the wall of the colon, compared to control mice. In situ intravital imaging revealed that mice with acute colitis showed significantly fewer fluorescent mesenteric lymphatic vessels, indicating impaired uptake of a lipid tracer within mesenteric lymphatics. Our in vivo NIRF imaging data demonstrated dilated dermal lymphatic vessels, which were confirmed by immunohistochemical staining of lymphatic vessels, and significantly reduced lymphatic contractile function in the skin of mice with DSS-induced acute colitis. Quantification of the fluorescent intensity remaining in the depot as a function of time showed that there was significantly higher Alexa680-BSA fluorescence in mice with DSS-induced acute colitis compared to pre-treatment with DSS, indicative of impaired lymphatic drainage.

CONCLUSION: The lymphatics are locally and systemically altered in acute colitis, and functional NIRF imaging is useful for noninvasively monitoring systemic lymphatic changes during inflammation.

[MODERN VIEW ON INTENSIVE THERAPY OF GASTRO-INTESTINAL HEMORRHAGE]

Basing on analysis of the treatment results in 47 patients for gastro-intestinal hemorrhage, the experience of application of a tranexamic acid in a content of infusion therapy and hemaxam per os was adduced. The data obtained witness the expediency of hemaxam application in a content of therapy on the stage of a hemorrhage letup and for the recurrence prevention.

Reversed portal flow: Clinical influence on the long-term outcomes in cirrhosis

AIM: To elucidate the natural history and the longitudinal outcomes in cirrhotic patients with non-forward portal flow (NFPF).

METHODS: The present retrospective study consisted of 222 cirrhotic patients (120 males and 102 females; age, 61.7 ± 11.1 years). The portal hemodynamics were evaluated at baseline and during the observation period using both pulsed and color Doppler ultrasonography. The diameter (mm), flow direction, mean flow velocity (cm/s), and mean flow volume (mL/min) were assessed at the portal trunk, the splenic vein, the superior mesenteric vein, and the collateral vessels. The average values from 2 to 4 measurements were used for the data analysis. The portal flow direction was defined as follows: forward portal flow (FPF) for continuous hepatopetal flow; bidirectional flow for to-and-fro flow; and reversed flow for continuous hepatofugal flow. The bidirectional flow and the reversed flow were classified as NFPF in this study. The clinical findings and prognosis were compared between the patients with FPF and those with NFPF. The median follow-up period was 40.9 mo (range, 0.3-156.5 mo).

RESULTS: Twenty-four patients (10.8%) demonstrated NFPF, accompanied by lower albumin level, worse Child-Pugh scores, and model for end-stage liver disease scores. The portal hemodynamic features in the patients with NFPF were smaller diameter of the portal trunk; presence of short gastric vein, splenorenal shunt, or inferior mesenteric vein; and advanced collateral vessels (diameter > 8.7 mm, flow velocity > 10.2 cm/s, and flow volume > 310 mL/min). The cumulative incidence rates of NFPF were 6.5% at 1 year, 14.5% at 3 years, and 23.1% at 5 years. The collateral vessels characterized by flow velocity > 9.5 cm/s and those located at the splenic hilum were significant predictive factors for developing NFPF. The cumulative survival rate was significantly lower in the patients with NFPF (72.2% at 1 year, 38.5% at 3 years, 38.5% at 5 years) than in those with forward portal flow (84.0% at 1 year, 67.8% at 3 years, 54.3% at 5 years, P = 0.0123) using the Child-Pugh B and C classifications.

CONCLUSION: NFPF has a significant negative effect on the prognosis of patients with worse liver function reserve, suggesting the need for careful management.

When Should a Patient with a Nonvariceal Upper Gastrointestinal Bleed Be Fed?

Nonvariceal upper gastrointestinal hemorrhage is a common cause for admission to the intensive care unit. Most patients are prohibited from oral or enteral feeding for 72 hours despite different risks for rebleeding. Fasting is believed to improve the ability to control intragastric pH, stabilize clots, and reduce the risk of rebleeding; however, studies have shown no difference in intragastric pH and complications in patients who received early feeding. Approximately 50% of patients are classified as low risk for rebleeding and can be safely fed immediately and discharged early, even on the same day as endoscopy. Only the patients with a high risk of rebleeding should be kept nil per os and be hospitalized for at least 72 hours after endoscopic treatment. Most high-risk lesions become low-risk lesions within 72 hours, and most rebleeding occurs within this time. Randomized controlled trials have demonstrated that early feeding does not have adverse consequences, however. More studies on the timing and type of nutrition in patients with high-risk stigmata are needed.

