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Introduction: Malnutrition is one of the most common complications of liver cirrhosis. Yet, little attention is paid in evaluating nutrition in this group of patients. This study aims to assess malnutrition among cirrhotic patients using a nutrition screening tool and anthropometry. Methods: This was a prospective, observational study of admitted patients with liver cirrhosis. In the study duration of 3months, 50 patients met the inclusion criteria and were included. Nutritional assessment was performed using the Royal Free Hospital Nutritional Prioritizing Tool (RFH-NPT), BMI and standard anthropometry including TSF,MUAC and MAMC. Results: The mean age was 51.56 ± 11.50 with a Male to Female ratio of 3:2. Chronic alcohol consumption (72%) was the most common etiology while management of tense as cites (40%) was the most common reason for hospital admission. 58% had Child Pugh Class C cirrhosis while the remaining 42% were Class B. The average MELD Nascore was 19.64 ± 6. Significant differences in anthropometric measurements including BMI, MUAC, TSF and MAMC were found between Child B and C cirrhosis. Similarly, those patients who had low, moderate and high-risk of malnutrition by the RFH-NPT had significant differences in anthropometric measurements between them. Conclusion: A significant number of patients had moderate to severe risk of malnutrition that correlated well with anthropometric measurements. The degree of malnutrition is parallel with the severity of liver disease among these patients. Both the RFH-NPT and anthropometry are relatively easy to perform and effective. Hence, they can be used as a practical means for identifying malnutrition among cirrhotic patients in routine clinical practice.

This prospective observational study aimed to clinically describe voriconazole administrations and trough concentrations in patients with Child–Pugh class C and to investigate the variability of trough concentration. A total of 144 voriconazole trough concentrations from 43 Child–Pugh class C patients were analyzed. The majority of patients (62.8%) received adjustments. The repeated measured trough concentration was higher than the first and final ones generally (median, 4.33 vs. 2.99, 3.90 mg/L). Eight patients with ideal initial concentrations later got supratherapeutic with no adjusted daily dose, implying accumulation. There was a significant difference in concentrations among the six groups by daily dose (p = 0.006). The bivariate correlation analysis showed that sex, CYP2C19 genotyping, daily dose, prothrombin time activity, international normalized ratio, platelet, and Model for end-stage liver disease score were significant factors for concentration. Subsequently, the first four factors mentioned above entered into a stepwise multiple linear regression model (variance inflation factor &lt, 5), implying that CYP2C19 testing makes sense for precision medicine of Child–Pugh class C cirrhosis patients. The equation fits well and explains the 34.8% variety of concentrations (R2 = 0.348). In conclusion, it needs more cautious administration clinically due to no recommendation for Child–Pugh class C patients in the medication label. The adjustment of the administration regimen should be mainly based on the results of repeated therapeutic drug monitoring.

Background/Aims: There is a controversy about the availability of invasive treatment for esophageal/gastric varices in patients with Child-Pugh class C (CP-C) end-stage liver cirrhosis (LC). We have evaluated the validity of invasive treatment with CP-C end-stage LC patients. Methods: The study enrolled 51 patients with CP-C end-stage LC who had undergone invasive treatment. The treatment modalities included endoscopic variceal ligation in 22 patients, endoscopic injection sclerotherapy in 17 patients, and balloon-occluded retrograde transvenous obliteration (BRTO) in 12 patients. We have investigated the overall survival (OS) rates and risk factors that contributed to death within one year after treatment. Results: The OS rate in all patients at one, three, and five years was 72.6%, 30.2%, and 15.1%, respectively. The OS rate in patients who received endoscopic treatment and the BRTO group at one, three, and five years was 67.6%, 28.2% and 14.1% and 90.0%, 36.0% and 18.0%, respectively. The average of Child-Pugh scores (CPS) from before treatment to one month after variceal treatment significantly improved from 10.53 to 10.02 (P=0.003). Three significant factors that contributed to death within one year after treatment included the presence of bleeding varices, high CPS (≥11), and high serum total bilirubin levels (≥4.0 mg/dL). Conclusions: The study demonstrated that patients with a CPS of up to 10 and less than 4.0 mg/dL of serum total bilirubin levels may not have a negative impact on prognosis after invasive treatment for esophageal/gastric varices despite their CP-C end-stage LC. (Clin Mol Hepatol 2019;25:183-189)

