Porto-pulmonary hypertension in decompensated cirrhosis and refractory ascites

The elimination of the aetiological factors causing liver injury is an important cornerstone in preventing progression and increasing survival in patients with cirrhosis. The authors present the case of a 63-year-old woman with a history of long-term alcohol abuse and consequent liver cirrhosis. Over the years, the patient presented progressive deterioration with severe malnutrition and had multiple hospital admissions due to decompensated cirrhosis, including refractory ascites, variceal bleeding and an extensive portal vein thrombosis (PVT). Anticoagulant therapy was not initiated due to a high risk of variceal bleeding. She eventually became abstinent, but PVT precluded a liver transplant. Over the following 10 years, her performance status gradually improved, with no new decompensation episodes and liver function normalization, although refractory ascites persisted. Abdominal CT showed spontaneous recanalization of the portal vein and a transjugular intrahepatic portosystemic shunt (TIPS) procedure was performed with gradual improvement of ascites. In this atypical case, an unexpected favourable evolution of advanced stage cirrhosis was observed with long-term improvement in clinical status and liver function, resulting in an estimated 10-year cumulative mortality rate of 99.98% and highlighting the importance of abstinence. Unexpectedly, spontaneous complete repermeabilization of the PVT was also observed, despite its extent and the absence of anticoagulation therapy.

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Successful Treatment with Crushed Sofosbuvir/Velpatasvir of a Patient with Decompensated Cirrhosis C and Thrombocytopenia

Case Reports in Gastroenterology ◽

10.1159/000518306 ◽

2021 ◽

pp. 729-735

Author(s):

Aiko Murayama ◽

Kazuto Tajiri ◽

Chiharu Kanegane ◽

Jun Murakami ◽

Yuka Hayashi ◽

...

Keyword(s):

Marked Decrease ◽

Antiviral Treatment ◽

Intractable Epilepsy ◽

Hcv Infection ◽

Refractory Ascites ◽

Decompensated Cirrhosis ◽

Decompensated Liver Cirrhosis ◽

Type C ◽

Gastric Feeding ◽

To Receive

A 36-year-old woman with decompensated liver cirrhosis type C was referred to our hospital to receive antiviral treatment for hepatitis C virus (HCV). She had been diagnosed with intractable epilepsy and cerebral palsy at birth and was managed by central venous nutrition and nasal gastric feeding. At age 34 years, she was diagnosed with thrombocytopenia, probably associated with HCV infection. She showed refractory ascites for several months and was therefore administered crushed sofosbuvir/velpatasvir tablets via a nasal gastric tube. Her HCV infection was successfully eradicated, her ascites disappeared, and thrombocytopenia improved with a marked decrease in platelet-associated IgG.

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Local Thrombolysis in Acute and Extended Portal Vein and TIPS Thrombosis in a Patient with Decompensated Cirrhosis and Protein S Deficiency

Journal of Gastrointestinal and Liver Diseases ◽

10.15403/jgld-1584 ◽

2020 ◽

Author(s):

Magdalena Rusu ◽

Maria Imbuzan ◽

Raluca Hategan ◽

Oana Nicoara-Farcau ◽

Horia Stefanescu ◽

...

Keyword(s):

Portal Vein ◽

Plasminogen Activator ◽

Tissue Plasminogen Activator ◽

Protein S ◽

Refractory Ascites ◽

Decompensated Cirrhosis ◽

Published Data ◽

Vein Thrombosis ◽

Local Thrombolysis ◽

Tissue Plasminogen

This report describes the use of local thrombolysis using a tissue plasminogen activator in a case of a patient with refractory ascites referred for transjugular intrahepatic portosystemic shunt (TIPS) insertion. After successful TIPS insertion, the patient developed acute extended portal vein and TIPS thrombosis, which were treated with local thrombolysis using a tissue plasminogen activator, followed by the complete resolution of ascites. Although there are only limited published data of local thrombolysis for acute splanchnic vein thrombosis, we also review the relevance of the problem in the context of advanced liver disease.

