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Biomedical subjects

E A Akriviadis

Publications and source records attributed to E A Akriviadis.

At least 19 recordsLinked to original sources
PubMed1998

Hepatocellular carcinoma.

BACKGROUND: Hepatocellular carcinoma is one of the world's most common malignancies. The aims of the present paper are to review data on (1) epidemiology and screening programmes for the early detection of the tumour and (2) advances in the diagnostic imaging and management. METHODS: Relevant English language articles, published between January 1985 and December 1997, were reviewed. Articles were identified through Medline search, using the key words 'hepatocellular carcinoma'. Articles cited in the bibliographies of these articles were searched manually. RESULTS: Hepatocellular carcinoma has a heterogeneous geographical distribution. Although its risk factors have been identified, the efficacy of screening programmes remains uncertain. Imaging has improved substantially with the recent application of dual-phase helical computed tomography and magnetic resonance imaging employing specific contrast agents. The comparative efficacy of conservative therapy and surgical resection is uncertain, since well controlled trials are lacking. CONCLUSION: Hepatocellular carcinoma is commonly a problem of two diseases, the malignancy itself and cirrhosis. This renders treatment rarely curative, even when surgical resection can be applied in a technically successful sense. Liver transplantation could be a definitive treatment but this is plagued by limited donor resources.

Carcinoma, Hepatocellular↗
PubMed1998

Transjugular intrahepatic portosystemic shunt: a successful treatment for hepatopulmonary syndrome.

Hepatopulmonary syndrome is a well described complication of chronic liver disease. Though uncommon, it carries a high morbidity and mortality. The pathogenesis of the syndrome has not been clearly defined. Portal hypertension seems to play a crucial role in the pathogenesis of the syndrome, probably by enhancing nitric oxide production. As yet, no pharmacological therapy has been proven effective. Many reports of successful reversal of the syndrome after liver transplantation have been published. We report a patient with hepatopulmonary syndrome who showed a significant and durable (4 months') improvement in his symptoms, arterial oxygenation, and intrapulmonary shunts, as calculated by radionuclide studies after transjugular intrahepatic portosystemic shunt placement. Transjugular intrahepatic portosystemic shunt may represent a durable treatment option for patients with hepatopulmonary syndrome.

Dilatation, Pathologic↗
PubMed1997

Treatment of biliary colic with diclofenac: a randomized, double-blind, placebo-controlled study.

BACKGROUND & AIMS: Nonsteroidal anti-inflammatory drugs (NSAIDs) have been used to relieve biliary colic. Follow-up was limited in previous studies, and the role of NSAIDs in the natural history of biliary colic has not been clarified. The purpose of this study was to evaluate the efficacy of diclofenac, a potent NSAID, in the the immediate symptomatic relief of biliary colic and the prevention of cholelithiasis-related complications. METHODS: Fifty-three patients with cholelithiasis and biliary colic were enrolled in this randomized, double-blind, placebo-controlled study. They received a single 75-mg (3 mL) intramuscular injection of diclofenac (n = 27) or similarly administered 3 mL of saline (n = 26). All patients were followed up for at least 3 days. The effect of either treatment was assessed by changes in the severity of pain and the development of cholelithiasis-related complications. RESULTS: Complete relief of pain was obtained in 21 diclofenac and in 7 placebo patients; progression to acute cholecystitis was observed in 4 and 11 patients, respectively. Fewer overall complications were observed in the diclofenac group. CONCLUSIONS: In patients with cholelithiasis who present with biliary colic, a single 75-mg intramuscular dose of diclofenac can provide satisfactory pain relief and decrease substantially the rate of progression to acute cholecystitis.

Acute Disease↗
PubMed1997

Prevalence of cryoglobulinemia in chronic hepatitis C virus infection and response to treatment with interferon-alpha.

