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Oppong B, Amponsah GM, Gyabaah S, Nicholas MK, Boateng S, Ameyaw PA, Asamoah DO, Nkum BC. Upper Gastrointestinal Endoscopic Findings and Their Clinical Correlates in Patients With Liver Cirrhosis in Northern Ghana. Cureus 2024; 16:e67725. [PMID: 39318930 PMCID: PMC11421874 DOI: 10.7759/cureus.67725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2024] [Indexed: 09/26/2024] Open
Abstract
Background and study aim Liver cirrhosis causes portal hypertension that leads to dysfunction of the gastrointestinal tract, which may result in complications including upper gastrointestinal (UGI) bleeding. This study sought to determine the prevalence and the clinical correlates of these UGI abnormalities in patients with liver cirrhosis receiving care at the Komfo Anokye Teaching Hospital in Kumasi, Ghana. Patients and methods One hundred and forty-five participants with liver cirrhosis were consecutively sampled and clinically evaluated for symptoms and signs of liver cirrhosis and then underwent esophagogastroduodenoscopy (EGD). Results The mean age of the respondents was 46.50 ± 12.14 years, with the majority being males (106, 73.10%) and in Child-Pugh class C (111, 76.55%). Fatigue (128, 88.28%) and ascites (127, 87.59%) were the most common symptoms and signs, respectively. Fatigue, itch, and ascites were significantly correlated with the severity of liver cirrhosis, with an adjusted odd ratio (AOR) (confidence interval (CI)) of 3.56 (1.11-11.47), p-value of 0.03, 4.35 (1.34-14.18), p-value of 0.02 and 22.50 (4.88-103.77), p-value < 0.01, respectively. Esophageal varices were the most common UGI endoscopic findings, occurring in 102 (70.34%) patients, and correlated with the severity of liver cirrhosis, AOR (CI) of 5.19 (1.70-15.87), p-value of 0.01. Other common findings included gastritis in 71 (48.97%), portal hypertensive gastropathy in 67 (46.2%), duodenitis in 49 (33.79%), and peptic ulcer in 46 (31.72%). Conclusions Fatigue, ascites, and esophageal varices were the most common symptoms, signs, and EGD findings, respectively. Fatigue, itch, ascites, esophageal varices, duodenitis, and gastric antral vascular ectasia correlate with the severity of liver cirrhosis.
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Affiliation(s)
- Bright Oppong
- Internal Medicine/Gastroenterolgy, Komfo Anokye Teaching Hospital, Kumasi, GHA
- Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, GHA
| | - Gordon M Amponsah
- Internal Medicine/Cardiology, Komfo Anokye Teaching Hospital, Kumasi, GHA
- Physiology, Kwame Nkrumah University of Science and Technology, Kumasi, GHA
| | - Solomon Gyabaah
- Internal Medicine, Komfo Anokye Teaching Hospital, Kumasi, GHA
| | | | - Sarpong Boateng
- Internal Medicine, Bridgeport Hospital/Yale New Haven Health, Bridgeport, USA
| | - Prince A Ameyaw
- Internal Medicine, Bridgeport Hospital/Yale New Haven Health, Bridgeport, USA
| | | | - Bernard C Nkum
- Internal Medicine/Cardiology, Kwame Nkrumah University of Science and Technology, Kumasi, GHA
- Medicine, Komfo Anokye Teaching Hospital, Kumasi, GHA
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Hill TL, Lascelles BDX, Blikslager A. Gastroduodenal Ulceration. SMALL ANIMAL SOFT TISSUE SURGERY 2023:41-52. [DOI: 10.1002/9781119693741.ch6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2025]
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Demetiou G, Augoustaki A, Kalaitzakis E. Endoscopic management and outcome of non-variceal bleeding in patients with liver cirrhosis: A systematic review. World J Gastrointest Endosc 2022. [DOI: 10.4253/wjge.v14.i3.164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Demetriou G, Augoustaki A, Kalaitzakis E. Endoscopic management and outcome of non-variceal bleeding in patients with liver cirrhosis: A systematic review. World J Gastrointest Endosc 2022; 14:163-175. [PMID: 35432740 PMCID: PMC8984531 DOI: 10.4253/wjge.v14.i3.163] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 10/08/2021] [Accepted: 02/10/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute non-variceal bleeding accounts for approximately 20% of all-cause bleeding episodes in patients with liver cirrhosis. It is associated with high morbidity and mortality therefore prompt diagnosis and endoscopic management are crucial.
AIM To evaluate available data on the efficacy of endoscopic treatment modalities used to control acute non-variceal gastrointestinal bleeding (GIB) in cirrhotic patients as well as to assess treatment outcomes.
METHODS Employing PRISMA methodology, the MEDLINE was searched through PubMed using appropriate MeSH terms. Data are reported in a summative manner and separately for each major non-variceal cause of bleeding.
RESULTS Overall, 23 studies were identified with a total of 1288 cirrhotic patients of whom 958/1288 underwent endoscopic therapy for acute non-variceal GIB. Peptic ulcer bleeding was the most common cause of acute non-variceal bleeding, followed by portal hypertensive gastropathy, gastric antral vascular ectasia, Mallory-Weiss syndrome, Dieaulafoy lesions, portal hypertensive colopathy, and hemorrhoids. Failure to control bleeding from all-causes of non-variceal GIB accounted for less than 3.5% of cirrhotic patients. Rebleeding (range 2%-25%) and mortality (range 3%-40%) rates varied, presumably due to study heterogeneity. Rebleeding was usually managed endoscopically and salvage therapy using arterial embolisation or surgery was undertaken in very few cases. Mortality was usually associated with liver function deterioration and other organ failure or infections rather than uncontrolled bleeding. Endoscopic treatment-related complications were extremely rare. Lower acute non-variceal bleeding was examined in two studies (197/1288 patients) achieving initial hemostasis in all patients using argon plasma coagulation for portal hypertensive colopathy and endoscopic band ligation or sclerotherapy for bleeding hemorrhoids (rebleeding range 10%-13%). Data on the efficacy of endoscopic therapy of cirrhotic patients vs non-cirrhotic controls with acute GIB are very scarce.
CONCLUSION Endotherapy seems to be efficient as a means to control non-variceal hemorrhage in cirrhosis, although published data are very limited, particularly those comparing cirrhotics with non-cirrhotics and those regarding acute bleeding from the lower gastrointestinal tract. Rebleeding and mortality rates appear to be relatively high, although firm conclusions may not be drawn due to study heterogeneity. Hopefully this review may stimulate further research on this subject and help clinicians administer optimal endoscopic therapy for cirrhotic patients.
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Affiliation(s)
- Georgios Demetriou
- Department of Gastroenterology, University Hospital of Heraklion, Heraklion 71500, Greece
| | - Aikaterini Augoustaki
- Department of Gastroenterology, University Hospital of Heraklion, Heraklion 71500, Greece
| | - Evangelos Kalaitzakis
- Department of Gastroenterology, University Hospital of Heraklion, Heraklion 71500, Greece
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Yoo GS, Yu JI, Park HC. Current role of proton beam therapy in patients with hepatocellular carcinoma. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2021; 10:175-182. [DOI: 10.18528/ijgii210043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 10/09/2021] [Accepted: 10/09/2021] [Indexed: 04/24/2025] Open
Affiliation(s)
- Gyu Sang Yoo
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Il Yu
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee Chul Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Kim B, Kim BJ, Yoon HJ, Lee H, Park JY, Choi CH, Kim JG. Atypical Scar Patterns after Gastric Endoscopic Submucosal Dissection. THE KOREAN JOURNAL OF HELICOBACTER AND UPPER GASTROINTESTINAL RESEARCH 2021. [DOI: 10.7704/kjhugr.2020.0047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background/Aims: Endoscopic submucosal dissection (ESD) for gastric neoplasms is a widely performed procedure. Local recurrence is rare, but various post-ESD scars are encountered during follow-up endoscopy. Therefore, we investigated atypical scar patterns and evaluated the associated factors.Materials and Methods: Clinicopathologic and endoscopic reviews of gastric neoplasms treated with ESD from January 2009 to December 2015 were conducted. Atypical scar patterns were classified as irregular erythema, nodularity, or mucosal defect.Results: A total of 264 patients with 274 gastric neoplasms, including 201 adenomas and 73 early gastric cancers, were enrolled. The key endoscopic findings at the resection scar were defined on the basis of gross morphology as follows: irregular erythema, mucosal defect (erosion or ulcer), and nodularity. An irregular erythema scar pattern was associated with male sex, a nodularity scar pattern with smoking, and a mucosal defect scar pattern with infra-angle location (angle and antrum) and cancer. An irregular erythema with nodularity scar pattern was also associated with male sex. An irregular erythema with nodularity and mucosal defect scar pattern was associated with liver disease and chronic kidney disease.Conclusions: The atypical scar patterns after gastric ESD are associated with various clinicopathologic factors.
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Misra V, Agrawal R, Misra SP. Portal hypertensive vasculopathy - An entity worth remembering with non-neoplastic gastrointestinal lesions. INDIAN J PATHOL MICR 2021; 64:S32-S42. [PMID: 34135136 DOI: 10.4103/ijpm.ijpm_201_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Portal hypertensive vasculopathy (PHV) represents an increase in the pressure in the portal circulation. This increased pressure leads to changes in the mucosa that can be appreciated endoscopically as well as histopathologically. Lesions can be observed in the entire gastrointestinal tract (GIT) including stomach, duodenum, jejunum and colon. The histological changes are appreciated mainly in the mucosal and submucosal blood vessels. A knowledge of these lesions as well as the changes helps in separating them from other close differentials with specific treatment to be instituted. The pathogenesis of the hemodynamic changes is not well-understood. The underlying factor is increased portal pressure. Studies indicate, that besides increased portal pressure other factors in combination led to the observed changes. Portal hypertensive gastropathy (PHG) is seen in the gastric body and fundus, while varices are noted in the cardia and fundus. Changes may be seen in the small intestine and throughout the colon with anorectal varices. Histopathological changes include dilated, congested and ectatic capillaries and edema in the lamina propria besides a large spectrum of other histopathological changes. Mucosal capillaries with thick irregular wall show absence of red blood cells in the lumen. Thickening of the vessel wall serves as a better marker than the vascular diameter when portal hypertension (PHT) is considered. Long standing cases may show fibrosis in lamina propria. At times, these changes may lead to occult gastrointestinal bleeding. Important differentials need to be ruled out in all the cases as the treatment and the outcome of all differs. Endoscopically or histopathologically if the mucosal changes are observed they should not be overlooked and a detailed work-up must be carried out.
