Over the past two decades, new treatment modalities have been introduced for the management of variceal bleeding. The aim of this retrospective study in a single center was to assess whether these treatments have improved the prognosis for cirrhotic patients with variceal bleeding. We reviewed the clinical records of all patients with cirrhosis admitted to our Liver Intensive Care Unit due to variceal bleeding during the years 1980, 1985, 1990, 1995, and 2000. Whereas balloon tamponade was still the first-line treatment in 1980, patients treated in 2000 received a vasoactive agent, an endoscopic treatment, and an antibiotic prophylaxis in, respectively, 90%, 100%, and 94% of cases. The in-hospital mortality rate steadily decreased over the study period: 42.6%, 29.9%, 25%, 16.2%, and 14.5% in 1980, 1985, 1990, 1995, and 2000, respectively (P < .05). Mortality decreased from 9% in 1980 to 0% in 2000 in Child-Turcotte-Pugh class A patients, from 46% to 0% in class B patients, and from 70% to 32% in class C patients. This improved survival was associated with a decrease of rebleeding (from 47% in 1980 to 13% in 2000) and bacterial infection rates (from 38% to 14%). On multivariable analysis, endoscopic therapy and antibiotic prophylaxis were independent predictors of survival. In conclusion, in-hospital mortality of patients with cirrhosis and variceal bleeding decreased threefold over the past two decades, in concurrence with an early and combined use of pharmacological and endoscopic therapies and short-term antibiotic prophylaxis.

Background: A recent study in patients with Budd-Chiari syndrome showed the value of a prognostic index including age, Pugh score, ascites and serum creatinine. Surgical portosystemic shunt did not appear to improve survival.Aims: To validate these findings in an independent sample; to evaluate a classification into three forms according to the presence of features of acute injury, chronic lesions, or both of them (types I, II or III, respectively); and to assess whether taking into account this classification would alter our previous conclusions.Methods: Multivariate Cox model survival analysis, first on 69 new patients; second, on these 69 and 54 previous patients, all diagnosed since 1985.Results: Previous prognostic index had a significant prognostic value (P < 0.0001) which was further improved by taking into account type III form (P < 0.001). Type III form was associated with the poorest outcome. No significant impact of surgical shunting on survival was disclosed.Conclusions: The prognosis of Budd-Chiari syndrome can be based on age, Pugh score, ascites, serum creatinine and the presence of features indicating acute injury superimposed on chronic lesions (type III form). The idea that surgical shunting has no significant impact on survival is reinforced by these findings. (C)2003 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.

Objective. - The aim of the study was to assess gastric protein loss in alcoholic cirrhotic patients, and to determine its role in the low serum albumin levels frequently observed in these patients.Methods. - Twenty-six alcoholic cirrhotic patients with ascites and serum albumin levels < 30 g/L were studied and compared to 6 healthy volunteers. Gastric protein loss was determined by measuring gastric clearance of alpha(1)-antitrypsin.Results. - Gastric clearance of alpha(1)-antitrypsin was 0.96 +/- 1.42 mL/h (median: 0.52; range: 0.11-6.54) in cirrhotic patients and 0.48 +/- 0.20 mL/h (median: 0.51) in healthy volunteers. Values in cirrhotic patients were not significantly different from healthy volunteers. However, 3 cirrhotic patients had high values of gastric clearance of alpha(1)-antitrypsin (2.84, 3.99 and 6.54 mL/h). Their serum albumin and protein levels were significantly lower than those in the 23 other patients (P < 0.05 and < 0.03, respectively. Severe portal hypertensive gastropathy was present in two out of these 3 patients and in two out of the 23 other patients.Conclusion. - Gastric protein loss is not significantly increased in liver cirrhosis. However, in a few patients, this loss is high and may play a role in low serum albumin levels.

