Clinical study on the relationship between liver cirrhosis,ascites,and hyponatremia

BACKGROUND Cirrhosis is a common liver disease,and ascites is one of the common clinical conditions.However,the clinical manifestations of ascites combined with hyponatremia as a high-risk condition and its relationship to patient prognosis have not been fully studied.AIM To explore the clinical manifestations,prognostic factors,and relationships of ascites with hyponatremia in patients with cirrhosis to provide better diagnostic and treatment strategies.METHODS In this study,we retrospectively analyzed the clinical data of 150 patients diagnosed with cirrhosis and ascites between 2017 and 2022.Patients were divided into two groups:ascites combined with hyponatremia group and ascites group.We compared the general characteristics,degree of hyponatremia,complications,treatment,and prognosis between the two groups.RESULTS In the study results,patients in the ascites combined with hyponatremia group showed an older average age(58.2±8.9 years),64.4%were male,and had a significantly longer hospitalization time(12.7±5.3 d).Hyponatremia was more severe in this group,with a mean serum sodium concentration of 128.5±4.3 mmol/L,which was significantly different from the ascites group of 137.6±2.1 mmol/L.Patients with ascites and hyponatremia were more likely to develop hepatic encephalopathy(56.2%vs 39.0%),renal impairment(45.2%vs 28.6%)and infection(37.0%vs 23.4%).Regarding treatment,this group more frequently used diuretics(80.8%vs 62.3%)and salt supplements(60.3%vs 38.9%).Multiple logistic regression analysis identified older age[Odds ratio(OR)=1.06,P=0.025]and male gender(OR=1.72,P=0.020)as risk factors for hyponatremia combined with ascites.Overall,patients with ascites and hyponatremia present a clear high-risk status,accompanied by severe complications and poor prognosis.CONCLUSION In patients with cirrhosis,ascites with hyponatremia is a high-risk condition that is often associated with severe complications.

Clinical Efficacy Observation of Pangfu Wan Yao Medicine in Treating Ascites of Liver Cirrhosis

Objective: To treat ascites in patients with grade 3 liver cirrhosis using traditional Chinese medicine, evaluate effectiveness and safety by observing improvements in physical and mental symptoms, explore optimal treatment measures, and benefit clinical practice. Methods: 40 patients with ascites of liver cirrhosis admitted to our department from October 2020 to October 2022 were selected. According to a random number table, all patients were divided into an observation group treated with Yao Medicine and a control group treated with conventional Western medicine, with 20 cases in each group. The improvement of adverse emotions was evaluated before and after treatment using the Self-Rating Depression Scale (SDS) and the Self-Rating Anxiety Scale (SAS). The changes in liver function indicators were observed to judge the efficacy and safety. Results: The effective rate in the observation group was 95.00%, and in the control group was 90.00%. The comparison between the two groups showed a significant increase in the effective rate in the observation group, with a statistically significant difference (P P P > 0.05). After treatment, compared with the control group, the observation group showed a significant decrease in SDS and SAS scores, with a statistically significant difference (P < 0.05). Conclusion: Yao Medicine can effectively improve the physical and mental symptoms of patients with ascites of liver cirrhosis, with good effectiveness and high safety.

Clinical efficacy of tolvaptan for treatment of refractory ascites in liver cirrhosis patients

AIM: To evaluate the efficacy and safety of tolvaptan to treat refractory ascites in decompensated liver cirrhosis patients with or without further complications, such as hepatorenal syndrome and/or hepatocellular carcinoma.

High circulating D-dimers are associated with ascites and hepatocellular carcinoma in liver cirrhosis

AIM: To measure plasma D-dimer levels in cirrhotic patients with and without ascites, assessing the effect of ascites resolution in D-dimer concentration. METHODS: Seventy consecutive cirrhotic patients (M = 44, F = 26, mean age 65 years, SD ± 13), observed from October 2005 to March 2006 were enrolled. Circulating D-dimer levels were measured using a latex-enhanced, immunoturbidimetric test. In patients with ascites (n = 42) the test was repeated after ascites resolution. RESULTS: Ascites was present in 42 patients (group A) and absent in 28 (group B). Group A patients had more advanced liver disease. Hepatocellular carcinoma (HCC) was diagnosed in 14 patients and was more frequent in group B. Above normal range D-dimers were found in 45/70 patients. High D-dimers were more frequent in group A than in group B (P = 0.001). High D-dimers were associated with presence of HCC (P = 0.048) only in group B. After ascites resolution, obtained in all patients, mean D-dimer values decreased in those 34 patients with high basal levels (P = 0.007), returning to normal in 17. CONCLUSION: In patients with liver cirrhosis, ascites and HCC are the main factors associated with increased fibrinolytic activity.

