Evangelos Kalaitzakis

Gastrointestinal symptoms in patients with liver cirrhosis: Associations with nutritional status and health-related quality of life

Objective. Gastrointestinal symptoms can lead to decreased food intake and thereby increased morbidity. There is a general lack of data on the prevalence of gastrointestinal symptoms and their potential association with malnutrition and health-related quality of life (QoL) in cirrhosis. Our aim was to prospectively evaluate gastrointestinal symptoms, malnutrition, and QoL in patients with cirrhosis. Material and methods. Two validated questionnaires were used to measure gastrointestinal symptoms (gastrointestinal symptom rating scale (GSRS)) and health-related QoL (SF-36) in 128 consecutive cirrhotics (mean age 57 years, Child-Pugh score 8.6, MELD score 13.2) at a tertiary referral center. The results were compared with those of controls from the general population. Nutritional status was assessed by anthropometry and estimation of recent weight change. Results. Compared to controls, cirrhotic patients showed higher gastrointestinal symptom severity (total GSRS score: 1.53, 95% CI 1.50–1.55 versus 2.21, 95% CI 2.04–2.38) and profound reductions in the SF-36 physical (47.0 95% CI 45.0–49.0 versus 37.9, 95% CI 35.7–40.1) and mental component summary scores (51.0 95% CI 49.0–53.0 versus 39.2 95% CI 36.7–41.6). There were no significant differences in any GSRS domain between patients with and those without malnutrition. Multivariate analysis showed that gastrointestinal symptom severity was associated with the Child-Pugh score (betau200a=u200a0.10, r<0.05), daily lactulose use (betau200a=u200a0.65, p<0.005), and the presence of gastrointestinal comorbidities (betau200a=u200a0.51, p<0.05). Negative weight change (betau200a=u200a−u200a0.72, p<0.05) and the SF-36 physical (betau200a=u200a−u200a4.26, p<0.005) and mental (betau200a=u200a−u200a4.53, p<0.005) summaries were independently related to gastrointestinal symptom severity. Conclusions. Patients with cirrhosis show increased severity of gastrointestinal symptoms, which are associated with recent weight loss and impaired health-related QoL. The severity of gastrointestinal symptoms seems to be related to the severity of cirrhosis.

The impact of eosinophilia and hepatic necrosis on prognosis in patients with drug‐induced liver injury

Backgroundu2002 Drug‐induced liver injury may be immunologically mediated or metabolically induced. Peripheral eosinophilia and liver eosinophilia in suspected drug‐induced liver injury generally supports the role of drug aetiology.

Malnutrition and diabetes mellitus are related to hepatic encephalopathy in patients with liver cirrhosis

Background/Aims: Studies on animal models of hepatic encephalopathy (HE) suggest that poor nutritional status may facilitate the development of HE. Insulin resistance and diabetes mellitus have recently been reported to affect cognition in patients with hepatitis C cirrhosis awaiting liver transplantation. Our aim was to investigate the effects of malnutrition and diabetes mellitus on HE in unselected patients with liver cirrhosis.

Coronary Artery Disease in Patients with Liver Cirrhosis

Background The prevalence of coronary artery disease (CAD) has been reported to be low in patients with liver cirrhosis. Previous studies have, however, included mostly patients with cirrhosis due to hepatitis C. We aimed to determine the prevalence and predictive factors of CAD in a cohort of consecutive patients with cirrhosis of various etiologies compared to the general population. Methods A total of 127 patients with cirrhosis were evaluated for a history of CAD and cardiovascular risk factors. Arterial blood pressure, fasting plasma glucose, and serum cholesterol were measured. Nutritional status was assessed by anthropometry and estimation of recent weight change. A group of 203 subjects from the general population with similar age and gender distribution, as well as smoking habits as the cirrhotic patients, served as controls. Results CAD was more common in cirrhotics compared to controls (20% vs. 12%, Pxa0=xa00.001). Compared to controls, cirrhotics had lower mean arterial blood pressure and serum cholesterol and a higher prevalence of diabetes, but did not differ significantly in the prevalence of hypertension or family history for CAD. In regression analysis, CAD was independently related to diabetes (odds ratio [OR] 5.47, 95% confidence interval [CI] 2.44–12.28), but not to liver cirrhosis. In the cirrhosis group, only alcoholic cirrhosis (OR 9.50, 95% CI 1.08–83.4) and age (OR 1.23 per year, 95% CI 1.06–1.43) were independently related to CAD. Conclusions Liver cirrhosis, per se, does not seem to confer a protective effect against CAD. In cirrhotics, older age and alcoholic etiology were independently related to CAD.