Chronic hepatitis C virus (HCV) infection is associated with a variety of clinically important extrahepatic abnormalities. We have assessed the prevalence of cryoglobulinemia and of the clinical syndrome associated with it in patients with chronic HCV infection. We also have evaluated the clinical, serologic, and biochemical response to antiviral treatment with interferon-alpha (IFN-alpha). Eighty-one patients with chronic liver disease associated with HCV infection were included. Cryoglobulins were sought in the serum. All patients were examined carefully for clinical manifestations of cryoglobulinemia (e.g., palpable purpura, Raynaud's syndrome, arthritis, peripheral neuropathy, Sjögren's syndrome, glomerulonephritis). Antiviral treatment with IFN-alpha, at a dose of 3 to 5 million units, 3 times weekly, was given to 20 patients with cryoglobulinemia. Cryoglobulins were detected in 45.7% of patients. Signs and symptoms of the clinical syndrome associated with cryoglobulinemia were present in 12.3% of the entire group of patients (27% of the subgroup with detectable cryoglobulins). Patients with cryoglobulinemia were older (mean age, 56 +/- 15 vs. 44 +/- 16 years; p = 0.002) and had a higher rate of cirrhosis (48.6% vs. 18.2%, rate ratio = 4.26, 95% confidence interval = 2.11 to 8.58, p = 0.00005) compared to patients without cryoglobulinemia. Cryoglobulins disappeared from the serum in 13 (65%) of the 20 patients who were treated for 6 to 12 months with IFN-alpha. This effect was affiliated in most patients with resolution of the clinical findings associated with cryoglobulinemia and return of transaminases to normal levels. Recurrence of cryoglobulinemia was observed in two thirds of the patients who were observed after treatment with IFN-alpha. We conclude that cryoglobulins are present in 45.7% of patients with chronic HCV infection. Symptoms or signs or both associated with the presence of cryoglobulins develop in a high proportion (27%) of these patients. Antiviral treatment with IFN-alpha leads to resolution of both cryoglobulinemia and the symptoms associated with it in most patients who also show a biochemical response to antiviral treatment. Recurrence is frequent after treatment withdrawal.

Adult↗
PubMed1997

Hemoperitoneum in patients with ascites.

OBJECTIVES: To review existing data on the pathophysiology and clinical presentation of hemoperitoneum in patients with ascites and to familiarize practicing clinicians who take care of such patients with the therapeutic options currently available for management of this complication. METHODS: Relevant English-language articles published between January 1988 and November 1996 were identified through MEDLINE search, using the key words "hemoperitoneum" and "ascites." Articles cited in the bibliographies of these articles were searched manually. Published papers that contained data on hemoperitoneum in general and on hemoperitoneum developing in patients with ascites were reviewed. RESULTS: In patients with ascites, hemoperitoneum can develop spontaneously or can follow abdominal trauma and diagnostic or therapeutic procedures. Spontaneous bleeding into ascites usually develops insidiously and may not cause hemodynamic instability, even in patients with cirrhosis. Massive acute hemoperitoneum from a ruptured intraperitoneal varix is an unusual complication of portal hypertension requiring prompt surgical treatment. Acute hemoperitoneum develops in 5-15% of patients with hepatocellular carcinoma requiring transcatheter arterial embolization. Metastatic liver tumors cause bloody ascites infrequently; however, this is a common complication of ovarian carcinoma. CONCLUSIONS: Hemoperitoneum is a severe complication in patients with ascites. When it develops spontaneously, it is usually related to the same disease process that caused the formation of ascites. Massive bloody ascites develops acutely after the rupture of intra-abdominal varices or hepatocellular carcinoma and requires aggressive interventional management. Based on a review of published data and on personal experience with patients suffering from end-stage liver disease, I propose an algorithm for the evaluation and treatment of patients with cirrhosis and hemoperitoneum.

Abdominal Injuries↗
PubMed1997

Hyponatremia of cirrhosis: role of vasopressin and decreased 'effective' plasma volume.