Therapeutic drug monitoring for voriconazole, an antifungal agent, is essential for maximizing efficacy and preventing toxicity. The aim of this study was to elucidate the optimal maintenance dose of voriconazole in patients with severe liver cirrhosis (Child-Pugh class C) by reviewing the plasma trough concentrations obtained by therapeutic drug monitoring and daily doses of voriconazole. We retrospectively evaluated 6 patients with Child-Pugh class C cirrhosis who received oral voriconazole treatment and were liver transplant recipients or were awaiting liver transplantation. We compared their voriconazole trough concentrations and daily maintenance doses to those of patients who did not have liver cirrhosis (n=56). We found that plasma voriconazole trough concentrations in all patients with Child-Pugh class C were almost within therapeutic range, and the median plasma trough concentration at steady state was not significantly different from that of patients who did not have liver cirrhosis. In addition, the median daily maintenance dose of voriconazole was significantly lower (2.13 mg/kg/d) than that of the control patients (6.27 mg/kg/d), suggesting that trough voriconazole concentrations are elevated in Child-Pugh class C patients. Thus, we conclude that oral voriconazole maintenance doses in patients with Child-Pugh class C should be reduced to approximately one-third that of patients with normal liver function, with the follow-up dose adjusted by therapeutic drug monitoring.

Aim Aim: To clarify the survival and prognostic factors in patients with Child–Turcotte–Pugh class C (CTP-C) cirrhosis. Methods From all candidates for deceased donor liver transplantation in Japan between 2007 and 2015, 1014 adult patients with CTP-C cirrhosis were retrospectively enrolled in this study. The hazard ratio (HR) of factors associated with mortality was estimated by the Cox proportional hazard model. The survival probabilities were evaluated by Kaplan–Meier analysis and the log–rank test. Results Median survival time of the entire cohort was 475 days. Univariate analysis identified age, CTP, Model for End-Stage Liver Disease (MELD) score, and primary biliary cholangitis (PBC) as significant variables associated with mortality and hepatitis B virus (HBV) infection as a close-to-significant variable. Multivariate analysis revealed that age-adjusted mortality risk increased by 59% and 12% per 1 score step up in CTP and MELD scores, respectively. The HRs for HBV infection and PBC were significant after adjustment for age and CTP score, and they showed a 26% lower risk and an 83% higher risk than hepatitis C virus (HCV) infection, respectively. After adjustment for age and MELD score, the HR was also significant for HBV infection, but lost statistical significance for PBC. The survival curves were well stratified by both CTP or MELD score and revealed significant difference in both HBV infection and PBC as compared to HCV infection. Conclusions In patients with CTP-C cirrhosis, CTP and MELD scores could well stratify the patients’ survival, and HBV infection and PBC as etiologies have an impact on survival.

Background & aims The prognostic role of gender in patients with liver cirrhosis is not fully understood. Our primary aim was to assess how gender affects cumulative incidence and risk of death without liver transplantation (LT) in cirrhotic patients with gastroesophageal varices. Secondary aims were to assess the relationship between gender and cause specific death, risk of variceal bleeding and incidence rates of gastroesophageal varices in patients with cirrhosis. Methods All new patients with gastroesophageal varices due to liver cirrhosis at Oslo University Hospital between 2006 and May 2016 were identified. Clinical data were retrieved retrospectively from hospital files. Causes of death were classified according to a specified protocol in cases of in-hospital-death, otherwise by data from the Norwegian Death Registry. Competing risk analyses were used to calculate cumulative incidences and risks of i) all-cause death, ii) cause-specific death and iii) variceal bleeding or re-bleeding. Results Cumulative one- and five years incidence of death without LT in 266 included patients were 28% and 51%, respectively. In univariate analysis, risk of death was positively associated with age, Child Pugh class, alcoholic liver disease and presentation with variceal bleeding, and negatively associated with female sex. In a multivariate model, risk of death without LT was associated with female sex (SHR 0.59 [0.40–0.86]), age (SHR 1.05 [1.04–1.07] per year), Child Pugh class B (SHR 1.54 [1.03–2.32]) and Child Pugh class C (SHR 4.29 [2.57–7.17]). Variceal bleeding caused 27% of deaths. Adjusting for age and Child Pugh score, a trend towards reduced risk of death due to variceal bleeding was seen in women (SHR 0.53; [0.26–1.06]). High alcohol consumption was associated with increased risk of first variceal bleeding, both at univariate analysis (SHR 7.73 [1.71–34.9]) and multivariate analysis (SHR 13.9 [2.51–77.0]). Conclusions Reduced mortality due to variceal bleeding may contribute to improved survival without LT in cirrhotic women with gastroesophageal varices.