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Affiliation(s)
- Vatsala Misra
- Department of Pathology and Gastroenterology, MLN Medical College, Prayagraj, Uttar Pradesh, India
| | - Ranjan Agrawal
- Department of Pathology, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India
| | - Sri Praksh Misra
- Department of Pathology and Gastroenterology, MLN Medical College, Prayagraj, Uttar Pradesh, India
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Jang WI, Bae SH, Kim MS, Han CJ, Park SC, Kim SB, Cho EH, Choi CW, Kim KS, Hwang S, Kim JH, Chang AR, Park Y, Kim ES, Kim WC, Jo S, Park HJ. A phase 2 multicenter study of stereotactic body radiotherapy for hepatocellular carcinoma: Safety and efficacy. Cancer 2019; 126:363-372. [PMID: 31747476 DOI: 10.1002/cncr.32502] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 07/10/2019] [Accepted: 07/13/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Although several prospective studies have reported the efficacy of stereotactic body radiotherapy (SBRT) for hepatocellular carcinoma (HCC), treatment-related toxicity varies and has not been determined. Therefore, the authors evaluated the safety and efficacy of SBRT for patients with HCC in a hepatitis B virus-endemic area. METHODS This multicenter phase 2 trial enrolled patients with unresectable HCC. Patients received SBRT with 45 to 60 Gy in 3 fractions. To evaluate gastroduodenal toxicity, esophagogastroduodenoscopy (EGD) was performed before and 2 months after SBRT. The primary endpoint was treatment-related severe toxicity at 1 year after SBRT. The secondary endpoints were the 2-year local control, progression-free survival, and overall survival rates. RESULTS In total, 74 patients were enrolled between January 2012 and April 2015, and 65 eligible patients were analyzed. One patient experienced radiation-induced liver disease with acute grade ≥3 toxicity 1 month after SBRT. In addition, 1 patient had a grade 3 esophageal ulcer with stenosis 5 months after SBRT. The actuarial rate of treatment-related severe toxicity at 1 year was 3%. The pre-SBRT and post-SBRT EGD findings were not significantly different among the 57 evaluable patients who underwent EGD. The 2-year and 3-year local control rates were 97% and 95%, respectively. The progression-free and overall survival rates were 48% and 84% at 2 years, respectively, and 36% and 76% at 3 years, respectively. CONCLUSIONS With a median follow-up of 41 months, this prospective multicenter study demonstrated that SBRT for patients with HCC is well tolerated and is an effective treatment modality.
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Affiliation(s)
- Won Il Jang
- Department of Radiation Oncology, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Sun Hyun Bae
- Department of Radiation Oncology, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Mi-Sook Kim
- Department of Radiation Oncology, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Chul Ju Han
- Department of Internal Medicine, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Su Cheol Park
- Department of Internal Medicine, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Sang Bum Kim
- Department of General Surgery, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Eung-Ho Cho
- Department of General Surgery, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Chul Won Choi
- Department of Radiation Oncology, Dongnam Institute of Radiological and Medical Sciences, Busan, Korea
| | - Kyung Su Kim
- Department of Radiation Oncology, Dongnam Institute of Radiological and Medical Sciences, Busan, Korea
| | - Sangyoun Hwang
- Department of Internal Medicine, Dongnam Institute of Radiological and Medical Sciences, Busan, Korea
| | - Jin Ho Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
| | - A Ram Chang
- Department of Radiation Oncology, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Younghee Park
- Department of Radiation Oncology, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Eun Seog Kim
- Department of Radiation Oncology, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Woo Chul Kim
- Department of Radiation Oncology, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Sunmi Jo
- Department of Radiation Oncology, Haeundae Paik Hospital, Inje University School of Medicine, Busan, Korea
| | - Hae Jin Park
- Department of Radiation Oncology, Hanyang University Hospital, Seoul, Korea
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Voulgaris T, Karagiannakis D, Siakavellas S, Kalogera D, Angelopoulos T, Chloupi E, Karamanolis G, Papatheodoridis G, Vlachogiannakos J. High prevalence of asymptomatic peptic ulcers diagnosed during screening endoscopy in patients with cirrhosis. Ann Gastroenterol 2019; 32:451-456. [PMID: 31474790 PMCID: PMC6686096 DOI: 10.20524/aog.2019.0399] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 05/05/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Peptic ulcer disease (PUD) is more prevalent in cirrhotics and this may aggravate prognosis. We investigated the prevalence of PUD in cirrhotics and its potential association with Helicobacter pylori (H. pylori) infection, the underlying etiology and severity of liver disease, and other manifestations of portal hypertension (PH). METHODS We enrolled consecutive asymptomatic cirrhotic patients who underwent screening endoscopy in a tertiary hospital during a 12-month period. We recorded the presence of PUD and the endoscopic findings associated with PH. H. pylori infection was documented through either histology or CLO-test. The diagnosis of cirrhosis was based on elastography, liver biopsy or a combination of clinical, biochemical and imaging data. RESULTS One hundred patients (M/F: 54/46, mean age: 61±14 years) were included in the analysis. Viral hepatitis (37%) and alcohol (22%) were the most common causes of cirrhosis. Child-Pugh stage was A/B/C: 60/35/5. PUD was found in 19 patients (14 gastric, 5 duodenal). H. pylori infection was diagnosed in 54%. Varices were detected in 59% (39% needed treatment). PH gastropathy was present in 81% (severe in 33%). The presence of PUD was unrelated to the etiology and the severity of liver disease or to other endoscopic manifestations of PH. No correlation was found between PUD and H. pylori infection. CONCLUSIONS A high prevalence of PUD was observed in our cirrhotic patients, although they were asymptomatic and had no known risk factors of ulcerogenicity. The value of screening endoscopy for the early diagnosis and treatment of PUD in cirrhotics deserves further investigation.
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Affiliation(s)
- Theodoros Voulgaris
- Academic Department of Gastroenterology and Hepatology, LAIKO General Hospital, University of Athens, Medical School, Athens, Greece
| | - Dimitrios Karagiannakis
- Academic Department of Gastroenterology and Hepatology, LAIKO General Hospital, University of Athens, Medical School, Athens, Greece
| | - Spyridon Siakavellas
- Academic Department of Gastroenterology and Hepatology, LAIKO General Hospital, University of Athens, Medical School, Athens, Greece
| | - Despina Kalogera
- Academic Department of Gastroenterology and Hepatology, LAIKO General Hospital, University of Athens, Medical School, Athens, Greece
| | - Theodoros Angelopoulos
- Academic Department of Gastroenterology and Hepatology, LAIKO General Hospital, University of Athens, Medical School, Athens, Greece
| | - Elissavet Chloupi
- Academic Department of Gastroenterology and Hepatology, LAIKO General Hospital, University of Athens, Medical School, Athens, Greece
| | - George Karamanolis
- Academic Department of Gastroenterology and Hepatology, LAIKO General Hospital, University of Athens, Medical School, Athens, Greece
| | - George Papatheodoridis
- Academic Department of Gastroenterology and Hepatology, LAIKO General Hospital, University of Athens, Medical School, Athens, Greece
| | - John Vlachogiannakos
- Academic Department of Gastroenterology and Hepatology, LAIKO General Hospital, University of Athens, Medical School, Athens, Greece
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Fouad TR, Abdelsameea E, Abdel-Razek W, Attia A, Mohamed A, Metwally K, Naguib M, Waked I. Upper gastrointestinal bleeding in Egyptian patients with cirrhosis: Post-therapeutic outcome and prognostic indicators. J Gastroenterol Hepatol 2019; 34:1604-1610. [PMID: 30937995 DOI: 10.1111/jgh.14659] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 01/26/2019] [Accepted: 03/10/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Upper gastrointestinal bleeding (UGIB) is a serious complication of portal hypertension in cirrhotic patients. The objective of this study is to identify the risk factors for morbidity and mortality occurring after an UGIB attack. METHODS A total of 1097 UGIB attacks in 690 patients with liver cirrhosis were studied. Their clinical, laboratory, and endoscopic data were reviewed. RESULTS Mean age 53.2 ± 10.6 (20-90) years, 78% men and the main cause of liver disease was hepatitis C (94.9%). Complications occurred after 467 attacks (42.6%): hepatic encephalopathy 31.4%, spontaneous bacterial peritonitis 18%, renal impairment 13.2%, and re-bleeding in 7.8%, while 199 patients (18.1%) died. Complications followed 78.4% of bleeding from gastric varices, 75% of post-interventional ulcers, 10.8% of peptic ulcers, and 5.9% of telangiectasias. By univariate analysis: packed red blood cells units transfused, transaminases, Child-Pugh (CP), model of end-stage liver disease (MELD), and albumin-bilirubin (ALBI) scores, beside the presence of hepatocellular carcinoma (HCC), previous hemorrhage in the previous 6 months, and the source of bleeding, were associated with occurrence of complications. By multivariate analysis, independent predictors of complications were CP, MELD, and ALBI scores (odds ratio, 95% confidence interval: 5.63, 3.55-8.93; 1.15, 1.11-1.19; and 2.11, 1.4-3.19, respectively) beside the presence of HCC (4.89, 2.48-9.64). Mortality predictors were packed red blood cells units transfused (1.11, 1.01-1.24), CP (5.1, 1.42-18.25) MELD (1.27, 1.21-1.32) scores, and presence of HCC (6.62, 2.93-14.95). CONCLUSION High CP, MELD, and ALBI scores beside the presence of HCC could predict poor outcome of UGIB. In the absence of these risk factors, early discharge could be considered if the source of bleeding is peptic ulcer or telangiectasia.
