Endoscopic Vacuum-assisted Closure in a Patient with an Overtube-induced Esophageal Perforation

An esophageal perforation is one of the most fatal clinical events, with a mortality rate of up to 21%. This may arise postoperatively or post-endoscopically. In the past, surgical treatment, such as an esophagectomy, was performed these cases. However, the procedure was challenging and had a high risk of postoperative complications. Recently, advancements in endoscopic techniques have been made, and endoscopic procedures became a common treatment modality for patients with esophageal perforation, even in those with underlying diseases. Among the endoscopic procedures, endoscopic vacuum-assisted closure (E-VAC) has been known to be safe and effective. We present the case of a 64-year-old female with advanced liver cirrhosis and an overtube-induced esophageal perforation during esophageal variceal ligation. She was successfully treated with E-VAC.

Portal hypertension is the main driver of liver stiffness in advanced liver cirrhosis

Liver stiffness (LS) is a novel non-invasive parameter widely used in clinical hepatology. LS correlates with liver fibrosis stage in non-cirrhotic patients. In cirrhotic patients it also shows good correlation with Hepatic Venous Pressure Gradient (HVPG). Our aim was to assess the contribution of liver fibrosis and portal hypertension to LS in patients with advanced liver cirrhosis. Eighty-one liver transplant candidates with liver cirrhosis of various aetiologies underwent direct HVPG and LS measurement by 2D shear-wave elastography (Aixplorer Multiwave, Supersonic Imagine, France). Liver collagen content was assessed in the explanted liver as collagen proportionate area (CPA) and hydroxyproline content (HP). The studied cohort included predominantly patients with Child-Pugh class B and C (63/81, 77.8 %), minority of patients were Child-Pugh A (18/81, 22.2 %). LS showed the best correlation with HVPG (r=0.719, p<0.001), correlation of LS with CPA (r=0.441, p<0.001) and HP/Amino Acids (r=0.414, p< 0.001) was weaker. Both variables expressing liver collagen content showed good correlation with each other (r=0.574, p<0.001). Multiple linear regression identified the strongest association between LS and HVPG (p<0.0001) and weaker association of LS with CPA (p = 0.01883). Stepwise modelling showed minimal increase in r2 after addition of CPA to HVPG (0.5073 vs. 0.5513). The derived formula expressing LS value formation is: LS=2.48 + (1.29 x HVPG) + (0.26 x CPA). We conclude that LS is determined predominantly by HVPG in patients with advanced liver cirrhosis whereas contribution of liver collagen content is relatively low.

Hepatic Hydrothorax in a Patient with Liver Cirrhosis: a Case Report

Hepatic hydrothorax is a transudative pleural effusion which presents in 5-10% patients with liver cirrhosis. Although fairly uncommon, it is associated with higher morbidity and lower survival rate. The mechanism is yet to be understood fully, but the most widely accepted pathogenesis involves the presence of portal hypertension, diaphragmatic defects, and negative intrathoracal pressure, all of which lead to the formation of unidirectional passage of ascitic fluid from peritoneal cavity into pleural space. Due to its origin, the pleural effusion has similar characteristics to ascitic fluid. We herein report the case of a 60-year-old woman with advanced liver cirrhosis and right-sided moderate hepatic hydrothorax. Treatment given to the patient includes diuretics, sodium restriction, and repeated thoracentesis. Subsequent evaluation of the patient revealed improvement both clinically and radiologically.

Lidocaine Toxicity in a Patient with Liver Cirrhosis Underwent Transcatheter Aortic Valve Implantation

Background: Lidocaine has been commonly used in many clinical settings. Nonetheless, systemic toxicity can be life-threatening and careful attention to dosing, especially among patients with liver dysfunction is important to minimize the risk of toxicity. Objective: The diagnosis of lidocaine toxicity is usually clinical, while rare, but may prove fatal. Methods: Here we discuss 60 years-old man with advanced liver cirrhosis, developed lidocaine-induced cardiovascular and neurotoxicity. Results: Our case study demonstrates a successful treatment of cardiovascular and neurotoxicity with intravenous lipid emulsion in the context of systemic lidocaine toxicity in a liver cirrhosis patient who received lidocaine as a local anesthetic. Conclusions: A high index of suspicion should be maintained for severe toxicity even after subcutaneous administration and prompt intralipid administration may prove lifesaving.

Liver stiffness measured by two-dimensional shear-wave elastography predicts hepatic vein pressure gradient at high values in liver transplant candidates with advanced liver cirrhosis