Health-related quality of life in patients with different stages of liver disease induced by hepatitis C

Objective. Patients with hepatitis C have been shown to have impaired health-related quality of life (HRQoL). The aim of this study was to determine HRQoL in patients in different stages of hepatitis C virus (HCV) and to compare HRQoL in HCV cirrhosis with non-HCV-induced cirrhosis. Material and methods. Out of 489 consecutive patients who fulfilled the inclusion criteria, 472 (96%) agreed to participate in the study: 158 patients with mild/moderate fibrosis with chronic hepatitis C (CHC group), 76 patients with HCV compensated cirrhosis (CC), 53 patients with HCV decompensated (DC) cirrhosis, 52 non-cirrhotic patients with sustained viral response (SVR), and a control group consisting of 32 patients with non-HCV CC and 101 with non-HCV DC who completed the Short Form-36 (SF-36) and EQ-5D questionnaire. Results. The CHC group had significantly lower SF-36 scores than healthy controls, with the exception of scores for the dimensions physical function and bodily pain. HCV patients with DC had lower scores in all SF-36 dimensions in comparison with those of the CHC group, as well as in physical and mental component summaries (p<0.001). In comparison with the CHC group, the HCV CC group had lower scores on the SF-36 general health dimension (p<0.05) and lower SF-36 physical component summary (PCS) scores (p<0.05). No major differences were seen in patients with HCV- and non-HCV-induced cirrhosis. Conclusions. Impairment in HRQoL in patients with HCV was associated with the severity of liver disease, patients with decompensated cirrhosis exhibiting the highest impairment in HRQoL. The etiology of liver disease does not seem to be important in determining HRQoL in cirrhosis.

Intestinal permeability in cirrhotic patients with and without ascites

Objective. It has been suggested that increased intestinal permeability plays a pathogenic role in bacterial infections, such as spontaneous bacterial peritonitis, in patients with liver cirrhosis. The aim of this study was to assess whether intestinal permeability is altered in cirrhotic patients with and without ascites. Material and methods. Intestinal permeability was assessed by a 51Cr-EDTA permeability test in 20 cirrhotic patients (10 with and 10 without ascites) along with 20 age- and gender-matched healthy controls. In six patients with ascites, the test was performed before and after therapeutic paracentesis. Results. The median (IQR) 24-h urinary excretion of 51Cr-EDTA was higher in patients with cirrhosis (1.94% (1.21–2.70%)) compared with that in controls (1.40% (1.09–1.99%); p<0.05). Patients with (2.05% (1.50–3.46%); p<0.05) but not those without ascites (1.94% (1.13–2.53%); p>0.1) had significantly higher excretion values compared with those of controls. Only one patient without ascites and a total of four patients with ascites had increased intestinal permeability (51Cr-EDTA excretionu200a>u200a95% confidence than that of controls; p>0.1). Paracentesis did not affect urinary 51Cr-EDTA excretion significantly (1.69% (1.16–2.86%) versus 1.30% (1.08–1.79%) before and after, respectively; p>0.1). No significant correlation was found between clinical severity scores for liver disease and intestinal permeability. Conclusions. Only a small proportion of patients with liver cirrhosis have increased intestinal permeability and it is unlikely that this plays any major role in predisposing these patients to infections.

Quality of life in short-bowel syndrome: Impact of fatigue and gastrointestinal symptoms

Objective. Patients with short-bowel syndrome (SBS) have impaired health-related quality of life (QoL). However, comparisons of QoL data with the data on other chronic gastrointestinal diseases are not available. The aim of this study was to assess QoL in SBS patients compared with that in the general population and with patients with inflammatory bowel disease (IBD). The potential relation between fatigue and gastrointestinal symptoms and impaired QoL in these patients was also investigated. Material and methods. Four validated questionnaires were used to measure aspects of QoL (SF-36), psychological distress (hospital anxiety and depression scale, HAD), fatigue (fatigue impact scale, FIS), and gastrointestinal symptoms (gastrointestinal symptom rating scale, GSRS) in 26/28 patients (93%) attending a SBS clinic (median age 62 years, 15 F/11 M) at a tertiary referral center. Persons from the general population (n=286) as well as patients with IBD (n=41) of similar age and gender distribution as the SBS group acted as controls. Results. SBS patients had significantly lower SF-36 physical and mental component summaries than those in the general population as well as significantly lower SF-36 physical (p<0.05) but not mental (p>0.05) component summaries compared with those of IBD patients. Fatigue and gastrointestinal symptoms were more severe in SBS patients than in IBD patients (p>0.05). The SF-36 physical component summary was independently related to the physical FIS dimension (beta=−0.4, p=0.004), the GSRS eating dysfunction dimension (beta=−0.31, p=0.025), and opiate use (beta=−0.28, p=0.031), regardless of diagnosis (SBS or IBD). Conclusions. Patients with SBS show poor QoL compared with that in the general population and also impairment of mainly physical health compared with that in patients with IBD. Fatigue and gastrointestinal symptoms are more severe in patients with SBS, which has an impact on QoL.