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Affiliation(s)
- Tamer R Fouad
- Hepatology Department, National Liver Institute, University of Menoufia, Shebeen El-Kom, Egypt
| | - Eman Abdelsameea
- Hepatology Department, National Liver Institute, University of Menoufia, Shebeen El-Kom, Egypt
| | - Wael Abdel-Razek
- Hepatology Department, National Liver Institute, University of Menoufia, Shebeen El-Kom, Egypt
| | - Ahmed Attia
- Hepatology Department, National Liver Institute, University of Menoufia, Shebeen El-Kom, Egypt
| | - Anwar Mohamed
- Hepatology Department, National Liver Institute, University of Menoufia, Shebeen El-Kom, Egypt
| | - Khaled Metwally
- Hepatology Department, National Liver Institute, University of Menoufia, Shebeen El-Kom, Egypt
| | - Mary Naguib
- Clinical Biochemistry Department, National Liver Institute, University of Menoufia, Shebeen El-Kom, Egypt
| | - Imam Waked
- Hepatology Department, National Liver Institute, University of Menoufia, Shebeen El-Kom, Egypt
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Park J, Jung J, Kim D, Jung IH, Park JH, Kim JH, Lee SW, Yoon SM. Long-term outcomes of the 2-week schedule of hypofractionated radiotherapy for recurrent hepatocellular carcinoma. BMC Cancer 2018; 18:1040. [PMID: 30367606 PMCID: PMC6203968 DOI: 10.1186/s12885-018-4953-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 10/15/2018] [Indexed: 02/07/2023] Open
Abstract
Background The 2-week schedule of hypofractionated radiotherapy as a salvage treatment for hepatocellular carcinoma (HCC) has previously exhibited promising results; this study aimed to assess its long-term clinical outcomes in patients with recurrent HCC ineligible for curative treatments. Methods We retrospectively enrolled 77 patients (84 lesions) with HCC who were treated with hypofractionated radiotherapy between December 2008 and July 2013. Primary inclusion criteria were HCC unsuitable for curative treatments and HCC located within 2 cm of a critical normal organ. We administered 3.5–5 Gy/fraction for 2 weeks, resulting in a total dose of 35–50 Gy. Results The median follow-up period was 33.6 (range, 4.8–78.3) months. The 3- and 5-year overall survival rates were 52.3% and 40.9%, respectively, and local control rates were 79.5% and 72.6% in all treated lesions, respectively. The 5-year local control rate was better in the higher radiation dose group than in the lower radiation dose group (50 Gy: 79.7% vs. < 50 Gy: 66.1%); however, the difference was not statistically significant (P = 0.493). We observed grade ≥ 3 hepatic toxicity in 2 (2.6%) patients and grade 3 gastrointestinal bleeding in 1 (1.3%) patient. However, grade ≥ 4 toxicity was not observed after hypofractionated radiotherapy. Conclusions The 2-week schedule of hypofractionated radiotherapy for recurrent HCC exhibited good local control and acceptable treatment-related toxicity during the long-term follow-up period. Thus, this fractionation schedule can be a potential salvage treatment option for recurrent HCC, particularly for tumors located close to a radiosensitive gastrointestinal organ. Electronic supplementary material The online version of this article (10.1186/s12885-018-4953-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jongmoo Park
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.,Department of Radiation Oncology, Chungbuk National University Hospital, Cheongju, 28644, Republic of Korea
| | - Jinhong Jung
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Daegeun Kim
- University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - In-Hye Jung
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Jin-Hong Park
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Jong Hoon Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Sang-Wook Lee
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Sang Min Yoon
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
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12
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Yoo GS, Yu JI, Park HC. Proton therapy for hepatocellular carcinoma: Current knowledges and future perspectives. World J Gastroenterol 2018; 24:3090-3100. [PMID: 30065555 PMCID: PMC6064962 DOI: 10.3748/wjg.v24.i28.3090] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 05/28/2018] [Accepted: 06/25/2018] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is the second leading cause of cancer-related death, as few patients can be treated with currently available curative local modalities. In patients with HCC where curative modalities are not feasible, radiation therapy (RT) has emerged as an alternative or combination therapy. With the development of various technologies, RT has been increasingly used for the management of HCC. Among these advances, proton beam therapy (PBT) has several unique physical properties that give it a finite range in a distal direction, and thus no exit dose along the beam path. Therefore, PBT has dosimetric advantages compared with X-ray therapy for the treatment of HCC. Indeed, various reports in the literature have described the favorable clinical outcomes and improved safety of PBT for HCC patients compared with X-ray therapy. However, there are some technical issues regarding the use of PBT in HCC, including uncertainty of organ motion and inaccuracy during calculation of tissue density and beam range, all of which may reduce the robustness of a PBT treatment plan. In this review, we discuss the physical properties, current clinical data, technical issues, and future perspectives on PBT for the treatment of HCC.
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Affiliation(s)
- Gyu Sang Yoo
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, South Korea
| | - Jeong Il Yu
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, South Korea
| | - Hee Chul Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, South Korea
- Department of Medical Device Management and Research, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Seoul 06351, South Korea
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Ardevol A, Ibañez-Sanz G, Profitos J, Aracil C, Castellvi JM, Alvarado E, Cachero A, Horta D, Miñana J, Gomez-Pastrana B, Pavel O, Dueñas E, Casas M, Planella M, Castellote J, Villanueva C. Survival of patients with cirrhosis and acute peptic ulcer bleeding compared with variceal bleeding using current first-line therapies. Hepatology 2018; 67:1458-1471. [PMID: 28714072 DOI: 10.1002/hep.29370] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 05/18/2017] [Accepted: 07/11/2017] [Indexed: 12/11/2022]
Abstract
UNLABELLED The presence of cirrhosis increases the mortality of patients with peptic ulcer bleeding (PUB). Both acute variceal bleeding (AVB) and PUB are associated with substantial mortality in cirrhosis. This multicenter cohort study was performed to assess whether the mortality of patients with cirrhosis with PUB is different from that of those with AVB. Patients with cirrhosis and acute gastrointestinal bleeding were consecutively included and treated with somatostatin and proton pump inhibitor infusion from admission and with antibiotic prophylaxis. Emergency endoscopy with endoscopic therapy was performed within the first 6 hours. 646 patients with AVB and 144 with PUB were included. There were baseline differences between groups, such as use of gastroerosive drugs or β-blockers. Child-Pugh and Model for End-Stage Liver Disease MELD scores were similar. Further bleeding was more frequent in the AVB group than those in the PUB group (18% vs. 10%; odds ratio [OR] = 0.50; 95% confidence interval [CI] = 0.29-0.88). However, mortality risk at 45 days was similar in both groups (19% in the AVB group vs. 17% in the PUB group; OR = 0.85; 95% CI = 0.55-1.33; P = 0.48). Different parameters, such as Child-Pugh score, acute kidney injury, acute on chronic liver failure, or presence of shock or bacterial infection, but not the cause of bleeding, were related to the risk of death. Only 2% of the PUB group versus 3% of the AVB group died with uncontrolled bleeding (P = 0.39), whereas the majority of patients in either group died from liver failure or attributed to other comorbidities. CONCLUSION Using current first-line therapy, patients with cirrhosis and acute peptic ulcer bleeding have a similar survival than those with variceal bleeding. The risk of further bleeding is higher in patients with variceal hemorrhage. However, few patients in both groups died from uncontrolled bleeding, rather the cause of death was usually related to liver failure or comorbidities. (Hepatology 2018;67:1458-1471).