OBJECTIVES:Assessment of prognosis in patients with cirrhosis admitted to an Intensive Care Unit remains unsatisfactory. The aims of this retrospective study were to determine the survival rates of patients admitted to an Intensive Care Unit, and to identify and validate prognostic indicators associated with a high mortality rate. METHODS:Two hundred and forty three patients with cirrhosis consecutively admitted to the Intensive Care Unit were studied. The main reasons for admission were upper gastrointestinal bleeding (n = 163), coma (n = 43), sepsis (n = 18), and liver failure (n = 13). Patients were divided into two groups: group 1 (n = 121) to identify prognostic indicators associated with a high mortality rate, and group 2 (n = 122) to validate these indicators. RESULTS:Intensive Care Unit and one year survival rates of patients with cirrhosis admitted for upper gastrointestinal hemorrhage were 76 and 50% respectively. These rates were 40 and 8% respectively for patients admitted for other reasons. In group 1, 4 predictive factors found at admission were identified to have independent significance by stepwise logistic regression: grade III or IV encephalopathy, prothrombin index, serum creatinine, and hypoxemia. On the other hand, the presence of shock on admission was associated with a 100% mortality rate. Two prognostic indicators were defined: shock requiring the administration of vasoactive drugs, and the presence of 3 out of the 4 following predictive factors: grade III or IV encephalopathy, mechanical ventilation, prothrombin index < 30%, and serum creatinine > 130 mumol/L. In group 2, the presence of at least one prognostic indicator at admission or during intensive care was associated with a 96% mortality rate. These indicators were present in 69% of patients who died. In 17 patients who died, but survived more than 24 hours in the Intensive Care Unit, indicators were present an average of 6.0 +/- 5.3 days before death. CONCLUSION:Common prognostic indicators may accurately predict death in patients with cirrhosis admitted to an Intensive Care Unit. These indicators could be helpful in identifying patients who will not benefit from intensive care.

BACKGROUND:Ursodiol (ursodeoxycholic acid) therapy leads to major improvements in patients with primary biliary cirrhosis. The benefit of long-term treatment is uncertain.METHODS:We randomly assigned 145 patients with biopsy-proved primary biliary cirrhosis to receive ursodiol (13 to 15 mg per kilogram of body weight per day) (72 patients) or placebo (73 patients). After two years of follow-up, because of the benefit from ursodiol, all patients completing the study received ursodiol in an open trial and were monitored for two more years. The end points in the assessment of efficacy were as follows: progression of disease, as defined by the presence of hyperbilirubinemia, variceal bleeding, ascites, or encephalopathy; liver transplantation or a referral for that procedure; and liver transplantation (or a referral) or death.RESULTS:Disease progressed significantly less frequently in the ursodiol group than in the placebo group (P < 0.002; relative risk, 0.28; 95 percent confidence interval, 0.12 to 0.63). The probability of liver transplantation or a referral for that procedure and the probability of transplantation or death were significantly lower in the group assigned to ursodiol than in the group assigned to placebo (for transplantation alone, P = 0.003; relative risk, 0.21; 95 percent confidence interval, 0.07 to 0.66; for transplantation or death, P = 0.005; relative risk, 0.32; 95 percent confidence interval, 0.14 to 0.74). High bilirubin levels and, to a lesser extent, signs of cirrhosis at entry into the trial were predictive of disease progression, liver transplantation or a referral, and transplantation or death.CONCLUSIONS:Long-term ursodiol therapy slows the progression of primary biliary cirrhosis and reduces the need for liver transplantation.

We tested the efficacy of maintenance treatment with alpha-2a interferon, 1 megaunit thrice weekly for 6 months, in preventing relapse of non-A, non-B/C hepatitis in remission after treatment with alpha interferon given thrice weekly according to the following dose schedule: 3 megaunits for 3 months, 2 megaunits for 2 months and 1 megaunit for 1 month. Fifty-three patients with hepatitis C in remission were randomly allocated to a treatment group (n=26) or a control group (n=27). A relapse (aminotransferase activity >1.5 times the upper limit of normal) occurred in 46% of the controls and 35% of the treated patients (NS). Maintenance treatment had no significant influence on histopathologic changes evaluated by three independent observers: in both groups the overall score for histologic lesions improved between the initiation of interferon therapy and the end of the study. We conclude that relapses in patients with non-A, non-B/C hepatitis in remission after treatment with alpha interferon at tapering doses are not prevented by maintenance therapy with low-dose alpha interferon. (C) Journal of Hepatology.