Esophageal variceal pressure influence on the effect of ligation

AIM: To explore the effect of in vitro porcine esophageal variceal pressure on complete ligation degree for polycyclic ligators.

METHODS: An in vitro model of experimental porcine venous vessels was used to test various venous pressures. Three treatment groups were designated according to the preset pressure range: P1 = 25-30 cmH₂O; P₂ = 35-40 cmH₂O; P₃ = 45-50 cmH₂O. The effect of pressure on ligation was assessed and compared among the groups.

RESULTS: Complete ligation was achieved at a rate of 56.25% (18/32) in group P₁, 37.5% (12/32) in group P₂, and 33.33% (11/33) in group P₃ (χ² = 3.6126; P = 0.0573).

CONCLUSION: Higher variceal pressures impair the ligation completion rate. Therefore, measuring variceal pressure may help predict the effect of endoscopic ligation and guide treatment choice.

Use of non-selective beta blockers in cirrhosis: The evidence we need before closing (or not) the window

Non selective beta blockers (NSBBs) are used in primary and secondary prophylaxis of portal hypertension-related bleeding in patients with cirrhosis. The efficacy of NSBBs treatment is predicted by hemodynamic response in term of reduction of the hepatic venous pressure gradient (HVPG) below 12 mmHg or at least 20% of the basal value. Nevertheless a relevant number of patients who do not achieve this HVPG reduction during NSBBs therapy do not bleed during follow up; this evidence suggests an additional non-hemodynamic advantage of NSBBs treatment to modify the natural history of cirrhosis. Recent studies have questioned the efficacy and safety of NSBBs in patients with advanced stage of liver disease characterized by refractory ascites and/or spontaneous bacterial peritonitis. These studies have suggested the existence of a defined and limited period to modify the natural history of cirrhosis by NSBBs: the “window hypothesis”. According with this hypothesis, patients with cirrhosis benefit from the use of NSBBs from the appearance of varices up to the development of an advanced stage of cirrhosis. Indeed, in patients with refractory ascites and/or spontaneous bacterial peritonitis the hemodynamic effects of NSBBs may expose to a high risk of further complications such as renal insufficiency and/or death. Methodological concerns and contrasting results counterbalance the evidence produced up to now on this issue and are the main topic of this editorial.

Monochromatic energy computed tomography image for active intestinal hemorrhage: A model investigation

AIM: To investigate the value of computed tomography (CT) spectral imaging in the evaluation of intestinal hemorrhage.

METHODS: Seven blood flow rates were simulated in vitro. Energy spectral CT and mixed-energy CT scans were performed for each rate (0.5, 0.4, 0.3, 0.2, 0.1, 0.05 and 0.025 mL/min). The detection rates and the contrast-to-noise ratios (CNRs) of the contrast agent extravasation regions were compared between the two scanning methods in the arterial phase (AP) and the portal venous phase (PVP). Comparisons of the CNR values between the PVP and the AP were made for each energy level and carried out using a completely random t test. A χ² test was used to compare the detection rates obtained from the two scanning methods.

RESULTS: The total detection rates for energy spectral CT and mixed-energy CT in the AP were 88.57% (31/35) and 65.71% (23/35), respectively, and the difference was significant (χ² = 5.185, P = 0.023); the total detection rates in the PVP were 100.00% (35/35) and 91.4% (32/35), respectively, and the difference was not significant (χ² = 1.393, P = 0.238). In the AP, the CNR of the contrast agent extravasation regions was 3.58 ± 2.09 on the mixed-energy CT images, but the CNRs were 8.78 ± 7.21 and 8.83 ± 6.75 at 50 and 60 keV, respectively, on the single-energy CT images, which were significantly different (3.58 ± 2.09 vs 8.78 ± 7.21, P = 0.031; 3.58 ± 2.09 vs 8.83 ± 6.75, P = 0.029). In the PVP, the differences between the CNRs at 40, 50 and 60 keV different monochromatic energy levels and the polychromatic energy images were significant (19.35 ± 10.89 vs 11.68 ± 6.38, P = 0.010; 20.82 ± 11.26 vs 11.68 ± 6.38, P = 0.001; 20.63 ± 10.07 vs 11.68 ± 6.38, P = 0.001). The CNRs at the different energy levels in the AP and the PVP were significantly different (t = -2.415, -2.380, -2.575, -2.762, -2.945, -3.157, -3.996 and -3.189).