Diagnosis and therapy of ascites in liver cirrhosis

Ascites is one of the major complications of liver cirrhosis and is associated with a poor prognosis. It is important to distinguish noncirrhotic from cirrhotic causes of ascites to guide therapy in patients with noncirrhotic ascites. Mild to moderate ascites is treated by salt restriction and diuretic therapy. The diuretic of choice is spironolactone. A combination treatment with furosemide might be necessary in patients who do not respond to spironolactone alone. Tense ascites is treated by paracentesis, followed by albumin infusion and diuretic therapy. Treatment options for refractory ascites include repeated paracentesis and transjugular intrahepatic portosystemic shunt placement in patients with a preserved liver function. Potential complications of ascites are spontaneous bacterial peritonitis (SBP) and hepatorenal syndrome (HRS). SBP is diagnosed by an ascitic neutrophil count > 250 cells/mm3 and is treated with antibiotics. Patients who survive a first episode of SBP or with a low protein concentration in the ascitic fluid require an antibiotic prophylaxis. The prognosis of untreated HRS type 1 is grave. Treatment consists of a combination of terlipressin and albumin. Hemodialysis might serve in selected patients as a bridging therapy to liver transplantation. Liver transplantation should be considered in all patients with ascites and liver cirrhosis.

Clinical outcome and predictors of survival after TIPS insertion in patients with liver cirrhosis

AIM： To determine the clinical outcome and predictors of survival after transjugular intrahepatic portosystemic stent shunt （TIPS） implantation in cirrhotic patients. METHODS： Eighty-one patients with liver cirrhosis and consequential portal hypertension had TIPS implanta- tion （bare metal） for either refractory ascites （RA） （n = 27） or variceal bleeding （VB） （n = 54）. Endpoints for the study were： technical success, stent occlusion and stent stenosis, rebleeding, RA and mortality. Clini- cal records of patients were collected and analysed. Baseline characteristics [e.g., age, sex, CHILD score and the model for end-stage liver disease score （MELD score）, underlying disease] were retrieved. The Kaplan- Meier method was employed to calculate survival from the time of TIPS implantation and comparisons were made by log rank test. A multivariate analysis of factors influencing survival was carried out using the Cox pro- portional hazards regression model. Results were ex- pressed as medians and ranges. Comparisons between groups were performed by using the Mann-Whitney U-test and the4,2 test as appropriate. RESULTS： No difference could be seen in terms of age, sex, underlying disease or degree of portal pressure gradient （PPG） reduction between the ascites and the bleeding group. The PPG significantly decreased from 23.4 ± 5.3 mmHg （VB） vs 22.1± 5.5 mmHg （RA） be- fore TIPS to 11.8 ±4.0 vs 11.7 ± 4.2 after TIPS im- plantation （P = 0.001 within each group）. There was a tendency towards more patients with stage CHILD A in the bleeding group compared to the ascites group （24 vs 6, P = 0.052）. The median survival for the ascites group was 29 mo compared to 〉 60 mo for the bleed- ing group （P = 0.009）. The number of radiological con- trols for stent patency was 6.3 for bleeders and 3.8 for ascites patients （P = 0.029）. Kaplan-Meier calculation indicated that stent occlusion at first control （P = 0.027）, ascites prior to TIPS implantation （P = 0.009）, CHILD stage （P = 0.013）, MELD score （P = 0.001） and those patients not having undergone liver transplantation （P = 0.024） were significant predictors of survival. In the Cox regression model, stent occlusion （P = 0.022）, RA （P = 0.043）, CHILD stage （P = 0.015） and MELD score （P = 0.004） turned out to be independent prognostic factors of survival. The anticoagulation management （P = 0.097）, the porto-systemic pressure gradient （P= 0.460） and rebleeding episodes （P = 0.765） had no significant effect on the overall survival. CONCLUSION： RA, stent occlusion, initial CHILD stage and MELD score are independent predictors of survival in patients with TIPS, speaking for a close follow-up in these circumstances.