BACKGROUND: The mechanism(s) of hyponatremia of cirrhosis is not completely clarified. Although increased vasopressin activity has been proposed in some studies, there have been reports disputing its role in the pathogenesis of profound hyponatremia in patients with decompensated liver disease. Methodologic flaws and lack of correlation with indices of circulatory dysfunction may have contributed to these discrepancies. The aims of the present study were to measure levels of vasopressin both in plasma and in urine and to correlate them with the volume-dependent hormonal systems of plasma renin activity (PRA) and atrial natriuretic factor (ANF). METHODS: Plasma vasopressin, ANF, and PRA were measured by radioimmunoassay in 19 patients with cirrhosis, ascites, and severe hyponatremia (mean serum sodium, 121.8 mmol/l) and 11 patients with cirrhosis and normal serum sodium (mean, 137.6 mmol/l). Vasopressin levels were also assessed by radioimmunoassay in urine. RESULTS: Patients with hyponatremia had higher plasma and urine vasopressin levels than patients with normal serum sodium concentrations (plasma, 2.9 versus 1.0 pg/ml, P = 0.0009; urine, 38.3 versus 12.3 ng/g creatinine, P = 0.0008). PRA was higher (4.8 versus 1.0 ng/ml/h, P = 0.0004) and plasma ANF lower (111.1 versus 148.7 pg/ml, P = 0.01) in patients with hyponatremia. CONCLUSIONS: These results indicate that plasma and urine vasopressin levels are inappropriately increased in patients with cirrhosis and severe hyponatremia. The concomitant increase of PRA and decrease of plasma ANF suggest that decreased 'effective' plasma volume generates nonosmotic stimuli for vasopressin hypersecretion in these patients.

Adult↗
PubMed1996

Serum/ascites albumin gradient: its value as a rational approach to the differential diagnosis of ascites.

BACKGROUND: The utility of differentiating ascites into 'transudate' and 'exudate' has recently been challenged. The aim of the present study was to compare the diagnostic accuracy of the serum/ascites albumin gradient, proposed as a new biochemical criterion for the differential diagnosis of ascites, with the markers traditionally used for the classification of peritoneal fluid into transudate and exudate. METHODS: Paired ascitic fluid and serum samples from 51 patients were examined with an established method for the diagnosis of the cause of ascitic fluid collection. Included in the study were 32 patients with ascites related to portal hypertension (cirrhosis, n = 28; 'cardiac' ascites, n = 2; Budd-Chiari, n = 2) and 19 patients with ascites not related to portal hypertension (peritoneal carcinomatosis, n = 17; tuberculous peritonitis, n = I; secondary bacterial peritonitis, n = 1). Specimens were collected during an episode of spontaneous bacterial peritonitis in 7 of 28 patients with cirrhosis. The serum/ascites albumin gradient was compared with ascitic fluid total protein, ascites/serum total protein ratio, ascites lactic dehydrogenase concentration, and ascites/serum lactic dehydrogenase ratio. RESULTS: The diagnostic accuracy was 98% for the serum/ascites albumin gradient compared with only 52%-80% for the four other markers tested. In patients with infected ascites, diagnostic accuracy was 89% for the albumin gradient and < or = 50% for the four other markers. CONCLUSIONS: The classification of ascites into transudate and exudate appears to be based on markers with low diagnostic accuracy. Differential diagnosis of ascites should be based on the serum/ascites albumin gradient, which is a reliable marker distinguishing ascites related to portal hypertension from all other causes of ascitic fluid collection, regardless of the presence of bacterial infection.

Ascites↗
PubMed1992

The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites.

OBJECTIVE: To compare the serum-ascites albumin gradient to the exudate-transudate concept in the classification of ascites. DESIGN: Prospective collection of ascitic fluid data from patients with well-characterized causes of ascites. SETTING: Hepatology inpatient and outpatient ward and consult service of a large, urban hospital. PATIENTS: A total of 901 paired serum and ascitic fluid samples were collected from consecutive patients with all forms of ascites. INTERVENTIONS: None. MAIN OUTCOME MEASURES: The utility of the serum-ascites albumin gradient and the old exudate-transudate concept (as defined by ascitic fluid total protein concentration [AFTP]) were compared for their ability in discriminating the cause for ascites formation. RESULTS: The albumin gradient correctly differentiated causes of ascites due to portal hypertension from those that were not due to portal hypertension 96.7% of the time. The AFTP, when used as defined in the old exudate-transudate concept, classified the causes of ascites correctly only 55.6% of the time. This resulted in part because the AFTP of most spontaneously infected samples (traditionally expected to be exudates) was low, and the AFTP of most cardiac ascites samples (traditionally expected to be transudates) was high. CONCLUSIONS: The exudate-transudate concept should be discarded in the classification of ascites. The serum-ascites albumin gradient is far more useful than the AFTP as a marker for portal hypertension, but the latter remains a useful adjunct in the differential diagnosis of ascites.