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Affiliation(s)
- Alba Ardevol
- Department of Gastroenterology, Hospital de Sant Pau, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain.,Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Gemma Ibañez-Sanz
- Hepatology and Liver Transplant Unit, IDIBELL, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Joaquim Profitos
- Department of Gastroenterology, Corporació Sanitària Parc Tauli, Sabadell, Barcelona, Spain
| | - Carles Aracil
- Department of Gastroenterology, Hospital Arnau de Vilanova, Lleida, Spain
| | - Josep M Castellvi
- Department of Gastroenterology, Hospital de Mataró, Barcelona, Spain
| | - Edilmar Alvarado
- Department of Gastroenterology, Hospital de Sant Pau, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain.,Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alba Cachero
- Hepatology and Liver Transplant Unit, IDIBELL, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Diana Horta
- Department of Gastroenterology, Corporació Sanitària Parc Tauli, Sabadell, Barcelona, Spain
| | - Josep Miñana
- Department of Gastroenterology, Hospital Arnau de Vilanova, Lleida, Spain
| | | | - Oana Pavel
- Department of Gastroenterology, Hospital de Sant Pau, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Eva Dueñas
- Hepatology and Liver Transplant Unit, IDIBELL, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Meritxell Casas
- Department of Gastroenterology, Corporació Sanitària Parc Tauli, Sabadell, Barcelona, Spain
| | | | - Jose Castellote
- Hepatology and Liver Transplant Unit, IDIBELL, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Candid Villanueva
- Department of Gastroenterology, Hospital de Sant Pau, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain.,Universitat Autònoma de Barcelona, Barcelona, Spain
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Nojkov B, Cappell MS. Distinctive aspects of peptic ulcer disease, Dieulafoy's lesion, and Mallory-Weiss syndrome in patients with advanced alcoholic liver disease or cirrhosis. World J Gastroenterol 2016; 22:446-466. [PMID: 26755890 PMCID: PMC4698507 DOI: 10.3748/wjg.v22.i1.446] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 09/11/2015] [Accepted: 11/24/2015] [Indexed: 02/06/2023] Open
Abstract
AIM To systematically review the data on distinctive aspects of peptic ulcer disease (PUD), Dieulafoy's lesion (DL), and Mallory-Weiss syndrome (MWS) in patients with advanced alcoholic liver disease (aALD), including alcoholic hepatitis or alcoholic cirrhosis. METHODS Computerized literature search performed via PubMed using the following medical subject heading terms and keywords: "alcoholic liver disease", "alcoholic hepatitis"," alcoholic cirrhosis", "cirrhosis", "liver disease", "upper gastrointestinal bleeding", "non-variceal upper gastrointestinal bleeding", "PUD", ''DL'', ''Mallory-Weiss tear", and "MWS''. RESULTS While the majority of acute gastrointestinal (GI) bleeding with aALD is related to portal hypertension, about 30%-40% of acute GI bleeding in patients with aALD is unrelated to portal hypertension. Such bleeding constitutes an important complication of aALD because of its frequency, severity, and associated mortality. Patients with cirrhosis have a markedly increased risk of PUD, which further increases with the progression of cirrhosis. Patients with cirrhosis or aALD and peptic ulcer bleeding (PUB) have worse clinical outcomes than other patients with PUB, including uncontrolled bleeding, rebleeding, and mortality. Alcohol consumption, nonsteroidal anti-inflammatory drug use, and portal hypertension may have a pathogenic role in the development of PUD in patients with aALD. Limited data suggest that Helicobacter pylori does not play a significant role in the pathogenesis of PUD in most cirrhotic patients. The frequency of bleeding from DL appears to be increased in patients with aALD. DL may be associated with an especially high mortality in these patients. MWS is strongly associated with heavy alcohol consumption from binge drinking or chronic alcoholism, and is associated with aALD. Patients with aALD have more severe MWS bleeding and are more likely to rebleed when compared to non-cirrhotics. Pre-endoscopic management of acute GI bleeding in patients with aALD unrelated to portal hypertension is similar to the management of aALD patients with GI bleeding from portal hypertension, because clinical distinction before endoscopy is difficult. Most patients require intensive care unit admission and attention to avoid over-transfusion, to correct electrolyte abnormalities and coagulopathies, and to administer antibiotic prophylaxis. Alcoholics should receive thiamine and be closely monitored for symptoms of alcohol withdrawal. Prompt endoscopy, after initial resuscitation, is essential to diagnose and appropriately treat these patients. Generally, the same endoscopic hemostatic techniques are used in patients bleeding from PUD, DL, or MWS in patients with aALD as in the general population. CONCLUSION Nonvariceal upper GI bleeding in patients with aALD has clinically important differences from that in the general population without aALD, including: more frequent and more severe bleeding from PUD, DL, or MWS.
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Chang SS, Hu HY. Helicobacter pylori: Effect of coexisting diseases and update on treatment regimens. World J Gastrointest Pharmacol Ther 2015; 6:127-136. [PMID: 26558147 PMCID: PMC4635153 DOI: 10.4292/wjgpt.v6.i4.127] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 06/10/2015] [Accepted: 09/15/2015] [Indexed: 02/06/2023] Open
Abstract
The presence of concomitant diseases is an independent predictive factor for non-Helicobacter pylori (H. pylori) peptic ulcers. Patients contracting concomitant diseases have an increased risk of developing ulcer disease through pathogenic mechanisms distinct from those of H. pylori infections. Factors other than H. pylori seem critical in peptic ulcer recurrence in end stage renal disease (ESRD) and cirrhotic patients. However, early H. pylori eradication is associated with a reduced risk of recurrent complicated peptic ulcers in patients with ESRD and liver cirrhosis. Resistances to triple therapy are currently detected using culture-based and molecular methods. Culture susceptibility testing before first- or second-line therapy is unadvisable. Using highly effective empiric first-line and rescue regimens can yield acceptable results. Sequential therapy has been included in a recent consensus report as a valid first-line option for eradicating H. pylori in geographic regions with high clarithromycin resistance. Two novel eradication regimens, namely concomitant and hybrid therapy, have proven more effective in patients with dual- (clarithromycin- and metronidazole-) resistant H. pylori strains. We aim to review the prevalence of and eradication therapy for H. pylori infection in patients with ESRD and cirrhosis. Moreover, we summarized the updated H. pylori eradication regimens.
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Schiekofer C, Vogt T, Reichrath J. [Erythropoietic protoporphyria. A rare differential diagnosis among photosensitive diseases]. Hautarzt 2015; 63:961-4. [PMID: 22802217 DOI: 10.1007/s00105-012-2423-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A 31-year-old woman presented with recurrent swelling, burning, prickling and itching of the arms and the hands which appeared after UV exposure in the summer. Simultaneously she often had chills, malaise, nausea and circulatory problems lasting for hours. She did not have erythema or wheals. She had been seen by a number of specialties but to no avail. Her deceased mother suffered from the same symptoms. On presentation she had no skin lesions. Laboratory testing showed a dramatic increase in total protoporphyrin, enabling us to diagnose erythropoietic protoporphyria. This is a rare, genetic metabolic disturbance in hematopoiesis, whose true prevalence is probably underestimated. Because of abnormal or absent function of ferrochelatase, protoporphyrin accumulates in blood, erythrocytes and tissue usually causing photosensitivity as the first clinical symptom. The prognosis depends on the severity of liver involvement. Because of the marked restrictions on activity, especially in avoiding UV exposition, the quality of life of the patients and their families are strongly influenced. The odyssey of our patient and her mother in finding a diagnosis demonstrates impressively that the EPP is an important photosensitizing disease which must not be forgotten.
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Affiliation(s)
- C Schiekofer
- Hautklinik und Poliklinik, Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum des Saarlandes, 66421, Homburg/Saar, Deutschland.
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Ippolito E, D'Angelillo RM, Fiore M, Molfese E, Trodella L, Ramella S. SBRT: A viable option for treating adrenal gland metastases. Rep Pract Oncol Radiother 2015; 20:484-90. [PMID: 26696789 DOI: 10.1016/j.rpor.2015.05.009] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 04/03/2015] [Accepted: 05/24/2015] [Indexed: 02/08/2023] Open
Abstract
The management strategy of adrenal metastases depends on different clinical situations. Adrenal metastasectomy in selected patients with isolated adrenal metastases is considered the treatment of choice, showing prolonged survival compared to chemotherapy alone. More recently, Stereotactic Body Radiation Therapy (SBRT) has emerged as an alternative local ablative treatment modality although limited data are available on the use of SBRT in treating adrenal gland metastases. Preliminary results are, however, encouraging, especially in selected patients with oligometastatic disease. We herewith review and discuss the potential role of SBRT as a local ablative treatment modality for adrenal metastases.
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Affiliation(s)
- Edy Ippolito
- Department of Radiotherapy, Campus Bio-Medico University, Via Alvaro del Portillo 21, 00128 Rome, Italy
| | - Rolando Maria D'Angelillo
- Department of Radiotherapy, Campus Bio-Medico University, Via Alvaro del Portillo 21, 00128 Rome, Italy
| | - Michele Fiore
- Department of Radiotherapy, Campus Bio-Medico University, Via Alvaro del Portillo 21, 00128 Rome, Italy
| | - Elisabetta Molfese
- Department of Radiotherapy, Campus Bio-Medico University, Via Alvaro del Portillo 21, 00128 Rome, Italy
| | - Lucio Trodella
- Department of Radiotherapy, Campus Bio-Medico University, Via Alvaro del Portillo 21, 00128 Rome, Italy
| | - Sara Ramella
- Department of Radiotherapy, Campus Bio-Medico University, Via Alvaro del Portillo 21, 00128 Rome, Italy
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Zanetto A, Senzolo M, Ferrarese A, Simioni P, Burra P, Rodríguez-Castro KI. Assessment of Bleeding Risk in Patients with Cirrhosis. CURRENT HEPATOLOGY REPORTS 2015; 14:9-18. [DOI: 10.1007/s11901-015-0250-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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19
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[Personnel calculation in health care: intensive care and intermediate care units]. Med Klin Intensivmed Notfmed 2014; 109:504-8. [PMID: 25330874 DOI: 10.1007/s00063-013-0343-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 08/19/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Personnel calculation in intensive care has been a subject of conflict for over 63 years. The aim of these remarks is primarily to indicate the current state of the discussions. METHOD The methods of working-scientific analyses in practice with the respective factors are shown. RESULT It seems clear that a fair personnel calculation is limited by scarce financial resources and political policy.
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20
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Abstract
OBIECTIVE The study aimed to investigate whether early Helicobacter pylori (H. pylori) eradication therapy in cirrhotic patients caused a dramatic reduction of recurrent peptic ulcers compared with those treated with a late eradication. METHODS We identified cirrhotic patients using the International Classifications of Diseases, Revision 9 (ICD-9-CM). Decompensated cirrhotic patients can apply for a catastrophic illness card and were identified via the ICD-9-CM codes 571.2, 571.5 and 571.6. Compensated cirrhotic patients were identified via the ICD-9-CM codes 571.2, 571.5 and 571.6, after excluded decompensated cirrhotic patients. We categorized patients into early (time lag ≤365 days after peptic ulcer diagnosis) and late (time lag >365 days) H. pylori eradication therapy groups. The end-point was the occurrence of recurrent peptic ulcers. Cox proportional hazards model was used to calculate the hazard ratios (HRs). RESULTS Altogether, 154 cirrhotic patients were included in the early H. pylori eradication group and 103 in the late H. pylori eradication group. Cirrhotic patients had a higher risk of recurrent peptic ulcers in the late H. pylori eradication group (HR 1.58, 95% CI 1.09-2.28, P = 0.015). However, the risk of recurrent peptic ulcers in alcoholic cirrhotic patients in both groups (HR 1.47, 95% CI 0.77-2.83, P = 0.247) was similar. CONCLUSIONS Early H. pylori eradication is associated with a lower risk of recurrent peptic ulcers in cirrhotic patients. H. pylori eradication is the mainstay for treating cirrhotic patients who have contracted peptic ulcers.