Increased intestinal macromolecular permeability and urine nitrite excretion associated with liver cirrhosis with ascites

AIM： To determine intestinal permeability, the serum tumor necrosis factor （TNF）-α level and urine nitric oxide （NO） metabolites are altered in liver cirrhosis （LC） with or without ascites. METHODS： Fifty-three patients with LC and 26 healthy control subjects were enrolled in the study. The intestinal permeability value is expressed as the percentage of polyethylene glycol （PEG） 400 and 3350 retrieval in 8-h urine samples as determined by high performance liquid chromatography. Serum TNF-α concentrations and urine NO metabolites were determined using an enzyme-linked immunosorbent assay （ELISA） and Greiss reaction method, respectively. RESULTS： The intestinal permeability index wassignificantly higher in patients with LC with ascites than in healthy control subjects or patients with LC without ascites （0.88 ± 0.12 vs 0.52 ± 0.05 or 0.53 ± 0.03, P 〈 0.05） and correlated with urine nitrite excretion （r = 0.98）. Interestingly, the serum TNF-α concentration was significantly higher in LC without ascites than in control subjects or in LC with ascites （198.9 ± 55.8 pg/mL vs 40.9 ± 12.3 pg/mL or 32.1 ± 13.3 pg/mL, P 〈 0.05）. Urine nitrite excretion was significantly higher in LC with ascites than in the control subjects or in LC without ascites（ 1170.9± 28.7 μmol/L vs 903.1 ± 55.1 μmol/L or 956.7 ± 47.7 μmol/L, P 〈 0.05）. COMCLUSIOM： Increased intestinal macromolecular permeability and NO is probably of importance in the pathophysiology and progression of LC with ascites, but the serum TNF-α concentration was not related to LC with ascites.

Proton pump inhibitor use increases mortality and hepatic decompensation in liver cirrhosis

BACKGROUND Proton pump inhibitors(PPIs)are widely prescribed,often without clear indications.There are conflicting data on its association with mortality risk and hepatic decompensation in cirrhotic patients.Furthermore,PPI users and PPI exposure in some studies have been poorly defined with many confounding factors.AIM To examine if PPI use increases mortality and hepatic decompensation and the impact of cumulative PPI dose exposure.METHODS Data from patients with decompensated liver cirrhosis were extracted from a hospital database between 2013 to 2017.PPI users were defined as cumulative defined daily dose(cDDD)≥28 within a landmark period,after hospitalisation for hepatic decompensation.Cox regression analysis for comparison was done after propensity score adjustment.Further risk of hepatic decompensation was analysed by Poisson regression.RESULTS Among 295 decompensated cirrhosis patients,238 were PPI users and 57 were non-users.PPI users had higher mortality compared to non-users[adjusted HR=2.10,(1.20-3.67);P=0.009].Longer PPI use with cDDD>90 was associated with higher mortality,compared to non-users[aHR=2.27,(1.10-5.14);P=0.038].PPI users had a higher incidence of hospitalization for hepatic decompensation[aRR=1.61,(1.30-2.11);P<0.001].CONCLUSION PPI use in decompensated cirrhosis is associated with increased risk of mortality and hepatic decompensation.Longer PPI exposure with cDDD>90 increases the risk of mortality.

Spontaneous bacterial peritonitis:A severe complication of liver cirrhosis

This report presents a survey of current knowledge concerning one of the relatively frequent and severe complications of liver cirrhosis and associated ascites-spontaneous bacterial peritonitis. Epidemiology,aetiology,pathogenesis,clinical manifestation,diagnosis and present possibilities of treatment are discussed.

