The Special Session on Liver Cirrhosis and Portal Hypertension was concluded

Speech by Professor Xu Xiaoyuan

      Esther Fages Contel, Director of East Asia Affairs of Kilefour, mentioned that hundreds of millions of people worldwide are affected by liver disease, and nearly 50% of patients with liver cirrhosis are in China. Liver cirrhosis and its related complications seriously affect the quality of life of patients, and bring heavy burden to patients, medical institutions and society. This meeting brought together many experts and scholars at home and abroad, believing that this is a very good opportunity to support the treatment progress of cirrhosis and its related complications in China.

Speech by Esther Fages Contel

      In the international frontier academic part, Professor Cristina Ripoll from Germany elaborated on the definition of first decompensation and the reasons for different definitions of first decompensation in several studies. Professor Ripoll pointed out that the survival rate of patients with liver cirrhosis was significantly reduced from the compensatory stage to the decompensated stage, so it was very important to prevent the occurrence of decompensated events for patients with liver cirrhosis in the compensatory stage. At present, the core events in the definition of first decompensation include variceal bleeding, ascites and hepatic encephalopathy. However, in different studies, the definition of first loss of compensation is quite different. The main reasons are as follows:

      First, the classic sub clinical forms of decompensation are included: mild hepatic encephalopathy, ascites detected by ultrasound, and chronic bleeding caused by portal hypertensive gastrointestinal disease. However, the subclinical form of decompensation is included in the definition of first decompensation, which lacks methodological and reliable evidence support.

      Second, events that may trigger decompensation are included, such as hepatocellular carcinoma, portal vein thrombosis, and bacterial infection. Taking bacterial infection as an example, studies have shown that bacterial infection has an impact on the survival rate of patients with decompensated cirrhosis, but has no impact on the survival rate of patients who have been in the compensatory period. Therefore, bacterial infection cannot be considered as a decompensation event of patients in the compensatory period.

      Third, events related to other liver parenchyma injuries (i.e. chronic acute liver failure, superimposed liver injury) were included. Jaundice in compensatory period is related to superimposed liver injury/chronic acute liver failure. However, in the current research on evaluating jaundice in compensatory period, there is no unified definition of the extent and duration of bilirubin increase, and there is no clear statement on whether/how to exclude superimposed liver injury. Therefore, jaundice has not been included in the definition of first decompensation, but the definition of first decompensation may be changed with the acquisition of more research data in the future.

      Fourth, further decompensation events are included. Further decompensation refers to the occurrence of a second decompensation event or jaundice, or recurrent events, or ascites related complications (intractable ascites, spontaneous bacterial peritonitis, hepatorenal syndrome - acute renal injury). Taking ascites related complications as an example, ascites is an event that occurs at the time of first decompensation. In the definition of first decompensation, the influence of intractable ascites, spontaneous bacterial peritonitis, hepatorenal syndrome and diluted hyponatremia, which are related complications based on ascites, has been considered.

Speech by Professor Cristina Ripoll

      Professor Virginia Hernandez Gaa from Spain shared the topic of treatment of gastric varices. She pointed out that about 20% of patients with liver cirrhosis develop gastric varices, and the rupture of gastric varices is associated with more severe bleeding, higher mortality and higher risk of rebleeding after spontaneous hemostasis. Therefore, the treatment goal of compensated cirrhosis patients with gastric varices is to prevent the occurrence of decompensated events, that is, to prevent the rupture and bleeding of gastric varices.

      The primary prevention of gastric varices bleeding is aimed at patients who have gastric varices but never have bleeding. An RCT study showed that only non selective β Receptor blocker (NSBB) can reduce portal vein pressure, and it can also be used as a disease modifying drug in the treatment of cirrhosis and gastric varices. At the same time, the proposal of Baveno collaboration group to prevent the first decompensation event (NSBB is recommended to prevent decompensation in patients with clinically significant portal hypertension) is also applicable to patients with gastric varices.

      The secondary prevention of gastric varices bleeding is aimed at patients who have experienced gastric varices bleeding in the past. Professor Hernandez Gee recommends the use of cyanoacrylate, transjugular intrahepatic portosystemic shunt (TIPS), and transvenous retrograde balloon catheter embolization (BRTO) for secondary prevention. Many studies have shown that endoscopic ultrasound guided single or combined use of cyanoacrylate, single or combined use of TIPS can significantly reduce the incidence of rebleeding. The study shows that TIPS and BRTO are better than cyanoacrylate in secondary prevention of gastric variceal bleeding, with no difference in survival rate. Professor Hernandez Gee pointed out that the choice of treatment methods should ultimately depend on the clinical and pathophysiological factors of patients and the expertise of local experts.

Speech by Professor Virginia Hernandez Gee

      In the academic part of "Voice of China", Professor Sun Yameng elaborated on the evaluation indicators of liver cirrhosis reversal and the reasons why some liver cirrhosis could not be reversed after etiological treatment. Professor Sun pointed out that studies at home and abroad have shown that liver cirrhosis can be reversed, but there are two problems that need further discussion.