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Affiliation(s)
- Shen-Shong Chang
- Division of Gastroenterology, Taipei City Hospital Yang-Ming Branch, Taipei, Taiwan, China; Department of Internal Medicine, Taipei City Hospital Yang-Ming Branch, Taipei, Taiwan, China; School of Medicine, National Yang-Ming University, Taipei, Taiwan, China
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21
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Venkatesh PGK, Parasa S, Njei B, Sanaka MR, Navaneethan U. Increased mortality with peptic ulcer bleeding in patients with both compensated and decompensated cirrhosis. Gastrointest Endosc 2014; 79:605-14.e3. [PMID: 24119507 DOI: 10.1016/j.gie.2013.08.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Accepted: 08/22/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Cirrhosis is associated with worse outcomes in peptic ulcer bleeding (PUB). There are no population-based studies from the United States on the impact of cirrhosis on PUB outcomes. OBJECTIVE To investigate the impact of cirrhosis on outcomes of patients with PUB. DESIGN Cross-sectional study. SETTING Nationwide Inpatient Sample 2009. PATIENTS International Classification of Diseases, the 9th revision, codes were used to identify patients with PUB and cirrhosis. The control group was patients with PUB without cirrhosis. MAIN OUTCOME MEASUREMENTS In-hospital mortality, length of stay, and hospitalization costs. RESULTS A total of 96,887 discharges with PUB as a diagnosis were identified-3574 with PUB and cirrhosis and 93,313 with PUB alone without cirrhosis. Mortality of PUB with concomitant cirrhosis was higher than in the control group without cirrhosis (5.5% vs 2%; P = .01); decompensated cirrhosis had higher mortality than did compensated cirrhosis (6.6% vs 3.9%; P = .01). In multivariate analysis, the presence of cirrhosis independently increased mortality (adjusted odds ratio (aOR) 3.3; 95% confidence interval [CI], 2.2-4.9). Stratified analysis showed that decompensated cirrhosis (aOR 4.4; 95% CI, 2.6-7.3) had higher mortality than compensated cirrhosis (aOR 1.9; 95% CI, 1.04-3.6). There was no difference in the proportion of patients who underwent endoscopy within 24 hours (51.9% vs 51.1%; P = .68) between those with cirrhosis and controls. Patients with cirrhosis received less surgical intervention (aOR 0.8; 95% CI, 0.6-0.9) compared with controls. Hospitalization costs also were increased in patients with decompensated cirrhosis. LIMITATIONS Administrative data set. CONCLUSION Both decompensated and compensated cirrhosis are associated with increased mortality in patients with PUB.
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Affiliation(s)
| | - Sravanthi Parasa
- Department of Medicine, Kansas University Medical Center, Kansas City, Kansas, USA
| | - Basile Njei
- Department of Medicine, University of Connecticut Health Center, Farmington, Connecticut, USA
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Park JH, Yoon SM, Lim YS, Kim SY, Shim JH, Kim KM, Lee HC, Cho B, Park G, Kim JH. Two-week schedule of hypofractionated radiotherapy as a local salvage treatment for small hepatocellular carcinoma. J Gastroenterol Hepatol 2013; 28:1638-42. [PMID: 23621519 DOI: 10.1111/jgh.12249] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/18/2013] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND AIM In cases of small hepatocellular carcinoma (HCC) where established curative treatment cannot be applied, stereotactic body radiotherapy (SBRT) has been used as a non-invasive alternative treatment modality. However, short-course SBRT may not be safe if the tumor is located around a critical normal organ. Therefore, we applied hypofractionated radiotherapy for these tumors and evaluated outcomes of this treatment. METHODS Between December 2008 and August 2011, 26 patients (28 lesions) with HCC were treated with hypofractionated radiotherapy. Inclusion criteria were HCC not suitable for surgery or other local ablative therapy, a tumor size < 6 cm, adequate hepatic function, an HCC located within 2 cm of a critical organ, and no evidence of vascular invasion. A dose of 4-5 Gy per fraction was given, with a total dose of 40-50 Gy over 2 weeks. RESULTS The overall response rate was 67.9%, with seven complete responses (25.0%) and 12 partial responses (42.9%) at 3 months after radiotherapy. The overall survival rates at 1 and 2 years were 88.5% and 67.2%, respectively. The local control rate at 2 years was 87.6%. The Intrahepatic recurrence-free and distant failure-free survival rates at 2 years were 36.5% and 68.2%, respectively. Grade ≥ 3 hepatic toxicity was observed in one patient. CONCLUSIONS Two-week schedule of hypofractionated radiotherapy for small HCC was feasible with good local control and safety. This fractionation schedule can be used as an alternative treatment option for HCC located close to a critical normal organ if short-course SBRT is not feasible.
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Affiliation(s)
- Jin-Hong Park
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Yoon H, Oh D, Park HC, Kang SW, Han Y, Lim DH, Paik SW. Predictive factors for gastroduodenal toxicity based on endoscopy following radiotherapy in patients with hepatocellular carcinoma. Strahlenther Onkol 2013; 189:541-6. [PMID: 23703401 DOI: 10.1007/s00066-013-0343-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Accepted: 03/06/2013] [Indexed: 12/25/2022]
Abstract
PURPOSE The aim of this work was to determine predictive factors for gastroduodenal (GD) toxicity in hepatocellular carcinoma (HCC) patients who were treated with radiotherapy (RT). PATIENTS AND METHODS A total of 90 HCC patients who underwent esophagogastroduodenoscopy (EGD) before and after RT were enrolled. RT was delivered as 30-50 Gy (median 37.5 Gy) in 2-5 Gy (median 3.5 Gy) per fraction. All endoscopic findings were reviewed and GD toxicities related to RT were graded by the Common Toxicity Criteria for Adverse Events, version 3.0. The predictive factors for the ≥ grade 2 GD toxicity were investigated. RESULTS Endoscopic findings showed erosive gastritis in 14 patients (16 %), gastric ulcers in 8 patients (9 %), erosive duodenitis in 15 patients (17 %), and duodenal ulcers in 14 patients (16 %). Grade 2 toxicity developed in 19 patients (21 %) and grade 3 toxicity developed in 8 patients (9 %). V25 for stomach and V35 for duodenum (volume receiving a RT dose of more than x Gy) were the most predictive factors for ≥ grade 2 toxicity. The gastric toxicity rate at 6 months was 2.9 % for V25 ≤ 6.3 % and 57.1 % for V25 > 6.3 %. The duodenal toxicity rate at 6 months was 9.4 % for V35 ≤ 5.4 % and 45.9 % for V35 > 5.4 %. By multivariate analysis including the clinical factors, V25 for stomach and V35 for duodenum were the significant factors. CONCLUSION EGD revealed that GD toxicity is common following RT for HCC. V25 for the stomach and V35 for the duodenum were the significant factors to predict ≥ grade 2 GD toxicity.
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Affiliation(s)
- H Yoon
- Department of Health Sciences and Technology, School of Medicine & Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Seoul, Korea
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Bae SH, Kim MS, Cho CK, Kang JK, Lee SY, Lee KN, Lee DH, Han CJ, Yang KY, Kim SB. Predictor of severe gastroduodenal toxicity after stereotactic body radiotherapy for abdominopelvic malignancies. Int J Radiat Oncol Biol Phys 2013; 84:e469-74. [PMID: 23078899 DOI: 10.1016/j.ijrobp.2012.06.005] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Indexed: 12/11/2022]
Abstract
PURPOSE To identify the predictors for the development of severe gastroduodenal toxicity (GDT) in patients treated with stereotactic body radiotherapy (SBRT) using 3 fractionations for abdominopelvic malignancies. METHODS AND MATERIALS From 2001 to 2011, 202 patients with abdominopelvic malignancies were treated with curative-intent SBRT. Among these patients, we retrospectively reviewed the clinical records of 40 patients with the eligibility criteria as follows: 3 fractionations, follow-up period≥1 year, absence of previous radiation therapy (RT) history or combination of external-beam RT and the presence of gastroduodenum (GD) that received a dose higher than 20% of prescribed dose. The median SBRT dose was 45 Gy (range, 33-60 Gy) with 3 fractions. We analyzed the clinical and dosimetric parameters, including multiple dose-volume histogram endpoints: V20 (volume of GD that received 20 Gy), V25, V30, V35, and Dmax (the maximum point dose). The grade of GDT was defined by the National Cancer Institute Common Toxicity Criteria version 4.0, and GDT≥grade 3 was defined as severe GDT. RESULTS The median time to the development of severe GDT was 6 months (range, 3-12 months). Severe GDT was found in 6 patients (15%). Dmax was the best dosimetric predictor for severe GDT. Dmax of 35 Gy and 38 Gy were respectively associated with a 5% and 10% probability of the development of severe GDT. A history of ulcer before SBRT was the best clinical predictor on univariate analysis (P=.0001). CONCLUSIONS We suggest that Dmax is a valuable predictor of severe GDT after SBRT using 3 fractionations for abdominopelvic malignancies. A history of ulcer before SBRT should be carefully considered as a clinical predictor, especially in patients who receive a high dose to GD.