Albumins↗
PubMed1991

Ascitic fluid and serum cefotaxime and desacetyl cefotaxime levels in patients treated for bacterial peritonitis.

Forty-one episodes of ascitic fluid infection were treated with cefotaxime 2 g intravenously every 8 hr, and ascitic fluid and serum were sampled 6, 12, 24, 48, and 96 hr after the first dose of antibiotic. Concentrations of cefotaxime and desacetyl cefotaxime were measured in ascitic fluid and serum by high-performance liquid chromatography. There was essentially 100% penetration of cefotaxime and metabolite from serum into ascitic fluid at all time points. Ascitic fluid was sterilized in 94% of episodes after the first dose of antibiotic. The ascitic fluid concentration of cefotaxime 6 hr after the first dose of antibiotic was greater than 20 times the minimal inhibitory concentration of the drug for 90% of the isolated flora. This rapid ascitic fluid penetration of cefotaxime in high concentration explains the rapid sterilization of ascitic fluid by the drug in the setting of bacterial peritonitis and obviates the need to give a loading dose or intraperitoneal injection.

Adult↗
PubMed1991

Short-course versus long-course antibiotic treatment of spontaneous bacterial peritonitis. A randomized controlled study of 100 patients.

In an attempt to determine the optimal duration of therapy of spontaneous bacterial peritonitis, 100 patients with neutrocytic ascites and suspected spontaneous bacterial peritonitis were randomized to short-course vs. long-course treatment groups. Empiric therapy was initiated before the results of ascitic fluid culture were available. Of the 90 patients who met strict criteria for spontaneous bacterial peritonitis or culture-negative neutrocytic ascites, 43 were randomized to a group receiving 5 days and 47 to a group receiving 10 days of single-agent cefotaxime, 2 g IV every 8 hours. Infection-related mortality (0% vs. 4.3%), hospitalization mortality (32.6% vs. 42.5%), bacteriologic cure (93.1% vs. 91.2%), and recurrence of ascitic fluid infection (11.6% vs. 12.8%) were not significantly different between the 5- and 10-day treatment groups, respectively. Recurrence rates were comparable to the values reported in the literature. The cost of antibiotic and antibiotic administration were significantly lower in the short-course group. Short-course treatment of spontaneous bacterial peritonitis is as efficacious as long-course therapy and significantly less expensive.

Bacterial Infections↗
PubMed1991

The opacity of portal hypertension-related ascites correlates with the fluid's triglyceride concentration.

To determine if an elevated triglyceride concentration can explain the opacity of some cirrhotic ascites specimens, the authors measured triglyceride concentration by Coulter DACOS (Hialeah, FL) on 133 paired serum and ascitic fluid specimens. The specimens were categorized as clear or cloudy by coded visual inspection. In addition, the ascitic fluid specimens were inspected for a lipid supernatant after 48 hours of refrigeration at 4 degrees C. The ascitic fluid triglyceride concentration of the 87 clear specimens was 1.9 +/- 1.0 mmol/L compared with 7.0 +/- 4.6 mmol/L for the opalescent specimens (P less than 0.001). Only 17% of the clear specimens demonstrated any lipid layer after refrigeration, compared with 94% of opalescent specimens (P less than 0.001). The triglyceride concentrations were not significantly different between the serum samples obtained from patients with clear compared with opalescent ascites. The opacity of portal hypertension-related ascites appears to be related to the triglyceride concentration of the fluid.

Ascites↗
PubMed1990

Failure of colchicine to improve short-term survival in patients with alcoholic hepatitis.