      First of all, the evaluation index of liver cirrhosis reversion. Liver biopsy is considered as the "gold standard" to evaluate the reversion of liver fibrosis, and has always relied on traditional fibrosis score, such as semi quantitative score. However, such a score requires two liver punctures before and after etiological treatment, and lacks prognostic information. Therefore, Professor Sun Yameng's team proposed a new pathological classification to evaluate the reversion of liver fibrosis/cirrhosis, namely P-I-R score. For patients with no change in the traditional score before and after treatment, the patients with the trend of liver cirrhosis reversion can be subdivided by using P-I-R classification, so only one liver puncture biopsy is required after the etiological treatment. Instantaneous elasticity measurement of liver can judge the degree of liver fibrosis by measuring liver stiffness (LSM), but whether LSM can evaluate the reversal of fibrosis is controversial. Hepatic vein pressure gradient (HVPG) and esophageal and gastric varices are also good indicators to evaluate the reversion of liver cirrhosis.

      Secondly, why did some liver cirrhosis not get reversed or even progressed after etiological treatment? Continued low levels of HBV DNA may be the driving factor. Other liver diseases may be combined, such as alcoholic liver disease and persistent nonalcoholic fatty liver disease (NAFLD).

Speech by Professor Sun Yameng

Discussion

      During the symposium, Professor Wu Chao of Nanjing Drum Tower Hospital asked whether TIPS could be used as a primary prevention in cirrhosis caused by special causes (such as schistosomiasis and malaria, which may be accompanied by megasplenomegaly and severe portal hypertension, but with good liver reserve). Professor Yang Changqing of Tongji Hospital affiliated to Tongji University asked whether TIPS could be used for primary prevention in patients with severe gastric varices. Professor Liu Fuquan of Beijing Shijitan Hospital affiliated to Capital Medical University asked the same patient why the results of hepatic vein pressure gradient (HVPG) and portal vein pressure gradient (PPG) were sometimes inconsistent. Professor Wang Xianbo from Beijing Ditan Hospital affiliated to Capital Medical University inquired whether probiotics have a secondary prevention effect on esophageal and gastric varices bleeding. Professor Guo Xiaoyan, the Second Affiliated Hospital of Xi'an Jiaotong University, asked Professor Virginia Hernandez Gee whether endoscopic ligation was more effective than tissue adhesive embolization when treating gastric fundus varices within 1cm. Professor Dai Yun from the First Hospital of Peking University asked about the research on the reversal of cirrhosis caused by other causes except hepatitis B virus. Professor Xu Jinghang, the First Hospital of Peking University, said that the definition of decompensated cirrhosis should not include jaundice.

      Professor Virginia Hernandez Gee believes that TIPS is an excellent tool to reduce portal vein pressure. However, when considering whether TIPS can be used as the primary prevention of cirrhosis with special causes (such as schistosomiasis and malaria), its side effects should be considered. It is very important to select the people who can really benefit from TIPS treatment. When treating patients with severe gastric fundus varices but no rupture bleeding, European doctors will first use NSBB instead of TIPS to reduce the patient's portal vein pressure, because not all gastric fundus varices will rupture bleeding. In addition, further research is needed to develop predictive indicators to accurately predict patients with gastric fundus varices who may have rupture and bleeding, and give priority to TIPS surgery for these patients.

      Professor Cristina Ripoll pointed out that liver cirrhosis recompensation refers to the patient returning from the decompensation period of liver cirrhosis to the compensatory period, but this definition proposed by the Baveno collaboration group is based on expert consensus rather than research basis. At present, the specific time for decompensated liver cirrhosis patients to obtain recompensation is still uncertain. In addition, the etiological treatment of patients with decompensated cirrhosis is very important, especially whether there are multiple causes, such as active treatment of viral infection, and whether the patients drink. In general, the concept of liver cirrhosis recompensation is very important, which brings hope for survival to patients.

      Professor Nan Yuemin, the Third Hospital of Hebei Medical University, said that the complications of liver cirrhosis during the decompensation period, whether ascites, hepatic encephalopathy or variceal bleeding, may lead to hypoalbuminemia based on secondary hypovolemia. Therefore, it is important to timely replenish albumin and improve blood volume when complications occur. In addition, with the progress of the disease, if the patient has recurrent bleeding, significantly reduced liver volume, significant portal hypertension, but cannot undergo liver transplantation, TIPS can be selected, and the patient's clinical manifestations, blood ammonia, liver function and other indicators can be closely monitored.

      Professor Sun Yameng from Beijing Friendship Hospital affiliated to Capital Medical University said that in addition to hepatitis B cirrhosis, our research team also studied the reversal of metabolic fatty liver disease cirrhosis and alcoholic cirrhosis. By comparing the histological results of liver puncture twice before and after treatment, a large proportion of patients can get the reversion of liver cirrhosis through etiological treatment (weight loss surgery/physical weight loss, abstinence from alcohol). In addition, the more serious the liver inflammatory activity before treatment, the higher the possibility of liver cirrhosis reversal after treatment. However, when the liver cirrhosis is serious to a certain extent, such as a very wide and dense fibrous septum, it is more difficult to reverse liver cirrhosis.

      At last, the President of the Conference, Professor Xu Xiaoyuan and Professor Jia Jidong, summarized the wonderful contents of the meeting. Professor Xu Xiaoyuan pointed out that this dialogue between China and the West has delivered many new ideas and good clinical experience to doctors, which has made us fruitful. Professor Jia Jidong expressed his gratitude for the academic exchange platform and commonweal support provided by Qilifu. I hope that in the future, we can not only continue the dialogue between Chinese and Western experts, but also further develop cooperation!