CONCLUSION: Monochromatic energy imaging spectral CT is superior to polychromatic energy images for the detection of intestinal hemorrhage, and the detection was easier in the PVP compared with the AP.

Ectopic variceal bleeding from colonic stoma: two case reports

Parastomal variceal bleeding is a rare complication of portal hypertension, which often occurs in a recurrent manner and might be life-threatening in extreme situations. Treatment options vary, and no standard therapy has been established. Herein, we report 2 such cases. The first patient suffered from parastomal variceal bleeding after Hartmann procedure for rectal cancer. Stomal revision was performed, but bleeding recurred 1 month later. The second patient developed the disease after Miles procedure for rectal cancer. Embolization via the percutaneous transhepatic approach was performed using the Onyx liquid embolic system (LES) (Micro Therapeutics Inc, dba ev3 Neurovascular) in combination with coils, and satisfactory results were obtained after a 4-month follow-up. Our cases illustrate that surgical revision should be used with caution as a temporary solution due to the high risk of rebleeding, whereas transhepatic embolization via the Onyx LES and coils could be considered a safe and effective choice for skillful managers.

Risk factors for early rebleeding and mortality in acute variceal hemorrhage

AIM: To investigate the risk factors for 6-wk rebleeding and mortality in acute variceal hemorrhage (AVH) patients treated by percutaneous transhepatic variceal embolization (PTVE).

METHODS: A retrospective cohort study of AVH patients who had undergone PTVE treatment was conducted between January 2010 and December 2012. Demographic information, medical histories, physical examination findings, and laboratory test results were collected. The PTVE procedure was performed as a rescue therapy for patients who failed endoscopic and pharmacologic treatment. Survival analysis was estimated using the Kaplan-Meier method and compared using the log-rank test. The multivariate analysis was performed using the Cox regression test to identify independent risk factors for rebleeding and mortality.

RESULTS: One hundred and one patients were included; 71 were males and the average age was 51 years. Twenty-one patients rebled within 6 wk. Patients with high-risk stigmata, PTVE with trunk obliteration, and a hepatic vein pressure gradient (HVPG) ≥ 20 mmHg were at increased risk for rebleeding (OR = 5.279, 95%CI: 2.782-38.454, P = 0.003; OR = 4.309, 95%CI: = 2.144-11.793, P < 0.001; and OR = 1.534, 95%CI: 1.062-2.216, P = 0.022, respectively). Thirteen patients died within 6 wk. A model for end-stage liver disease (MELD) score ≥ 18 and an HVPG ≥ 20 mmHg were associated with 6-wk mortality (OR = 2.162, 95%CI: 1.145-4.084, P = 0.017 and OR = 1.423, 95%CI: 1.222-1.657, P < 0.001, respectively).

CONCLUSION: MELD score and HVPG in combination allow for early identification of patients with AVH who are at substantially increased risk of death over the short term.

[Gastrointestinal disorders in patients with renal impairment]

In the study the most common gastroenterological disorders among patients with CRF are reviewed. It was shown two main types of such disorders: as a manifestation of the underlying disease (CKD) or as an associated disease. It was determined that anorexia, nausea, vomiting, constipation, gastrointestinal bleeding, and acute abdominal pain are the most common gastroenterological symptoms. The necessity of further studying of the pathogenetic mechanisms of gastroenterological disorders in the case of presence of CRF and the importance of an integrated approach to the screening and management of patients with CRF was shown.

Transjugular intrahepatic portosystemic shunt

Transjugular intrahepatic portosystemic shunt (TIPS) is an established procedure for the complications of portal hypertension. The largest body of evidence for its use has been supported for recurrent or refractory variceal bleeding and refractory ascites. Its use has also been advocated for acute variceal bleed, hepatic hydrothorax, and hepatorenal syndrome. With the replacement of bare metal stents with polytetrafluoroethylene-covered stents, shunt patency has improved dramatically, thus, improving outcomes. Therefore, reassessment of its utility, management of its complications, and understanding of various TIPS techniques is important.

