Encefalopatia hepática: relatório da 1ª reunião monotemática da Sociedade Brasileira de Hepatologia / Hepatic encephalopathy: report 1st monothematic meeting of the Brazilian Society

A encefalopatia hepática (EH) é um distúrbio funcional do sistema nervoso central (SNC) associado à insufi ciência hepática, de fisiopatologia multifatorial e complexa. Devido aos avanços no conhecimento sobre o manejo da EH na cirrose e na insuficiência hepática aguda (IHA), a diretoria da Sociedade Brasileira de Hepatologia (SBH) promoveu uma reunião monotemática acerca da fi siopatologia, diagnóstico e tratamento da EH, abordando aspectos controversos relacionados ao tema. Com a utilização de sistemática da medicina baseada em evidências, foram abordados o manejo da EH e da hipertensão intracraniana na IHA, o manejo da EH episódica na cirrose, as controvérsias no manejo da EH e a abordagem da EH mínima. O objetivo desta revisão é resumir os principais tópicos discutidos na reunião monotemática e apresentar recomendações sobre o manejo da síndrome votadas pelo painel de expertos da SBH.

Hepatic encephalopathy (HE) is a functional disorder of the central nervous system (CNS) associated with liver failure, either end-stage chronic liver disease or fulminant hepatic failure. Its pathogenesis remains complex and poorly understood. In view of recent advances in the management of HE, the Brazilian Society of Hepatology endorsed a monothematic meetingregarding HE in order to gather experts in the to discuss related data and to draw evidence-based recommendations concerning: management of HE and intracranial hypertension in FHF, treatment of episodic HE in cirrhosis, controversies in the management of EH including difficult to treat cases and diagnostic and treatment challenges for minimal HE. The purpose of this review is to summarize the lectures and recommendations made by the panel of experts of the Brazilian Society of Hepatology.

Occult B infection in the Brazilian northeastern region: a preliminary report

A sentinel study on viral hepatitis is currently being carried out in the village of Cavunge in a semiarid rural region of the state of Bahia, northeastern Brazil. This study has identified individuals in whom anti-HBc IgG was the only serological marker for hepatitis B virus (HBV). This serological pattern may constitute evidence of occult HBV infection. This study Investigated the possibility of occult hepatitis B virus infection in individuals in a rural community who tested positive for anti-HBc IgG alone. A cross-sectional population-based study. ELISA III was performed on serum samples to test for serological viral markers, and ultrasensitive PCR (US-PCR) was used to assess viremia. Among the 1,536 serum samples, 3.6 percent (n=55) were positive for anti-HBc alone. Four years after this first serological survey, 31 of those 55 individuals (56.3 percent) were retested, and 11 (35.5 percent) remained anti-HBc positive alone. Two of these 31 (6.5 percent) were HBV-DNA positive based on US-PCR, with normal aminotransferase levels in both cases. Cases of occult hepatitis B infection were identified in this semiarid rural community of northeastern Brazil, where endemicity of HBV is moderate.

Urinary tract infection in non-hospitalized patients with cirrhosis and no symptoms of urinary tract infection: a case series study

Bacterial infections are important factors in decompensation, and they increase the mortality rate of patients with liver cirrhosis. The most common infections among these patients are spontaneous bacterial peritonitis, pneumonia, skin infections and urinary tract infections (UTI). This transversal study evaluated the frequency of UTI in non-hospitalized patients with cirrhosis followed in a hepatology outpatient unit. Patients with clinical, laboratorial, echographic and/or histological diagnosis of cirrhosis were evaluated from April 2002 to August 2004. Patients who accepted participating in this study were submitted to clinical evaluation and the following laboratorial examinations: urine analysis, urine culture, blood culture and hepatic function tests. Patients with symptoms of UTI, diabetis, prostatic disease were excluded. Eighty-two patients with cirrhosis were studied. Their mean age was 51 years (SD = 11); 73 percent were male. Hepatitis C virus was the main etiology in 45 percent of the cases. The Child-Pugh B functional class was observed in 52 percent of the cases. Urine cultures were positive in 4.9 percent of these patients. In this study of non-hospitalized cirrhotic patients, with no symptoms of UTI, the frequency of urinary tract infection was approximately 5 percent. The bacteria found were E. coli and Klebsiella pneumonia. We conclude that it is necessary to screen for UTI in such patients.

Serological markers of hepatitis A, B and C viruses in rural communities of the semiarid Brazilian Northeast

In the village of Cavunge, located in a dry tropical, semiarid rural region of the state of Bahia, Brazil, a sentinel study on viral hepatitis is underway. We report on the first part of the study. The objective of this study was to determine the prevalence of serological markers for hepatitis A, B and C in the village. Cross sectional study. Blood samples were tested for serological markers of hepatitis A (HAV), B (HBV) and C (HCV) through ELISA-III assay. In HBsAg and anti-HCV carriers, HCV-RNA and HBV-DNA were checked by PCR. The prevalence of anti-HAV IgG was 83.3 percent (1,210/1,452), being higher among residents from the village (87.4 percent) than in residents from the rural area (79.5 percent); it also higher among individuals older than 10 years of age. The prevalence of HBsAg was 2.6 percent (38/1,476), 9.3 percent anti-HBc (137/1,476) and 10.5 percent (155/1,476) anti-HBs of. In more than half (58.1 percent; 90/155) of anti-HBs carriers, this was the only serological marker found. In 3.7 percent of the population, (55/1,476), anti-HBc was the only serological marker found. All HBV carriers were infected by genotype A. Only 0.4 percent (6/1,536) presented anti-HCV antibodies and only one of them was viremic, being infected with genotype 1. The prevalence of patients with antibodies against hepatitis A virus in the village of Cavunge was high, but the prevalence of B virus was moderate, with only genotype A among HBV carriers. The prevalence of C virus was very low, contrasting with the situation in large Brazilian urban centers.

