Giorgia Nicolini

Incidence and natural history of small esophageal varices in cirrhotic patients

BACKGROUND/AIMS The incidence and natural history of small esophageal varices (EV) in cirrhotics may influence the frequency of endoscopies and the decision to start a pharmacological treatment in these patients. METHODS We prospectively evaluated 206 cirrhotics, 113 without varices and 93 with small EV, during a mean follow-up of 37+/-22 months. Patients with previous gastrointestinal bleeding or receiving any treatment for portal hypertension were excluded. Endoscopy was performed every 12 months. RESULTS The rate of incidence of EV was 5% (95%CI: 0.8-8.2%) at 1 year and 28% (21.0-35.0%) at 3 years. The rate of EV progression was 12% (5.6-18.4%) at 1 year and 31% (21.2-40.8%) at 3 years. Post-alcoholic origin of cirrhosis, Child-Pughs class (B or C) and the finding of red wale marks at first examination were predictors for the variceal progression. The two-years risk of bleeding from EV was higher in patients with small varices upon enrollment than in those without varices: 12% (95% CI: 5.2-18.8%) vs. 2% (0.1-4.1%); (P<0.01). Predictor for bleeding was the presence of red wale marks at first endoscopy. CONCLUSIONS In patients with no or small EV, endoscopy surveillance should be planned taking into account cause and degree of liver dysfunction.

Malnutrition is a risk factor in cirrhotic patients undergoing surgery

Cirrhotic patients may become candidates for elective and emergency surgery. This may be due to conditions requiring operations such as cholecystectomy, herniotomy, or gastrointestinal malignancies, more common in cirrhotics when compared with the general population, or to complications of the liver disease such as resectable hepatocellular carcinomas or surgical portosystemic shunts to treat portal hypertension. It has been estimated that 10% of cirrhotics undergo at least one operative procedure during the final 2 y of their lives. Many studies have documented a high risk of morbidity and mortality associated with surgical procedures in these patients, and several factors influencing the postoperative outcome have been identified. Malnutrition, which is frequently encountered in cirrhotic patients, has been shown to have an important impact on the surgical risk. A poor nutrition status also has been associated with a higher risk of complications and mortality in patients undergoing liver transplantation. Few data are available concerning the perioperative nutrition support in surgical cirrhotic patients. The results of these studies are sometimes encouraging in reporting that the nutrition therapy may improve the clinical outcome in cirrhotic patients undergoing general surgery and/or liver transplantation. The limited number of patients and their heterogeneity, however, do not allow definitive conclusions, and more research on this issue is needed.

The Natural History of Portal Hypertensive Gastropathy in Patients with Liver Cirrhosis and Mild Portal Hypertension

BACKGROUND:Portal hypertensive gastropathy is a potential cause of bleeding in patients with liver cirrhosis. Studies on its natural history have often included patients submitted to endoscopic or pharmacological treatment for portal hypertension.PATIENTS AND METHODS:A total of 222 cirrhotic patients with mild degree of portal hypertension (i.e., with no or small varices at entry, without previous gastrointestinal bleeding and medical, endoscopic, or angiographic treatment) were followed up with upper endoscopy every 12 months for 47 ± 28 months.RESULTS:Upon enrollment 48 patients presented portal hypertensive gastropathy (43 mild and 5 severe) and the presence of esophageal varices was the only independent predictor of the presence of this gastric lesion at multivariate analysis. The incidence of portal hypertensive gastropathy was 3.0% (1.1–4.9%) at 1 yr and 24% (18.1–29.9%) at 3 yr, while the progression was 3% (1–6.9%) at 1 yr and 14% (4.2–23.8%) at 3 yr. The presence of esophageal varices and the Child-Pugh class B or C at enrollment were predictive of the incidence of portal hypertensive gastropathy, while only Child-Pugh class B or C was correlated with the progression from mild to severe, at multivariate analysis. During follow-up 16 patients bled from portal hypertensive gastropathy (9 acutely and 7 chronically) and one patient died of exsanguination from this lesion.CONCLUSIONS:The natural history of portal hypertensive gastropathy is significantly influenced by the severity of liver disease and severity of portal hypertension. Acute bleeding from portal hypertensive gastropathy is infrequent but may be severe.

