Peter Ghali

Chylous Ascites: Evaluation and Management

Chylous ascites refers to the accumulation of lipid-rich lymph in the peritoneal cavity due to disruption of the lymphatic system secondary to traumatic injury or obstruction. Worldwide, abdominal malignancy, cirrhosis, and tuberculosis are the commonest causes of CA in adults, the latter being most prevalent in developing countries, whereas congenital abnormalities of the lymphatic system and trauma are commonest in children. The presence of a milky, creamy appearing ascitic fluid with triglyceride content above 200 mg/dL is diagnostic, and, in the majority of cases, unless there is a strong suspicion of malignancy, further investigations are not required in patients with cirrhosis. If an underlying cause is identified, targeted therapy is possible, but most cases will be treated conservatively, with dietary support including high-protein and low-fat diets supplemented with medium-chain triglycerides, therapeutic paracentesis, total parenteral nutrition, and somatostatins. Rarely, resistant cases have been treated by transjugular intrahepatic portosystemic shunt, surgical exploration, or peritoneovenous shunt.

A meta-analysis of nutritional supplementation for management of hospitalized alcoholic hepatitis

BACKGROUND Alcoholic liver disease (ALD) is associated with a high risk of morbidity and mortality. Malnutrition accompanies this condition and may be both a consequence of and contributor to the pathology. Many trials have investigated the benefits of providing supplemental nutrition in the management of patients with ALD. The present study is a meta-analysis of the available evidence. METHOD A meta-analysis of randomized controlled studies comparing nutritional supplementation plus a normal hospital diet versus diet alone. RESULTS Seven randomized controlled studies including 262 patients with ALD were identified. Pooled analysis revealed no statistical difference in mortality between groups given special nutritional therapy versus a normal balanced diet (OR 0.80 [95% CI 0.42 to 1.52]). In addition, nutrition did not significantly improve ascites (OR 1.29 [95% CI 0.52 to 3.20]) or any biochemical parameters. However, encephalopathy showed a significant improvement or resolution (OR 0.24 [95% CI 0.06 to 0.93]). CONCLUSION Nutritional supplementation provided no mortality benefit in patients with ALD, and neither ascites nor biochemical parameters significantly improved. However, encephalopathy was significantly ameliorated and, therefore, nutritional supplementation should be encouraged in that setting.

Antioxidant Therapy in Nonalcoholic Steatohepatitis

Nonalcoholic steatohepatitis (NASH) affects up to 3% of the North American population. It occurs as a manifestation of the insulin-resistant state and oxidative stress is thought to be a key component of its pathophysiology. Exercise and diet, which are the mainstay of therapy, are difficult to achieve and maintain with a disappointing long-term compliance record. There is growing literature on the potential for antioxidant therapy. The recent literature strongly suggests that vitamin E supplementation and other putative free radical scavengers and/or antioxidants are beneficial in improving biochemical and histological parameters in NASH.

Early changes in kidney function predict long-term chronic kidney disease and mortality in patients after liver transplantation.

Background. Chronic kidney disease (CKD) is a well-known complication after liver transplantation (LT) and is associated with increased mortality. The purpose of this study was to determine risk factors of advanced CKD and mortality after LT. Methods. Four hundred forty-five adult patients underwent LT between June 1990 and September 2007 and survived more than 1 month. Multivariate Cox regression analyses were performed for time to CKD stage 4 (glomerular filtration rate [GFR] ≤30 mL/min), time to chronic dialysis, and all-cause mortality. Several patient and disease characteristics were used as independent pre- and posttransplant variables. We specifically analyzed a drop more than or equal to 30% in the estimated GFR (eGFR) during the first year posttransplant. Results. Diabetes mellitus pretransplant and a drop more than or equal to 30% in the eGFR between 3 and 12 months predicted CKD stage 4 (odds ratio [OR] 4.1, 95% confidence interval [CI] 1.9–5.4, P<0.001 and OR 16.1, 95% CI 5.9–44.5, P<0.0001, respectively), the need for chronic dialysis (OR 3.8, 95% CI 1.1–13.2, P=0.03 and OR 14.6, 95% CI 3.0–71.4, P<0.001, respectively), and all-cause mortality (OR 1.9, 95% CI 1.2–2.9, P=0.004 and OR 2.6, 95% CI 1.6–4.4, P<0.001, respectively), more than 1 year after LT. Conclusions. Diabetes mellitus pretransplant and a drop more than or equal to 30% in the eGFR within the first year are strong predictors of advanced CKD, chronic dialysis, and death more than 1 year after LT. These easily determined clinical variables define a population at risk for CKD who should be targeted for renal protection strategies.

