Biomedical subjects

T Fejfar

Publications and source records attributed to T Fejfar.

7 recordsLinked to original sources

PubMed2006

[MELD score in prediction of early mortality in patients suffering refractory ascites treated by TIPS].

UNLABELLED: Transjugular Intrahepatic Portosystemic Shunt (TIPS) is now well established in the treatment of complications of symptomatic portal hypertension such as acute or recurrent variceal bleeding, refractory ascites and Budd-Chiari syndrome. In some patients with refractory ascites who belong to group C according to Child-Pugh classification (score around 12), the indication of the procedure could be very questionable and early mortality is quite high. However, in some cases, the subgroup of such risky patients can profit from TIPS. Child-Pugh classification is used for the stratification of the patients routinely. During the last decade other scoring systems occured to bring a better prognostic value. MELD (Model for End stage Liver Disease) score, based only on laboratory values is one of them. Comparison of these two scoring systems in patients treated by TIPS in previous trials brought certain discrepancy, but MELD score seems to be better in predicting early mortality. The aim of our study was to determine retrospectively the predictive accuracy of MELD score for the early mortality in comparison to Child-Pugh score in patients treated for refractory ascites by TIPS. METHODS: We evaluated 110 patients (mean age 55 years) with liver cirrhosis (61% of patients with alcoholic etiology), who underwent TIPS for refractory ascites in our center from September 1992 to December 2003. MELD and Child-Pugh score was calculated and then compared between groups with early (one month), three month and one year mortality, and those who survived over this period (one, three and twelve months), comparing MELD and Child-Pugh score (ROC analysis and Student's T test were used). RESULTS: Mean follow up was 23 months. Average MELD score in the whole group was (16). In patients, who died within one month the score before TIPS was 21, three months 20 and 18 one year. Comparing MELD score between subgroups and then Child-Pugh score, only for MELD score there was a statistically significant difference (p < 0.05) in one month. Using ROC (AUC) analysis, discriminant power of MELD score was superior to Child-Pugh score for one (0.73 vs 0.63) and three month (0.73 vs 0.67) mortality. The discriminant power for one year mortality was low in both scores. CONCLUSION: MELD scoring system is a better tool to predict the risk of early mortality in patients with refractory ascites treated by TIPS than Child-Pugh classification. The discriminant power was low in both scores in one year horizon.

Ascites↗

PubMed2005

[Budd-Chiari syndrome and TIPS--twelve years' experience].

BACKGROUND: Massive thrombosis of hepatic veins is clinically the most serious type of Budd-Chiari syndrome (BCS). Ischemic impairment is the basic problem in case of acute or fulminate course of BCS. Restitution of blood drainage within the liver is a key therapeutic approach in such situation. In chronic course of the disease, symptoms of portal hypertension as ascites, G1 bleeding or hepatorenal syndrome are more common. The portosystemic shunt leads both to blood outflow restitution and to the decrease of portal hypertension. TIPS is a promising method due to minimal perioperative risk for the patient in critical situation and also due to its easiness of use. The aim of our study was to determine the clinical outcome in patients with BCS treated by TIPS in a retrospective analysis. METHODS AND RESULTS: During 12 years 23 patients with intraparenchymal thrombotic occlusion of hepatic veins were treated using TIPS, 17% were children, only 4 patients (17%) were men, the median age was 33.3 years (range 13 to 75 years). One third of the procedures was performed as urgent. In 2/3 of patients thrombosis developed in relation to myeloproliferative syndrome, in nearly 1/3 the origin of thrombosis was not detected. In 2 patients a defect of coagulation was revealed. In the first 11 patients the bare stent was used, the consecutive 12 patients received the ePTFE covered stent (stentgraft). Six patients died during follow-up: I due to fulminate liver failure, 2 due to liver failure caused by acute shunt occlusion, 1 due to the progression of the underlying hematooncological disease; the reason of death in 2 patients was not known. One patient was treated by OLTx during follow-up. The 17 surviving patients are in good condition with good shunt function although they need anticoagulant therapy and intermittent reinterventions. The average period between revisions was 2-3 years, 2 patients had no revision of TIPS for 4 years. The use of ePTFE covered stents had no effect on the number of early occlusions (approx. 18%), the occurrence of late stenoses and occlusions was substantially decreased (p=0.04, log-rank test). CONCLUSIONS: Standing on this experience we consider TIPS, in accordance with literature data, an advantageous therapeutic approach in Budd-Chiari syndrome caused by massive liver vein thrombosis. If the follow up treatment is rigorous, the TIPS usually ensures the necessary perfusion and the function of the liver So it may spare the patients of objectionable liver transplantation.

