Pedro Alarcón III - Academia.edu (original) (raw)
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Papers by Pedro Alarcón III
Portal hypertension (PH) is one of the most important causes of morbidity and mortality in patien... more Portal hypertension (PH) is one of the most important causes of morbidity and mortality in patients with chronic liver disease. PH measurement is crucial to stage and predict the clinical outcome of liver cirrhosis. Measurement of hepatic vein pressure gradient is considered the gold standard for assessment of the degree of PH; however, it is an invasive method and has not been used widely. Thus, noninvasive methods have been proposed recently. We critically evaluated serum markers, abdominal ultrasonography, and particularly liver and spleen stiffness measurement, which represent the more promising methods to stage PH degree and to assess the presence/absence of esophageal varices (EV). A literature search was carried out on MEDLINE, EMBASE, Web of Science, and Scopus for articles and abstracts. The search terms used included 'liver cirrhosis', 'portal hypertension', 'liver stiffness', 'spleen stiffness', 'ultrasonography', and 'portal hypertension serum biomarker'. The articles cited were selected on the basis of their relevance to the objective of the review. The results of available studies indicate that individually, these methods have a mild accuracy in predicting the presence of EV, and thus they cannot substitute endoscopy to predict EV. When these tests were used in combination, their accuracy increased. In addition to the PH staging, several serum markers and spleen stiffness measurement can predict the clinical outcome of liver cirrhosis with a good accuracy, comparable to that of hepatic vein pressure gradient. In the future, noninvasive methods could be used to select patients requiring further investigations to identify the best tailored clinical management. Eur J Gastroenterol Hepatol 27:992–1001
Background Portal vein thrombosis (PVT) is a complication of cirrhosis. However, whether PVT wors... more Background Portal vein thrombosis (PVT) is a complication of cirrhosis. However, whether PVT worsens cirrhosis outcome is a debated issue. Aim To report an update on the management of PVT. Methods A review was performed on the outcome, prevention, and treatment of PVT. Results Some studies suggest that PVT could worsen the rate of hepatic decompensation and survival of cirrhosis, whereas others report a non-negative impact of PVT in the outcome of cirrhosis. Therefore, the prognostic value of PVT in cirrhosis remains a gray zone. One single randomized-controlled trial reported that enoxaparin could prevent PVT, delay the occurrence of hepatic decompensation, and improve survival. However, no further study data confirmed this assumption and the issue is not actually generalizable. Numerous studies report that anticoagulation determines a relatively high rate of portal vein recanalization in cirrhotics PVT. However, further data are warranted to confirm the risk-to-benefit of anticoagulation, especially bleeding. Transjugular intrahepatic portosystemic shunt (TIPS) has been reported to be effective as a treatment of PVT in cirrhosis, with the advantage of avoiding the risk of bleeding linked to anticoagulation. However, there are no data comparing TIPS with anticoagulation as a treatment of PVT in cirrhosis. Furthermore, there is no evidence on whether both anticoagulation and TIPS improve survival. Conclusion It is uncertain whether PVT affects cirrhosis outcome. Further data are needed to weigh the risk/benefit ratio of enoxaparin for the prevention of PVT in cirrhosis. Anticoagulation or TIPS should probably be indicated in liver transplantation candidates, but avoided in patients not suitable for liver transplantation and with an otherwise poor prognosis. Future studies should evaluate which subgroup of cirrhotics with PVT may benefit from treatment. Management of PVT in cirrhosis should be personalized. Eur J Gastroenterol Hepatol 00:000–000
Resumen Concepto. La hepatitis autoinmune (HAI) es una enfermedad inflamatoria crónica del hígado... more Resumen Concepto. La hepatitis autoinmune (HAI) es una enfermedad inflamatoria crónica del hígado de etiología desconocida que ocurre en personas de todas las edades y se caracteriza por cursar con citolisis, hiper-gammaglobulinemia, niveles elevados de IgG, presencia de autoanticuerpos circulantes y hepatitis de la interfase. Manifestaciones clínicas. La presentación clínica es muy variable, desde el paciente totalmente asinto-mático el que comienza con un cuadro de hepatitis fulminante. Diagnóstico. Por lo tanto, la HAI se debe considerar durante el estudio diagnóstico de cualquier aumen-to en los niveles de enzimas hepáticas. Tratamiento. La HAI responde generalmente de manera excelente al tratamiento inmunosupresor, que debe instaurarse lo más rápidamente posible para prevenir el deterioro progresivo, promover la remisión y mejorar la supervivencia a largo plazo. Los corticosteroides dosificados adecuadamente son la base del tratamiento de inducción de remisión, mientras que el mantenimiento de esta remisión se logra mejor mediante azatioprina. Las alternativas terapéuticas son necesarias en un pequeño grupo de pacientes que responden de forma insuficiente a estos fármacos o son intolerantes a los mismos por efectos se-cundarios. Abstract Autoimmune hepatitis Concept. Autoimmune hepatitis is a chronic inflammatory liver disease of unknown cause that occurs in people of all ages and is characterized by elevated transaminase and immunoglobulin G levels, hipergammaglobulimemia, circulating autoantibodies and interface hepatitis. Clinical manifestations. Presentation is highly variable, ranging from asymptomatic disease to fulminant hepatic failure. Diagnosis. Therefore, autoimmune hepatitis should be considered during the diagnostic workup of any increase in liver enzyme levels. Treatment. Autoimmune hepatitis is exquisitely responsive to immunosuppressive treatment, which should be instituted promptly to prevent rapid deterioration and promote remission and long-term survival. Adequately dosed steroids are the mainstay of remission induction treatment, while remission maintenance is best achieved by azathioprine. Therapeutic alternatives are required in a small group of patients responding insufficiently to these drugs or intolerant of their side effects.
