RESUMO
INTRODUCTION AND OBJECTIVES: Psychosocial stressors related to the coronavirus-19 (COVID-19) pandemic increased alcohol consumption. The effect on patients with alcohol-related liver diseases remains unclear. MATERIALS AND METHODS: Hospitalizations at a tertiary care center due to alcohol-related liver disease from March 1 through August 31 in 2019 (pre-pandemic cohort) and 2020 (pandemic cohort) were reviewed retrospectively. Differences in patient demographics, disease features, and outcomes were estimated in patients with alcoholic hepatitis utilizing T-tests, Mann-Whitney tests, Chi-square and Fisher Exact Tests and Anova models and logistic regression models in patients with alcoholic cirrhosis. RESULTS: 146 patients with alcoholic hepatitis and 305 patients with alcoholic cirrhosis were admitted during the pandemic compared to 75 and 396 in the pre-pandemic cohort. Despite similar median Maddrey Scores (41.20 vs. 37.45, p=0.57), patients were 25% less likely to receive steroids during the pandemic. Patients with alcoholic hepatitis admitted during the pandemic were more likely to have hepatic encephalopathy (0.13; 95% CI:0.01, 0.25), variceal hemorrhage (0.14; 95% CI:0.04, 0.25), require oxygen (0.11; 95% CI:0.01, 0.21), vasopressors (OR:3.49; 95% CI:1.27, 12.01) and hemodialysis (OR:3.70; 95% CI:1.22, 15.13). On average, patients with alcoholic cirrhosis had MELD-Na scores 3.77 points higher (95% CI:1.05, 13.46) as compared to the pre-pandemic and had higher odds of experiencing hepatic encephalopathy (OR:1.34; 95% CI:1.04, 1.73), spontaneous bacterial peritonitis (OR:1.88; 95% CI:1.03, 3.43), ascites (OR:1.40, 95% CI:1.10, 1.79), vasopressors (OR:1.68, 95% CI:1.14, 2.46) or inpatient mortality (OR:2.00, 95% CI:1.33, 2.99) than the pre-pandemic. CONCLUSIONS: Patients with alcohol-related liver disease experienced worse outcomes during the pandemic.
Assuntos
COVID-19 , Varizes Esofágicas e Gástricas , Encefalopatia Hepática , Hepatite Alcoólica , Humanos , Cirrose Hepática Alcoólica/epidemiologia , Cirrose Hepática Alcoólica/terapia , Encefalopatia Hepática/epidemiologia , Pandemias , Hepatite Alcoólica/diagnóstico , Hepatite Alcoólica/epidemiologia , Estudos Retrospectivos , Hemorragia Gastrointestinal , Prognóstico , COVID-19/epidemiologia , Cirrose Hepática/diagnóstico , Cirrose Hepática/epidemiologiaRESUMO
INTRODUCTION AND AIM: Excessive alcohol consumption is a public health concern worldwide and has been associated with high mortality rates. This study aimed to determine the prevalence of alcohol consumption and its influence on the prognosis of hospitalized cirrhotic patients in a tertiary care hospital. MATERIAL AND METHODS: We reviewed the medical records of all patients with hepatic cirrosis admitted between January 2009 and December 2014, in a referral center for liver disease in southern Brazil. Data on clinical outcomes, associated conditions, infections, and mortality were collected and compared between alcoholic and nonalcoholic patients. RESULTS: The sample consisted of 388 patients; 259 (66.7%) were men. One hundred fifty-two (39.2%) were classified as heavy use of alcohol. Most alcoholic patients were men (n = 144; 94.7%). Mean age was 55.6 ± 8.9 years. Hepatic decompensations and infections were more prevalent in alcoholic patient. Spontaneous bacterial peritonitis and respiratory tract infection accounted for most of the infections. Excessive alcohol consumption was associated with mortality (P = 0.009) in multivariate analysis. CONCLUSION: On the present study, the prevalence of heavy use of alcohol was high and associated with a poorer prognosis in hospitalized cirrhotic patients, increasing the risk of infection and death.