Adolescent↗

PubMed2002

[Spontaneous bacterial peritonitis in the Czech Republic].

The objective of the study was to assess the prevalence and more detailed data pertaining to the incidence of spontaneous bacterial peritonitis (SBP) in the Czech Republic. The authors examined 99 patients with cirrhosis of the liver and ascites. SBP was diagnosed in a high percentage--35 patients, i.e. 35.4%. It was found more frequently in patients with an alcoholic etiology of cirrhosis who had a history of subfebrile and febrile temperatures and increasing trend of ascites. For the diagnosis the increase of leucocytes in serum and C reactive protein levels may prove useful. Lower values of total protein and albumin in ascites predispose to the development of this infection. Reduction of the number of thrombocytes in the group of patients with SBP indicates the influence of portal hypertension in the etiology of this disease.

Adult↗

PubMed2002

[Hepatic encephalopathy after TIPS--retrospective study].

UNLABELLED: Hepatic encephalopathy (HE) is the main neuropsychiatric complication in cirrhosis of the liver. It develops slowly, begins by alteration of sleep and proceeds via flapping tremor to sopor, coma. Among known factors which promote its development are age, high dietary protein intake, haemorrhage into the GIT and the use of sedatives. Transjugular portosystemic anastomosis (TIPS) as a therapeutic method in complications of portal hypertension is associated with a higher incidence of HE. The objective of the work was to assess by retrospective investigations of patients with cirrhosis of the liver after TIPS the incidence of clinically significant HE and identify risk factors for the development of HE. MATERIAL AND METHODS: The group comprised 256 patients with cirrhosis of the liver after TIPS. This number included 59 diabetic and 197 non-diabetic patients, 7 patients suffered from chronic renal insufficiency and were in a regular dialyzation programme. The presence of HE was evaluated clinically. RESULTS: HE was found in 51% patients above 60 years of age, vs. 27% in younger patients (p = 0.002). The authors did not observe a difference in the incidence of HE in relation to sex, stage of cirrhosis, diameter of the stent nor the drop of the portosystemic gradient. In diabetic patients HE developed in 45.8% (27 of 59), as compared with 30% (59 of 197) in non-diabetic patients (p = 0.02). Multivariance analysis revealed however that the group of diabetic patients had a higher average age and thus the incidence of HE was statistically significantly conditioned by age and not by the presence of diabetes. CONCLUSION: The risk group for HE in our patients were those above 60 years of age and patients with another than ethylic etiology of liver cirrhosis. There was no direct relationship between the development of HE and other investigated parameters. Although there was no difference in the incidence of HE in relation to the diameter of the inserted stent or portosystemic gradient and its reduction, in case of unsuccessful conservative treatment with lactulose and diet, HE can be resolved by narrowing of the shunt by insertion of a reducing stent.

Adolescent↗

PubMed2002

[Rifaximin in the treatment of hepatic encephalopathy].

Hepatic encephalopathy is a frequent and serious complication of liver cirrhosis. Usually it is treated by non-absorbable disaccharides or antibiotics and its treatment is often difficult and associated with undesirable effects. The objective of our investigation was to evaluate the safety and effectiveness of a new antibiotic used in this indication--rifaximine. With rifaximine, 400 mg three times per day, a total of 25 patients were treated for a 10-day period. Significant improvement of the manifestations of encephalopathy occurred (evaluated by the grade of encephalopathy, test of combining numerals, the degree of flapping tremor and the arterial ammonia level). None of the patients developed undesirable effects. Rifaximine seems an effective, safe drug for hepatic encephalopathy.

Anti-Infective Agents↗

PubMed2002

[Effect of transjugular portosystemic shunt on insulin resistance].