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Affiliation(s)
- Sun Hyun Bae
- Department of Radiation Oncology, Korea Institute of Radiological & Medical Sciences, Seoul, Korea
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Moezi L, Heidari R, Amirghofran Z, Nekooeian AA, Monabati A, Dehpour AR. Enhanced anti-ulcer effect of pioglitazone on gastric ulcers in cirrhotic rats: The role of nitric oxide and IL-1β. Pharmacol Rep 2013; 65:134-43. [DOI: 10.1016/s1734-1140(13)70971-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Revised: 10/15/2012] [Indexed: 02/09/2023]
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Non-variceal gastrointestinal bleeding in patients with liver cirrhosis: a review. Dig Dis Sci 2012; 57:2743-54. [PMID: 22661272 DOI: 10.1007/s10620-012-2229-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Accepted: 05/01/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND Non-variceal gastrointestinal (NVGI) bleeding in cirrhosis may be associated with life-threatening complications similar to variceal bleeding. AIM To review NVGI bleeding in cirrhosis. METHODS MEDLINE, Scopus, and ISI Web of Knowledge were searched, using the textwords "portal hypertensive gastropathy," "gastric vascular ectasia," "peptic ulcer," "Dieulafoy's," "Mallory-Weiss syndrome," "portal hypertensive enteropathy," "portal hypertensive colopathy," "hemorrhoids," and "cirrhosis." RESULTS Portal hypertensive gastropathy (PHG) and gastric vascular ectasia (GVE) are gastric lesions that most commonly present as chronic anemia; acute upper GI (UGI) bleeding is a rare manifestation. Management of PHG-related bleeding is mainly pharmacological, whereas endoscopic intervention is favored in GVE-related bleeding. Shunt therapies or more invasive techniques are restricted in refractory cases. Despite its high incidence in cirrhotic patients, peptic ulcer accounts for a relatively small proportion of UGI bleeding in this patient population. However, in contrary to general population, the pathogenetic role of Helicobacter pylori infection remains questionable. Finally, other causes of UGI bleeding include Dieulafoy's lesion, Mallory-Weiss syndrome, and portal hypertensive enteropathy. The most common non-variceal endoscopic findings reported in patients with lower gastrointestinal bleeding are portal hypertensive colopathy and hemorrhoids. However, the vast majority of studies are case reports and, therefore, the incidence, diagnosis, and risk of bleeding remain undefined. Endoscopic interventions, shunting procedures, and surgical techniques have been described in this setting. CONCLUSIONS The data on NVGI bleeding in liver cirrhosis are surprisingly scanty. Large, multicenter epidemiological studies are needed to better assess prevalence and incidence and, most importantly, randomized studies should be performed to evaluate the success rates of therapeutic algorithms.
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Musumba C. Letter: peptic ulcer bleeding in patients with cirrhosis. Aliment Pharmacol Ther 2012; 36:597-8; author reply 598. [PMID: 22913844 DOI: 10.1111/j.1365-2036.2012.05184.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Hsu YC, Lin JT, Chen TT, Wu MS, Wu CY. Long-term risk of recurrent peptic ulcer bleeding in patients with liver cirrhosis: a 10-year nationwide cohort study. Hepatology 2012; 56:698-705. [PMID: 22378148 DOI: 10.1002/hep.25684] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Accepted: 02/15/2012] [Indexed: 02/06/2023]
Abstract
UNLABELLED Peptic ulcer bleeding leads to substantial morbidity and mortality in patients with liver cirrhosis, but their long-term risk of recurrent bleeding remains elusive. This nationwide cohort study aimed to elucidate the association between cirrhosis and recurrent peptic ulcer bleeding by analyzing the Taiwan National Health Insurance Research Database. We enrolled a total of 9,711 patients who had cirrhosis with clinical complications of portal hypertension from all patients (n = 271,030) hospitalized for peptic ulcer bleeding between January 1997 and December 2006, along with 38,844 controls who were matched at a 1:4 proportion for age, sex, and antisecretory agents. We accounted for death as the competing cause of risk when calculating the cumulative incidences and hazard ratios of recurrent bleeding during the 10-year study period. Overall, patients with cirrhosis had a significantly higher death-adjusted rebleeding rate compared with controls (1 year, 14.4% versus 11.3%; 5 years, 26.1% versus 22.5%; 10 years, 28.4% versus 27.1%; P < 0.001). The modified Cox proportional hazard model verified that cirrhosis was significantly associated with peptic ulcer rebleeding (adjusted hazard ratio, 3.19; 95% confidence interval, 2.62-3.88), but also uncovered a seemingly paradoxical interaction between cirrhosis and age. Multivariate stratified analysis further revealed that the rebleeding risk after adjustment for death diminished with age in patients with cirrhosis, whose risk of death far exceeded that of rebleeding when they grew old. CONCLUSION Liver cirrhosis is associated with long-term risk of recurrent peptic ulcer bleeding, although the risk declines with age because of death being the competing cause. Effective therapy should be sought to reduce this excessive risk in these critically ill patients, particularly for those at younger age with longer life expectancy.
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Affiliation(s)
- Yao-Chun Hsu
- Department of Internal Medicine, E-Da Hospital/I-Shou University, Kaohsiung, Taiwan
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Kang JK, Kim MS, Cho CK, Yang KM, Yoo HJ, Kim JH, Bae SH, Jung DH, Kim KB, Lee DH, Han CJ, Kim J, Park SC, Kim YH. Stereotactic body radiation therapy for inoperable hepatocellular carcinoma as a local salvage treatment after incomplete transarterial chemoembolization. Cancer 2012; 118:5424-31. [DOI: 10.1002/cncr.27533] [Citation(s) in RCA: 243] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Revised: 01/26/2012] [Accepted: 02/14/2012] [Indexed: 12/12/2022]
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Chon YE, Seong J, Kim BK, Cha J, Kim SU, Park JY, Ahn SH, Han KH, Chon CY, Shin SK, Kim DY. Gastroduodenal complications after concurrent chemoradiation therapy in patients with hepatocellular carcinoma: endoscopic findings and risk factors. Int J Radiat Oncol Biol Phys 2011; 81:1343-1351. [PMID: 20934268 DOI: 10.1016/j.ijrobp.2010.07.1986] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Revised: 06/17/2010] [Accepted: 07/16/2010] [Indexed: 01/03/2023]
Abstract
PURPOSE Concurrent chemoradiation therapy (CCRT) is useful in advanced hepatocellular carcinoma (HCC), but little is known about radiation-induced gastroduodenal complications following therapy. To determine risk factors, we investigated the prevalence and patterns of gastroduodenal complications following CCRT using endoscopy. METHODS AND MATERIALS Enrolled in the study were 123 patients treated with CCRT for unresectable HCC between January 1998 and December 2005. Radiation-induced gastroduodenal complications were defined as radiation gastritis/duodenitis, radiation gastric/duodenal ulcer, or other gastroduodenal toxicity associated with radiation, based on Common Terminology Criteria for Adverse Events (CTCAE 3.0). Serious gastroduodenal complications were defined as events occurring within 12 months from completion of CCRT, those requiring prompt therapeutic intervention, or symptoms equivalent to Grade 3 or 4 radiation-related gastroduodenal toxicity, including nausea or vomiting, based on CTCAE 3.0. RESULTS A month after completion of CCRT, 65 (52.8%) patients displayed endoscopic evidence of radiation-induced gastroduodenal complications. Radiation gastric and duodenal ulcers were found in 32 (26.0%) and 20 (16.3%) patients, respectively; radiation gastritis and duodenitis were found in 50 (40.7%) and 42 (34.1%) patients, respectively. Radiation-related bleeding was observed in 13 patients (10.6%). Serious gastroduodenal complications occurred in 18 patients (14.6%) and were significantly more frequent in patients with liver cirrhosis than in those without cirrhosis (p=0.043). There were no radiation-related deaths. CONCLUSIONS Endoscopically detectable radiation-induced gastroduodenal complications were common in HCC following CCRT. Although serious complications were uncommon, the frequency was higher in patients with liver cirrhosis; thus, these patients should be closely monitored when receiving CCRT.
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Affiliation(s)
- Young Eun Chon
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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Chen YH, Lin HC, Lou HY. Increased risk of low birthweight, infants small for gestational age, and preterm delivery for women with peptic ulcer. Am J Obstet Gynecol 2010; 202:164.e1-8. [PMID: 20113692 DOI: 10.1016/j.ajog.2009.09.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2009] [Revised: 06/21/2009] [Accepted: 09/24/2009] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The objective of the study was to determine whether maternal peptic ulcer disease (PUD) is associated with increased risk of adverse pregnancy outcomes, using a nationwide population-based dataset. STUDY DESIGN We identified a total of 2120 women who gave birth from 2001 to 2003 with a diagnosis of PUD during pregnancy. Then 10,600 unaffected pregnant women were matched with cases in age and year of delivery. Multivariate logistic regression analyses were performed for estimation. RESULTS We found that PUD was independently associated with a 1.18-fold risk of low birthweight (95% confidence interval [CI], 1.01-1.30), a 1.20-fold risk of preterm delivery (95% CI, 1.02-1.41), and a 1.25-fold (95% CI, 1.11-1.41) higher risk of babies small for gestational age, compared with unaffected mothers, after adjusting for potential confounders. In further examining women with treated PUD, improved effects of PUD medication on the risks of adverse neonate outcomes were not identified. CONCLUSION We document increased risk of adverse birth outcomes for women with PUD during pregnancy.