Liver stiffness is a reliable non-invasive predictor of Hepatic Venous Pressure Gradient (HVPG) above 10 mm Hg. However, it failed to predict higher thresholds of HVPG. Our aim was to investigate whether liver stiffness and selected previously published non-invasive blood biomarkers could predict higher HVPG thresholds in liver transplant candidates without ongoing alcohol use. One hundred and nine liver transplant candidates with liver cirrhosis of various aetiologies underwent direct HVPG measurement, liver stiffness measurement by 2D shear-wave elastography (Aixplorer Multiwave, Supersonic Imagine, France) and assessment of blood HVPG biomarkers (osteopontin, VCAM-1, IL-6, TNF-α, IL-1ra/IL-1F3 and ELF score). The correlation between liver stiffness and HVPG was linear up to 30 mm Hg of HVPG (r = 0.765, p < 0.0001). The regression lines had similar slopes for HVPG values below and above 16 mm Hg (p > 0.05) and the correlation in patients with HVPG <16 mm Hg (r = 0.456, p = 0.01) was similar to patients with HVPG ≥ 16 mm Hg (r = 0.499, p < 0.0001). The correlation was similar in the subgroup patients with alcoholic (r = 0.718, p < 0.0001), NASH (r = 0.740, p = 0.008), cryptogenic (r = 0.648, p = 0,0377), cholestatic and autoimmune (r = 0.706, p < 0.0001) and viral cirrhosis (r = 0.756, p < 0.0001). Liver stiffness distinguished patients with HVPG above 16, and 20 mm Hg with AUROCs 0.90243, and 0.86824, sensitivity 0.7656, and 0.7027, and specificity 0.9333, and 0.8750. All studied blood biomarkers correlated better with liver stiffness than with HVPG and their AUROCs did not exceed 0.8 at both HVPG thresholds. Therefore, a composite predictor superior to liver stiffness could not be established. We conclude that liver stiffness is a clinically reliable predictor of higher HVPG thresholds in non-drinking subjects with advanced liver cirrhosis.

Covid-19 and hepato-gastroenterology

The new coronavirus disease (covid-19) pandemic has become a global health and social issue with specific context in gastroenterology and hepatology. The organisational and restrictive measures are similar to those in other instrumental specialties and include the protection of patients and staff in reaction to the current epidemiological situation and presumed infection route. In addition to this specific protection, the effects of covid-19 on other aspects of the field leading to potential limitation of health care and adversely affecting other diseases must be minimised. In endoscopy, this protection is predominantly oral in focus due to the respiratory route of the infection; transmission through excrement and instruments is possible but insignificant. Gastrointestinal and liver manifestations of the infection represent a significant part of the overall symptomatology and may correlate with the severity of the disease. Covid-19 does not deteriorate the course of inflammatory bowel disease (IBD) and likewise, the immunosuppressive and biological treatment of IBD patients does not worsen in the course of the infection. Higher mortality was reported with corticosteroid therapy. The combination of liver disease and covid-19 is under investigation. Viral hepatitis does not represent a significant risk; however, non-alcoholic steatohepatitis and advanced liver cirrhosis are risk factors. The available data on the effects of transplantation are sporadic; its insignificance is further supported by our own experience at IKEM as well as documented data on renal insufficiency and kidney transplant, which show a higher risk. Furthermore, interactions of antiviral and immunosuppressive drugs are being investigated. Atazanavir, lopinavir and to a lesser extent chloroquine and hydrochloroquine are not considered to be suitable. On the other hand, there are no considerable interactions with remdesivir.

Prevalence of Acute Kidney Injury in Patients with Liver Cirrhosis

Introduction: Acute kidney injury is a common and life-threatening event in patients with liver cirrhosis occurring in approximately 20-50% of hospitalized patients of liver cirrhosis. Pre-renal acute kidney injury, the hepatorenal syndrome type of acute kidney injury and acute tubular necrosis represent the common causes. The aim of this study was to study the profile of acute kidney injury in patients with liver cirrhosis. Methods: Consecutive patients of liver cirrhosis admitted in Liver unit of Bir Hospital were studied to see the presence of acute kidney injury in this hospital based descriptive cross-sectional study. Clinical and laboratory parameters along with various clinical outcome were compared between different groups categorized by the severity of liver disease and renal dysfunction. Results: Out of 302 liver cirrhosis patients, 56 (18.5%) had acute kidney injury among which 23 (46%) were found to have pre-renal acute kidney injury, 15 (30%) with hepatorenal syndrome– acute kidney injury and 12 (24%) with intrinsic renal disease. Patients with higher stages of acute kidney injury had longer duration of hospital stay and hepatorenal syndrome-acute kidney injury was seen in patients with higher grade of ascites and with hyponatremia. Conclusions: Acute kidney injury is a common occurrence in patients with advanced liver cirrhosis with pre-renal acute kidney injury being the commonest cause. Median hospital stay is directly affected by the severity of acute kidney injury and hepatorenal syndrome–acute kidney injury was seen in patients with higher grade of ascites and hyponatremia. Early identification of patients at high risk for acute kidney injury may help to reduce mortality and contain costs.

Spastic paraparesis associated with advanced liver cirrhosis: a condition obscure in terms of treatment and prognosis

Hepatic myelopathy or spastic paraparesis of liver disease is an insidious onset condition with pure motor spastic paraparesis without sensory, bladder or bowel involvement in patients with chronic liver disease, in which the neurological dysfunction cannot be explained by other causes. It is a rare, relentlessly progressive and mostly irreversible neurological complication resulting from portosystemic shunts occurring spontaneously, created surgically or due to ‘functional shunting’. In some cases, no evidence of shunting is elicitable due to difficulty in locating the hidden collaterals. We report this rare case of a 33-year-old man with chronic liver disease presenting with spastic paraparesis after 11 months of resolution of an episode of hepatic encephalopathy.