Mónica Alonso González

Value of the hepatic venous pressure gradient to monitor drug therapy for portal hypertension: a meta-analysis.

OBJECTIVES:The use of the hepatic venous pressure gradient (HVPG) to assess the efficacy of the pharmacological treatment of portal hypertension in cirrhosis is controversial. Our aim was to establish whether target HVPG reduction predicts variceal bleeding in cirrhotic patients receiving variceal bleeding prophylaxis.METHODS:Data sources were MEDLINE, EMBASE, Cochrane Controlled Trials Register, citation lists, and abstracts (most recent search March 2006). Cohorts of patients on drug therapy from randomized and nonrandomized studies correlating variceal bleeding and HVPG change were used. Heterogeneity was explored by metaregression analysis.RESULTS:Ten studies totaling 595 patients undergoing two HVPG measurements were identified. The RR of bleeding was lower in patients achieving an overall (HVPG ≤12 mmHg or decrease ≥20%) (0.27, 95% CI 0.14–0.52), complete (HVPG ≤12 mmHg) (0.48, CI 0.28–0.81), or partial (HVPG decrease ≥20%) (0.41, CI 0.20–0.81) response, with significant heterogeneity. Regression analysis identified the interval between the HVPG measurements significantly associated with the RR of bleeding. Heterogeneity was no longer significant after exclusion of an outlier trial, which showed the longest interval to HVPG remeasurement and the lowest quality score. Even considering nonevaluable patients because of bleeding as HVPG responders, the RR of bleeding was lower in overall responders than in nonresponders (0.66, CI 0.51–0.86). Overall response was associated with lower liver-related mortality (RR 0.58, CI 0.37–0.91).CONCLUSIONS:Current evidence supports the validity of HVPG end points to monitor drug therapy efficacy for variceal bleeding prophylaxis. HVPG monitoring also provides valuable prognostic information.

Portal Hypertension–Related Complications After Acute Portal Vein Thrombosis: Impact of Early Anticoagulation

BACKGROUND & AIMS Acute portal vein thrombosis (APVT) is a rare disorder that causes chronic portal hypertension if recanalization is not obtained. However, response to anticoagulation and long-term prognosis of APVT are not well-defined. METHODS Thirty-eight patients diagnosed with APVT between 1995 and 2003 from 5 Spanish referral hospitals, in whom cirrhosis and malignancy were specifically excluded, were included in this retrospective study. The response to anticoagulation therapy and development of portal hypertension-related complications during follow-up were evaluated. RESULTS Mean follow-up was 43 months (range, 6-112 months). Recanalization occurred in 12 of 27 patients receiving anticoagulation versus 0 of 11 patients who did not receive anticoagulation (P = .008). Rates of recanalization were influenced by the precocity of heparin administration and the number of underlying prothrombotic conditions. Follow-up upper endoscopy performed in 29 patients disclosed gastroesophageal varices in 16 (55%). Varices appeared as early as 1 month after APVT. However, in most patients varices were detected in successive endoscopies, mainly during the first year. Two-year actuarial probability of variceal bleeding was 12% and for ascites 16%. Five-year survival was 87%. Mortality was related to the APVT episode in 2 cases and to an underlying hematologic disorder in one. CONCLUSIONS Anticoagulation achieved recanalization in about 40% of patients. Most patients not achieving recanalization will develop gastroesophageal varices during follow-up. However, development of variceal bleeding and ascites is infrequent, and survival is satisfactory.

The extent of the collateral circulation influences the postprandial increase in portal pressure in patients with cirrhosis