Assuntos
Consumo de Bebidas Alcoólicas/efeitos adversos , Consumo de Bebidas Alcoólicas/epidemiologia , Cirrose Hepática Alcoólica/epidemiologia , Encaminhamento e Consulta , Centros de Atenção Terciária , Idoso , Consumo de Bebidas Alcoólicas/mortalidade , Brasil/epidemiologia , Estudos Transversais , Feminino , Mortalidade Hospitalar , Humanos , Cirrose Hepática Alcoólica/diagnóstico , Cirrose Hepática Alcoólica/mortalidade , Cirrose Hepática Alcoólica/terapia , Masculino , Prontuários Médicos , Pessoa de Meia-Idade , Admissão do Paciente , Prevalência , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Fatores de TempoRESUMO
The burden of alcoholic liver disease continues to be a major public health problem worldwide. The spectrum of disease ranges from fatty liver to cirrhosis and hepatocellular carcinoma. Alcoholic hepatitis (AH) is a type of acute-on-chronic liver failure and the most severe form of alcoholic liver disease. Severe AH carries a poor short-term prognosis and its management is still challenging, with scarce advances in the last decades. Corticosteroids are still the first line of therapy in severe cases. Unfortunately, many patients do not respond and novel targeted therapies are urgently needed. Liver transplantation has shown extraordinary results in non-responders to corticosteroids however; its applicability is very low. This review summarizes the epidemiology, natural history, risk factors and pathogenesis of alcoholic liver disease with special focus on the latest advances in prognostic stratification and therapy of patients with alcoholic hepatitis.
Assuntos
Insuficiência Hepática Crônica Agudizada/fisiopatologia , Fígado Gorduroso Alcoólico/fisiopatologia , Hepatite Alcoólica/fisiopatologia , Insuficiência Hepática Crônica Agudizada/epidemiologia , Insuficiência Hepática Crônica Agudizada/terapia , Corticosteroides/uso terapêutico , Fígado Gorduroso Alcoólico/epidemiologia , Fígado Gorduroso Alcoólico/terapia , Hepatite Alcoólica/epidemiologia , Hepatite Alcoólica/terapia , Humanos , Cirrose Hepática Alcoólica/epidemiologia , Cirrose Hepática Alcoólica/fisiopatologia , Cirrose Hepática Alcoólica/terapia , Transplante de Fígado , Prognóstico , Fatores de RiscoRESUMO
Excessive alcohol consumption is an important cause of preventable morbidity and mortality. We have to bealert to chronic alcohol usage or abuse. Simple tests (AUDIT, CAGE) can be applied quickly on outpatientcare. We highlight advances in understanding the immune and molecular mechanisms; there is disruptionof the intestinal barrier with bacterial translocation, as well as endotoxins which activate the livers innateimmunity, causing apoptosis, necrosis, inflammation and fibrosis. Alcoholic hepatitis is most common inpatients between 40 and 60 years of age, preferably male with jaundice, fever, ascites, hepatomegaly. Thediagnosis is confirmed with a history of alcoholic consumption, mild to moderate AST and ALT values,a AST/ALT ratio > 2, hyperbilirrubinemia and prolonged prothrombin time. There are scores to evaluatethe severity and the need of corticoid therapy, such as modified Maddrey discriminating function andMELD score. Lille score assesses the response to treatment in the seventh day. The risks and benefits ofliver biopsy should be evaluated individually. The cornerstone of treatment remains alcohol abstinence.Nutritional management must be carefully monitored. Proteins requirements are standardized based onweight. The use of corticoids with 40 mg of prednisolone each day is the most widely accepted therapy,indicated on patients with MMDF higher than 32 or MELD score higher than 21. If Lille score is higherthan 0.45 at the seven day under corticoid therapy, treatment must be interrupted. The use of pentoxifyllinewould only be effective for prevention of hepatorenal syndrome...