Aspectos sociodemográficos da soroprevalência de marcadores do vírus da hepatite A no povoado de Cavunge, região do semi-árido do Estado da Bahia / Sociodemographical aspects of seroprevalence of hepatitis A virus in the settlement of Cavunge, a semi-arid region of Bahia State

No Povoado de Cavunge, semi-árido da Bahia, foi realizado estudo sobre as hepatites com objetivo de avaliar a prevalência de portadores de IgG anti-VHA. Foram avaliados 891 moradores e 85,9 por cento foram soropositivos. A prevalência foi semelhante entre os sexos. Na zona urbana houve aumento da prevalência com a idade.

Soroprevalência de anticorpos contra o virus da hepatite A em região do semi-arido do estado da Bahia / Seroprevalence of anti-HAV antibodies in the semiarid region of the state of Bahia

As hepatites virais apresentam importante problema de saúde pública em todo mundo. Estudos de base populacional que investiguem os portadores do vírus da hepatite A (VHA) são escassos, sobretudo no semi-árido nordestino do Brasil, mas de fundamental importância para melhor dimensionar o problema e planejar medidas de controle. No povoado de Cavunge, localizado na região do semi-árido do estado da Bahia, está em andamento estudo sentinela sobre as hepatites virais. Objetivo: Determinar a soropositividade da hepatite A em comunidade rural do semi-árido do estado da Bahia; avaliar os aspectos socioepidemiológicos asociados à transmissão do VHA. Métodos: Estudo transversal. Após a aplicação de questionário ssociodemográfico foi realizada a colheita de sangue venoso para pesquisa de anticorpos séricos(IgG) anti-VHA (método ELISA) em 1.452 pessoas residentes na área urbana ou rural do povoado de Cavunge. Resultado: 83,3por cento(n=1.210) da amostra foram soropositivos. A proporção de soropoditivos foi semelhante entre os sexos, embora houvesse aumento significativo desses percentuais relativos à idade (p<0,001) e entre os residentes da área urbana (p<0,01). A maior prevalência da infecção ocorreu na segunda e terceira décadas de idade. Conclusão: Foi elevada a prevalência de portadores de anticorpos contra o virus da hepatite A no povoado da Cavunge e aumentou com a idade

Current aspects of antibiotic prophylaxis for upper gastrointestinal bleeding in cirrhosis patients

Bacterial infection is a common complication in cirrhotic patients. The portal hypertension as well as the immune depression observed in these patients can explain this high incidence of bacterial infection. Because of the high probability of cirrhotic patients to develop infections, antibiotic prophylaxis is warranted in some conditions, such as upper gastrointestinal bleeding or after spontaneous bacterial peritonitis. Nevertheless, antibiotic prophylaxis is not widely recommended for cirrhotic patients

Comparative study of bacterial infection prevalence between cirrhotic patients with and without upper gastrointestional bleeding

Bacterial infection is a frequent complication in patients with chronic liver disease, mainly during the advanced stages. There is evidence that the main factors that contribute to a predisposition to infection in cirrhotic patients are related to hepatic failure with consequent immunodeficiency. Invasive procedures (diagnostic or therapeutic) can predispose to baceterial infections, and upper gastrointestinal bleeding (UGB) is considered a potentially important risk factor. A group of cirrhotic patients (child B and C Pugh groups) were evaluated retrospectively by chart reviews regarding the prevalence of bacterial infection during hospitalization to determine whether UGB was a risk factor. An infection was considered present if a specific organ system was identified or if fever (>38§C) persisted for more than 24 hours with associated leukocytosis. Spontaneous bacterial peritonitis was based on classical criteria. Eighty-nine patients were evaluated. Fourty-six patients presented with UGB, and 43 patients had no UGB (control). There were infections recorded in 25/46 (54 percent) patients with UGB, and 15/43 (35 percent) in those without UGB (p=0.065). The ratio of the number of infections/admitted patients, was significantly larger in the group with UGB (0.78 ñ 0.89 vs. 0.39 ñ 0.62; p=0.028) since patients had more than one infection. In the UGB group compared to non UGB group, ascites was more frequent (67 percent vs. 42 percent; p=0.027); they were more likely to have undergone endoscopic procedures (p<0.001) and the mean ñ SD for platelets count was smaller (96,114 ñ 57,563 vs. 145,674 ñ 104,083; p=0.007). The results show that UGB is an important contribution to bacterial infection among Child B and C cirrhotic patients.