Resumen Objetivo: Realizar una revisión actual sobre el síndrome hepatorrenal, dado que represent... more Resumen Objetivo: Realizar una revisión actual sobre el síndrome hepatorrenal, dado que representa una complicación de gran impacto en la supervivencia del paciente cirrótico. Reconocerlo y tratarlo oportunamente, puede mejorar el pronóstico de estos pacientes. El síndrome hepatorrenal se define como la insuficiencia renal funcional y reversible que ocurre en pacientes con insuficiencia hepática avanzada e hipertensión portal. Se produce por vasoconstricción severa de la circulación renal. Está asociado con mayor riesgo de falle-cimiento pre-trasplante hepático, mayor frecuencia de complicación posterior al trasplante y menor sobrevida posterior a cirugía. La hipertensión portal severa es la principal responsable dentro de la fisiopatología de este síndrome; sin embargo, la respuesta pro-inflamatoria des-encadenada por la translocación bacteriana a partir de la luz intestinal también juega un papel importante. Los criterios diagnósticos fueron revisados recientemente por el Club Internacional de Ascitis (2007). La forma más aceptada para clasificarlo lo divide en tipo 1 y tipo 2, dependiendo del tiempo de evolución y rapidez de progresión. El diagnóstico temprano es crucial para iniciar el tratamiento. El tratamiento aceptado ac-tualmente consiste en vasopresores y albumina en infusión, éste ha demostrado mejorar la supervivencia de estos pacientes mientras se espera realizar el trasplante hepático. Es impor-tante identificar pacientes con infecciones bacterianas, en particular peritonitis bacteriana espontánea, en ellos la administración de albumina en infusión ha resultado efectiva para prevenir el desarrollo de síndrome hepatorrenal.
Portal hypertension (PH) is one of the most important causes of morbidity and mortality in patien... more Portal hypertension (PH) is one of the most important causes of morbidity and mortality in patients with chronic liver disease. PH measurement is crucial to stage and predict the clinical outcome of liver cirrhosis. Measurement of hepatic vein pressure gradient is considered the gold standard for assessment of the degree of PH; however, it is an invasive method and has not been used widely. Thus, noninvasive methods have been proposed recently. We critically evaluated serum markers, abdominal ultrasonography, and particularly liver and spleen stiffness measurement, which represent the more promising methods to stage PH degree and to assess the presence/absence of esophageal varices (EV). A literature search was carried out on MEDLINE, EMBASE, Web of Science, and Scopus for articles and abstracts. The search terms used included 'liver cirrhosis', 'portal hypertension', 'liver stiffness', 'spleen stiffness', 'ultrasonography', and 'portal hypertension serum biomarker'. The articles cited were selected on the basis of their relevance to the objective of the review. The results of available studies indicate that individually, these methods have a mild accuracy in predicting the presence of EV, and thus they cannot substitute endoscopy to predict EV. When these tests were used in combination, their accuracy increased. In addition to the PH staging, several serum markers and spleen stiffness measurement can predict the clinical outcome of liver cirrhosis with a good accuracy, comparable to that of hepatic vein pressure gradient. In the future, noninvasive methods could be used to select patients requiring further investigations to identify the best tailored clinical management. Eur J Gastroenterol Hepatol 27:992–1001
Background Portal vein thrombosis (PVT) is a complication of cirrhosis. However, whether PVT wors... more Background Portal vein thrombosis (PVT) is a complication of cirrhosis. However, whether PVT worsens cirrhosis outcome is a debated issue. Aim To report an update on the management of PVT. Methods A review was performed on the outcome, prevention, and treatment of PVT. Results Some studies suggest that PVT could worsen the rate of hepatic decompensation and survival of cirrhosis, whereas others report a non-negative impact of PVT in the outcome of cirrhosis. Therefore, the prognostic value of PVT in cirrhosis remains a gray zone. One single randomized-controlled trial reported that enoxaparin could prevent PVT, delay the occurrence of hepatic decompensation, and improve survival. However, no further study data confirmed this assumption and the issue is not actually generalizable. Numerous studies report that anticoagulation determines a relatively high rate of portal vein recanalization in cirrhotics PVT. However, further data are warranted to confirm the risk-to-benefit of anticoagulation, especially bleeding. Transjugular intrahepatic portosystemic shunt (TIPS) has been reported to be effective as a treatment of PVT in cirrhosis, with the advantage of avoiding the risk of bleeding linked to