Two-year risedronate treatment for osteoporosis in patients with esophageal varices: a non-randomized clinical trial.

BACKGROUND: Bisphosphonates are the mainstay of osteoporosis treatment, but their use for patients with esophageal varices has been avoided due to the risk of esophagitis, which may cause variceal bleeding. Since most clinical trials assessing osteoporosis treatment last 2-3 years, this study aimed to evaluate a 2-year risedronate treatment for patients with esophageal varices and liver cirrhosis. METHODS: The study received Institutional Review Board approval, and the sample was divided into two groups according to bone mineral density (BMD). Cirrhosis severity and endoscopic findings at baseline were similar between the groups. The intervention group had 51 patients with osteoporosis, who received oral risedronate 35 mg weekly plus calcium and vitamin D supplements. The control group had 51 patients with osteopenia, receiving only the supplements. Scheduled esophagogastroduodenoscopies and BMD measurements were carried out. RESULTS: The adjusted esophagitis risk was higher in the intervention group; however, none of the subjects had digestive bleeding. Lumbar spine BMD increased in the intervention group (- 3.06 ± 0.71 to - 2.33 ± 0.90; p < 0.001) and in the control group (- 1.38 ± 0.77 to - 1.10 ± 1.05; p = 0.012). Femoral neck BMD did not change in the intervention group (- 1.64 ± 0.91 to - 1.71 ± 0.95; p = 0.220), but tended to decrease in the control group (- 1.00 ± 0.74 to - 1.09 ± 0.82; p = 0.053). CONCLUSION: Oral risedronate was effective and did not cause gastrointestinal bleeding in cirrhotic patients with esophageal varices under endoscopic surveillance.

MicroRNA expression in inflammatory bowel disease-associated colorectal cancer.

MicroRNAs (miRNAs) are non-coding RNA molecules composed of 19-25 nucleotides that regulate gene expression and play a central role in the regulation of several immune-mediated disorders, including inflammatory bowel diseases (IBD). IBD, represented by ulcerative colitis and Crohn's disease, is characterized by chronic intestinal inflammation associated with an increased risk of colorectal cancer (CRC). CRC is one of the most prevalent tumors in the world, and its main risk factors are obesity, physical inactivity, smoking, alcoholism, advanced age, and some eating habits, in addition to chronic intestinal inflammatory processes and the use of immunosuppressants administered to IBD patients. Recent studies have identified miRNAs associated with an increased risk of developing CRC in this population. The identification of miRNAs involved in this tumorigenic process could be useful to stratify cancer risk development for patients with IBD and to monitor and assess prognosis. Thus, the present review aimed to summarize the role of miRNAs as biomarkers for the diagnosis and prognosis of IBD-associated CRC. In the future, therapies based on miRNA modulation could be used both in clinical practice to achieve remission of the disease and restore the quality of life for patients with IBD, and to identify the patients with IBD at high risk for tumor development.

Mixed and disseminated paracoccidioidomycosis after liver transplantation: Case report.

Paracoccidioidomycosis (PCM) is a systemic granulomatous fungal infection rarely associated with solid organ transplantation. We report the second case of PCM in an adult after liver transplantation. A 47-year-old woman who had undergone liver transplantation was hospitalized for flu-like symptoms and multiple erythematous ulcerated skin papules. There was lymphadenopathy, pulmonary compromise, and quickly progression to septic shock. PCM was confirmed by skin biopsy and serologic tests, and a satisfactory response to amphotericin B was achieved.

Refining dual-energy x-ray absorptiometry data to predict mortality among cirrhotic outpatients: A retrospective study.

OBJECTIVE: The aim of this study was to compare the effects of muscle wasting according to measures obtained by different limb muscle mass indexes, to find the best mortality predictor among outpatients with cirrhosis. METHODS: Patients with liver cirrhosis (N = 210) were submitted to dual-energy x-ray absorptiometry (DXA). Appendicular muscle mass (AMM), AMM index (AMMI), upper limb muscle mass (ULMM), and ULMM index (ULMMI) were calculated. The Model for End-Stage Liver Disease, anthropometric measures, and the presence of ascites and edema were also registered. Multiple logistic regressions were performed to determine mortality predictors; the area under the receiver operating characteristic curve was used to establish the best cutoff point to predict mortality. RESULTS: The mean follow-up duration was 49 ± 15.59 mo. ULMM and ULMMI were clearly associated with mortality (P = 0.007 and 0.001, respectively), whereas AMM and AMMI were not. After calculating the cutoff points for men and women, the presence of a depleted ULMMI as a categorical variable was associated with a mortality risk 2.5 times higher. CONCLUSIONS: The results suggest that using ULMMI is better than AMMI for predicting mortality of outpatients with cirrhosis, thus offering a better measure to detect muscle wasting in this population using DXA.