El consumo excesivo de alcohol es una causa importante de morbimortalidad prevenible. Debemos estaratentos en detectar a pacientes con dependencia o abuso crónico de alcohol. Test sencillos (AUDIT, CAGE)pueden aplicarse rápidamente en consulta ambulatoria. Destacamos avances en el conocimiento moleculare inmunológico, existe disrupción de la barrera intestinal con translocación bacteriana y endotoxinas conactivación del sistema inmune innato del hígado, produciendo apoptosis celular, necrosis e inflamación yfibrosis. La hepatitis alcohólica se presenta principalmente en pacientes entre 40 y 60 años, preferentementeen varones con ictericia, fiebre, ascitis, hepatomegalia. El diagnóstico se confirma con antecedentes deingesta alcohólica, GOT y GPT elevadas en forma leve o moderada, relación GOT/GPT mayor de 2, hiperbilirrubinemiay tiempo de protrombina prolongado. Existen scores para evaluar la gravedad y necesidad demanejo con corticoides como función discriminante de Maddrey modificada y MELD. El puntaje de Lilleevalúa respuesta del tratamiento al séptimo día. El riesgo/beneficio de la biopsia hepática se evalúa caso acaso. La piedra angular del tratamiento sigue siendo la abstinencia. Manejo nutricional debe ser riguroso.Requerimientos proteicos están estandarizados por peso. La terapia con corticoides (prednisolona 40 mg/día) es la más ampliamente aceptada, con indicación en pacientes con FDMm mayor a 32 o MELD mayora 21. Si el puntaje de Lille es mayor de 0,45 a los 7 días con corticoides, deben suspenderse. Pentoxifilinasólo tendría efecto en prevenir el desarrollo de síndrome hepatorrenal (SHR). Hay nuevas terapias enevaluación, como el uso de G-CSF...
Assuntos
Humanos , Alcoolismo/complicações , Bebidas Alcoólicas/efeitos adversos , Hepatopatias Alcoólicas/diagnóstico , Hepatopatias Alcoólicas/terapia , Cirrose Hepática Alcoólica/diagnóstico , Cirrose Hepática Alcoólica/terapia , Hepatite Alcoólica/diagnóstico , Hepatite Alcoólica/terapia , Hepatopatias Alcoólicas/epidemiologia , Fatores de Risco , Fatores SexuaisRESUMO
A positive crossmatch has been associated with increased risk in liver transplantation. To study the clinical significance of preformed donor-specific human leukocyte antigen antibodies (DSAs) in liver transplantation, we reviewed patients who underwent liver transplantation with a strongly positive flow cytometry crossmatch. DSAs were evaluated with a Luminex solid phase assay. The complement-fixing ability of DSAs was tested with a complement component 1q (C1q) assay. Using an assay correlation between complement-dependent cytotoxicity crossmatch, flow cytometry crossmatch, and DSA results, we reviewed the effects of DSAs on the outcomes of our patients as well as reported cases in the literature. Five of 69 liver recipients had a strongly positive crossmatch: 4 had a positive T cell crossmatch [median channel shift (MCS) = 383.5 ± 38.9], and 5 had a positive B cell crossmatch (MCS = 408.8 ± 52.3). The DSAs were class I only in 1 patient, class I and II in 3 patients, and class II only in 1 patient. Cholestasis, acute rejection, or both were observed in 3 of the 4 patients with a positive T cell crossmatch with an MCS approximately greater than 300. The C1q assay was positive for 3 patients. Two had either persistent cholestasis or early acute rejection. One patient who was treated with preemptive intravenous immunoglobulin had an unremarkable outcome despite a positive C1q result. One of the 2 patients with a negative C1q assay experienced persistent cholestasis and early and recurrent acute rejection; the other had an unremarkable outcome. None of the patients died or lost a graft within the first year of transplantation. Our study suggests that human leukocyte antigen antibody screening, flow cytometry crossmatch MCS levels, DSA mean fluorescent intensity levels, and C1q assays may be useful in assessing the risk of antibody-mediated rejection and timely interventions in liver transplantation.
Assuntos
Antígenos HLA/imunologia , Falência Hepática/imunologia , Falência Hepática/terapia , Transplante de Fígado/métodos , Adulto , Anticorpos/imunologia , Colestase/imunologia , Complemento C1q/imunologia , Fígado Gorduroso/terapia , Feminino , Fibrose/terapia , Citometria de Fluxo , Rejeição de Enxerto , Teste de Histocompatibilidade , Humanos , Cirrose Hepática Alcoólica/terapia , Cirrose Hepática Biliar/terapia , Lúpus Eritematoso Sistêmico/complicações , Masculino , Pessoa de Meia-Idade , Hepatopatia Gordurosa não Alcoólica , Risco , Índice de Gravidade de Doença , Síndrome de Sjogren/complicações , Resultado do TratamentoRESUMO
Malnutrition in the cirrhotic patient is associated to a higher morbidity and mortality rate; however, the diagnosis is complex, so the study objective was to assess the nutritional status using different methods. Adult patients with alcoholic liver cirrhosis treated in the Liver Clinic of the Mexico's General Hospital were evaluated. Anthropometric measurements and a 24 hours recall were made; screening tools (Malnutrition Universal Screening Tool, Nutritional Risk Screening-2002) and a method for assessing nutritional status specifically in cirrhotic patients (Royal Free Hospital Global Assessment) were used. We included 62 patients, 51.6% of them were men. Malnutrition by arm muscle area was 31.3% in men and 10% in women, and by arm fat area was 23.3% in women and 3.1% in men (p < 0.05). With the screening tools the percentages of malnutrition risk were 43.5% and 54.8% respectively, vs. 1.6% identified as "low weight" with the Body Mass Index. With the Royal Free Hospital Global Assessment tool the percentage of malnutrition was 45.2%. Patients with malnutrition had an energy and protein intake significantly lower than the well-nourished: 19.7 kcal/kg and 0.89 g/kg vs 30 kcal/kg and 1.25 g/kg (p < 0.005). Malnutrition is a common complication in patients with liver cirrhosis. Men have higher depletion of muscle mass and women a higher loss of body fat. The Body Mass Index is not a reliable tool for assessing malnutrition. It's advisable to use tools with indicators of body composition such as the Royal Free Hospital Global Assessment.
