Liver cirrhosis and left ventricle diastolic dysfunction: Systematic review

BACKGROUND Liver cirrhosis is a chronic hepatic disease which is associated with cardiovascular abnormalities.Hyperdynamic circulation in liver cirrhosis causes functional and structural cardiac alterations.The prevalence of left ventricle diastolic dysfunction(LVDD)in cirrhotic patients ranges from 25.7%to as high as 81.4%as reported in different studies.In several studies the severity of diastolic dysfunction(DD)correlated with a degree of liver failure and the rate of dysfunction was higher in patients with decompensated cirrhosis compared with compensated.Future directions of comprehensive assessment of cardiac function in cirrhotic patients might provide a better prognosis for these patients.AIM To clarify the correlation between the severity of liver cirrhosis and left ventricle diastolic dysfunction in the existing literature.METHODS Through January and February of 2019 at Vilnius University we conducted a systematic review of the global existing literature on the prevalence of left ventricle diastolic dysfunction in patients with liver cirrhosis.We searched for articles in PubMed,Medline and Web of science databases.Articles were selected by using adequate inclusion and exclusion criteria.Our interest was the outcome of likely correlation between the severity of cirrhosis[evaluated by Child-Pugh classes,Model For End-Stage Liver Disease(MELD)scores]and left ventricle diastolic dysfunction[classified according to American Society of Echocardiography(ASE)guidelines(2009,2016)],as well as relative risk of dysfunction in cirrhotic patients.Subgroup analyses were performed to evaluate the ratio and grades of left ventricle diastolic dysfunction with respect to cirrhosis severity.RESULTS A total of 1149 articles and abstracts met the initial search criteria.Sixteen articles which met the predefined eligibility criteria were included in the final analysis.Overall,1067 patients(out of them 723 men)with liver cirrhosis were evaluated for left ventricle diastolic dysfunction.In our systemic analysis we have found that 51.2%of cirrhotic patients had left ventricle diastolic dysfunction diagnosed and the grade 1 was the most prevalent(59.2%,P<0.001)among them,the grade 3 had been rarely diagnosed-only 5.1%.The data about the prevalence of diastolic dysfunction in cirrhotic patients depending on Child-Pugh Classes was available from 5 studies(365 patients overall)and only in 1 research diastolic dysfunction was found being associated with severity of liver cirrhosis(P<0.005).We established that diastolic dysfunction was diagnosed in 44.6%of Child-Pugh A class patients,in 62%of Child B class and in 63.3%of Child C patients(P=0.028).The proportion of patients with higher diastolic dysfunction grades increases in more severe cirrhosis presentation(P<0.001).There was no difference between mean MELD scores in patients with and without diastolic dysfunction and in different diastolic dysfunction groups.In all studies diastolic dysfunction was more frequent in patients with ascites.CONCLUSION This systemic analysis suggests that left ventricle diastolic dysfunction is an attribute of liver cirrhosis which has not received sufficient attention from clinicians so far.Future suggestions of a comprehensive assessment of cardiac function in cirrhotic patients might provide a better prognosis for these patients and give hint for better understanding of the left ventricle diastolic dysfunction pathogenesis in liver cirrhosis.

Gut microbiota contribution to hepatocellular carcinoma manifestation in non-alcoholic steatohepatitis

Recently,the gut microbiota has been recognized as an obvious active player in addition to liver steatosis/steatohepatitis in the pathophysiological mechanisms of the development of hepatocellular carcinoma(HCC),even in the absence of cirrhosis.Evidence from clinical and experimental studies shows the association of specific changes in the gut microbiome and the direct contribution to maintaining liver inflammation and/or cancerogenesis in nonalcoholic fatty liver disease-induced HCC.The composition of the gut microbiota differs significantly in obese and lean individuals,especially in the abundance of pro-inflammatory lipopolysaccharide-producing phyla,and,after establishing steatohepatitis,it undergoes minor changes during the progression of the disease toward advanced fibrosis.Experimental studies proved that the microbiota of obese subjects can induce steatohepatitis in normally fed mice.On the contrary,the transplantation of healthy microbiota to obese mice relieves steatosis.However,further studies are needed to confirm these findings and the mechanisms involved.In this review,we have evaluated well-documented clinical and experimental research on the role of the gut microbiota in the manifestation and promotion of HCC in nonalcoholic steatohepatitis(NASH).Furthermore,a literature review of microbiota alterations and consequences of dysbiosis for the promotion of NASH-induced HCC was performed,and the advantages and limitations of the microbiota as an early marker of the diagnosis of HCC were discussed.

