H epatic encephalopathy (HE) continues to be a major clinical problem. In subjects with acute liver failure, patients can succumb to a neurologic death, with brain edema and intracranial hypertension. 1 In patients with cirrhosis, the Child classification recognizes the prognostic significance of HE. 2 The current decade has not witnessed major therapeutic breakthroughs in this area. However, there is a need to delineate better research tools in preparation for new developments, and define mild forms of the disorder and their response to treatment. Drugs that work directly on the brain will become increasingly available for clinical testing. The current epidemic of hepatitis C is increasing the number of patients with cirrhosis and raising questions about alterations in biological functions, such as sleep and appetite, that are intertwined with the significance and pathogenesis of minimal (subclinical) encephalopathy.Under this light, the Organisation Mondiale de Gastroentér-ologie commissioned a Working Party to reach a consensus in this area and to present it at the 11th World Congress of Gastroenterology (WCOG) in Vienna (1998). The study of the changes in mental state in patients with liver disease requires the expertise of several disciplines, including hepatology, neurology, and neuropsychology, all represented in the composition of the Working Party. Four questions were tackled:1 Gastroenterology; EEG, electroencephalogram; NCT, number connection test; TIPS, transjugular portal-systemic shunt; PET, positron emission tomography. From the

Background & Aims-Hepatorenal syndrome (HRS) type 1 is a progressive functional renal failure in subjects with advanced liver disease. The aim of this study was to evaluate the efficacy and safety of terlipressin, a systemic arterial vasoconstrictor, for cirrhosis type 1 HRS.

Normal coagulation has classically been conceptualized as a Y-shaped pathway, with distinct "intrinsic" and "extrinsic" components initiated by factor XII or factor VIIa/ tissue factor, respectively, and converging in a "common" pathway at the level of the FXa/FVa (prothrombinase) complex. Until recently, the lack of an established alternative concept of hemostasis has meant that most physicians view the "cascade" as a

The present consensus details the intensive care management of patients with acute liver failure. Such guidelines may be useful not only for the management of individual patients with acute liver failure, but also to improve the uniformity of practices across academic centers for the purpose of collaborative studies.

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Hepatitis is a rare complication of herpes simplex virus (HSV), often leading to acute liver failure (ALF), liver transplantation (LT), and/or death. Our aim was to identify variables associated with either survival or progression (death/LT), based on an analysis of cases in the literature and our institution. A total of 137 cases (132 literature, 5 institutional) of HSV hepatitis were identified. The main features at clinical presentation were fever (98%), coagulopathy (84%), and encephalopathy (80%). Rash was seen in less than half of patients. Most cases (58%) were first diagnosed at autopsy and the diagnosis was suspected clinically prior to tissue confirmation in only 23%. Overall, 74% of cases progressed to death or LT, with 51% in acyclovirtreated patients as compared to 88% in the untreated subjects (P ϭ 0.03). Variables on presentation associated with death or need for LT compared to spontaneous survival: male gender, age Ͼ40 yr, immunocompromised state, ALT Ͼ5,000 U/L, platelet count Ͻ75 ϫ 10 3 /L, coagulopathy, encephalopathy, and absence of antiviral therapy. In conclusion, HSV hepatitis has a high mortality and is often clinically unsuspected. Patients who are male, older, immunocompromised, and/or presenting with significant liver dysfunction are more likely to progress to death and should thus be evaluated for LT early. Based on the frequent delay in HSV diagnosis, low risk-benefit ratio, and significantly improved outcomes, empiric acyclovir therapy for patients presenting with ALF of unknown etiology is recommended until HSV hepatitis is excluded.

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Little information is available on acute liver failure (ALF) in the United States. We gathered demographic data retrospectively for a 2-year period from July 1994 to June 1996 on all cases of ALF from 13 hospitals (12 liver transplant centers). Data on the patients included age, hepatic coma grade on admission, presumed cause, transplantation, and outcome. Among 295 patients, 74 (25%) survived spontaneously, 121 (41%) underwent transplantation, and 99 (34%) died without undergoing transplantation. Ninety-two of 121 patients (76%) survived 1 year after transplantation. Acetaminophen overdose was the most frequent cause (60 patients; 20%), followed by cryptogenic/non A non B non C (NANBNC; 15%), idiosyncratic drug reactions (12%), hepatitis B (10%), and hepatitis A (7%). Spontaneous survival rates were highest for patients with acetaminophen overdose (57%) and hepatitis A (40%) and lowest for those with Wilson's disease (no survivors of 18 patients). The transplantation rate was highest for Wilson's disease (17 of 18 patients; 94%) and lowest for autoimmune hepatitis (29%) and acetaminophen overdose (12%). Age did not differ between survivors and nonsurvivors, perhaps reflecting a selection bias for patients transferred to liver transplant centers. Coma grade on admission was not a significant determinant of outcome, but showed a trend toward affecting both survival and transplantation rate. These findings on retrospectively studied patients from the United States differ from those previously gathered in the United Kingdom and France, highlighting the need for further study of trends in each country.