Validation of automated blood cell counter for the determination of polymorphonuclear cell count in the ascitic fluid of cirrhotic patients with or without spontaneous bacterial peritonitis.

OBJECTIVE:Polymorphonuclear (PMN) cell count in ascitic fluid is the most useful test for the diagnosis of spontaneous bacterial peritonitis (SBP). We evaluated the validity of an automated blood cell counter for the PMN determination in ascitic fluid by comparing it with the traditional hematologic method with a light microscope in a manual counting chamber.METHODS:A total of 130 ascitic fluid samples were collected from 74 consecutive cirrhotics. The agreement between the two techniques was assessed according to Bland and Altmans method. The sensitivity, specificity, and positive and negative predictive values of the automated blood cell counter were calculated by considering the diagnosis of SBP as a PMN count ≥ 250 cells/mm3, determined by the manual method as the “gold standard.”RESULTS:The mean PMN counts assessed by the manual method and the automated blood cell counter were 124 ± 301 cells/mm3 and 130 ± 339 cells/mm3, respectively (p = 0.89, ns). The mean ± SD of the difference between manual and automated measurements was 6 ± 61 cells/mm3, whereas the limits of agreement were +127 cells/mm3 (95% CI = +108 to +147) and −115 cells/mm3 (95%CI = −96 to −135). SBP was diagnosed in 11 patients. All but one were correctly identified with the automated blood cell counter, with a sensitivity of 94% and a specificity of 100%; positive and negative predictive values were 100% and 99.1%, respectively.CONCLUSIONS:The manual method and the automated blood cell counter have a good agreement in the PMN determination in ascitic fluid, and the automated blood cell counter is a reliable tool for rapid diagnosis of SBP.

Helicobacter pylori eradication: Sequential therapy and Lactobacillus reuteri supplementation

AIM To evaluate the role of sequential therapy and Lactobacillus reuteri (L. reuteri) supplementation, in the eradication treatment of Helicobacter pylori (H. pylori). METHODS H. pylori infection was diagnosed in 90 adult dyspeptic patients. Patients were excluded if previously treated for H. pylori infection or if they were taking a proton pump inhibitor (PPI), H2-receptor antagonist or antibiotics. Patients were assigned to receive one of the following therapies: (1) 7-d triple therapy (PPI plus clarithromycin and amoxicillin or metronidazole) plus L. reuteri supplementation during antibiotic treatment; (2) 7-d triple therapy plus L. reuteri supplementation after antibiotic treatment; (3) sequential regimen (5-d PPI plus amoxicillin therapy followed by a 5-d PPI, clarithromycin and tinidazole) plus L. reuteri supplementation during antibiotic treatment; and (4) sequential regimen plus L. reuteri supplementation after antibiotic treatment. Successful eradication therapy was defined as a negative urea breath test at least 4 wk following treatment. RESULTS Ninety adult dyspeptic patients were enrolled, and 83 (30 male, 53 female; mean age 57 ± 13 years) completed the study. Nineteen patients were administered a 7-d triple treatment: 11 with L. reuteri supplementation during and 8 after therapy. Sixty-four patients were administered a sequential regimen: 32 with L. reuteri supplementation during and 32 after therapy. The eradication rate was significantly higher in the sequential group compared with the 7-d triple regimen (88% vs 63%, P = 0.01). No difference was found between two types of PPI. No difference in eradication rates was observed between patients submitted to L. reuteri supplementation during or after antibiotic treatment. Compliance with therapy was excellent in all patients. No difference in adverse effects was observed between the different antibiotic treatments and between patients submitted to L. reuteri supplementation during and after antibiotic treatment. There was a low incidence of adverse effects in all groups of patients with sequential therapy, probably due to the presence of the L. reuteri supplementation. CONCLUSION The sequential treatment regimen achieved a significantly higher eradication rate of H. pylori compared with standard 7-d regimen. L. reuteri supplementation could reduce the frequency and the intensity of antibiotic-associated side-effects.