Antibiotic resistance in patients with liver cirrhosis:Prevalence and current approach to tackle

Regardless of etiology,complications with bacterial infection in patients with cirrhosis are reported in the range of 25%-46%according to the most recent data.Due to frequent episodes of bacterial infection and repetitive antibiotic treatment,most often with broad-spectrum gram negative coverage,patients with cirrhosis are at increased risk of encountering multidrug resistant bacteria,and this raises concern.In such patients,extended-spectrum beta-lactamase and AmpCproducing Enterobacterales,methicillin-or vancomycin-resistant Staphylococcus aureus,vancomycin-resistant Enterococci,carbapenem-resistant Pseudomonas aeruginosa,and Acinetobacter baumannii,all of which are difficult to treat,are the most common.That is why novel approaches to the prophylaxis and treatment of bacterial infections to avoid antibiotic resistance have recently been developed.At the same time,our knowledge of resistance mechanisms is constantly updated.This review summarizes the current situation regarding the burden of antibiotic resistance,including the prevalence and mechanisms of intrinsic and acquired resistance in bacterial species that most frequently cause complications in patients with liver cirrhosis and recent developments on how to deal with multidrug resistant bacteria.

Effects of COVID-19 on the liver:The experience of a single center

BACKGROUND The coronavirus disease 2019(COVID-19)was perhaps the most severe global health crisis in living memory.Alongside respiratory symptoms,elevated liver enzymes,abnormal liver function,and even acute liver failure were reported in patients suffering from severe acute respiratory disease coronavirus 2 pneumonia.However,the precise triggers of these forms of liver damage and how they affect the course and outcomes of COVID-19 itself remain unclear.AIM To analyze the impact of liver enzyme abnormalities on the severity and outcomes of COVID-19 in hospitalized patients.METHODS In this study,684 depersonalized medical records from patients hospitalized with COVID-19 during the 2020-2021 period were analyzed.COVID-19 was diagnosed according to the guidelines of the National Institutes of Health(2021).Patients were assigned to two groups:those with elevated liver enzymes(Group 1:603 patients),where at least one out of four liver enzymes were elevated(following the norm of hospital laboratory tests:alanine aminotransferase(ALT)≥40,aspartate aminotransferase(AST)≥40,gamma-glutamyl transferase≥36,or alkaline phosphatase≥150)at any point of hospitalization,from admission to discharge;and the control group(Group 2:81 patients),with normal liver enzymes during hospitalization.COVID-19 severity was assessed according to the interim World Health Organization guidance(2022).Data on viral pneumonia complications,laboratory tests,and underlying diseases were also collected and analyzed.RESULTS In total,603(88.2%)patients produced abnormal liver test results.ALT and AST levels were elevated by a factor of less than 3 in 54.9%and 74.8%of cases with increased enzyme levels,respectively.Patients in Group 1 had almost double the chance of bacterial viral pneumonia complications[odds ratio(OR)=1.73,P=0.0217],required oxygen supply more often,and displayed higher biochemical inflammation indices than those in Group 2.No differences in other COVID-19 complications or underlying diseases were observed between groups.Preexisting hepatitis of a different etiology was rarely documented(in only 3.5%of patients),and had no impact on the severity of COVID-19.Only 5(0.73%)patients experienced acute liver failure,4 of whom died.Overall,the majority of the deceased patients(17 out of 20)had elevated liver enzymes,and most were male.All deceased patients had at least one underlying disease or combination thereof,and the deceased suffered significantly more often from heart diseases,hypertension,and urinary tract infections than those who made recoveries.Alongside male gender(OR=1.72,P=0.0161)and older age(OR=1.02,P=0.0234),diabetes(OR=3.22,P=0.0016)and hyperlipidemia(OR=2.67,P=0.0238),but not obesity,were confirmed as independent factors associated with more a severe COVID-19 infection in our cohort.CONCLUSION In our study,the presence of liver impairment allows us to predict a more severe inflammation with a higher risk of bacterial complication and worse outcomes of COVID-19.Therefore,patients with severe disease forms should have their liver tests monitored regularly and their results should be considered when selecting treatment to avoid further liver damage or even insufficiency.

Complicated course of biliary inflammatory myofibroblastic tumor mimicking hilar cholangiocarcinoma:A case report and literature review

BACKGROUND The inflammatory myofibroblastic tumor(IMT)is a rare,idiopathic,usually benign,mass-forming disease with myofibroblastic proliferation and a varying amount of inflammatory cells.Although it can affect various organs,the biliary tract is a rare localization of primary IMT,clinically,endoscopically and radiologically imitating cholangiocarcinoma.The treatment options are based only on clinical practice experience.CASE SUMMARY A 70-year-old woman was referred to our center due to progressive fatigue,weight loss,abdominal pain,night sweats,and elevated liver enzymes.Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography(ERCP)revealed proximal common hepatic duct and hilar biliary strictures extending bilaterally to lobular bile ducts.Although initial clinical,endoscopic and radiological signs were typical for hilar cholangiocarcinoma,histological examination showed no signs of malignancy.In total,8 biopsies using different approaches were performed(several biopsies from dominant stricture during ERCP and direct cholangioscopy;ultrasound-guided liver biopsy;diagnostic laparoscopy with liver and lymph node biopsies).Histological examination revealed signs of IMT,and the final diagnosis of biliary IMT was stated.Although IMT is usually a benign disease,in our case,it was complicated.All pharmacological treatment measures were ineffective.The patient still needs permanent stenting,suffers from recurrent infections and mechanical jaundice.Despite that,the patient already survived 24 mo.CONCLUSION IMT presenting with hilar biliary strictures is a unique diagnostic and clinical challenge as it is indistinguishable from cholangiocarcinoma,and there are no evidence-based treatment options.Our goal is to increase the understanding of this rare disease and its possible course.