Multivariate predictive model for asymptomatic spontaneous bacterial peritonitis in patients with liver cirrhosis

BACKGROUNDSpontaneous bacterial peritonitis (SBP) is a detrimental infection of the asciticfluid in liver cirrhosis patients, with high mortality and morbidity. Earlydiagnosis and timely antibiotic administration have successfully decreased themortality rate to 20%-25%. However, many patients cannot be diagnosed in theearly stages due to the absence of classical SBP symptoms. Early diagnosis ofasymptomatic SBP remains a great challenge in the clinic.AIMTo establish a multivariate predictive model for early diagnosis of asymptomaticSBP using positive microbial cultures from liver cirrhosis patients with ascites.METHODSA total of 98 asymptomatic SBP patients and 98 ascites liver cirrhosis patients withnegative microbial cultures were included in the case and control groups,respectively. Multiple linear stepwise regression analysis was performed toidentify potential indicators for asymptomatic SBP diagnosis. The diagnosticperformance of the model was estimated using the receiver operatingcharacteristic curve.RESULTSPatients in the case group were more likely to have advanced disease stages,cirrhosis related-complications, worsened hematology and ascites, and higher mortality. Based on multivariate analysis, the predictive model was as follows: y (P) = 0.018 + 0.312 × MELD (model of end-stage liver disease) + 0.263 × PMN(ascites polymorphonuclear) + 0.184 × N (blood neutrophil percentage) + 0.233 ×HCC (hepatocellular carcinoma) + 0.189 × renal dysfunction. The area under thecurve value of the established model was 0.872, revealing its high diagnosticpotential. The diagnostic sensitivity was 73.5% (72/98), the specificity was 86.7%(85/98), and the diagnostic efficacy was 80.1%.CONCLUSIONOur predictive model is based on the MELD score, polymorphonuclear cells,blood N, hepatocellular carcinoma, and renal dysfunction. This model mayimprove the early diagnosis of asymptomatic SBP.

Use of ^(18)F-FDG PET/CT to locate primary malignancies in patients with hepatic cirrhosis and malignant ascites

Objective：Ascites in patients with hepatic cirrhosis is caused by cirrhosis in most cases.For most malignant ascites,the primary malignancy could be readily identified using conventional imaging methods,e.g.,computer tomography （CT） and magnetic resonance imaging （MRI）.However,in a small fraction of the patients,the primary malignancy remains occult even with these examinations.In this retrospective study,we assessed the usefulness of 18F-FDG PET/CT in patients with hepatic cirrhosis and malignant ascites of otherwise unknown origin.Methods：Twenty-eight patients with malignant ascites of unknown primary sites after CT,MRI and ultrasound during the period of five years between January 2008 and December 2012 had received 18F-FDG PET/CT.Medical records of these patients were reviewed and analyzed.Results：Elevated 18F-FDG absorption was found in 23 of 28 cases in the following sites：gastrointestinal tract （n=10,43.5％）,prostate （n=5,21.7％）,peritoneum （n=4,13.3％）,and ovary （n=4,13.3％）.Cancer was confirmed by pathology in 20 cases after open or laparoscopic surgeries.Five patients were found to have benign ascites,among which,3 were found to be false positive due to tuberculosis.SUV values were significantly higher for tumors than for benign lesions （mean values,6.95 vs.2.94; P=0.005）.Conclusions：The 18F-FDG PET/CT can be as a powerful imaging tool in identifying tissue origin in liver cirrhosis patients suspected of cancers or with cancers of unknown primary sites.

Colon signet-ring cell carcinoma with chylous ascites caused by immunosuppressants following liver transplantation:A case report