Assuntos
Cirrose Hepática Alcoólica/diagnóstico , Avaliação Nutricional , Idoso , Antropometria , Índice de Massa Corporal , Peso Corporal , Feminino , Hospitais Gerais , Humanos , Cirrose Hepática Alcoólica/terapia , Masculino , Desnutrição/diagnóstico , Desnutrição/etiologia , México , Pessoa de Meia-IdadeRESUMO
PURPOSE: The aim of this study was to analyse the changes in transfusion requirements, in patients submitted to orthotopic liver transplantation from cadaveric donors, with the use of intraoperative red blood cell salvage (Cell Saver). METHODS: Data from 41 transplants were analysed. Intraoperative blood loss was calculated from the cell salvage, suction and the swabs. The autologous and heterologous transfusions were recorded The red blood salvage was performed using the Cell Saver 5 System (Haemonetics). For analysis the patients were divided in two groups: one that used the Cell Saver and another that didn't. RESULTS: The median age of the patients was 50 years and the main indication for liver transplantation was cirrhosis (35 cases-85.3%). The median blood loss was 8362+3994 ml (with the Cell Saver) and 10824+7002 ml (without the Cell Saver) and the median transfusion of heterologous packed red blood cells was 9.6+8 units (with the Cell Saver) compared to 22.3+21 units (without the Cell Saver). CONCLUSIONS: The Cells Saver has the potential to reduce the need for heterologous blood transfusion reducing the risks of transmissible diseases.
Assuntos
Perda Sanguínea Cirúrgica/prevenção & controle , Transfusão de Sangue/estatística & dados numéricos , Cuidados Intraoperatórios , Transplante de Fígado/métodos , Adulto , Idoso , Transfusão de Sangue/métodos , Feminino , Hepatite/terapia , Humanos , Cirrose Hepática Alcoólica/terapia , Masculino , Pessoa de Meia-Idade , Padrões de Prática Médica , Índice de Gravidade de Doença , Reação Transfusional , Resultado do TratamentoRESUMO
PURPOSE: The aim of this study was to analyse the changes in transfusion requirements, in patients submitted to orthotopic liver transpantation from cadaveric donors, with the use of intraoperative red blood cell salvage (Cell Saver). METHODS: Data from 41 transplants were analysed. Intraoperative blood loss was calculated from the cell salvage, suction and the swabs. The autologous and heterologous transfusions were recorded The red blood salvage was performed using the Cell Saver 5 System (Haemonetics).. For analysis the patients were divided in two groups: one that used the Cell Saver and another that didn't. RESULTS: The median age of the patients was 50 years and the main indication for liver transplantation was cirrhosis (35 cases - 85.3 percent). The median blood loss was 8362 + 3994 ml (with the Cell Saver) and 10824 + 7002 ml (without the Cell Saver) and the median transfusion of heterologous packed red blood cells was 9,6 + 8 units (with the Cell Saver) compared to 22,3 + 21 units (without the Cell Saver). CONCLUSIONS: The Cells Saver has the potential to reduce the need for heterologous blood transfusion reducing the risks of transmissible diseases.