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Impact of Bacterial Translocation on Sarcopenia in Patients with Decompensated Cirrhosis

Nutrients ◽

10.3390/nu11102379 ◽

2019 ◽

Vol 11 (10) ◽

pp. 2379 ◽

Cited By ~ 1

Author(s):

Tsien ◽

Antonova ◽

Such ◽

Garcia-Martinez ◽

Wong

Keyword(s):

Chronic Inflammation ◽

Bacterial Translocation ◽

Hospital Admissions ◽

Nutritional Assessment ◽

Care Center ◽

Tertiary Care ◽

Caloric Intake ◽

Refractory Ascites ◽

Decompensated Cirrhosis ◽

Bacterial Dna

Advanced liver disease is associated with a persistent inflammatory state, derived from abnormal bacterial translocation from the gut, which may contribute to the development of sarcopenia in cirrhosis. We aim to document the association of chronic inflammation and bacterial translocation with the presence of sarcopenia in cirrhosis. We prospectively followed cirrhotic patients aged 18–70 years with medically refractory ascites at a single tertiary care center in Toronto, Canada. The baseline data included patient demographic variables, the presence of bacterial DNA in serum/ascitic fluid, systemic inflammatory response syndrome (SIRS) status, and nutritional assessment. Thirty-one patients were enrolled, 18 (58.1%) were sarcopenic, 9 (29%) had bacterial DNA in serum and ascites fluid. The mean MELD score was 11.5 ± 4.0 (6–23). Sarcopenic and non-sarcopenic patients did not differ significantly in their baseline MELD scores, caloric intake, resting energy expenditure, the incidence of bacterial translocation, or SIRS. While sarcopenia was not linked to increased hospital admissions or death, it was strongly associated with increased episodes of acute kidney injury (3 vs. 0, p = 0.05). This pilot study did not demonstrate an association between sarcopenia and SIRS or bacterial translocation. These results should be confirmed in future larger studies, encompassing a greater number of chronic inflammation events and quantifying levels of bacterial DNA.

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Portopulmonary hypertension in decompensated cirrhosis with refractory ascites

Gut ◽

10.1136/gut.52.9.1355 ◽

2003 ◽

Vol 52 (9) ◽

pp. 1355-1362 ◽

Cited By ~ 114

Author(s):

F S Benjaminov

Keyword(s):

Refractory Ascites ◽

Decompensated Cirrhosis ◽

Portopulmonary Hypertension

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Clinical implications of prompt ascitic drain removal among cirrhosis with refractory ascites

Singapore Medical Journal ◽

10.11622/smedj.2021049 ◽

2021 ◽

Author(s):

YJ Wong ◽

HM Lum ◽

PT Tan ◽

EK Teo ◽

JY Tan ◽

...

Keyword(s):

Ascitic Fluid ◽

Alcoholic Cirrhosis ◽

Meld Score ◽

Refractory Ascites ◽

Decompensated Cirrhosis ◽

Resistant Organism ◽

Bacterial Peritonitis ◽

Drain Removal ◽

Large Volume Paracentesis ◽

End Stage

Introduction: Large-volume paracentesis (LVP) is the first-line treatment for decompensated cirrhosis with refractory ascites. While ascitic drain removal (ADR) within 72 hours was once considered safe, it was uncertain if ADR within 24 hours could further reduce the risk of ascitic drain-related bacterial peritonitis (AdBP). This study aimed to investigate the association between the timing of ADR and the presence of AdBP. Methods: All cirrhotics with refractory ascites who underwent LVP in our institution from 2014 to 2017 were studied. AdBP was diagnosed based on ascitic fluid neutrophil count ≥ 250 cells/mm3 or positive ascitic fluid culture following recent paracentesis within two weeks. Results: A total of 131 patients who underwent LVP were followed up for 1,806 patient-months. Their mean age was 68.3 ± 11.6 years, and 65.6% were male. Their mean Model for End-Stage Liver Disease (MELD) score was 15.2. The overall incidence of AdBP was 5.3%. ADR beyond 24 hours was significantly associated with longer median length of stay (five days vs. three days, p < 0.001), higher risk of AdBP (0% vs. 8.9%, p = 0.042) and AKI following LVP (odds ratio 20.0, 95% confidence interval 2.4–164.2, p = 0.021). Overall survival was similar in patients with ADR within and beyond 24 hours. Conclusion: ADR within 24 hours is associated with reduced risk of AdBP and AKI. As AdBP is associated with resistant organism and AKI, we recommend prompt ADR within 24 hours, especially among patients who have Child-Pugh C with alcoholic cirrhosis.

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Frailty in Nonalcoholic Fatty Liver Cirrhosis: A Comparison with Alcoholic Cirrhosis, Risk Patterns, and Impact on Prognosis

Canadian Journal of Gastroenterology and Hepatology ◽

10.1155/2021/5576531 ◽

2021 ◽

Vol 2021 ◽

pp. 1-10

Author(s):

Lubomir Skladany ◽

Pavol Molcan ◽

Jana Vnencakova ◽

Petra Vrbova ◽

Michal Kukla ◽

...