Background: Cirrhosis of liver refers to a progressive condition that disrupts the normal architecture of the liver. It is increasingly recognized that cirrhosis per se can cause cardiac dysfunction. The aim was to assess cardiovascular dysfunction electrocardiographically and echocardiographically in patients with cirrhosis of liver and to find the correlation between cardiovascular dysfunction and severity of liver cirrhosis as per child-PUGH score.Methods: Total 90 patients of cirrhosis of liver of both sexes were included in this cross-sectional study conducted from January 2018 to August 2019 in SGRDIMSR, Sri Amritsar. The severity of liver cirrhosis was assessed as per Child Pugh Score. QTc interval was calculated by Bazett’s formula. Systolic and Diastolic dysfunction was seen on 2D-echocardiography.Results: QTc interval increased linearly with the severity of liver cirrhosis. Mean values of QTc in Child Pugh Class A=425.00(±20.97), Class B=437.35(±42.60), Class C=479.71(±29.48) with p value of 0.04 which is significant. Diastolic dysfunction was also related with the severity of liver cirrhosis. In Child Pugh Class A= 2(33%) patients had grade 1 diastolic dysfunction, Class B=23(59%) patients had grade 1 diastolic dysfunction while in Child Pugh Class C=3(7%) had grade 1 diastolic dysfunction, 33(73%) patients had grade 2 diastolic dysfunction and 1(2%) patients had grade 3 diastolic dysfunction with p value of 0.04 which is significant. Systolic function was found normal in all the patients.Conclusions: Diastolic dysfunction and QTc interval prolongation are both related with the severity of liver cirrhosis and are major criteria of cirrhotic cardiomyopathy.

Objective: Zinc is a vital trace element and its deficiency in cirrhosis might potentiate the development of hepatic encephalopathy. The objective of this study was to assess the zinc levels in serum of patients having viral cirrhosis and compare it with normal healthy controls. Methods: This study was conducted in Department of Gastroenterology, Liaquat National hospital and medical college, Karachi, Pakistan; from January 2014 to December 2014. Total of 45 patients with the mean age of 52.44±8.7 years were included. The three groups of patients were made including Child Pugh Class Score B (Group-1), Child Pugh Class C (Group-2) and healthy controls (Group-3) having 15 patients in each group. Zinc levels in serum were evaluated by the help of atomic absorption spectrometry (Normal range50-150 µg/dl). Results: Total of 45 subjects was enrolled in this study. Overall prevalence of zinc deficiency was noted in 13(28.9%) patients. Mean value of zinc levels in group 1,2 and 3 were 68.09±20.85, 50.69±15.86 and 92.91±17.18µg/dL respectively. Highly statistical difference was observed in the mean zinc level between three groups p=0.0001. An inverse correlation was observed between Child Pugh Score and the zinc level in serum r=-0.498. Conclusion: Patients suffering from advanced cirrhosis appeared to have lower serum zinc levels. In patients suffering from viral cirrhosis having hepatic encephalopathy, zinc supplementation might improve clinical outcome.

Background/Aims There is a controversy about the availability of invasive treatment for esophageal/gastric varices in patients with Child-Pugh class C (CP-C) end-stage liver cirrhosis (LC). We have evaluated the validity of invasive treatment with CP-C end-stage LC patients. Methods The study enrolled 51 patients with CP-C end-stage LC who had undergone invasive treatment. The treatment modalities included endoscopic variceal ligation in 22 patients, endoscopic injection sclerotherapy in 17 patients, and balloon-occluded retrograde transvenous obliteration (BRTO) in 12 patients. We have investigated the overall survival (OS) rates and risk factors that contributed to death within one year after treatment. Results The OS rate in all patients at one, three, and five years was 72.6%, 30.2%, and 15.1%, respectively. The OS rate in patients who received endoscopic treatment and the BRTO group at one, three, and five years was 67.6%, 28.2% and 14.1% and 90.0%, 36.0% and 18.0%, respectively. The average of Child-Pugh scores (CPS) from before treatment to one month after variceal treatment significantly improved from 10.53 to 10.02 (P=0.003). Three significant factors that contributed to death within one year after treatment included the presence of bleeding varices, high CPS (≥11), and high serum total bilirubin levels (≥4.0 mg/dL). Conclusions The study demonstrated that patients with a CPS of up to 10 and less than 4.0 mg/dL of serum total bilirubin levels may not have a negative impact on prognosis after invasive treatment for esophageal/gastric varices despite their CP-C end-stage LC.