Long-term follow-up of patients with mild to moderate drug-induced liver injury

Aim To evaluate the long‐term prognosis of patients diagnosed with drug‐induced liver injury, and the nature of the liver injury.

Gut Transit Is Associated With Gastrointestinal Symptoms and Gut Hormone Profile in Patients With Cirrhosis

BACKGROUND & AIMSnLiver cirrhosis is associated with increased prevalence of gastrointestinal symptoms, insulin resistance, and altered gut transit. We aimed to assess the prevalence of gut transit abnormalities in patients with cirrhosis, compared with healthy controls, and to evaluate the relation of gut transit with gastrointestinal symptoms and postprandial glucose and hormone profiles.nnnMETHODSnHalf gastric emptying, small bowel residence, and colonic filling times were measured with a validated radiologic procedure in 42 consecutive patients with cirrhosis. In a subgroup of 25 patients, gastrointestinal symptoms were evaluated by using a validated questionnaire and a caloric satiation test. Postprandial glucose, insulin, leptin, ghrelin, glucagon-like peptide 1, and PYY responses were also studied. Eighty-three healthy subjects served as controls for the transit studies and 10 for the hormone analyses.nnnRESULTSnOf patients with cirrhosis, 24% had delayed gastric emptying and 38% had prolonged small bowel transit (P < .05 compared with controls). Delayed gastric emptying was related to postprandial fullness and prolonged small bowel transit to diarrhea and abdominal pain (P < .05 for all). The patients with cirrhosis had increased postprandial glucose, insulin, and glucagon-like peptide 1 responses and reduced postprandial ghrelin. Delayed gastric emptying was related to increased postprandial glucose and reduced postprandial ghrelin. Prolonged small bowel transit was related to increased postprandial glucose and insulin and reduced postprandial ghrelin.nnnCONCLUSIONSnA high proportion of patients with cirrhosis exhibit delayed gastric emptying or small bowel transit, which is related to gastrointestinal symptoms. Postprandial hyperglycemia, hyperinsulinemia, and hypoghrelinemia might be linked to delayed gut transit in cirrhosis.

Type and etiology of liver cirrhosis are not related to the presence of hepatic encephalopathy or health-related quality of life: a cross-sectional study

BackgroundHepatic encephalopathy has a negative impact on health-related quality of life (QoL) in liver cirrhosis. There are scarce and conflicting data on whether type or etiology of liver cirrhosis could be related to hepatic encephalopathy in patients with cirrhosis. We aimed to determine the impact of cirrhosis etiology on hepatic encephalopathy and whether hepatic encephalopathy affects health-related QoL among patients with cirrhosis of different etiologies.MethodsA total of 156 cirrhotic patients were prospectively evaluated for the presence of hepatic encephalopathy according to the West-Haven criteria as well as by means of two psychometric tests. Patients with cryptogenic cirrhosis or cirrhosis due to mixed hepatocellular/cholestatic etiologies were excluded. Fasting plasma glucose levels were also measured. QoL was evaluated by means of a validated questionnaire (SF-36).ResultsDiabetes mellitus was more common in patients with hepatocellular cirrhosis compared to those with cholestatic cirrhosis but the two groups did not differ in cirrhosis severity or the prevalence of hepatic encephalopathy (p > 0.05). The groups of patients with cirrhosis due to alcohol, hepatitis C, or cholestatic liver disease did not differ in severity of liver cirrhosis or the prevalence of hepatic encephalopathy (p > 0.05). Patients with cirrhosis of different etiologies did not differ in any SF-36 domain (p > 0.05). In multivariate analysis, performance at neuropsychological testing was independently related only to age, diabetes mellitus, and the Child-Pugh score whereas the SF-36 physical component summary only to the Child-Pugh score and hepatic encephalopathy.ConclusionCirrhosis etiology does not seem to be related to hepatic encephalopathy or health-related QoL. Cognitive impairment is associated mainly with age, liver disease severity and diabetes mellitus.