Impact of insidious gastrointestinal blood loss on endurance performance in an elite rower

Gastrointestinal (GI) blood loss is a possible reason for anemia in athletes. To quantify the impact on endurance performance, we present data of a world-class rower who developed anemia due to GI blood loss but maintained his training volume. Eight months after recording four normal hematological values over 6 months, an anemic state was detected. Total hemoglobin mass (tHbmass) was reduced from 1267 g to 917 g (-28%) and [Hb] was reduced from 176 g/L to 122 g/L (-31%). Blood volume (BV) remained largely unchanged at 8162 mL and 8261 mL, respectively. VO2max was decreased from 5.8 L/min to 4.8 L/min (-17%), but remained ~0.4 L/min higher than calculated from tHbmass. Power at [lactate] 2 mmol/L (P2) and 4 mmol/L (P4) decreased by 12% and 14%, respectively. Ten months after detection of the anemic state, the athlete had recovered and tHbmass (9%) as well as VO2max (3%), P2 (7%) and P4 (5%) were higher than before anemia. GI blood loss was most likely caused by the intake of non steroidal anti-inflammatory drugs and/or a bleeding Meckel's diverticulum, the latter been diagnosed and surgically removed 3 years later after two rapid bleedings had occurred. Data demonstrate the impact of a tHbmass reduction leading to a substantial but mitigated decrease in submaximal performance and VO2max in an elite athlete. 10 months later, higher levels of tHbmass, VO2max, and endurance performance were observed. However, the underlying mechanisms for the apparent increase in tHbmass remain unclear.

Predicting mortality in patients with in-hospital nonvariceal upper GI bleeding: a prospective, multicenter database study

BACKGROUND

Nonvariceal upper GI bleeding (NVUGIB) that occurs in patients already hospitalized for another condition is associated with increased mortality, but outcome predictors have not been consistently identified.

OBJECTIVE

To assess clinical outcomes of NVUGIB and identify predictors of mortality from NVUGIB in patients with in-hospital bleeding compared with outpatients.

DESIGN

Secondary analysis of prospectively collected data from 2 nationwide multicenter databases. Descriptive, inferential, and multivariate logistic regression models were carried out in 338 inpatients (68.6 ± 16.4 years of age, 68% male patients) and 1979 outpatients (67.8 ± 17 years of age, 66% male patients). A predictive model was constructed using the risk factors identified at multivariate analysis, weighted according to the contribution of each factor.

SETTINGS

A total of 23 Italian community and tertiary care centers.

PATIENTS

Consecutive patients admitted for acute NVUGIB.

INTERVENTIONS

Early endoscopy, medical and endoscopic treatment as appropriate.

MAIN OUTCOME MEASUREMENTS

Recurrent bleeding, surgery, and 30-day mortality.

RESULTS

The mortality rate in patients with in-hospital bleeding was significantly higher than that in outpatients (8.9% vs 3.8%; odds ratio [OR] 2.44; 95% confidence interval [CI], 1.57-3.79; P < .0001). Hemodynamic instability on presentation (OR 7.31; 95% CI, 2.71-19.65) and the presence of severe comorbidity (OR 6.72; 95% CI, 1.87-24.0) were the strongest predictors of death for in-hospital bleeders. Other independent predictors of mortality were a history of peptic ulcer disease and failed endoscopic treatment. Rebleeding was a strong predictor of death only for outpatients (OR 5.22; 95% CI, 2.45-11.10). Risk factors had a different prognostic impact on the 2 populations, resulting in a significantly different prognostic accuracy of the model (area under the receiver-operating characteristic curve = 0.83; 95% CI, 0.77-0-93 vs 0.74; 95% CI, 0.68-0.80; P < .02).

LIMITATIONS

Study design not experimental, no data on ward specialty, potential referral bias.

CONCLUSIONS

In-hospital bleeders have a significantly higher risk of death because they are sicker and more often hemodynamically unstable than outpatients. Predictors of death have a different impact in the 2 populations.

Shunting branch of portal vein and stent position predict survival after transjugular intrahepatic portosystemic shunt

AIM: To evaluate the effect of the shunting branch of the portal vein (PV) (left or right) and the initial stent position (optimal or suboptimal) of a transjugular intrahepatic portosystemic shunt (TIPS).