Background and study aims: The results of endoscopic treatment with elastic band ligation for esophageal variceal bleeding in patients with Child-Pugh class C cirrhosis remain poor. In comparison with treatment with elastic band ligation, we have found lower rates of rebleeding and mortality with n-butyl-2-cyanoacrylate injections. Thus, the aim of the current study was to describe our unit’s 10 years of experience with injection of n-butyl-2-cyanoacrylate to control esophageal variceal ruptures in patients with Child-Pugh class C cirrhosis. Patients and methods: A single-center, retrospective study was conducted. Sixty-three patients with Child-Pugh class C cirrhosis had been admitted to the center with an acute episode of esophageal variceal bleeding. All were treated with injection of n-butyl-2-cyanoacrylate. The patients were assigned to 1 of 2 groups according to their Child-Pugh class C cirrhosis scores: group I (score range, 10 through 13 points) and group II (score, 14 or 15 points). The 3 variables studied were rates of initial failure to control bleeding, failure to prevent rebleeding (secondary prophylaxis), and mortality. Patients in the 2 groups (group I, n = 50; group II, n = 13) had similar characteristics. Results: Bleeding was successfully controlled in almost 75 % of the patients during the first 5 days after treatment, with no significant differences observed between groups I and II. There were no significant differences between the 2 groups with respect to mortality rate for the first 5 days after treatment. Thirty-four patients (54 %) were free of bleeding at 6 weeks after treatment, with a significant difference noted between the groups: group I, 64 %, versus group II, 15.4 % (P

Background and aims Bacterial infections of ascitic fluid of cirrhotic patients are related to high morbidity and mortality. The aim of the study was to determine the variants of ascitic fluid bacterial infection in patients with advanced cirrhosis (Child Pugh Class C). Materials and methods We analyzed 35 consecutive cirrhotic patients of Child Pugh Class C with ascites attending the outpatient department (OPD) of Hepatology Department, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from January 2008 to December 2009. Clinical and laboratory parameters of these patients were recorded. Results Among the total 35 patients, eight patients were symptomatic and 27 patients were asymptomatic. Out of eight symptomatic patients, two had ascitic fluid bacterial infection (25%), whereas six of 27 asymptomatic patients (22.2%) had ascitic fluid bacterial infection. Conclusion Bacterial infection should always be considered in patients with ascites with liver cirrhosis irrespective of their symptoms. How to cite this article Sarker JA, Alam MS, Khan M, Mahtab MA, Ashraf MS, Khondaker FA. Variant of Ascitic Fluid Bacterial Infections in Patients of Liver Cirrhosis. Euroasian J Hepato-Gastro-enterol 2015;5(2):131-133.

To evaluate the utility of emergent transcatheter arterial embolization for spontaneously ruptured hepatocellular carcinoma (HCC) in patients with Child-Pugh class C (CPC) liver cirrhosis presenting hemorrhagic shock.A study of all 94 patients was retrospectively conducted from January 2006 to January 2016. Sixty patients underwent conservative treatment (control group) and 34 underwent embolization.Embolization provided better stabilization of hemodynamic status than conservative treatment (91.2% vs 61.7%), with greater overall survival (OS) rates at 30, 60, and 120 days (73.5%, 52.9%, and 29.4% vs 33.3%, 13.3%, and 0%, respectively). Mean follow-up duration was 51.07 days (range, 3-237 d). Median survival time was longer for the embolization group than the control group, specifically for patients with a shock index (SI) of ≥ 0.6 to1 (106.0 d ± 39.4 vs 34.0 d ± 4.7) or ≥ 1 (18.0 d ± 7.5 vs 11.0 d ± 3.2), those with CPC scores 10 or 11 (88.0 d ± 29.4 vs 28.0 d ± 4.5), and those with segmental (165.0 d ± 20.6 vs 34.0 d ± 9.7) or lobar (54.0 d ± 7.9 vs 26.0 d ± 3.4) portal vein tumor thrombus (PVTT). SI ≥ 1, Child-Pugh score of 12/13, tumor size ≥ 10 cm, and PVTT were independent factors in poor prognosis for OS.Emergent transcatheter arterial embolization is an effective intervention for ruptured HCC in patients with CPC liver function in hemorrhagic shock, particularly those with a SI ≥ 1, Child-Pugh scores of 10/11, and first- or lower-order PVTT.