Colchicine treatment was used in this randomized placebo-controlled trial in patients with severe acute alcoholic hepatitis [serum bilirubin greater than or equal to 5 mg/dL (85.5 mumol/L) mean, 17.5 +/- 7.5 mg/dL (299.25 +/- 128.25 mumol/L)]. Hospitalization mortality and morbidity and the effect on biochemical test results were the end points of the treatment. Patients in the two groups were evenly matched by demographics and laboratory test results. Mean time to study entry was less than 7 days from admission. The duration of the trial was 30 days. Thirty-six patients (24 men, 12 women) received colchicine (1 mg orally every morning) and 36 (25 men, 11 women) received an identical placebo. Seven (19%) colchicine-treated and six (17%) control patients died during the index hospitalization after a mean of 17.4 +/- 10.8 and 17.8 +/- 5.3 days, respectively (NS). During a 4-month follow-up period from entry into the trial, there were two additional deaths in each group. No differences between placebo- and colchicine-treated patients were observed in any of the laboratory parameters (serum bilirubin, aspartate transaminase, alanine transaminase, prothrombin activity, albumin, white blood cell count, hemoglobin, and creatinine) that were followed up over the 30-day treatment period. The frequency of complications did not differ statistically between the two groups. This study showed no effect of colchicine treatment on mortality and morbidity of severe alcoholic hepatitis. Colchicine cannot be recommended for the treatment of patients with alcoholic hepatitis.

Acute Disease↗
PubMed1990

Utility of an algorithm in differentiating spontaneous from secondary bacterial peritonitis.

To prospectively assess the value of an algorithm in differentiating spontaneous from secondary bacterial peritonitis, we performed serial paracenteses in 43 episodes of ascitic fluid infection (28 spontaneous and 15 secondary) in 40 patients. The algorithm involved identification of (a) secondary peritonitis associated with gut perforation, based on previously proposed criteria in patients with neutrocytic ascites (ascitic fluid total protein greater than 1 g/dl, glucose less than 50 mg/dl, and lactate dehydrogenase greater than the upper limit of normal for serum) and (b) separation of spontaneous from secondary peritonitis (unassociated with perforation) based on the response of the ascitic fluid cell count to antibiotic therapy. The perforation criteria had 100% sensitivity in detecting episodes of actual gut perforation; their specificity, however, was low (45%). After 48 h of treatment the concentration of ascitic fluid neutrophils was below the baseline pretreatment value in all episodes of spontaneous peritonitis but in only two thirds of the patients with secondary peritonitis. This algorithm is useful in (a) identifying patients who have infected ascites associated with perforation of an intraabdominal viscus, and (b) differentiating spontaneous from nonperforation secondary peritonitis on the basis of the response of the ascitic fluid cell count to appropriate antibiotic therapy. The optimal time for repeat paracentesis in patients with infected ascites appears to be 48 h after initiation of treatment.

Algorithms↗
PubMed1990

Bedside inoculation of blood culture bottles with ascitic fluid is superior to delayed inoculation in the detection of spontaneous bacterial peritonitis.

Ascitic fluids from patients suspected of having spontaneous bacterial peritonitis were inoculated into blood culture bottles (i) at the bedside and (ii) in the laboratory after a delay. In 29 episodes in which the bedside bottles were culture positive, only 22 (75.9%) of the laboratory-inoculated sets demonstrated growth; this difference was statistically significant (P less than 0.02).

Ascitic Fluid↗
PubMed1989

Polymorphonuclear cell count response and duration of antibiotic therapy in spontaneous bacterial peritonitis.

The purposes of this study were (a) to measure serially ascitic fluid polymorphonuclear cell response in treated spontaneous bacterial peritonitis and (b) to determine whether an ascitic fluid polymorphonuclear cell count of less than 250 per mm3 on serial paracenteses was a satisfactory endpoint for antibiotic therapy. Thirty of 33 patients showed an exponential fall in ascitic fluid polymorphonuclear cell count after 48 hr of antibiotic therapy; the magnitude of decrease correlated with survival (p less than 0.01). Among the patients whose antibiotic therapy was discontinued when the ascitic fluid polymorphonuclear cell count reached 250 per mm3 or less, the duration of therapy was considerably shorter than for the patients who received "conventional" therapy (p less than 0.01). Recurrence of spontaneous bacterial peritonitis was similar in the two groups. Mortality correlated with the severity of underlying liver disease but not with duration of antibiotic therapy.

Anti-Bacterial Agents↗
PubMed1989

Spontaneous rupture of nonparasitic cyst of the liver.

A case of spontaneous rupture of a nonparasitic liver cyst, documented by serial computed tomography scans, is reported. The patient was closely followed clinically after the rupture of the cyst and was treated conservatively, without surgical intervention. No peritonitis developed. This unusual complication of nonparasitic simple liver cysts may not always require surgery.

Cysts↗