BACKGROUND Chylous ascites is caused by disruption of the lymphatic system,which is characterized by the accumulation of a turbid fluid containing high levels of triglycerides within the abdominal cavity.The two most common causes are cirrhosis and tuberculosis,and colon signer ring cell carcinoma(SRCC)due to the use of immunosuppressants is extremely rare in cirrhotic patients after liver transplantation,making it prone to misdiagnosis and missed diagnosis.CASE SUMMARY A 52-year-old man who underwent liver transplantation and was administered with immunosuppressants for 8 months was admitted with a 3-month history of progressive abdominal distention.Initially,based on lymphoscintigraphy and lymphangiography,lymphatic obstruction was considered,and cystellar chyli decompression with band lysis and external membrane stripping of the lymphatic duct was performed.However,his abdominal distention was persistent without resolution.Abdominal paracentesis revealed allogenic cells in the ascites,and immunohistochemistry analysis revealed adenocarcinoma cells with phenotypic features suggestive of a gastrointestinal origin.Gastrointestinal endoscopy was performed,and biopsy showed atypical signet ring cells in the ileocecal valve.The patient eventually died after a three-month follow-up due to progression of the tumor.CONCLUSION Colon SRCC,caused by immunosuppressants,is an unusual but un-neglected cause of chylous ascites.

Drainage of ascites in cirrhosis

For cirrhotic refractory ascites,diuretics combined with albumin and vasoactive drugs are the first-line choice for ascites management.However,their therapeutic effects are limited,and most refractory ascites do not respond to medication treat-ment,necessitating consideration of drainage or surgical interventions.Con-sequently,numerous drainage methods for cirrhotic ascites have emerged,including large-volume paracentesis,transjugular intrahepatic portosystemic shunt,peritoneovenous shunt,automated low-flow ascites pump,cell-free and concentrated ascites reinfusion therapy,and peritoneal catheter drainage.This review introduces the advantages and disadvantages of these methods in different aspects,as well as indications and contraindications for this disease.

Correlation between serum markers and transjugular intrahepatic portosystemic shunt prognosis in patients with cirrhotic ascites

BACKGROUND Individuals with refractory ascites in the context of liver cirrhosis typically face an adverse prognosis.The transjugular intrahepatic portosystemic shunt(TIPS)is an efficacious intervention,but there is a lack of reliable tools for postoperative pro-gnosis assessment.Previously utilized clinical biochemical markers,such as the serum albumin concentration(Alb),sodium(Na+)concentration,and serum creatinine(Scr),have limited predictive value.Therefore,the quest for novel,specific biomarkers to evaluate the post-TIPS prognosis in patients with liver cirrhosis and refractory ascites holds significant practical importance.A retrospective analysis was conducted on 75 patients with liver cirrhosis and refractory ascites who underwent TIPS at our institution from August 2019 to August 2021.These patients were followed up regularly for two years,and the death toll was meticulously documented.The patients were allocated into a survival group(n=45 patients)or a deceased group(n=30 patients)based on their prognosis status.The clinical data of the two groups were collected,and Child-Pugh scores and MELD scores were calculated for analysis.Spearman correlation analysis was carried out to evaluate the correlation of prognosis with Child-Pugh grade,MELD score,and Cys C level.Additionally,a multiple-factor analysis utilizing the Cox proportional hazard model was used to identify independent risk factors affecting the post-TIPS prognosis of patients with liver cirrhosis and refractory ascites.The receiver operating characteristic curve(ROC)ascertained the predictive value of the Cys C concen-tration,Child-Pugh grade,and MELD score for the prognosis of liver cirrhosis with refractory ascites in post-TIPS patients.RESULTS During a 2-year follow-up period,among 75 patients with liver cirrhosis and refractory ascites who underwent TIPS treatment,30 patients(40.00%)passed away.The deceased cohort exhibited heightened aspartate aminotrans-ferase,alanine aminotransferase,total bilirubin,Scr,prothrombin time,Cys C,international normalized ratio,Child-Pugh,and MELD scores compared to those of the survival cohort,while Alb and Na+levels were attenuated in the deceased group(P<0.05).Spearman analysis revealed moderate to high positive correlations between prognosis and Child-Pugh score,MELD score,and Cys C level(r=0.709,0.749,0.671,P<0.05).Multivariate analysis using the Cox proportional hazard model demonstrated that the independent risk factors for post-TIPS prognosis in patients with liver cirrhosis and refractory ascites were Cys C(HR=3.802;95%CI:1.313-11.015),Child-Pugh(HR=3.030;95%CI:1.858-4.943),and MELD(HR=1.222;95%CI:1.073-1.393)scores.ROC analysis confirmed that,compared to those of the classic prognostic models for Child-Pugh and MELD scores,the predictive accuracy of Cys C for post-TIPS prognosis in patients with liver cirrhosis and refractory ascites was slightly lower.This analysis yielded sensitivity and specificity values of 83.33%and 82.22%,respectively.The area under the curve value at this juncture was 0.883,with an optimal cutoff value set at 1.95 mg/L.CONCLUSION Monitoring the serum Cys C concentration is valuable for assessing the post-TIPS prognosis in patients with liver cirrhosis and refractory ascites.Predictive models based on serum Cys C levels,as opposed to Scr levels,are more beneficial for evaluating the condition and prognosis of patients with ascites due to cirrhosis.