Pasteurella multocida, a zoonotic agent transmitted by canines and felines, has been very rarely reported to cause bacterial peritonitis in humans. Pasteurella multocida peritonitis is associated with high mortality even with appropriate treatment, therefore its early recognition is essential. We report a case of Pasteurella multocida peritonitis following cat scratch in a patient with Child Pugh Class C alcoholic cirrhosis, culminating in multiple organ failure and death.

Background: Hepatic encephalopathy (HE) is a common complication of liver disease that requires intensive care management. The prevalence of HE is increasing during recent period. The most important factors of HE are alcohol consumption, chronic hepatitis, hepatotoxic drugs and unhealthy changes in life style. There were only relatively few studies from our region on the changing profile of hepatic encephalopathy under the background of life style changes. This study was conducted with the aim to detect the changing pattern of clinical profile, precipitants and to assess the prognosis of patients with hepatic encephalopathy.Methods: This was a prospective study for a period of 18 months since January 2012 at Academy of Medical Sciences, Pariyaram, Kannur, a tertiary care centre situated in the northern part of Kerala. Patients admitted in the medical and gastroenterology wards and intensive care units that fulfilled the inclusion criteria were enrolled in this study.Results: Among the 76 patients with HE, 60 were suffering from CLD and 16 due to acute liver failure. The common etiologies for HE in CLD patients were Alcoholic cirrhosis (63%), Cryptogenic cirrhosis (17%) and cirrhosis due to chronic HBV (10%) and HCV hepatitis (7%) respectively. Among the CLD patients at the start of observation majority were in Child Pugh class B and C. Based on West Haven grading most of them had Grade 2 and 3 HE. Majority with Grade 1, 2 and 3 improved where as those with Grade 4 and Grade 3 in Child Pugh class C worsened. The common precipitants of HE were GI bleed, dyselectrolemia, constipation and infections. Among these precipitants a statistically significant association for a worse outcome was present only with infection. Leptospirosis and deliberate self-harm due to ingestion of hepatotoxic rodenticide and paracetamol were the leading cause of hepatic encephalopathy in acute liver failureConclusions: In present study HE was most commonly seen in patients with alcoholic liver disease. Cryptogenic cirrhosis associated with other life style diseases was the second common condition. Among all precipitating factors infection appeared as a statistically significant factor predicting a worse outcome. Health education among alcoholic patients and life style modifications to prevent cryptogenic cirrhosis are of paramount importance in curtailing the increase in incidence of HE in this region.

Open heart surgery in patients with Child-Pugh class C liver cirrhosis has a high mortality rate and is generally considered to be contraindicated. A patient with liver cirrhosis (Child-Pugh class C) underwent mandatory complex open heart surgery due to severe heart failure. The perioperative management, including the prophylactic use of intraaortic balloon pumping to increase the hepatic blood flow and the early initiation of continuous veno-venous hemodialysis to avoid hepatic congestion, enabled the patient to survive.

The authors report the case of a patient who presented with small bowel obstruction while awaiting liver transplant for Child-Pugh class C cirrhosis. He underwent emergency liver transplant with resection of the small bowel after the obstruction did not improve with conservative management. The authors believe this is the first case of successful emergency liver transplant with resection of the small bowel in a patient with decompensated Child-Pugh class C liver cirrhosis and strangulated umbilical hernia. This case suggests the possibility of improved outcomes of emergency hernia repair in patients with liver cirrhosis when small bowel resection is combined with liver transplant.