Safety and efficacy of risedronate for patients with esophageal varices and liver cirrhosis: a non-randomized clinical trial.

Despite the high prevalence of osteoporosis in liver cirrhosis, the indication of bisphosphonates for patients with esophageal varices has been avoided due to risk of digestive mucosal damage. Therefore, this study aimed to evaluate the safety profile of risedronate treatment for patients with osteoporosis, liver cirrhosis and esophageal varices with low risk of bleeding. A total of 120 patients were allocated into two groups according to their bone mineral density measured by dual-energy X-ray absorptiometry. In the intervention group, 57 subjects with osteoporosis received oral risedronate at 35 mg weekly plus daily calcium and vitamin D supplementation. In the control group, 63 subjects with osteopenia received only calcium and vitamin D. The groups received the treatment for one year and underwent surveillance endoscopies at six and 12 months, as well as a control dual-energy X-ray absorptiometry after a 12-month follow-up. The study received Institutional Review Board approval. The groups had not only comparable Model for End-stage Liver Disease score and esophageal varices degree, but also similar incidence of digestive adverse effects. A significant improvement was achieved in the intervention group in the lumbar spine T score (p < 0.001). The results suggest that risedronate may be safely used in liver cirrhosis and esophageal varices with low bleeding risk under endoscopic surveillance, thus allowing bone mass recovery.

Which of the branched-chain amino acids increases cerebral blood flow in hepatic encephalopathy? A double-blind randomized trial.

Branched-chain amino acids increase the brain perfusion of patients with hepatic encephalopathy (HE), but the amino acid and the mechanisms involved are still unknown. This study compared brain perfusion and clinical improvement during leucine or isoleucine supplementation. After randomization, 27 subjects with cirrhosis and HE received leucine or isoleucine supplements for one year. Brain single Photon Emission Computed Tomography (SPECT) and dynamic brain scintigraphy (DBS) were performed pretreatment and at 1, 8 and 12 months of supplementation. Brain perfusion was increased only in the isoleucine group at 8 months of treatment by both SPECT and DBS (p < 0.001 and p = 0.05, respectively) and by SPECT at the 12th month (p < 0.05). This was associated with hepatic encephalopathy improvement at 8 and 12 months (p = 0.008 and 0.004, respectively), which was not observed in the leucine group (p = 0.313 and 0.055, respectively). Isoleucine supplementation achieved a better impact on brain perfusion restoration in HE.

Handgrip strength as a predictor of bone mineral density in outpatients with cirrhosis.

BACKGROUND AND AIM: Osteoporosis is well recognized as a cirrhosis complication; however, most studies assessing this condition included only patients on liver transplantation lists with an elevated rate of bone diseases. While general population studies show that handgrip strength is clearly associated with bone mineral density, until now this tool has not been applied to patients with cirrhosis in relation to their bone condition. This study aimed to evaluate whether handgrip strength, bone, and liver tests may be useful as predictors of bone disease in outpatients with cirrhosis. METHODS: One hundred twenty-nine subjects were included (77 men and 52 women). Dual-energy X-ray absorptiometry was applied to evaluate lumbar-spine and femoral-neck T scores. Osteoporosis/osteopenia rates were 26.3%/35.6% in the lumbar spine and 6.9%/41.8% in the femoral neck, respectively. Model selections were based on backward procedures to find the best predictors of low T scores. RESULTS: For lumbar spine, only low handgrip strength and high parathyroid hormone levels were clearly related to low T scores. For femoral neck, only age was associated with low T scores. CONCLUSIONS: Handgrip strength may serve as an effective predictor of low lumbar spine T score among outpatients with cirrhosis. As cirrhosis affects the lumbar spine more than the femoral neck, these results suggest that handgrip strength should be tested in all patients with cirrhosis as a first indicator of bone health.

Embolization of splenorenal shunt associated to portal vein thrombosis and hepatic encephalopathy.