OBJETIVO: O objetivo desse estudo foi analisar as mundanças na quantidade de transfusão necessária com uso do Intraoperative red blood cell salvage (Cell saver), em pacientes submetidos a transplante ortotópico de fígado, doador cadáver. MÉTODOS: Foram avaliados dados de 41 pacientes submetidos a transplante de fígado. O sangramento foi calculado de acordo com débito do aspirador, compressas e captação do Cell saver. A reposição necessária foi avaliada de acordo com a quantidade de transfusão heteróloga e autóloga. Para análise dos dados os pacientes foram dividos em dois grupos: com e sem uso de Cell saver. RESULTADOS: A mediana de idade foi 50 anos e principal indicação de transplante foi cirrose hepática com 35 casos (85,3 por cento). A mediana de sangramento durante o procedimento cirúrgico 8362 + 3994 ml (com cell saver) e 10824 + 7002 ml (sem cell saver) e a mediana de transfusão de concentrado de hemácias heterólogo, durante o período de internação hospitalar 9,6 + 8 unidades (com cell saver) compar 22,3 + 21 unidades (sem cell saver). CONCLUSÃO: Uso de Cell Saver tem um potential para reduzir a quantidade de transfusão heteróloga, dimuindo o risco de transmissão de doenças.
Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Perda Sanguínea Cirúrgica/prevenção & controle , Transfusão de Sangue/métodos , Cuidados Intraoperatórios , Transplante de Fígado/métodos , Transfusão de Sangue/efeitos adversos , Hepatite/terapia , Cirrose Hepática Alcoólica/terapia , Padrões de Prática Médica , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
Although the interaction between alcohol and the liver has been the subject of intensive investigation since many years, several uncertainties remain to be solved. Good examples of what we need to learn are: The real number of patients with alcohol-induced liver disease (AILD), the dose of alcohol "safe" for the liver, the genetic predisposition to the damage or, on the other side of the coin, protecting from the damage. Rather recently, however, part of these questions started to be clarified, thus permitting a better definition of the role of each of these factors in AILD. In parallel to the clinical approach to AILD, the unveiling of the molecular and biochemical mechanisms involved in AILD has progressed and proved to be important in both a better understanding of the disease and, more important, in a more rational treatment of these disorders. This review will focus on what we currently know of AILD in clinical, biochemical and molecular terms and what we need to address in the future.
Assuntos
Hepatopatias Alcoólicas/fisiopatologia , Animais , Feminino , Humanos , Cirrose Hepática Alcoólica/genética , Cirrose Hepática Alcoólica/fisiopatologia , Cirrose Hepática Alcoólica/terapia , Hepatopatias Alcoólicas/genética , Hepatopatias Alcoólicas/terapia , Modelos Animais , Ratos , Fatores de RiscoRESUMO
BACKGROUND: Ascites can occur after hepatic diseases causing dyspnea, coughing and pain. When associated with pleural effusion it can also increase respiratory distress. In a bibliographic survey hydrothorax has been observed in up to 20% of the patients and the kind of treatment is still being discussed. OBJECTIVE: This case report shows the occurrence of a large volume of ascites and pleural effusion in a cirrhotic patient and his treatment. METHODS: Report the case of a patient with hepatic cirrhosis due to chronic alcoholism and massive pleural effusion and ascites. He was submitted to several pleural paracenteses without success. Scintigraphy showed the presence of ascites and confirmed a possible pleuroperitoneal communication. The thoracic surgery group was called and after evaluation it was decided to submit the patient to a pulmonary decortication and chemical pleurodesis. RESULTS: These procedures were carried out with success. The pleural effusion was solved and the treatment of ascites was decided upon because the patient did not accept any surgical procedure. CONCLUSION: This treatment could be applied to patients with hydrothorax who could not be submitted to a liver transplantation.
