-
Clinics in Liver Disease Aug 2024This review provides an in-depth exploration of portal hypertension (PH) and its implications in various surgical procedures. The prevalence of clinically significant PH... (Review)
Review
This review provides an in-depth exploration of portal hypertension (PH) and its implications in various surgical procedures. The prevalence of clinically significant PH is 50% to 60% in compensated cirrhosis and 100% in decompensated cirrhosis. The feasibility and safety of hepatic and nonhepatic surgical procedures in patients with PH has been shown. Adequate preoperative risk assessment and optimization of PH are integral parts of patient assessment. The occurrence of adverse outcomes after surgery has decreased over time in this specific population, due to the development of techniques and improved perioperative multidisciplinary care.
Topics: Hypertension, Portal; Humans; Liver Cirrhosis; Risk Assessment; Esophageal and Gastric Varices
PubMed: 38945643
DOI: 10.1016/j.cld.2024.04.001 -
Clinics in Liver Disease Aug 2024Portal hypertension has cerebral consequences via its causes and complications, namely hepatic encephalopathy (HE), a common and devastating brain disturbance caused by... (Review)
Review
Portal hypertension has cerebral consequences via its causes and complications, namely hepatic encephalopathy (HE), a common and devastating brain disturbance caused by liver insufficiency and portosystemic shunting. The pathogenesis involves hyperammonemia and systemic inflammation. Symptoms are disturbed personality and reduced attention. HE is minimal or grades I to IV (coma). Bouts of HE are episodic and often recurrent. Initial treatment is of events that precipitated the episode and exclusion of nonhepatic causes. Specific anti-HE treatment is lactulose. By recurrence, rifaximin is add-on. Anti-HE treatment is efficacious also for prophylaxis, but emergence of HE marks advanced liver disease and a dismal prognosis.
Topics: Hepatic Encephalopathy; Humans; Hypertension, Portal; Lactulose; Rifaximin; Gastrointestinal Agents; Hyperammonemia
PubMed: 38945642
DOI: 10.1016/j.cld.2024.03.008 -
Clinics in Liver Disease Aug 2024Patients with cirrhosis and clinically significant portal hypertension are at high risk of developing bacterial infections (BIs) that are the most common trigger of... (Review)
Review
Patients with cirrhosis and clinically significant portal hypertension are at high risk of developing bacterial infections (BIs) that are the most common trigger of acute decompensation and acute-on-chronic liver failure. Furthermore, after decompensation, the risk of developing BIs further increases in an ominous vicious circle. BIs may be subtle, and they should be ruled out in all patients at admission and in case of deterioration. Timely administration of adequate empirical antibiotics is the cornerstone of treatment. Herein, we reviewed current evidences about pathogenesis, clinical implications and management of BIs in patients with cirrhosis and portal hypertension.
Topics: Humans; Hypertension, Portal; Liver Cirrhosis; Bacterial Infections; Anti-Bacterial Agents; Acute-On-Chronic Liver Failure
PubMed: 38945641
DOI: 10.1016/j.cld.2024.03.007 -
Clinics in Liver Disease Aug 2024Acute kidney injury (AKI) is a common complication among patients with decompensated cirrhosis and its development is associated with worse prognosis in terms of... (Review)
Review
Acute kidney injury (AKI) is a common complication among patients with decompensated cirrhosis and its development is associated with worse prognosis in terms of survival. Patients with decompensated cirrhosis may develop a unique type of AKI, known as hepatorenal syndrome (HRS-AKI), characterized by marked impairment of kidney function due to haemodynamic changes that occur in late stages of liver cirrhosis. Besides, patients with cirrhosis also may develop chronic alterations of kidney function (chronic kidney disease, CKD), the incidence of which is increasing markedly and may be associated with clinical complications. The aim of this review is to provide the reader with an update of the most relevant aspects of alterations of kidney function in patients with cirrhossi that may be useful for theri clinical practice.
Topics: Humans; Hypertension, Portal; Hepatorenal Syndrome; Acute Kidney Injury; Liver Cirrhosis; Renal Insufficiency, Chronic
PubMed: 38945640
DOI: 10.1016/j.cld.2024.03.011 -
Clinics in Liver Disease Aug 2024In portal hypertension, acute variceal bleed is the cause of 2/3rd of all upper gastrointestinal bleeding episodes. It is a life-threatening emergency in patients with... (Review)
Review
In portal hypertension, acute variceal bleed is the cause of 2/3rd of all upper gastrointestinal bleeding episodes. It is a life-threatening emergency in patients with cirrhosis. Nonselective beta-blockers by decreasing the hepatic venous pressure gradient are the mainstay of medical therapy for the prevention of variceal bleeding and rebleeding. Evaluation of the severity of bleed, hemodynamic resuscitation, prophylactic antibiotic, and intravenous splanchnic vasoconstrictors should precede the endoscopy procedure. Endoscopic band ligation is the recommended endotherapy. Rescue transjugular intrahepatic port-systemic shunt (TIPS) is recommended for variceal bleed refractory to endotherapy. In patients with a high risk of failure of combined pharmacologic and endoscopic therapy, pre-emptive TIPS may improve the outcome. For gastric varices, "Sarin classification" is universally applied as it is simple and has therapeutic implication. For IGV1 and GOV2, injection cyanoacrylate glue is considered the endotherapy of choice. Endoscopic ultrasound is a useful modality in the management of gastric varices.
