Search

Three-dimensional (3D) visualization involves feature extraction and 3D reconstruction of CT images using a computer processing technology. It is a tool for displaying, describing, and interpreting 3D anatomy and morphological features of organs, thus providing intuitive, stereoscopic, and accurate methods for clinical decision-making. It has played an increasingly significant role in the diagnosis and management of liver diseases. Over the last decade, it has been proven safe and effective to use 3D simulation software for pre-hepatectomy assessment, virtual hepatectomy, and measurement of liver volumes in blood flow areas of the portal vein; meanwhile, the use of 3D models in combination with hydrodynamic analysis has become a novel non-invasive method for diagnosis and detection of portal hypertension. We herein describe the progress of research on 3D visualization, its workflow, current situation, challenges, opportunities, and its capacity to improve clinical decision-making, emphasizing its utility for patients with liver diseases. Current advances in modern imaging technologies have promised a further increase in diagnostic efficacy of liver diseases. For example, complex internal anatomy of the liver and detailed morphological features of liver lesions can be reflected from CT-based 3D models. A meta-analysis reported that the application of 3D visualization technology in the diagnosis and management of primary hepatocellular carcinoma has significant or extremely significant differences over the control group in terms of intraoperative blood loss, postoperative complications, recovery of postoperative liver function, operation time, hospitalization time, and tumor recurrence on short-term follow-up. However, the acquisition of high-quality CT images and the use of these images for 3D visualization processing lack a unified standard, quality control system, and homogeneity, which might hinder the evaluation of application efficacy in different clinical centers, causing enormous inconvenience to clinical practice and scientific research. Therefore, rigorous operating guidelines and quality control systems need to be established for 3D visualization of liver to develop it to become a mature technology. Herein, we provide recommendations for the research on diagnosis and management of 3D visualization in liver diseases to meet this urgent need in this research field.

As doenças do fígado e das vias biliares são causas comuns de morbidade e mortalidade. Procedimentos invasivos com finalidade diagnóstica e terapêutica são frequentemente recomendados nos casos de doenças hepatobiliares. O reconhecimento das indicações e limitações das técnicas comumente empregadas é crucial para uma adequada seleção dos pacientes, maximizando os resultados positivos e reduzindo o risco de complicações. Em 2018, a Sociedade Brasileira de Hepatologia (SBH), em colaboração com a Sociedade Brasileira de Radiologia Intervencionista e Cirurgia Endovascular (SOBRICE) e a Sociedade Brasileira de Endoscopia Digestiva (SOBED) realizaram um encontro exclusivamente voltado para a discussão dos procedimentos invasivos nas doenças hepatobiliares. Este texto resume as principais recomendações discutidas durante o evento, e tem a intenção de auxiliar clínicos, gastroenterologistas, hepatologistas, radiologistas e endoscopistas no uso adequado dos procedimentos invasivos para manejo de pacientes com doenças hepatobiliares. Liver and biliary tract diseases are common causes of morbidity and mortality worldwide. Invasive procedures are usually performed in those patients with hepatobiliary diseases for both diagnostic and therapeutic purposes. Defining proper indications and restraints of commonly used techniques is crucial for proper patient selection, maximizing positive results and limiting complications. In 2018, the Brazilian Society of Hepato­logy (SBH) in cooperation with the Brazilian Society of Interventional Radiology and Endovascular surgery (SOBRICE) and the Brazilian Society of Digestive Endoscopy (SOBED) sponsored a joint single-topic meeting on invasive procedures in patients with hepatobiliary diseases. This paper summarizes the proceedings of the aforementioned meeting. It is intended to guide clinicians, gastroenterologists, hepatologists, radiologists, and endoscopists for the proper use of invasive procedures for management of patients with hepatobiliary diseases.