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Affiliation(s)
- Yi-Hua Chen
- School of Public Health, Taipei Medical University Hospital, Taipei, Taiwan
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Kim H, Lim DH, Paik SW, Yoo BC, Koh KG, Lee JH, Choi MS, Park W, Park HC, Huh SJ, Choi DH, Ahn YC. Predictive factors of gastroduodenal toxicity in cirrhotic patients after three-dimensional conformal radiotherapy for hepatocellular carcinoma. Radiother Oncol 2009; 93:302-6. [PMID: 19524314 DOI: 10.1016/j.radonc.2009.05.017] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2009] [Revised: 05/20/2009] [Accepted: 05/20/2009] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND PURPOSE To identify predictive factors for the development of gastroduodenal toxicity (GDT) in cirrhotic patients treated with three-dimensional conformal radiotherapy (3D-CRT) for hepatocellular carcinoma (HCC). MATERIALS AND METHODS We retrospectively analyzed dose-volume histograms (DVHs) and clinical records of 73 cirrhotic patients treated with 3D-CRT for HCC. The median radiation dose was 36 Gy (range, 30-54 Gy) with a daily dose of 3 Gy. The grade of GDT was defined by the Common Toxicity Criteria Version 2. The predictive factors of grade 3 GDT were identified. RESULTS Grade 3 GDT was found in 9 patients. Patient's age and the percentage of gastroduodenal volume receiving more than 35 Gy (V(35)) significantly affected the development of grade 3 GDT. Patients over 50 years of age developed grade 3 GDT more frequently than patients under 50 years of age. The risk of grade 3 GDT grew exponentially as V(35) increased. The 1-year actuarial rate of grade 3 GDT in patients with V(35)<5% is significantly lower than that in patients with a V(35)> or =5% (4% vs. 48%, p<.01). CONCLUSIONS Patient's age and V(35) were the most predictive factors for the development of grade 3 GDT in patients treated with RT.
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Affiliation(s)
- Haeyoung Kim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Perini RF, Camara PRS, Ferraz JGP. Pathogenesis of portal hypertensive gastropathy: translating basic research into clinical practice. Nat Rev Gastroenterol Hepatol 2009; 6:150-8. [PMID: 19190600 DOI: 10.1038/ncpgasthep1356] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2008] [Accepted: 12/19/2008] [Indexed: 12/19/2022]
Abstract
Portal hypertensive gastropathy (PHG) is often seen in patients with portal hypertension, and can lead to transfusion-dependent anemia as well as acute, life-threatening bleeding episodes. This Review focuses on the mechanisms that underlie the pathogenesis of PHG that provide reasonable grounds for the treatment of this condition, and ultimately enable translation of basic research into clinical practice. Increased portal pressure associated with cirrhosis and liver dysfunction is critical for the development of clinically significant PHG, and leads to impaired gastric mucosal defense mechanisms that render the stomach susceptible to mucosal injury. The use of pharmacological agents such as beta-blockers reduces the frequency of bleeding episodes in PHG. As a last resort, surgical decompression of the portal system, transjugular intrahepatic stent placement and liver transplantation can resolve this condition. Elimination of known risk factors for gastric injury such as alcohol, aspirin and traditional NSAIDs is critical. The role of Helicobacter pylori colonization of the gastric mucosa in PHG is not clear. Careful and critical interpretation of human and experimental data can be helpful to establish a rationale for the medical management of this important condition.
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Tzathas C, Triantafyllou K, Mallas E, Triantafyllou G, Ladas SD. Effect of Helicobacter pylori eradication and antisecretory maintenance therapy on peptic ulcer recurrence in cirrhotic patients: a prospective, cohort 2-year follow-up study. J Clin Gastroenterol 2008; 42:744-749. [PMID: 18277886 DOI: 10.1097/mcg.0b013e3180381571] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The role of Helicobacter pylori eradication to cure peptic ulcer disease in patients with cirrhosis is not clear. AIM To investigate the course of peptic ulcer disease in cirrhotics, first after healing with either H. pylori eradication or omeprazole therapy and second while on omeprazole maintenance therapy after recurrence. METHODS Prospective cohort study in a tertiary-care hospital in Greece. Out of 365 consecutive cirrhotic patients who underwent endoscopy, 67 had peptic ulcer and 30 were enrolled. H. pylori positive patients received eradication therapy and H. pylori negative patients received omeprazole treatment. Follow-up endoscopies were performed at 12 and 24 months or when symptoms recurred. Patients with ulcer recurrence were treated with omeprazole maintenance therapy. The main outcome measurement of the study was peptic ulcer relapse rate during follow-up. RESULTS Twenty-eight patients with healed ulcers were followed for up to 2 years. During follow-up, ulcer relapsed in 17 patients (8/18 H. pylori positive and 9/10 H. pylori negative at study entry, P=0.041), including 2 patients who died from ulcer bleeding. No further ulcer relapse was observed in the remaining 15 patients who received omeprazole maintenance therapy for the rest of follow-up. H. pylori negative status (P=0.002) and severity of cirrhosis (P=0.015) at study entry were independently related to shorter peptic ulcer relapse-free time. CONCLUSIONS H. pylori eradication does not protect all cirrhotics from ulcer recurrence and the majority of ulcers recur in H. pylori negative patients. Therefore, omeprazole maintenance treatment is mandatory, irrespectively of H. pylori status.
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Kim DJ, Kim HY, Kim SJ, Hahn TH, Jang MK, Baik GH, Kim JB, Park SH, Lee MS, Park CK. Helicobacter pylori infection and peptic ulcer disease in patients with liver cirrhosis. Korean J Intern Med 2008; 23:16-21. [PMID: 18363275 PMCID: PMC2686959 DOI: 10.3904/kjim.2008.23.1.16] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2007] [Accepted: 02/11/2008] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND/AIMS We investigated the prevalence and relationship of peptic ulcer disease and Helicobacter pylori infection to liver cirrhosis. METHODS We examined 288 patients with liver cirrhosis, 322 patients with non-ulcer dyspepsia, and 339 patients with peptic ulcer disease. Rapid urease test and Wright-Giemsa staining were used for diagnosis of H. pylori infection. RESULTS The prevalence of peptic ulcer disease in patients with cirrhosis was 24.3%. The prevalence of peptic ulcer disease in patients with cirrhosis divided into Child-Pugh classes A, B, and C was 22.3%, 21.0%, and 31.3%, respectively (p > 0.05). The prevalence of H. pylori infection in the patients with cirrhosis, non-ulcer dyspepsia, and peptic ulcer without chronic liver disease were 35.1%, 62.4%, and 73.7%, respectively (p < 0.001). The prevalence of H. pylori infection did not differ depending on whether there was peptic ulcer (35.6%) or not (34.9%) in patients with liver cirrhosis (p > 0.05). The prevalence of H. pylori infection in patients with hepatitis virus-related liver cirrhosis and in the patients with alcohol-related liver cirrhosis was 42.5% and 22.0%, respectively (p < 0.001). The prevalence of H. pylori infection in patients with Child-Pugh classes A, B, and C liver cirrhosis was 51.5%, 30.5%, and 20.0%, respectively (p < 0.001). CONCLUSIONS Factors other than H. pylori may be involved in the pathogenesis of peptic ulcer disease in the setting of liver cirrhosis.
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Affiliation(s)
- Dong Joon Kim
- Department of Internal Medicine, Chuncheon Sacred Heart Hospital, College of Medicine, Hallym University, Chuncheon, Korea.
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Seth AK, Badminton MN, Mirza D, Russell S, Elias E. Liver transplantation for porphyria: who, when, and how? Liver Transpl 2007; 13:1219-27. [PMID: 17763398 DOI: 10.1002/lt.21261] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Porphyrias are a heterogenous group of diseases that may result in disabling or life threatening neurovisceral symptoms and/or cutaneous photosensitivity. In acute intermittent porphyria, the clinical features, particularly neurological symptoms, may be life-threatening and disabling. Conventional treatment with human hemin, though effective in reducing symptoms, does not reverse neuropathy when structural nerve damage has occurred and may cause intense phlebitis. Liver transplantation (LT) may be considered as treatment for those with repeated life-threatening acute attacks resulting in poor quality of life, requirement of ventilatory support, and progressive loss of venous access due to hemin infusion. Patients with variegate porphyria (VP) present after puberty with neurovisceral symptoms and skin manifestations. LT resolved VP in the 1 patient reported in the literature. Aminolaevulinic acid dehydratase deficient porphyria is a rare autosomal recessive disorder and a child who presented with failure to thrive and required transfusions and parenteral nutrition did not improve with LT. In erythropoietic protoporphyria (EPP), there is excessive production of protoporphyrin in the bone marrow. Protoporphyrin is hepatotoxic and pigment loading of hepatocytes and bile canalicular sludging may result in progressive cholestasis and cirrhosis. LT is beneficial for such patients with end-stage liver disease. Perioperative management includes use of filters on operative lights to prevent skin burns and intestinal perforation. Other concerns include development of neuropathy, biliary complications, and recurrent liver disease. This review addresses the rationale, patient selection, evaluation, management issues, and technique of performing LT in various types of porphyria.
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Affiliation(s)
- Avnish Kumar Seth
- Liver and Hepatobiliary Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
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Seckin Y, Harputluoglu MMM, Batcioglu K, Karincaoglu M, Yildirim B, Oner RI, Uyumlu B, Aydogdu N, Hilmioglu F. Gastric tissue oxidative changes in portal hypertension and cirrhosis. Dig Dis Sci 2007; 52:1154-8. [PMID: 17345161 DOI: 10.1007/s10620-006-9139-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2005] [Accepted: 11/10/2005] [Indexed: 12/09/2022]
Abstract
Gastric mucosal lesions are very common in portal hypertension and cirrhosis. The aim of this study was to assess for oxidative gastric tissue damage in cirrhosis and evaluate relations with portal hypertension and cirrhosis parameters. The study included 30 patients with cirrhosis and 30 controls. Each patient's history, physical examination, and laboratory findings were recorded, and multiple biopsies of the gastric antrum were obtained at endoscopy. A set of antral biopsies was also collected from each control subject. Each tissue specimen was analyzed for levels of glutathione peroxidase (GPX), superoxide dismutase (SOD), and catalase (CAT) activity and level of malondialdehyde (MDA). Patients' gastric GPX, SOD, and CAT levels were significantly lower, and MDA levels were higher, than in the control group. The GPX activity level in the specimens was moderately negatively correlated with portal vein diameter (P<0.05, r=-0.45) and spleen length (P<0.05, r=-0.45). In this study gastric tissue oxidative markers showed that antral oxidative factors worsen in cirrhosis. Oxidative stress may not be a clinical condition but it obviously shows gastric tissue damage and may explain many patients' gastric lesions and hemorrhage.