Prognostic Value of Non-Invasive Fibrosis and Steatosis Tools, Hepatic Venous Pressure Gradient (HVPG) and Histology in Nonalcoholic Steatohepatitis

Background & Aims Non-invasive diagnostic methods for liver fibrosis predict clinical outcomes in viral hepatitis and nonalcoholic fatty liver disease (NAFLD). We specifically evaluated prognostic value of non-invasive fibrosis methods in nonalcoholic steatohepatitis (NASH) against hepatic venous pressure gradient (HVPG) and liver histology. Methods This was a retrospective cohort study of 148 consecutive patients who met the following criteria: transjugular liver biopsy with HVPG measurement; biopsy-proven NASH; absence of decompensation; AST-to-Platelets Ratio Index (APRI), fibrosis-4 (FIB-4), NAFLD fibrosis score, ultrasound, hepatic steatosis index and Xenon-133 scan available within 6 months from biopsy; a minimum follow-up of 1 year. Outcomes were defined by death, liver transplantation, cirrhosis complications. Kaplan–Meier and Cox regression analyses were employed to estimate incidence and predictors of outcomes, respectively. Prognostic value was expressed as area under the curve (AUC). Results During a median follow-up of 5 years (interquartile range 3-8), 16.2% developed outcomes, including 7.4% who died or underwent liver transplantation. After adjustment for age, sex, diabetes, the following fibrosis tools predicted outcomes: HVPG >10mmHg (HR=9.60; 95% confidence interval [CI] 3.07-30.12), histologic fibrosis F3-F4 (HR=3.14; 1.41-6.95), APRI >1.5 (HR=5.02; 1.6-15.7), FIB-4 >3.25 (HR=6.33; 1.98-20.2), NAFLD fibrosis score >0.676 (HR=11.9; 3.79-37.4). Prognostic value was as follows: histologic fibrosis stage, AUC=0.85 (95% CI 0.76-0.93); HVPG, AUC=0.81 (0.70-0.91); APRI, AUC=0.89 (0.82-0.96); FIB-4, AUC=0.89 (0.83-0.95); NAFLD fibrosis score, AUC=0.79 (0.69-0.91). Neither histologic steatosis nor non-invasive steatosis methods predicted outcomes (AUC<0.50). Conclusions Non-invasive methods for liver fibrosis predict outcomes of patients with NASH. They could be used for serial monitoring, risk stratification and targeted interventions.

Prevention and Management of Gastroesophageal Varices in Cirrhosis

Variceal hemorrhage is one of the major complications of liver cirrhosis associated with significant mortality and morbidity. Its management has evolved over the past decade and has substantially reduced the rate of first and recurrent bleeding while decreasing mortality. In general, treatment of esophageal varices can be divided into three categories: primary prophylaxis (prevention of first episode of bleeding), management of acute bleeding, and secondary prophylaxis (prevention of recurrent hemorrhage). The goal of this paper is to describe the current evidence behind the management of esophageal varices. We will discuss indications for primary prophylaxis and the different modes of therapy, pharmacological and interventional treatment in acute bleeding, and therapeutic options in preventing recurrent bleeding. The indications for TIPS will also be reviewed including its possible benefits in acute variceal hemorrhage.

Characterization of hepatitis B virus genotypes and quantitative hepatitis B surface antigen titres in North American tertiary referral liver centres.

Hepatitis B virus (HBV) genotype and quantitative hepatitis B surface antigen (qHBsAg) have been related to clinical outcome. In this nationwide cross‐sectional study, we aimed to investigate the epidemiology and clinical significance of HBV genotype and qHBsAg in patients with chronic hepatitis B (CHB).