UNLABELLED: Patients with cirrhosis of the liver suffer from hyperinsulinaemia and a certain degree of insulin resistance. More frequently than in the rest of the population they have diabetes. Transjugular intrahepatic portosystemic shunts (TIPS) as a therapeutic method in complications of portal hypertension lead to rapid haemodynamic changes in the liver. The objective of the submitted work was to assess whether TIPS has an impact on insulinaemia and whether it influences insulin resistance in patients with cirrhosis of the liver. GROUP AND METHODS: The authors evaluated a group of 22 patients with cirrhosis of the liver (10 diabetics and 12 subjects without diabetes) indicated for TIPS. They investigated the insulin and C-peptide concentration in blood obtained by catheterization from the hepatic and portal vein before and after TIPS and in the peripheral blood before TIPS, 1 hour, 1 day, 1 week and 1 month after TIPS. The insulin resistance was examined by the method of the hyperinsulin euglycaemic clamp (HEC) before TIPS, 1 day, 1 week, and 1 month after TIPS. The levels of C-peptide and insulin were assessed by the IRMA method. The blood sugar level in HEC was measured by means of a Hemocue apparatus. The results were evaluated by the non-parametric Wilcoxon test for two dependent samples. RESULTS: Both groups (diabetics and non-diabetics) were comparable as to age, sex, etiology of liver cirrhosis and indication for TIPS. After introduction of TIPS a change of insulin clearance occurred (p = 0.01) and a change of the insulin level in the hepatic vein immediately after TIPS (p = 0.02). Insulin clearance before TIPS was 37-90% (median 54%) and after TIPS it declined to 0-79% (median 38%) (p = 0.01). Already 1 hour after the operation the authors observed a rise of the insulin level in peripheral blood as compared with baseline values (p = 0.002). Statistically significant hyperinsulinaemia persisted one month after TIPS (p = 0.005). Values of C-peptide did not change significantly in time, neither in the hepatic vein nor in the peripheral blood. On examination of IR no statistically significant changes occurred after TIPS. On evaluation of different groups of diabetics and non-diabetics the IR was more marked in patients with DM (mean M = 1.7 mg/kg/min.) than in patients without DM (3.7 mg/kg/min.) (p = 0.03). The authors did not record significant changes of IR in time in different groups. Compensation of DM was not influenced by TIPS. The fasting blood sugar levels before TIPS and 1 month after TIPS were comparable. CONCLUSION: After TIPS a rise of the insulin level in peripheral blood occurred due to the reduced insulin clearance in the liver. Despite hyperinsulinaemia which persisted for one month after the operation, the insulin resistance did not deteriorate. Compensation of diabetes was not affected by TIPS.

Adult↗

PubMed2002

[Principles of conservative treatment of severe acute pancreatitis].

The main principles of conservative treatment of severe acute pancreatitis include early diagnosis of the disease, diagnosis of its severe form and assessment of the etiology of pancreatitis, replacement of fluids, adjustment of the milieu intérieur, administration of antibiotics in patients with confirmed necroses, in particular if they exceed 25 - 30%, early endoscpic treatment of pancreatitis with a biliary etiology, adequate nutrition, prevention and treatment of complications. The diagnosis of pancreatitis is based on clinical examination, biochemical evidence of elevated amylase and lipase concentrations and on the imaging of the pancreas. In the severe form necroses of the pancreas are present or other local complications and/or organ dysfunction. As regards assessment of the etiology rapid diagnosis of biliary pancreatitis is fundamental as it leads to therapeutic consequences. Fluid replacement should not be discontinued even during transport and diagnostic procedures. Infection remains the main cause of mortality in patients who got over the hypovolaemic stage of pancreatitis. Antibiotics are therefore indicated in all patients with necroses or biliary infection. Systemic complications include renal failure, pulmonary failure, coagulopathy, cardiac and hepatic failure--frequently manifested as combined multiple organ dysfunction. Local complications such as pseudocysts, abscesses, compression conditioned stenoses of the bile ducts or haemorrhage from impaired visceral arteries are treated as a rule in an interdisciplinary manner with preference of less invasive procedures. Clinical deterioration of patients in particular the development of multiple organ failure in patients with extensive infiltrates and necroses is caused in the great majority of cases by infection of necroses and is an indication for early, usually surgical intervention.

Acute Disease↗