METHODS: We retrospectively reviewed 307 consecutive cirrhotic patients who underwent TIPS placement for variceal bleeding from March 2001 to July 2010 at our center. The left PV was used in 221 patients and the right PV in the remaining 86 patients. And, 224 and 83 patients have optimal stent position and sub-optimal stent positions, respectively. The patients were followed until October 2011 or their death. Hepatic encephalopathy, shunt dysfunction, and survival were evaluated as outcomes. The difference between the groups was compared by Kaplan-Meier analysis. A Cox regression model was employed to evaluate the predictors.

RESULTS: Among the patients who underwent TIPS to the left PV, the risk of hepatic encephalopathy (P = 0.002) and mortality were lower (P < 0.001) compared to those to the right PV. Patients who underwent TIPS with optimal initial stent position had a higher primary patency (P < 0.001) and better survival (P = 0.006) than those with suboptimal initial stent position. The shunting branch of the portal vein and the initial stent position were independent predictors of hepatic encephalopathy and shunt dysfunction after TIPS, respectively. And, both were independent predictors of survival.

CONCLUSION: TIPS placed to the left portal vein with optimal stent position may reduce the risk of hepatic encephalopathy and improve the primary patency rates, thereby prolonging survival.

Assessment of risk of complications in cirrhosis using portal thallium scans

AIM: To investigate the usefulness of a novel thallium scan shunt index for assessing portosystemic shunt-related cirrhotic complications.

METHODS: We enrolled 209 chronic hepatitis B-related cirrhosis patients. After rectal thallium instillation, radioactive isotope activity in the heart and liver was measured. The ratio of radiation uptake between the heart and the liver was calculated (the shunt index). This value indicates the degree of portosystemic circulation shunting. Blood tests, serum biochemistry tests, abdominal ultrasonography, gastroscopy and examination of clinical features such as the occurrence of varices, bleeding and hepatic encephalopathy were performed. Multivariate analysis was used to identify independent risk factors for complications. We compared the cumulative incidence rates of complications during the follow-up period.

RESULTS: The thallium scan shunt index was significantly higher in the decompensated liver cirrhosis group than in the compensated liver cirrhosis group (0.91 ± 0.39 vs 0.39 ± 0.32, P < 0.001). It was also higher in the varices group, the hepatic encephalopathy group, and the variceal bleeding group than in the control group (P < 0.001). Multivariate analysis showed that the index was an independent risk factor for predicting decompensated liver cirrhosis. When the cut-off value was 0.75, the shunt index had a sensitivity of 82.6%, a specificity of 84%, a positive predictive value of 61.5%, and a negative predictive value of 94.4% in diagnosing decompensated cirrhosis. When the shunt index was greater than 0.75, there was a significant increase in the number of decompensated events.

CONCLUSION: The thallium shunt index is a good predictor of cirrhosis-related complications.

[Influence of mydocalm on the degree of intra-abdominal hypertension and local blood circulation in the intestinal wall in experiment]

The effect of mydocalm (tolperison, 5 mg/kg single dose) on the dynamics of intra-abdominal hypertension (IAH), blood circulation regulation, and oxygen balance in the tissues of intestinal wall were studied in acute experiments on rabbits. Using a special stand of original design, the initial IAH level was modeled at 200 mm H2O with the subsequent stopping of further receipt of liquid during 3 hours in an elastic container in the abdominal cavity. During 3-h observation without drug administration, no changes in IAH due to the tone of muscles of the frontal abdominal wall takes place, but there is progressive deceleration of local blood flow (-35.33 + 0.99%, p < 0.01), suppressed dilation (-20.02 + 0.54%, p < 0.01) and constriction (-60.45 + 1.17%, p < 0.01) reactivity of vessels, and decreased oxygen tension (-47.18 + 0.75%, p < 0.01) in the intestinal wall at the end of experiment. The introduction of mydocalm reduces the tone of muscles of the frontal abdominal wall, which leads to a decrease in IAH (maximum effect after 1.5 hours, -20.81 + 0.84%, p < 0.01) and prevents decrease in the local blood flow (-26.77 + 0.41%, p < 0.01), suppression of dilation (-16.51 + 0.34%, p < 0.01) and constriction (-37.85 + 0.61%, p < 0.01) reactivity of vessels, and reduction in oxygen tension (-36.60 + 1.18%, p < 0.01) at the end of experiment. The administration of mydocalm can extend the limits of application of a conservative therapy for patients with IAH and to improve the results.