Background Cirrhotic cardiomyopathy is characterized by an attenuated contractile response to stress. Long-term exposure of β-adrenergic receptors to persistently high levels of catecholamines has been implicated in its pathogenesis. We hypothesized that β-blockade with metoprolol could reverse the changes in heart function and morphology in cirrhotic cardiomyopathy. Patients and methods In this prospective randomized trial, we included 78 patients aged between 18 and 60 years with abnormal cardiac output response under dobutamine stress echocardiography, without primary cardiac disease or a history of alcohol intake. Patients were assigned randomly to receive metoprolol or placebo for 6 months. The primary endpoint was the improvement in cardiac output response to stress, measured by an increase in the left ventricle stroke volume more than 30%. Results Three (7.3%) patients in the metoprolol group and nine (24.3%) patients in the placebo group showed improved stroke volume (P=0.057). Diastolic dysfunction was found in two (4.8%) patients before and in five (15.6%) patients after therapy in the metoprolol group, and in 10 (27%) patients before and nine (31%) patients after therapy in the placebo group (P=0.67). After treatment, no echocardiography parameter of morphology was significantly different between metoprolol or placebo groups. No significant differences were observed in noradrenaline, plasma renin activity, and troponin levels between groups. Cirrhosis-related clinical events, including hospitalizations and mortality, were not significantly different between the two groups. Six months of therapy with β-blocker did not ameliorate heart function and morphology in patients with cirrhotic cardiomyopathy.

Background Patients with cirrhosis have high risk of bacterial infections and cirrhosis decompensation, resulting in admission to emergency department (ED). However, there are no criteria developed in the ED to identify patients with cirrhosis with bacterial infection and with high mortality risk. Study objective The objective of the study is to identify variables from ED arrival associated with bacterial infections and inhospital mortality. Methods This is a retrospective single-center study using a tertiary hospital's database to identify consecutive ED patients with decompensated cirrhosis. Clinical variables and laboratory results were obtained by chart review. Logistic regression models were built to determine variables independently associated with bacterial infection and mortality. Scores using these variables were designed. Results One hundred forty-nine patients were enrolled, most of them males (77.9%) with alcoholic cirrhosis (53%) and advanced liver disease (Child-Pugh C, 47.2%). Bacterial infections were diagnosed in 72 patients (48.3%), and 36 (24.2%) died during hospital stay. Variables independently associated with bacterial infection were lymphocytes less than or equal to 900/mm 3 (odds ratio [OR], 3.85 [95% confidence interval {CI}, 1.47-10]; P = .006) and C-reactive protein greater than 59.4 mg/L (OR, 5.05 [95% CI, 1.93-13.2]; P = .001). Variables independently associated with mortality were creatinine greater than 1.5 mg/dL (OR, 4.35 [95% CI, 1.87-10.1]; P = .001) and international normalized ratio greater than 1.65 (OR, 3.71 [95% CI, 1.6-8.61]; P = .002). Scores designed to predict bacterial infection and mortality (Mortality in Cirrhosis Emergency Department Score) had an area under the receiver operating characteristic curve of 0.82 and 0.801, respectively. The Mortality in Cirrhosis Emergency Department Score performed better than Model for End-Stage Liver Disease score. Conclusions In this cohort of ED patients with decompensated cirrhosis, lymphopenia and elevated C-reactive protein were related to bacterial infections, and elevated creatinine and international normalized ratio were related to mortality. Scores built with these variables should be prospectively validated.