Mucosa-associated lymphoid tissue lymphoma simulating Crohn’s disease:A case report

BACKGROUND Differential diagnosis between extranodal marginal zone lymphoma of mucosaassociated lymphoid tissue and inflammatory bowel disease is mainly based on histopathologic evaluation of intestinal biopsies,although there is no single definitive diagnostic investigation and that circumstance can lead to misdiagnosis in particular cases.Herein we present a rare,ulcerative form of marginal zone lymphoma which mimics the Crohn’s disease(CD)of upper digestive tract.CASE SUMMARY A 50-year-old man was presented with recurrent episodes of malaise and melena also weight loss.Enteroscopy of the small bowel demonstrated an ulcer in the jejunum.Microscopically,biopsies showed lymphoplasmacytic infiltrate.Diagnosis of CD was made.Primary treatment consisted of prednisone and azathioprine and was followed by azathioprine 100 mg per day with good clinical response in the following 2 years until relapse.At this time the results of endoscopic biopsies derived from proximal wall of stomach revealed Helicobacter pylori-negative marginal zone lymphoma of the gastric fundus.Immunophenotyping confirmed atypical CD20-positive cell population.Based on these biopsies,marginal zone lymphoma of mucosa-associated lymphoid tissue was diagnosed.Unfortunately,the contact with the patient was lost until one year later he was hospitalized with nausea,vomiting and severe pain because of gastrointestinal perforation.Four months later after laparotomy,the patient was treated with a course of chemotherapy.Complete remission was observed following 6 cycles of treatment.CONCLUSION This case report highlights the clinical relevance of knowledge and awareness of marginal zone lymphoma simulating CD.

Management of Flood syndrome:What can we do better?

Approximately 20%of cirrhotic patients with ascites develop umbilical herniation.These patients usually suffer from multisystemic complications of cirrhosis,have a significantly higher risk of infection,and require accurate surveillance–especially in the context of the coronavirus disease 2019 pandemic.The rupture of an umbilical hernia,is an uncommon,life-threatening complication of largevolume ascites and end-stage liver disease resulting in spontaneous paracentesis,also known as Flood syndrome.Flood syndrome remains a challenging condition for clinicians,as recommendations for its management are lacking,and the available evidence for the best treatment approach remains controversial.In this paper,four key questions are addressed regarding the management and prevention of Flood syndrome:(1)Which is the best treatment approach–conservative treatment or urgent surgery?(2)How can we establish the individual risk for herniation and possible hernia rupture in cirrhotic patients?(3)How can we prevent umbilical hernia ruptures?And(4)How can we manage these patients in the conditions created by the coronavirus disease 2019 pandemic?

Multi-organ IgG4-related disease continues to mislead clinicians: A case report and literature review

BACKGROUND Immunoglobulin G4-related disease(IgG4-RD)is a multisystemic mass forming immune-mediated disease that affects almost every organ and is a diagnostic challenge for every clinician.There is a lack of adequate epidemiological data worldwide,and evidence-based treatment recommendations are not yet established.We report the first case of IgG4-RD from Lithuania and the Baltic Sea region presented with thyroiditis,orbital myositis,orbitopathy,uveitis,scleritis,sialadenitis,autoimmune pancreatitis and prostatitis.CASE SUMMARY A 54-year-old Caucasian male was admitted to our tertiary Centre complaining of severe weight loss,diarrhoea,abdominal pain,salivary gland swelling,sicca symptoms and diplopia.On examination,bilateral palpable masses in the projection of major salivary glands,severe protrusion of the left eyeball and cachexia were noted.The patient was previously diagnosed with autoimmune thyroiditis and endocrine ophthalmopathy.The magnetic resonance imaging(MRI)of the head revealed enlarged extraocular muscles indicating orbital myositis.The biopsy from the salivary gland mass indicated sialadenitis.Abdominal MRI showed signs of autoimmune pancreatitis,and a serological test revealed the elevated serum IgG4 concentration.The patient was then diagnosed with IgG4-RD and successfully treated with prednisolone.There was a significant clinical,serological and radiological improvement after one month of treatment and no signs of relapse within twenty months.However,it took almost 18 years and the efforts of eight different medical specialists to establish the correct diagnosis.CONCLUSION A comprehensive approach to the patient is essential to improving the recognition of rare immune system conditions,such as IgG4-RD.

Menstrual cycle abnormalities in women with inflammatory bowel disease and effects of biological therapy on gynecological pathology

Inflammatory bowel disease(IBD)is a chronic condition that affects young individuals in their reproductive years.It may have long-term implications on their reproductive,sexual,and mental health.IBD has been related to menstrual abnormalities.Furthermore,the administration of biological therapy can also result in gynecological issues in addition to the disease itself.The purpose of this review was to present potential menstrual cycle problems in patients with IBD,as well as the impact of adalimumab and other anti-tumor necrosis factor medications on gynecological pathology.