Assuntos
Antibacterianos/administração & dosagem , Hidrotórax/terapia , Cirrose Hepática Alcoólica/complicações , Pleurodese/métodos , Tetraciclina/administração & dosagem , Adulto , Ascite/etiologia , Ascite/terapia , Humanos , Hidrotórax/etiologia , Cirrose Hepática Alcoólica/terapia , Masculino , ParacenteseRESUMO
Some recent proposals in management of alcoholic liver disease are discussed focusing on early diagnosis and treatment of alcohol abuse itself, alcoholic hepatitis early mortality, clinical meaning of nutritional therapy, serological approach and treatment of hepatic fibrosis, and problems in liver transplantation for end stage alcoholic liver cirrhosis. CAGE or similar systematized brief questionnaires, and desialylated transferrin/total transferrin ratio as serological marker, seems to be interesting contributions to "hidden" alcohol abuse diagnosis and abstinence control while psycho-social support and voluntary incorporation to self-aid groups are the best weapons to reach persistent abstinence. Corticosteroids seems to improve survival in a selected group of patients with severe alcoholic hepatitis, specially in those presenting encephalopathy but free of GI bleeding, decompensated diabetes, active infections, pancreatitis, and other contraindications or adverse effects of these drugs. Relationship between direct toxicity and nutritional deficiencies in pathogenesis of alcoholic liver injury are not clear enough, but malnutrition is generally present in patients requiring hospitalization, and related to clinical severity; oral, enteral or parenteral nutritional supplementation in this order of preference according to patients condition, associated or not with steroid anabolics, are useful in cases with moderate to severe alcoholic hepatitis or decompensated cirrhosis to eliminate the catabolic state, reaching a better nitrogen balance and liver function tests, without special adverse effects. A special role on liver regeneration is discussed. Antioxidants and supernutrients are special "modern" aspects of nutritional therapy in alcoholic liver disease generally related to the MEOS activation in chronic alcoholism, the excessive production of free radicals, and the depletion of glutathione, membrane phospholipids (specially phosphatidycholine), and vitamin A, E, and C. Natural supplements as soybean polyunsaturated lecithin, with high concentration of phosphatidycholine, or oral supplementation with natural metabolic products depleted from the liver of chronic heavy drinkers, such SAMe, have an interesting rationale based on experimental and clinical findings besides availability and costs. Carotenoids and tocopherols supplementation seems to be an useful tool, but are limited in the case of vitamin A because its special toxicity in chronic alcoholism. Serological markers of metabolism of liver connective tissue are clearly involved in fibrogenesis process and other inflammatory connected events; standardization of laboratory methods surely will result in new possibilities of non-invasive valuation of liver injury, evolution and therapeutic response; special histological damage such as sinusoidal "cappilarization" (type i.v. collagen and laminin), endothelial sinusoidal cell function (seric hyaluronate), or collagenase activity (TIMP-1 or tissue inhibitor of metalloproteinases-1) seems to be valuable by these new technologies.(ABSTRACT TRUNCATED AT 400 WORDS)
Assuntos
Hepatopatias Alcoólicas/terapia , Corticosteroides/uso terapêutico , Anabolizantes/uso terapêutico , Antioxidantes/uso terapêutico , Hepatite Alcoólica/terapia , Humanos , Fígado/metabolismo , Cirrose Hepática Alcoólica/diagnóstico , Cirrose Hepática Alcoólica/terapia , Hepatopatias Alcoólicas/diagnóstico , Transplante de Fígado , Distúrbios Nutricionais/terapia , Apoio Nutricional , Estresse OxidativoRESUMO
Some recent proposals in management of alcoholic liver disease are discussed focusing on early diagnosis and treatment of alcohol abuse itself, alcoholic hepatitis early mortality, clinical meaning of nutrional therapy, serological approach and treatment of hepatic fibrosis, and problems in liver transplantation for end stage alcoholic liver cirrhosis. CAGE or similar systematized brief questionnaires, and desialylated transferrin/total transferrin ratio as serological marker, seeems to be interesting contributions to "hidden" alcohol abuse diagnosis and abstinence control while psyco-social support and voluntary incorporation to self-aid groups are the best weapons to reach persistent abstinence. Corticosteroids seems to improve survival in a selected group of patients with severe alcoholic hepatitis, specially in those presenting encefalopathy but free of Gl bleeding, decompensated diabetes, active infections, pancreatitis, and other contraindications or adverse effects of these drugs. Relationship between direct toxicity and nutritional deficiencies in pathogenesis of alcoholic liver injury are not clear enough, but malnutrition is generally present in patients requiring hospitalization, and related to clinical severity; oral, enteral or parenteral nutritional suplementation in this order of preference according to patients condition, associated or not with steroid anabolics, are useful in cases with moderate to severe alcoholic hepatitis or decompensated cirrhosis to eliminate the catabolic state, reaching a better nitrogen balance and liver function tests, without special adverse effects. A special role on liver regeneration is discussed...
