Clinically significant portal hypertension (CSPH) is responsible for most of the complications in patients with cirrhosis. Liver stiffness (LS) measurement by vibration-controlled transient elastography (VCTE) is currently used to evaluate CSPH. Bi-dimensional shear wave elastography from General Electric (2D-SWE.GE) has not yet been validated for the diagnosis of PHT. Our aims were to test whether 2D-SWE.GE-LS is able to evaluate CSPH, to determine the reliability criteria of the method and to compare its accuracy with that of VCTE-LS in this clinical setting. Patients with chronic liver disease referred to hepatic catheterization (HVPG) were consecutively enrolled. HVPG and LS by both VCTE and 2D-SWE.GE were performed on the same day. The diagnostic performance of each LS method was compared against HVPG and between each other. 2D-SWE.GE-LS was possible in 123/127 (96.90 %) patients. The ability to record at least 5 LS measurements by 2D-SWE.GE and IQR < 30 % were the only features associated with reliable results. 2D-SWE.GE-LS was highly correlated with HVPG (r = 0.704; p < 0.0001), especially if HVPG < 10 mmHg and was significantly higher in patients with CSPH (15.52 vs. 8.14 kPa; p < 0.0001). For a cut-off value of 11.3 kPa, the AUROC of 2D-SWE.GE-LS to detect CSPH was 0.91, which was not inferior to VCTE-LS (0.92; p = 0.79). The diagnostic accuracy of LS by 2D-SWE.GE-LS to detect CSPH was similar with the one of VCTE-LS (83.74 % vs. 85.37 %; p = 0.238). The diagnostic accuracy was not enhanced by using different cut-off values which enhanced the sensitivity or the specificity. However, in the subgroup of compensated patients with alcoholic liver disease, 2D-SWE.GE-LS classified CSPH better than VCTE-LS (93.33 % vs. 85.71 %, p = 0.039). 2D-SWE.GE-LS has good accuracy, not inferior to VCTE-LS, for the diagnosis of CSPH.ZIEL: Klinisch signifikante portale Hypertonie (CSPH) ist für die meisten Komplikationen bei Patienten mit Zirrhose verantwortlich. Die Messung der Lebersteifigkeit (LS) mittels vibrationsgesteuerter transienter Elastografie (VCTE) wird derzeit zur Abschätzung einer CSPH verwendet. Die 2-dimensionale Scherwellenelastografie von General Electric (2D-SWE.GE) wurde für die Diagnose der PHT noch nicht validiert. Unser Ziel war es zu untersuchen, ob die LS mittels 2D-SWE.GE in der Lage ist, eine CSPH abzuschätzen, die Zuverlässigkeitskriterien der Methode zu bestimmen und ihre Treffsicherheit in diesem klinischen Anwendungsbereich mit der VCTE-LS zu vergleichen. Patienten mit chronischer Lebererkrankung, die für einen Lebervenendruckgradienten (HVPG) mittels Lebervenenkatheter vorgesehen wurden, wurden nacheinander eingeschlossen. HVPG und LS wurden sowohl mittels VCTE als auch 2D-SWE.GE am selben Tag durchgeführt. Die diagnostische Leistung jeder LS-Methode wurde mit dem HVPG sowie untereinander verglichen. 2D-SWE.GE-LS war bei 123/127 (96,90 %) Patienten durchführbar. Die Fähigkeit, mindestens 5 LS-Messungen mit 2D-SWE.GE und einer IQR < 30 % aufzuzeichnen, waren die einzigen Parameter, die zu zuverlässigen Ergebnissen führten. Die 2D-SWE.GE-LS korrelierte stark mit dem HVPG (r = 0,704; p < 0,0001), insbesondere bei HVPG < 1 mmHg, und war bei Patienten mit CSPH signifikant höher (15,52 vs. 8,14 kPa; p < 0,0001). Bei einen Cut-off von 11,3 kPa betrug die AUROC der 2D-SWE.GE-LS zum Nachweis einer CSPH 0,91, was der VCTE-LS nicht unterlegen war (0,92; p = 0,79). Die diagnostische Genauigkeit der LS mittels 2D-SWE.GE-LS zur Erkennung von einer CSPH war ähnlich wie bei VCTE-LS (83,74 % gegenüber 85,37 %; p = 0,238). Die diagnostische Genauigkeit wurde durch den Einsatz unterschiedlicher Cut-offs, die die Sensitivität oder Spezifität erhöhten, nicht verbessert. In der Untergruppe der kompensierten Patienten mit alkoholbedingter Lebererkrankung klassifizierte die 2D-SWE.GE-LS eine CSPH jedoch besser als die VCTE-LS (93,33 % gegenüber 85,71 %, p = 0,039). Für die Diagnose der CSPH zeigt die 2D-SWE.GE-LS eine gute Treffsicherheit – diese ist nicht schlechter als die der VCTE-LS.