Background: In cirrhosis, repeated flares of portal pressure and collateral blood flow provoked by postprandial hyperaemia may contribute to variceal dilation and rupture. Aim: To examine the effect of the extent of the collateral circulation on the postprandial increase in portal pressure observed in cirrhosis. Patients and methods: The hepatic venous pressure gradient (HVPG), hepatic blood flow and azygos blood flow were measured in 64 patients with cirrhosis before and after a standard liquid meal. Results: Peak increases in HVPG (median+14.9%), hepatic blood flow (median+25.4%), and azygos blood flow (median+32.2%) occurred at 30 min after the meal. Compared with patients with marked postprandial increase in HVPG (above the median, n = 32), those showing mild (<15%, n = 32) increase in HVPG had a higher baseline azygos flow (p<0.01) and underwent a greater postprandial increase in azygos flow (p<0.02). Hepatic blood flow increased similarly in both groups. Postprandial increases in HVPG were inversely correlated (p<0.001) with both baseline azygos flow (r = −0.69) and its postprandial increase (r = −0.72). Food intake increased nitric oxide products in the azygos (p<0.01), but not in the hepatic vein. Large varices (p<0.01) and previous variceal bleeding (p<0.001) were more frequent in patients with mild increase in HVPG. Conclusions: Postprandial hyperaemia simultaneously increases HVPG and collateral flow. The extent of the collateral circulation determines the HVPG response to food intake. Patients with extensive collateralisation show less pronounced postprandial increases in HVPG, but associated with marked flares in collateral flow. Collateral vessels preserve their ability to dilate in response to increased blood flow.

Rentabilidad de la biopsia ampliada con 10 muestras prostáticas: Estudio prospectivo sobre 222 pacientes

Resumen es: Objetivo: Actualmente no esta establecido ni el numero de muestras ni de biopsias para el correcto diagnostico del cancer prostatico. Presentamos nuestra...

TOLERANCIA Y COMPLICACIONES DE LA BIOPSIA TRANSRECTAL ECODIRIGIDA PROSTÁTICA AMPLIADA A DIEZ CILINDROS. PAPEL DEL BLOQUEO DE HACES NEUROVASCULARES CON LIDOCAÍNA

OBJECTIVES The growing interest on increasing the number of biopsy samples during ultrasound guided prostatic biopsies moved us to evaluate the tolerability and complications of the extensive biopsy with/without blockage of neurovascular bundles. METHODS A group of 222 patients underwent prostatic biopsy with the aim to obtain 10 cores on each. After evaluation of the first 50 cases performed without anesthesia, decision was taken to proceed with neurovascular blockage with 2% lidocaine, comparatively evaluating both groups for results on tolerability, complications and global adverse events. RESULTS The aimed number of cores could not be completed in 16% of the patients without anesthesia in comparison with 2.33% with anesthesia (p < 0.002); the biopsy was qualified as painful or very painful by 10.9% and 1.9% respectively (p < 0.0002). The results of the visual analogical scale for pain were 2.46 +/- 1.67 and 4.5 +/- 2.11 for the anesthesia/without anesthesia groups respectively, with mild-moderate vagal reactions in 28% of these latter in comparison with 7.7% in patients receiving lidocaine. Rectal bleeding was the most worrying complication, being moderate-severe in 4.7% of the patients, with 2% hospital admission. CONCLUSIONS The increase in the number of ultrasound guided prostatic biopsy samples may be associated with a higher frequency of complications, mainly bleeding, and requires the application of local anesthesia due to worse tolerance. Neurovascular bundle blockage with lidocaine is very effective to diminish biopsy associated pain.Resumen es: OBJETIVO: El creciente interes por ampliar el numero de muestras obtenidas durante la biopsia transrectal ecodirigida prostatica nos ha hecho evaluar la ...

RESULTADOS DE UNA SERIE DE 6000 PACIENTES CON BIOPSIA TRANSRECTAL ECODIRIGIDA DE PRÓSTATA. PARTE I: ANATOMÍA PATOLÓGICA, TACTO RECTAL, ECOGRAFÍA TRANSRECTAL Y PSA.

Resumen es: OBJETIVOS: Analizar los resultados de la Biopsia Transrectal Ecodirigida (BTE) prostatica realizadas en 6000 pacientes asi como su relacion con los difer...

Results of a series of transrectal ultrasound guided biopsy of the prostate in 6000 patients: Part II: PSA derived parameters

Resumen es: OBJETIVO: En esta serie se revisan los resultados de 6000 pacientes biopsiados en una o mas ocasiones por sospecha de CP, analizando el papel que puedan ...

Papel del volumen prostático en la biopsia transrectal ecodirigida de próstata: ¿es un marcador tan importante como el PSA?

Resumen es: Resumen.- OBJETIVO: La limitacion del PSA para identificar a los pacientes con cancer prostatico ha hecho que se definan diferentes parametros que aument...