Assuntos
Humanos , Hepatopatias Alcoólicas/terapia , Corticosteroides/uso terapêutico , Anabolizantes/uso terapêutico , Antioxidantes/uso terapêutico , Cirrose Hepática Alcoólica/diagnóstico , Cirrose Hepática Alcoólica/terapia , Fígado/metabolismo , Hepatite Alcoólica/terapia , Hepatopatias Alcoólicas/diagnóstico , Distúrbios Nutricionais/terapia , Apoio Nutricional , Estresse OxidativoRESUMO
Some recent proposals in management of alcoholic liver disease are discussed focusing on early diagnosis and treatment of alcohol abuse itself, alcoholic hepatitis early mortality, clinical meaning of nutrional therapy, serological approach and treatment of hepatic fibrosis, and problems in liver transplantation for end stage alcoholic liver cirrhosis. CAGE or similar systematized brief questionnaires, and desialylated transferrin/total transferrin ratio as serological marker, seeems to be interesting contributions to "hidden" alcohol abuse diagnosis and abstinence control while psyco-social support and voluntary incorporation to self-aid groups are the best weapons to reach persistent abstinence. Corticosteroids seems to improve survival in a selected group of patients with severe alcoholic hepatitis, specially in those presenting encefalopathy but free of Gl bleeding, decompensated diabetes, active infections, pancreatitis, and other contraindications or adverse effects of these drugs. Relationship between direct toxicity and nutritional deficiencies in pathogenesis of alcoholic liver injury are not clear enough, but malnutrition is generally present in patients requiring hospitalization, and related to clinical severity; oral, enteral or parenteral nutritional suplementation in this order of preference according to patients condition, associated or not with steroid anabolics, are useful in cases with moderate to severe alcoholic hepatitis or decompensated cirrhosis to eliminate the catabolic state, reaching a better nitrogen balance and liver function tests, without special adverse effects. A special role on liver regeneration is discussed... (AU)
Assuntos
Humanos , Hepatopatias Alcoólicas/terapia , Hepatopatias Alcoólicas/diagnóstico , Hepatite Alcoólica/terapia , Cirrose Hepática Alcoólica/diagnóstico , Cirrose Hepática Alcoólica/terapia , Fígado/metabolismo , Corticosteroides/uso terapêutico , Anabolizantes/uso terapêutico , Antioxidantes/uso terapêutico , Distúrbios Nutricionais/terapia , Apoio Nutricional , Estresse OxidativoRESUMO
El estudio presenta revisiones sobre las múltiples posibilidades terapéuticas médicas que se han utilizado y actualmente se utilizan en el control y tratamiento de las várices esofágicas por hipertensión portal. De igual manera explica la forma o procedimientos que deben seguirse para abordar un paciente con várices esofágicas sangrantes
Assuntos
Cirrose Hepática Alcoólica/terapia , Hipertensão Portal , Hepatopatias , Varizes Esofágicas e Gástricas/terapia , Vasoconstritores , Vasopressinas/efeitos adversos , Vasopressinas/uso terapêuticoRESUMO
Forty-one patients with cirrhosis and tense ascites were randomized to receive daily paracentesis of 5 liters associated with Dextran 70 as volume expander (6 g for each 1000 ml of ascites removed) (group I = 20 patients) or paracentesis with albumin (6 g for each 1000 ml of ascites) (group II = 21 patients). The basal clinical features, laboratory data, and plasma renin activity were similar in both groups. The volume of ascites removed was 12.9 +/- 4.4 and 10.9 +/- 3.7 liters in group I and II, respectively (n.s.). No significant changes were observed in liver and renal function tests, KPTT, platelet count, factor VIII, serum electrolytes or plasma renin activity 24 and 96 h after the last paracentesis in both groups, except for a decrease in bilirubin in group I and a transient increase of serum albumin in group II. Four patients developed complications in each group, mainly hyponatremia, while one patient in each group developed renal impairment. One patient from group I died with hepatic encephalopathy. Moreover, the probability of survival and readmission to the hospital because of tense ascites were similar in both groups of patients during the follow-up. The treatment cost with Dextran 70 was 15.50 dollars vs. 364.30 dollars with albumin for each patient treated. These results indicate that repeated large volume paracentesis associated with Dextran 70 is as effective and safe as paracentesis associated with albumin in cirrhotic patients with tense ascites. However, due to its reduced cost, paracentesis with Dextran 70 may be considered the treatment of choice in cirrhotic patients with tense ascites without liver cancer and renal failure.