Heart and liver were already put into reciprocal interaction when attempting to explain the health-disease process from the humoral theory. This suggestion attributed to Empedocles (490 BC), and later applied to medicine by Hippocrates (460 BC) and Galen (AD 129), despite being devoid of any pathophysiological basis, suggested that such organs were protagonists of illness by participating in the production of blood and yellow bile, two of the four humors whose imbalance would be closely related to the emergence of diseases. With the progress of knowledge of physiology and pathophysiology, the close relationship between heart and liver has been defined more precisely. In this article, we will discuss the cardiohepatic interactions subdividing them didactically in the following: (1) impact of heart diseases on the liver; (2) effects of liver failure and portal hypertension on the heart; and (3) concomitant diseases affecting both the liver and the heart. Impact of heart disease on the liver (cardiac hepatopathy) The liver is an organ sensitive to hemodynamic changes. Due to its high metabolic activity, it receives around 25% of the cardiac output, coming by two systems of blood vessels: the hepatic artery and the portal vein. The venous drainage occurs by hepatic veins and the inferior vena cava, which have no valves, resulting in direct transmission of the rise of right heart filling pressures to the liver. The systemic circulatory disorders transmitted to the liver determine two major forms of liver damage: the ischemic hepatitis and the congestive liver disease or congestive liver (formerly named cardiac cirrhosis). The former, called "shock liver", today known as ischemic hepatitis, occurs in some cases of cardiogenic shock. There is a predominant change of the aminotransferases (ALT and AST), with elevation up to 10 to 20 times the upper limit of the normal value1. Such hepatitis should be differentiated from those caused by drugs (many of them used in cardiology), acute viral hepatitis and from chronic hepatitis exacerbation of different etiologies. To aid in the differential diagnosis, the pattern of the curve of aminotransferases should be taken into account, with aminotransferases increasing a few hours after the injury and improving with the resolution of the circulatory dysfunction. Serum levels start to reduce within 48 to 72 hours after the event, with normalization in 10 to 14 days. Another feature that assists in identifying the ischemic hepatitis is the marked increase in lactic dehydrogenase, which doesn't usually happen in hepatitis by other causes. Congestive liver disease is more frequent than ischemic hepatitis. Studies on liver biopsy in candidates for implantable ventricular assistance devices show findings compatible with cirrhosis in 34% of patients2. Congestive liver disease can manifest itself with pain in the right hypochondrium, sensation of abdominal growth and early satiety. In laboratorial tests, changes suggestive of cholestasis are displayed, i.e. increased canaliculares enzymes, with varying degrees of elevated bilirubins. Around 19% of outpatients show elevation of these markers. The finding of increasing canaliculares enzymes in blood demonstrates greater severity of heart failure (HF)3. Recently, with the incorporation of new technologies for the treatment of refractory HF, the assessment of hepatic effects has gained importance. Liver markers denote the prognosis in candidates for implantable ventricular assistance devices. The MELD score (Model for End-Stage Liver Disease), numeric scale of severity in the short term for liver disease and extensively used in the management of liver transplantation lists, has emerged as a promising marker to identify the best candidates for treatment with such devices.

Purpose: Up to 50% of deaths in the perioperative period of liver transplantation are attributed to cardiovascular events. The existence of cardiovascular disease increases the perioperative risk and mortality in the first month post-transplant. There is no specific score validated for preoperative liver transplantation evaluation, nor clinical predictors that identify those patients who need thorough assessment and care. The aim of this study is to identify predictors of the presence of heart disease among patients evaluated for liver transplantation. Methods: 453 outpatients consecutively evaluated in the waiting list for liver transplantation underwent a cardiological assessment protocol that included: history and physical examination, estimation of functional capacity, electrocardiography, chest radiography and echocardiography. Myocardial perfusion scintigraphy, dobutamine stress echocardiography or coronary angiography were performed in patients with moderated or high likelihood of coronary disease. The severity of cirrhosis was estimated by MELD score (Model for End-Stage Liver Disease), which is calculated from laboratory tests (prothrombin time, bilirubin and creatinine). Statistical analysis: Continuous variables were presented as mean and standard deviation or median. Categorical variables were presented as proportions and/or percentages. Continuous variables were compared with the Mann-Whitney test and categorical variables with the chi-square test. The p value