Tuberculosis remains one of the most important infectious disease worldwide and skeletal form has an incidence between 3% and 10%, depending on geographic area. The thoracolumbar junction is the most commonly involved in vertebral tuberculosis; some radiologic features are specifics, but other could be indistinguishable from that of lymphoma or metastases. We discuss the case of a 80-year-old man presented with a 2-month history of thoracolumbar pain, fatigability and fever. The vertebral radiography showed narrowing of the intervertebral disc space between T1 and T12, adjacent irregularity, erosion and lisis of vertebres, features visibles also on computed tomography. After the exclusion of the other causes of osteolisis, we started a standard regimen of tuberculostatic treatment and after one month of treatment the symptoms of patient improved noticeably. Other problems of diagnostic and treatment modalities of spinal tuberculosis are discussed.
Bacterial infections are associated with high mortality rates in patients with decompensated cirrhosis. Early diagnosis with the available diagnostic tools is challenging. Metabolomics is a novel technique with a widespread application in hepatology. The aims of our study were to find new biomarkers for decompensated cirrhosis and for those with overlapping bacterial infections.43 patients with compensated and 54 patients with decompensated cirrhosis were enrolled in the study. In patients with decompensation, a complete infectious workup was performed at admission. Blood and ascitic fluid were collected and stored at -80° C until performing the metabolomic analysis. Statistical analysis was performed using the Metaboanalyst 4.0 software.36 patients (66%) in the decompensated group were infected. Among them, 15 had multiple infections; thus, finally, 52 infections were diagnosed. The main metabolic pathways affected in patients with decompensated cirrhosis were those related to lipid metabolism, involving acylcarnitines, stearic acid derivatives, and 12/15 HETE-GABA. N-oleoyl ethanolamine was the most promising biomarker for bacterial infection diagnosis. Moreover, prostaglandin E2/D2/H2 and N-oleoyl alanine levels were higher in Gram- positive infections and ceramides (d16:2/18:0), in Gram-negative infections, respectively. L-phenylalanine (m/z=166.09) and lysophosphatidylethanolamine (18:3/0:0) were the two most relevant identified ascitic biomarkers for spontaneous bacterial peritonitis diagnosis.The lipid and energetic metabolic pathways were the most affected in patients with decompensated cirrhosis and those with overlapping infections.
Portal vein thrombosis (PVT) is a frequent complication of cirrhosis. Benefit, safety, and duration of anticoagulant treatment in this setting are controversial issues. The aim of this study was to analyze the course of PVT in a large cohort of cirrhotic patients undergoing or not anticoagulation therapy.The data of 182 patients who presented between January 2008 and March 2016 with cirrhosis and PVT with at least 3 months of follow-up after the first PVT detection were analyzed. Eighty-one patients received anticoagulants and 101 were untreated per physician discretion.The extension of the thrombosis decreased by >50% in 46 (56.8%, with complete recanalization in 31/46) patients under anticoagulation and in 26 (25.7%) untreated patients. Of the 46 patients who underwent recanalization, 17 (36%) suffered recurrent thrombosis after stopping anticoagulation therapy. Kaplan-Meier analysis showed a higher survival rate in the treated group (p = 0.010). At multivariate analysis, anticoagulation was an independent factor associated with longer survival (HR:0.30, CI:0.10-0.91, p = 0.014). The Child-Turcotte-Pugh classes B/C negatively influenced survival (hazard ratio, (HR):3.09, confidence interval (CI):1.14-8.36, p = 0.027 for Child-Turcotte-Pugh B and HR:9.27, CI:2.67-32.23, p < 0.001 for Child-Turcotte-Pugh C). Bleeding complications occurred in 22 (21.8%) untreated and 16 (19.7%) treated patients, but in only four cases was it judged to be related to the anticoagulant treatment. No death was reported as a consequence of the bleeding events.Anticoagulant treatment is a safe and effective treatment leading to partial or complete recanalization of the portal venous system in 56.8% of cases, improving the survival of patients with cirrhosis and PVT. Discontinuation of the therapy is associated with a high rate of PVT recurrence.
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