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Affiliation(s)
- Yuksel Seckin
- Department of Gastroenterology and Biochemistry, Inonu University, Turgut Ozal Tip Merkezi, 44000, Malatya, Turkey
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Superina RA, Alonso EM. Medical and surgical management of portal hypertension in children. ACTA ACUST UNITED AC 2006; 9:432-43. [PMID: 16942669 DOI: 10.1007/bf02738533] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
The treatment of portal hypertension in children has undergone considerable evolution in the past decade. The treatment offered depends on the cause of the hypertension and the underlying health of the liver. The diagnosis of portal hypertension often can be made by the history and physical examination. Upper gastrointestinal bleeding in the presence of splenic enlargement is pathognomonic for portal hypertension. Bleeding and hypersplenism are the principal symptoms. Treatment of bleeding starts with confirming the diagnosis with esophageal and gastric endoscopy. The patient is admitted to an intensive care unit and started on intravenous octreotide. Banding or sclerosis of esophageal varices will result in cessation of the bleeding but not a permanent cure. A careful investigation for the cause of the portal hypertension should be done. This includes imaging studies of intra-abdominal arteries and veins, a liver biopsy, and liver function tests, including coagulation studies. For patients with extrahepatic portal vein thrombosis, early consideration should be given to surgical treatment with a meso-Rex bypass. Patients with liver disease should be treated for the underlying disorder and undergo regular endoscopic monitoring for recurrence of varices. Patients with well-compensated cirrhosis should be considered for selective surgical shunting, and those with advanced disease for liver transplantation. The benefit of long-term beta blockers in children has not been proven by clinical trials.
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Affiliation(s)
- Riccardo A Superina
- Division of Transplant Surgery, Children’s Memorial Hospital, 2300 Children’s Plaza, Box 57, Chicago, IL 60614, USA.
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Castro-Fernández M, Sánchez-Muñoz D, Galán-Jurado MV, Larraona JL, Suárez E, Lamas E, Rodríguez-Hornillo MC, Pabón M. [Influence of nonsteroidal antiinflammatory drugs in gastrointestinal bleeding due to gastroduodenal ulcers or erosions in patients with liver cirrhosis]. GASTROENTEROLOGIA Y HEPATOLOGIA 2006; 29:11-4. [PMID: 16393624 DOI: 10.1157/13083251] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Peptic ulcer disease, with or without complications, is more common in patients with liver cirrhosis than in the general population. Factors associated with portal hypertension are involved in its pathogenesis. The prevalence of Helicobacter pylori infection in patients with liver cirrhosis and the general population is similar. The aim of the present study was to determine the influence of nonsteroidal antiinflammatory drugs (NSAIDs) in the etiology of bleeding peptic ulcer disease in patients with liver cirrhosis. PATIENTS AND METHODS We studied 35 patients with liver cirrhosis and gastrointestinal bleeding due to gastroduodenal ulcers or erosions (group A), 125 noncirrhotic patients with gastrointestinal bleeding due to gastroduodenal ulcers or erosions (group B), and 70 patients with liver cirrhosis who were admitted to hospital without gastrointestinal bleeding (group C). All patients were questioned about NSAID consumption, including aspirin, during the week prior to hospital admission. RESULTS NSAID consumption was reported by 15 patients (42.8%) in group A, 102 patients (58.2%) in group B, and 6 patients (8.5%) in group C. Statistically significant differences were obtained when the results for group A were compared with those for group C. CONCLUSIONS NSAID consumption in patients with liver cirrhosis without gastrointestinal bleeding was low (8.5%) and was much lower than that observed in patients with cirrhosis admitted to hospital for bleeding due to gastroduodenal ulcers or erosions (42.8%). As occurs in the general population, NSAIDs play a significant role in the pathogenesis of bleeding due to peptic ulcer disease in patients with liver cirrhosis and portal hypertension.
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Affiliation(s)
- M Castro-Fernández
- Sección de Aparato Digestivo, Hospital Universitario de Valme, Sevilla, Spain
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Trepanier LA. Potential interactions between non-steroidal anti-inflammatory drugs and other drugs. J Vet Emerg Crit Care (San Antonio) 2005. [DOI: 10.1111/j.1476-4431.2005.00167.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Saad RJ, Chey WD. Peptic ulcer disease in patients with chronic liver disease: looking beyond bugs and drugs. Gastrointest Endosc 2005; 62:357-9. [PMID: 16111951 DOI: 10.1016/j.gie.2005.06.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2005] [Accepted: 06/06/2005] [Indexed: 02/06/2023]
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Eroglu Y, Emerick KM, Whitingon PF, Alonso EM. Octreotide therapy for control of acute gastrointestinal bleeding in children. J Pediatr Gastroenterol Nutr 2004; 38:41-7. [PMID: 14676593 DOI: 10.1097/00005176-200401000-00011] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To evaluate the outcomes of octreotide use in children with gastrointestinal bleeding with or without portal hypertension. METHODS The medical charts of children who received continuous octreotide infusion for the indication of gastrointestinal bleeding from January 1995 to December 2000 were retrospectively reviewed. RESULTS Twenty-one children with portal hypertension received octreotide infusions (1-2 microg/kg/h) during 35 gastrointestinal bleeding episodes. The duration of infusion ranged from 19 hours to 7 days. Bleeding ceased in 71% of children. Post-treatment rebleeding occurred in 52%, and the mortality was 19%. Response to octreotide, rebleeding, and mortality did not differ significantly between patients with or without intrinsic liver disease. Twelve children with gastrointestinal bleeding unrelated to portal hypertension received octreotide during 14 episodes. The duration of octreotide ranged from 3 hours to 36 days. Fifty percent of children had resolution of bleeding during the infusion. Post-treatment rebleeding occurred in 29%, and the mortality was 50%. No major adverse events were observed in either group. CONCLUSIONS A high rate of bleeding control was achieved with octreotide during acute gastrointestinal bleeding in children with portal hypertension. However, controlled studies are needed for more definitive description of its clinical effects. The role of octreotide is less clear in gastrointestinal bleeding unrelated to portal hypertension.
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Affiliation(s)
- Y Eroglu
- Department of Gastroenterology, Hepatology and Nutrition, Children's Memorial Hospital, Northwestern University Medical School, Chicago, IL 60614, USA
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Birney Y, Redmond EM, Sitzmann JV, Cahill PA. Eicosanoids in cirrhosis and portal hypertension. Prostaglandins Other Lipid Mediat 2003; 72:3-18. [PMID: 14626493 DOI: 10.1016/s1098-8823(03)00080-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In the last decade, the knowledge of the pathogenesis of portal hypertension and cirrhosis has increased dramatically. In portal hypertension, almost all the known vasoactive systems/substances are activated or increased and the most recent studies have stressed the importance of the endothelial factors, in particular, prostaglandins. Prostaglandins are formed following the oxygenation of arachidonic acid by the cyclooxygenase (Cox) pathway. An important consideration in portal hypertension and cirrhosis in the periphery is the altered hemodynamic profile and its contributory role in controlling endothelial release of these vasoactive substances. Prostaglandins are released from the endothelium in response to both humoral and mechanical stimuli and can profoundly affect both intrahepatic and peripheral vascular resistance. Within the liver, intrahepatic resistance is altered due to a diminution in sinusoidal responsiveness to vasodilators and an increase in prostanoid vasoconstrictor responsiveness. This review will examine the contributory role of both hormonal and/or hemodynamic force-induced changes in prostaglandin production and signaling in cirrhosis and portal hypertension and the consequence of these changes on the structural and functional response of both the vasculature and the liver.
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Affiliation(s)
- Yvonne Birney
- School of Biotechnology, Dublin City University, Glasnevin, Dublin 9, Ireland
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44
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Abstract
Portal hypertension (PHT) is a common clinical syndrome associated with chronic liver diseases; it is characterized by a pathological increase in portal pressure. Pharmacotherapy for PHT is aimed at reducing both intrahepatic vascular tone and elevated splanchnic blood flow. Due to the altered hemodynamic profile in PHT, dramatic changes in mechanical forces, both pressure and flow, may play a pivotal role in controlling endothelial and vascular smooth muscle cell signaling, structure, and function in cirrhotics. Nitric oxide, prostacyclin, endothelial-derived contracting factors, and endothelial-derived hyperpolarizing factor are powerful vasoactive substances released from the endothelium in response to both humoral and mechanical stimuli that can profoundly affect both the function and structure of the underlying vascular smooth muscle. This review will examine the contributory role of hormonal- and mechanical force-induced changes in endothelial function and signaling and the consequence of these changes on the structural and functional response of the underlying vascular smooth muscle. It will focus on the pivotal role of hormonal and mechanical force-induced endothelial release of vasoactive substances in dictating the reactivity of the underlying vascular smooth muscle, i.e., whether hyporeactive or hyperreactive, and will examine the extent to which these substances may exert a protective and/or detrimental influence on the structure of the underlying vascular smooth muscle in both a normal hemodynamic environment and following hemodynamic perturbations typical of PHT and cirrhosis. Finally, it will discuss the intracellular processes that regulate the release/expression of these vasoactive substances and that control the transformation of this normally protective cell to one that may promote the development of vasculopathy in PHT.
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Affiliation(s)
- P A Cahill
- School of Biotechnology, Dublin City University, Glasnevin Dublin 9, Ireland.
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