Natural history and outcomes of patients with liver cirrhosis complicated by hepatic hydrothorax

BACKGROUNDHepatic hydrothorax (HH) is an uncommon and difficult-to-manage complicationof cirrhosis with limited treatment options.AIMTo define the clinical outcomes of patients presenting with HH managed withcurrent standards-of-care and to identify factors associated with mortality.METHODSCirrhotic patients with HH presenting to 3 tertiary centres from 2010 to 2018 wereretrospectively identified. HH was defined as pleural effusion in the absence ofcardiopulmonary disease. The primary outcomes were overall and transplant-freesurvival at 12-mo after the index admission. Cox proportional hazards analysiswas used to determine factors associated with the primary outcomes.RESULTSOverall, 84 patients were included (mean age, 58 years) with a mean model forend-stage liver disease score of 29. Management with diuretics alone achievedlong-term resolution of HH in only 12% patients. At least one thoracocentesis wasperformed in 73.8% patients, transjugular intrahepatic portosystemic shuntinsertion in 11.9% patients and 33% patients received liver transplantation within12-mo of index admission. Overall patient survival and transplant-free survival at12 mo were 68% and 41% respectively. At multivariable analysis, current smoking [hazard ratio (HR) = 8.65, 95% confidence interval (CI): 3.43-21.9, P < 0.001) and acute kidneyinjury (AKI) (HR = 2.91, 95%CI: 1.21-6.97, P = 0.017) were associated with a significantly increasedrisk of mortality.CONCLUSIONCirrhotic patients with HH are a challenging population with a poor 12-mo survival despitecurrent treatments. Current smoking and episodes of AKI are potential modifiable factors affectingsurvival. HH is often refractory of diuretic therapy and transplant assessment should beconsidered in all cases.

Hemorrhagic ascites from spontaneous ectopic mesenteric varices rupture in NASH induced cirrhosis and successful outcome:A case report

Bleeding from gastro-esophageal varices can often present as the first decompensating event in patients with cirrhosis. This can be a potentially life threatening event associated with a 15%-20% early mortality. We present a rare case of new onset ascites due to intra-abdominal hemorrhage from ruptured mesenteric varices; in a 37 years old male with newly diagnosed nonalcoholic steatohepatitis induced cirrhosis as the first decompensating event. The patient was successfully resuscitated with emergent evacuation of ascites for diagnosis, identification and control of bleeding mesenteric varices and eventually orthotopic liver transplantation with successful outcome. Various clinical presentations, available treatment options and outcomes of ectopic variceal bleeding are discussed in this report.

Current approaches to the management of patients with cirrhotic ascites

This review describes current approaches to the management of patients with cirrhotic ascites in relation to the severity of its clinical manifestations. The PubMed database, the Google Scholar retrieval system, the Cochrane Database of Systematic Reviews, and the reference lists from related articles were used to search for relevant publications. Articles corresponding to the aim of the review were selected for 1991-2018 using the keywords:“liver cirrhosis,”“portal hypertension,”“ascites,”“pathogenesis,”“diagnostics,” and “treatment.” Uncomplicated and refractory ascites in patients with cirrhosis were the inclusion criteria. The literature analysis has shown that despite the achievements of modern hepatology, the presence of ascites is associated with poor prognosis and high mortality. The key to successful management of patients with ascites may be the stratification of the risk of an adverse outcome and personalized therapy. Pathogenetically based approach to the choice of pharmacotherapy and optimization of minimally invasive methods of treatment may improve the quality of life and increase the survival rate of this category of patients.