Hepatitis B and the infected health care worker: public safety at what cost?

Public safety and the right of the health care worker to practise without prejudice based on underlying illness may be at odds for those affected by the hepatitis B virus (HBV). Nevertheless, HBV does not preclude entry into a health care profession, and the risk of transmission from health care worker to patient is not uniform across the spectrum of health care fields. In the present article, the authors present an overview of the literature regarding transmission of HBV from the health care worker to the patient, and the current recommendations that vary from province to province within Canada. The establishment of national guidelines to standardize monitoring of HBV infection among health care workers would improve health care workplace safety and patient care.

Improvement of gastrointestinal health status in subjects consuming Lactobacillus reuteri NCIMB 30242 capsules: a post-hoc analysis of a randomized controlled trial

Objective: Gastrointestinal (GI) symptoms are conditions that are frequently observed in clinical practice. A post-hoc analysis has been undertaken to evaluate the effect of bile salt hydrolase-active L. reuteri NCIMB 30242 on GI health status based on Rome III questionnaire response in otherwise healthy hypercholesterolemic subjects. Research design/Methods: A total of 127 subjects received either L. reuteri NCIMB 30242 or placebo capsules over a 9-week intervention in a randomized, double-blind, placebo-controlled, parallel-arm, multicenter study. Subjects were asked to complete the Rome III diagnostic GI questionnaire prior to the baseline and end point visits of the clinical study. Main outcome measure: GI health status was evaluated, per questionnaire, by assessing all questions with 5- or 7-point response scales for symptoms of the stomach and intestines. Results: Subjects receiving L. reuteri NCIMB 30242 reported significant improvements in general GI health status (p = 0.029) and in symptoms related to diarrhea (p = 0.018) as compared to placebo over the intervention period. Further, a greater proportion of L. reuteri-treated subjects showed improved general GI health status (p = 0.042) and improved diarrhea symptoms (p = 0.03). Conclusions: L. reuteri NCIMB 30242 capsules appear to be well tolerated and potentially beneficial for GI health status. Further clinical investigation is warranted for the treatment of functional GI disorders.

Smoking increases recurrent viral hepatitis after liver transplantation

Smoking is a common behavior among transplant candidates. The aim of this study was to evaluate the effects of smoking on a range of complications after liver transplantation. We reviewed data about patient demographics and various complications after liver transplantation that were recorded in the McGill University Health Centre liver transplant database over a 14‐year period. χ2 and multivariate analyses were performed. Four hundred forty‐four liver transplants were performed from 1990 to 2004, and 63 were repeat transplants. Only primary liver transplant recipients were included in our analysis. Smokers (ie, active or former smokers) were more likely to be male (77.9% versus 62.7%, P = 0.009) and Caucasian (88.4% versus 78.0%, P = 0.03). The median survival time was 13.23 years for smokers and was not estimable for nonsmokers because of censoring. The median recurrent viral hepatitis–free survival time was 0.87 years for smokers and 4.10 years for nonsmokers (P = 0.03). The following variables were not found to be associated with the smoking status: patient survival (P = 0.78), time to biliary complications after liver transplantation (P = 0.67), time to the first rejection episode after liver transplantation (P = 0.61), and time to depression after liver transplantation (P = 0.67). A Cox proportional hazards regression showed that recurrent viral hepatitis–free survival was still strongly associated with smoking [HR = 2.04, 95% confidence interval (CI) = 1.13‐3.68, P = 0.018] and was marginally associated with East Asian race (HR = 0.26, 95% CI = 0.06‐1.06, P = 0.06) and male sex (HR = 0.59, 95% CI = 0.34‐1.02, P = 0.06). In conclusion, recurrent viral hepatitis–free survival was decreased for smokers after liver transplantation, likely because of the adverse effects of tobacco on immunological host defenses. Overall, the biliary complication–free, depression‐free, and rejection‐free survival rates were similar for smokers and nonsmokers. These findings suggest that smoking cessation should be encouraged, particularly in recipients undergoing transplantation for viral hepatitis. Liver Transpl, 2012.