Keyword(s):

Fatty Liver ◽

Cox Model ◽

Frailty Index ◽

Alcoholic Cirrhosis ◽

Meld Score ◽

Adverse Outcomes ◽

Refractory Ascites ◽

Decompensated Cirrhosis ◽

Nonalcoholic Fatty Liver ◽

All Cause Mortality

Background. Physical frailty increases susceptibility to stressors and predicts adverse outcomes of cirrhosis. Data on disease course in different etiologies are scarce, so we aimed to compare the prevalence and risk factors of frailty and its impact on prognosis in nonalcoholic fatty liver (NAFLD) and alcoholic (ALD) cirrhosis. Patients and Methods. Cirrhosis registry RH7 operates since 2014 and includes hospitalized patients with decompensated cirrhosis, pre-LT evaluation, or curable hepatocellular carcinoma (HCC). From the RH7, we identified 280 ALD and 105 NAFLD patients with at least 6 months of follow-up. Results. Patients with NAFLD compared with ALD were older and had a higher proportion of females, higher body mass index (BMI) and mid-arm circumference (MAC), lower MELD score, CRP, and lower proportion of refractory ascites. The liver frailty index did not differ, and the prevalence of HCC was higher (17.1 vs. 6.8%, p = 0.002 ). Age, sex, serum albumin, and C-reactive protein (CRP) were independent predictors of frailty. In NAFLD, frailty was also associated with BMI and MAC and in ALD, with the MELD score. The Cox model adjusted for age, sex, MELD, CRP, HCC, and LFI showed that NAFLD patients had higher all-cause mortality (HR = 1.88 95% CI 1.32–2.67, p < 0.001 ) and were more sensitive to the increase in LFI (HR = 1.51, 95% CI 1.05–2.2). Conclusion. Patients with NAFLD cirrhosis had a comparable prevalence of frailty compared to ALD. Although prognostic indices showed less advanced disease, NAFLD patients were more sensitive to frailty, which reflected their higher overall disease burden and led to higher all-cause mortality.

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Optimal management of cirrhotic ascites: A review for internal medicine physicians

Journal of Translational Internal Medicine ◽

10.2478/jtim-2020-0035 ◽

2020 ◽

Vol 8 (4) ◽

pp. 220-236

Author(s):

Andrea Gallo ◽

Cristina Dedionigi ◽

Chiara Civitelli ◽

Anna Panzeri ◽

Chiara Corradi ◽

...

Keyword(s):

Internal Medicine ◽

Liver Cirrhosis ◽

Salt Intake ◽

Abdominal Cavity ◽

Specific Treatment ◽

Clinical History ◽

Refractory Ascites ◽

Decompensated Cirrhosis ◽

Pharmacological Management ◽

Effective Measure

AbstractClinical history of liver cirrhosis is characterised by two phases: the asymptomatic phase, also termed ‘compensated cirrhosis’, and the phase of complications due to the development of portal hypertension and liver dysfunction, also termed ‘decompensated cirrhosis’, in which patients may develop ascites, the most frequent and clinically relevant complication of liver cirrhosis. Ascites can be classified into uncomplicated and complicated according to the development of refractoriness, spontaneous bacterial peritonitis (SBP) or the association with hepatorenal syndrome (HRS). In this narrative review, we will extensively discuss the optimal pharmacological and non-pharmacological management of cirrhotic ascites with the aim to offer an updated practical guide to Internal Medicine physicians. According to the amount of fluid in the abdominal cavity, uncomplicated ascites is graded from 1 to 3, and the cornerstone of its management consists of restriction of salt intake, diuretics and large-volume paracentesis (LVP); in recent years, long-term administration of human albumin has acquired a new interesting role. Refractory ascites is primarily managed with LVP and transjugular intrahepatic portosystemic shunt (TIPS) placement in selected patients. The occurrence of renal impairment, especially HRS, worsens the prognosis of patients with cirrhotic ascites and deserves a specific treatment. Also, the management of SBP faces the rising and alarming spread of antibiotic resistance. Hepatic hydrothorax may even complicate the course of the disease and its management is a challenge. Last but not least, liver transplantation (LT) is the ultimate and more effective measure to offer to patients with cirrhotic ascites, particularly when complications occur.

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