anticoagulation. However, there are no data comparing TIPS with anticoagulation as a treatment of PVT in cirrhosis. Furthermore, there is no evidence on whether both anticoagulation and TIPS improve survival. Conclusion It is uncertain whether PVT affects cirrhosis outcome. Further data are needed to weigh the risk/benefit ratio of enoxaparin for the prevention of PVT in cirrhosis. Anticoagulation or TIPS should probably be indicated in liver transplantation candidates, but avoided in patients not suitable for liver transplantation and with an otherwise poor prognosis. Future studies should evaluate which subgroup of cirrhotics with PVT may benefit from treatment. Management of PVT in cirrhosis should be personalized. Eur J Gastroenterol Hepatol 00:000–000
Resumen Concepto. La hepatitis autoinmune (HAI) es una enfermedad inflamatoria crónica del hígado... more Resumen Concepto. La hepatitis autoinmune (HAI) es una enfermedad inflamatoria crónica del hígado de etiología desconocida que ocurre en personas de todas las edades y se caracteriza por cursar con citolisis, hiper-gammaglobulinemia, niveles elevados de IgG, presencia de autoanticuerpos circulantes y hepatitis de la interfase. Manifestaciones clínicas. La presentación clínica es muy variable, desde el paciente totalmente asinto-mático el que comienza con un cuadro de hepatitis fulminante. Diagnóstico. Por lo tanto, la HAI se debe considerar durante el estudio diagnóstico de cualquier aumen-to en los niveles de enzimas hepáticas. Tratamiento. La HAI responde generalmente de manera excelente al tratamiento inmunosupresor, que debe instaurarse lo más rápidamente posible para prevenir el deterioro progresivo, promover la remisión y mejorar la supervivencia a largo plazo. Los corticosteroides dosificados adecuadamente son la base del tratamiento de inducción de remisión, mientras que el mantenimiento de esta remisión se logra mejor mediante azatioprina. Las alternativas terapéuticas son necesarias en un pequeño grupo de pacientes que responden de forma insuficiente a estos fármacos o son intolerantes a los mismos por efectos se-cundarios. Abstract Autoimmune hepatitis Concept. Autoimmune hepatitis is a chronic inflammatory liver disease of unknown cause that occurs in people of all ages and is characterized by elevated transaminase and immunoglobulin G levels, hipergammaglobulimemia, circulating autoantibodies and interface hepatitis. Clinical manifestations. Presentation is highly variable, ranging from asymptomatic disease to fulminant hepatic failure. Diagnosis. Therefore, autoimmune hepatitis should be considered during the diagnostic workup of any increase in liver enzyme levels. Treatment. Autoimmune hepatitis is exquisitely responsive to immunosuppressive treatment, which should be instituted promptly to prevent rapid deterioration and promote remission and long-term survival. Adequately dosed steroids are the mainstay of remission induction treatment, while remission maintenance is best achieved by azathioprine. Therapeutic alternatives are required in a small group of patients responding insufficiently to these drugs or intolerant of their side effects.
Resumen Objetivo: Realizar una revisión actual sobre el síndrome hepatorrenal, dado que represent... more Resumen Objetivo: Realizar una revisión actual sobre el síndrome hepatorrenal, dado que representa una complicación de gran impacto en la supervivencia del paciente cirrótico. Reconocerlo y tratarlo oportunamente, puede mejorar el pronóstico de estos pacientes. El síndrome hepatorrenal se define como la insuficiencia renal funcional y reversible que ocurre en pacientes con insuficiencia hepática avanzada e hipertensión portal. Se produce por vasoconstricción severa de la circulación renal. Está asociado con mayor riesgo de falle-cimiento pre-trasplante hepático, mayor frecuencia de complicación posterior al trasplante y menor sobrevida posterior a cirugía. La hipertensión portal severa es la principal responsable dentro de la fisiopatología de este síndrome; sin embargo, la respuesta pro-inflamatoria des-encadenada por la translocación bacteriana a partir de la luz intestinal también juega un papel importante. Los criterios diagnósticos fueron revisados recientemente por el Club Internacional de Ascitis (2007). La forma más aceptada para clasificarlo lo divide en tipo 1 y tipo 2, dependiendo del tiempo de evolución y rapidez de progresión. El diagnóstico temprano es crucial para iniciar el tratamiento. El tratamiento aceptado ac-tualmente consiste en vasopresores y albumina en infusión, éste ha demostrado mejorar la supervivencia de estos pacientes mientras se espera realizar el trasplante hepático. Es impor-tante identificar pacientes con infecciones bacterianas, en particular peritonitis bacteriana espontánea, en ellos la administración de albumina en infusión ha resultado efectiva para prevenir el desarrollo de síndrome hepatorrenal.