Introdução: A ligadura elástica de varizes de esôfago (LEVE) é um método de tratamento endoscópico amplamente utilizado. Apesar da sua reconhecida eficácia, em torno de 5% a 10% dos pacientes tratados apresentam úlceras hemorrágicas no local de aplicação da ligadura, com difícil controle do sangramento. Até o momento, não está claro na literatura os possíveis fatores preditivos da ocorrência dessa complicação. Objetivo: Avaliar a prevalência e determinar os fatores de risco para sangramento por úlcera após ligadura elástica de varizes esofagianas em pacientes com hipertensão portal cirrótica. Pacientes e métodos: Estudo retrospectivo de pacientes com cirrose submetidos à ligadura elástica de varizes de esôfago no período de janeiro de 2006 a dezembro de 2013. Critérios de inclusão: candidatos a LEVE e idade >= 18 anos . Critérios de exclusão: portadores de TIPS, gestantes e falta de dados (prontuário não disponível para consulta). As variáveis clínicas, laboratoriais e endoscópicas dos pacientes foram avaliados quanto à sua influência na ocorrência de hemorragia digestiva alta (HDA) após LEVE mediante modelos de regressões logísticas uni e multivariadas. Os resultados foram validados internamente pelos métodos \"leave-one-out\" e Bootstrap. Foi adotado um nível de significância de 5%. Resultados: Foram avaliados 40.061 exames de endoscopia, sendo selecionados 513 pacientes submetidos à LEVE. Entre estes pacientes, vinte e um (4,1%) apresentaram sangramento após LEVE . Os 492 restantes foram classificados como controle. Não houve diferenças entre os grupos com relação à etiologia da doença hepática. Os pacientes que sangraram após LEVE freqüentemente apresentavam ascite (p= 0,028), etilismo ativo (p=0,013), albumina sérica mais baixa (p < 0,001) e predominantemente classificados como Child C (p=0,004). Não se verificou associação entre sangramento e sinais vermelhos ou tipo de profilaxia de sangramento varicoso. Utilizando o modelo de regressão logística multivariada com os componentes da classificação de Child, observamos que a albumina (OR:0,17, IC95%:0,08-0,37 ,p < 0,001) e o número de sessões de LEVE (OR:1,29, IC95%:1,04-1,59, p=0,021) estiveram associados ao evento sangramento após LEVE. No modelo com o estádio Child permanecem significantes o número de sessões de LEVE (OR:1,25, IC95%:1,02-1,54 ,p=0,032) e observamos que o estadiamento Child C (OR:6,81, IC95%:2,18-21,25, p=0,001) foi associado ao aumento do risco de sangramento. Verificou-se maior poder de discriminação (AUC 0,80) no modelo utilizando o nível de albumina sérica e o número de sessões de LEVE. Neste modelo, a sensibilidade foi 81,0%, a especificidade foi 69,9% e a acurácia 70,4%. Na validação interna cruzada por \"leave-one-out\" a sensibilidade foi 76,2%, especificidade 69,7% e a acurácia 70% e por Bootstrap foi 77,3%,71,9%, a acurácia 72,2% respectivamente BACKGROUND AND AIMS:Band ligation of esophageal varices (EVBL) is a widely used endoscopic treatment method. Despite its recognized efficacy, around 5% to 10% of treated patients have hemorrhagic ulcers at the ligature site, with difficult bleeding control. So far, it is not clear in the literature the possible predictors of the occurrence of this complication. Evaluate the prevalence and determine risk factors for ulcer bleeding after band ligation of esophageal varices in patients with cirrhotic portal hypertension. METHODS: Retrospective study of patients with cirrhosis who underwent band ligation of esophageal varices from January 2006 to December 2013. Inclusion criteria: EVBL candidates and age >= 18 years. Exclusion criteria: TIPS patients, pregnant women and lack of data (medical records not available for consultation). The clinical, laboratory and endoscopic variables of the patients were evaluated for their influence on the occurrence of upper gastrointestinal hemorrhage after EVBL using univariate and multivariate logistic regression models. The results were internally validated by the leave-one-out and bootstrap methods. A significance level of 5% was adopted RESULTS: 40,061 endoscopy exams were evaluated, and 513 patients undergoing EVBL were selected. Among these patients, twenty-one (4.1%) had bleeding after EVBL. The remaining 492 were classified as controls. There were no differences between groups regarding the etiology of liver disease. Patients who bled after EVBL most frequently had ascites (p=0.028), active alcoholism (p=0.013), lower serum albumin (p < 0.001) and predominantly classified as Child C (p=0.004). There was no association between bleeding and red signs or type of varicose bleeding prophylaxis. Using the multivariate logistic regression model with the components of the Child classification, we observed that albumin (OR: 0.17, 95% CI:0.08-0.37, p < 0.001) and the number of EVBL sessions (OR: 1.29, 95% CI:1.04-1.59, p=0.021) were associated with the bleeding event after EVBL. In the Child stage model, the number of EVBL sessions (OR: 1.25, 95% CI: 1.02-1.54, p=0.032) remained significant, and we observed that Child C staging (OR: 6.81, 95% CI: 2.18-21.25, p=0.001) was associated with increased risk of bleeding. Higher discriminating power (AUC 0.80) was found in the model using serum albumin level and number of EVBL sessions. In this model, sensitivity was 81.0%, specificity was 69.9% and accuracy 70.4%. In the internal validation crossed by \"leave-one-out\" sensitivity was 76.2%, specificity 69.7% and accuracy 70% and Bootstrap was 77.3%, 71.9%, accuracy 72.2%. respectively