UNLABELLED: Hepatic encephalopathy (HE) is a cognitive disturbance characterized by neuropsychiatric alterations. It occurs in acute and chronic hepatic disease and also in patients with portosystemic shunts. The presence of these portosystemic shunts allows the passage of nitrogenous substances from the intestines through systemic veins without liver depuration. Therefore, the embolization of these shunts has been performed to control HE manifestations, but the presence of portal vein thrombosis is considered a contraindication. In this presentation we show a cirrhotic patient with severe HE and portal vein thrombosis who was submitted to embolization of a large portosystemic shunt. CASE REPORT: a 57 years-old cirrhotic patient who had been hospitalized many times for persistent HE and hepatic coma, even without precipitant factors. She had a wide portosystemic shunt and also portal vein thrombosis. The abdominal angiography confirmed the splenorenal shunt and showed other shunts. The larger shunt was embolized through placement of microcoils, and the patient had no recurrence of overt HE. There was a little increase of esophageal and gastric varices, but no endoscopic treatment was needed. Since portosystemic shunts are frequent causes of recurrent HE in cirrhotic patients, portal vein thrombosis should be considered a relative contraindication to perform a shunt embolization. However, in particular cases with many shunts and severe HE, we found that one of these shunts can be safely embolized and this procedure can be sufficient to obtain a good HE recovery. In conclusion, we reported a case of persistent HE due to a wide portosystemic shunt associated with portal vein thrombosis. As the patient had other shunts, she was successfully treated by embolization of the larger shunt.

Redução do MELD em pacientes na lista de transplante hepático após o uso de aminoácidos de cadeia ramificada: relato de caso / Reduction of MELD in patients on the liver transplant list after using chain amino acids: case report

A cirrose hepática (CH) é uma doença com altas taxas de mortalidade e que apresenta, como único tratamento definitivo, o transplante hepático (TH). Infelizmente, nem todos os pacientes têm acesso ao TH e muitos acabam morrendo ainda na lista de transplante. O uso de aminoácidos de cadeia ramificada (AACR) já é amplamente conhecido como tratamento eficaz para a melhora da qualidade de vida destes pacientes. Neste relato, pela primeira vez, documentou-se uma grande melhora clínica e laboratorial em um paciente após o tratamento com AACR, que permitiu ao paciente sair inclusive da lista de transplante. Além da diminuição do escore MELD, houve reestabilização do peso corporal e melhora da qualidade de vida, documentada pelo questionário SF-36.

Liver cirrhosis (LC) is a disease with high mortality rates and its only definitive treatment is the orthotopic liver transplantation (OLT). Unfortunately, not all patients have access to OLT and many of them end up dying on the transplant waiting list. The use of branched chain amino acids (BCAA) is widely known as an effective treatment for improving the quality of life of these patients. For the first time, in this paper we documented a great improvement of clinical and laboratorial tests of a patient treated with BCAA, which allowed him to be out of the transplant waiting list. In addition to the increase of the MELD score, the patient achieved restabilization of body weight and recovery of the quality of life registered by the SF-36 questionnaire.

Pancreatic paracoccidioidomycosis simulating malignant neoplasia: case report.

Paracoccidioidomycosis is a systemic granulomatous disease caused by fungus, and must be considered in the differential diagnosis of intra-abdominal tumors in endemic areas. We report a rare case of paracoccidioidomycosis in the pancreas. A 45-year-old man was referred to our institution with a 2-mo history of epigastric abdominal pain that was not diet-related, with night sweating, inappetence, weight loss, jaundice, pruritus, choluria, and acholic feces, without signs of sepsis or palpable tumors. Abdominal ultrasonography (US) showed a solid mass of approximately 7 cm × 5.5 cm on the pancreas head. Abdominal computerized tomography showed dilation of the biliary tract, an enlarged pancreas (up to 4.5 in the head region), with dilation of the major pancreatic duct. The patient underwent exploratory laparotomy, and the surgical description consisted of a tumor, measuring 7 to 8 cm with a poorly-defined margin, adhering to posterior planes and mesenteric vessels, showing an enlarged bile duct. External drainage of the biliary tract, Roux-en-Y gastroenteroanastomosis, lymph node excision, and biopsies were performed, but malignant neoplasia was not found. Microscopic analysis showed chronic pancreatitis and a granulomatous chronic inflammatory process in the choledochal lymph node. Acid-alcohol resistant bacillus and fungus screening were negative. Fine-needle aspiration of the pancreas was performed under US guidance. The smear was compatible with infection by Paracoccidioides brasiliensis. We report a rare case of paracoccidioidomycosis simulating a malignant neoplasia in the pancreas head.