Topics: Humans; Hypertension, Portal; Gastrointestinal Hemorrhage; Esophageal and Gastric Varices; Portasystemic Shunt, Transjugular Intrahepatic; Ligation; Adrenergic beta-Antagonists; Liver Cirrhosis
PubMed: 38945639
DOI: 10.1016/j.cld.2024.03.006 -
Clinics in Liver Disease Aug 2024Portopulmonary hypertension (POPH), hepatopulmonary syndrome, and hepatic hydrothorax constitute significant complications of portal hypertension, with important... (Review)
Review
Portopulmonary hypertension (POPH), hepatopulmonary syndrome, and hepatic hydrothorax constitute significant complications of portal hypertension, with important implications for management and liver transplantation (LT) candidacy. POPH is characterized by obstruction and remodeling of the pulmonary resistance arterial bed. Hepatopulmonary syndrome is the most common pulmonary vascular disorder, characterized by intrapulmonary vascular dilatations causing impaired gas exchange. LT may improve prognosis in select patients with POPH. LT is the only effective treatment of hepatopulmonary syndrome. Hepatic hydrothorax is defined as transudative pleural fluid accumulation that is not explained by primary cardiopulmonary or pleural disease. LT is the definitive cure for hepatic hydrothorax.
Topics: Humans; Hypertension, Portal; Hepatopulmonary Syndrome; Hydrothorax; Hypertension, Pulmonary; Liver Transplantation
PubMed: 38945638
DOI: 10.1016/j.cld.2024.03.005 -
Clinics in Liver Disease Aug 2024Porto-sinusoidal vascular disease (PSVD) is the medical diagnosis for a patient who has portal hypertension in the absence of cirrhosis on liver biopsy. There are... (Review)
Review
Porto-sinusoidal vascular disease (PSVD) is the medical diagnosis for a patient who has portal hypertension in the absence of cirrhosis on liver biopsy. There are several specific histologic findings for PSVD, including obliterative portal venopathy, nodular regenerative hyperplasia, and incomplete septal fibrosis. Epidemiologic reports vary widely among regions; PSVD comprises less than 10% of causes of portal hypertension in Western countries but incidence has been found to be as high as 48% in India. There is an expansive list of etiologies that have been reported to cause PSVD.
Topics: Humans; Hypertension, Portal; Hepatic Veno-Occlusive Disease; Portal Vein
PubMed: 38945637
DOI: 10.1016/j.cld.2024.03.004 -
Clinics in Liver Disease Aug 2024Interventions for portal hypertension are continuously evolving and expanding beyond the realm of medical management. When complications such as varices and ascites... (Review)
Review
Interventions for portal hypertension are continuously evolving and expanding beyond the realm of medical management. When complications such as varices and ascites persist despite conservative interventions, procedures including transjugular intrahepatic portosystemic shunt creation, transvenous obliteration, portal vein recanalization, splenic artery embolization, surgical shunt creation, and devascularization are all potential interventions detailed in this article. Selection of the optimal procedure to address the underlying cause, treat symptoms, and, in some cases, bridge to liver transplantation depends on the specific etiology of portal hypertension and the patient's comorbidities.
Topics: Humans; Hypertension, Portal; Portasystemic Shunt, Transjugular Intrahepatic; Embolization, Therapeutic; Portal Vein; Esophageal and Gastric Varices; Splenic Artery; Portasystemic Shunt, Surgical; Liver Transplantation
PubMed: 38945636
DOI: 10.1016/j.cld.2024.03.003 -
Clinics in Liver Disease Aug 2024Portal hypertension is the key mechanism driving the transition from compensated to decompensated cirrhosis. In this review, the authors described the pathophysiology of... (Review)
Review
Portal hypertension is the key mechanism driving the transition from compensated to decompensated cirrhosis. In this review, the authors described the pathophysiology of portal hypertension in cirrhosis and the rationale of pharmacologic treatment of portal hypertension. We discussed both etiologic and nonetiologic treatment of portal hypertension and the specific clinical scenarios how nonselective beta-blocker can be used in patients with cirrhosis. Finally, the authors summarized the evidence for emerging alternatives for portal hypertension in patients with cirrhosis.
Topics: Hypertension, Portal; Humans; Adrenergic beta-Antagonists; Liver Cirrhosis; Antihypertensive Agents; Esophageal and Gastric Varices
PubMed: 38945635
DOI: 10.1016/j.cld.2024.03.002 -
Clinics in Liver Disease Aug 2024The progressive use of noninvasive tests (NITs) has changed the way hepatologists diagnose and manage patients with chronic liver disease, mainly because of their... (Review)
Review
The progressive use of noninvasive tests (NITs) has changed the way hepatologists diagnose and manage patients with chronic liver disease, mainly because of their easiness to use and the ability to be repeated during follow-up. Liver stiffness measurement is the NIT with more scientific evidence. NITs have demonstrated to be useful to detect not only liver fibrosis but also the presence of clinically significant portal hypertension. Moreover, current evidence supports they can also be useful to evaluate the prognosis of patients with chronic liver disease.
Topics: Humans; Hypertension, Portal; Elasticity Imaging Techniques; Liver Cirrhosis; Liver; Prognosis; Esophageal and Gastric Varices
PubMed: 38945634
DOI: 10.1016/j.cld.2024.03.010