Pure laparoscopic hepatectomy for hepatocellular carcinoma with chronic liver disease

Pure laparoscopic hepatectomy is a less invasive procedure than conventional open hepatectomy for the resection of hepatic lesions. Increases in experiences with the technique, in combination with advances in technology, have promoted the popularity of pure laparoscopic hepatectomy. However, indications for usage and potential contraindications of the procedure remain unresolved. The characteristics and specific advantages of the procedure, especially for hepatocellular carcinoma(HCC) patients with chronic liver diseases,are reviewed and discussed in this paper. For cirrhotic patients with liver tumors, pure laparoscopic hepatectomy minimizes destruction of the collateral blood and lymphatic flow from laparotomy and mobilization, and mesenchymal injury from compression. Therefore, pure laparoscopic hepatectomy has the specific advantage of minimal postoperative ascites production that leads to lowering the risk of disturbance in water or electrolyte balance and hypoproteinemia. It minimizes complications that routinely trigger postoperative serious liver failure. Under adequate patient positioning and port arrangement, the partial resection of the liver in the area of subphrenic space, peri-inferior vena cava area or next to the attachment of retro-peritoneum is facilitated in pure laparoscopic surgery by providing good vision and manipulation in the small operative field.Furthermore, the features of reduced post-operative adhesion, good vision, and manipulation within the small area between the adhesions make this procedure safer in the context of repeat hepatectomy procedures.These improved features are especially advantageous for patients with liver cirrhosis and multicentric and/or metachronous HCCs.

Do vasopressin V2 receptor antagonists benefit cirrhotics with refractory ascites?

Hyponatremia is a frequent complication of advanced cirrhosis with ascites associated with increased morbidity and mortality. It is caused by an impairment in the renal capacity to eliminate solute-free water and is considered to be related to persistent secretionof vasopressin despite low serum osmolality. This nonosmotic release of vasopressin is mediated by the autonomic nervous system, which senses the underfilling of arterial vascular component. This reduction of effective arterial blood volume is closely related to the development of ascites. Although the short-time effects of vasopressin V2 receptor antagonists(vaptans) on hyponatremia and ascites have been repeatedly reported, their effects on the long-term management of cirrhotic ascites have not been established yet. Considering that their effects on water diuresis and their safety are limited by severe underfilling state of patients, cautious approaches with adequate monitoring are needed to advanced cirrhosis. Proper indication, adequate doses and new possibility of combination therapy should be explored in the future controlled study. As hyponatremia is frequent obstacle to ascites management, judicious combination with low-dose diuretics may decrease the incidence of refractory ascites. Although vaptans show much promise in the treatment of advanced cirrhosis, the problem of high cost should be solved for the future.

Spontaneous bacterial peritonitis: The clinical challenge of a leaky gut and a cirrhotic liver

Spontaneous bacterial peritonitis(SBP) is a frequent, life-threatening bacterial infection in patients with liver cirrhosis and ascites. Portal hypertension leads to increased bacterial translocation from the intestine. Failure to eliminate invading pathogens due to immune defects associated with advanced liver disease on the background of genetic predisposition may result in SBP. The efficacy of antibiotic treatment and prophylaxis has declined due to the spread of multi-resistant bacteria. Patients with nosocomial SBP and with prior antibiotictreatment are at a particularly high risk for infection with resistant bacteria. Therefore, it is important to adapt empirical treatment to these risk factors and to the local resistance profile. Rifaximin, an oral, nonabsorbable antibiotic, has been proposed to prevent SBP, but may be useful only in a subset of patients. Since novel antibiotic classes are lacking, we have to develop prophylactic strategies which do not induce bacterial resistance. Farnesoid X receptor agonists may be a candidate, but so far, clinical studies are not available. New diagnostic tests which can be carried out quickly at the patient's site and provide additional prognostic information would be helpful. Furthermore, we need tools to predict antibiotic resistance in order to tailor first-line antibiotic treatment of spontaneous bacterial peritonitis to the individual patient and to reduce mortality.