Nat. Rev. Gastroenterol. Hepatol. doi: /nrgastro

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Nat. Rev. Gastroenterol. Hepatol. doi:10.1038/nrgastro.2016.168 Figure 5 Factors promoting infections and sepsis in patients with liver cirrhosis Figure 5 | Factors promoting infections and sepsis in patients with liver cirrhosis. Patients with liver cirrhosis display a complex immune dysfunction, an altered gut microbiota and increased bacterial translocation through the intestinal wall. The presence of portal hypertension leads to appearance of portosystemic shunts that decrease bacterial clearance in the liver. Portal hypertension might also result in overactive spleen (hypersplenism) with an increased degradation of circulating blood cells and consecutive impairment of microbial defence. An altered bile composition, a delayed intestinal transit time, decreased gastric acid production and a disturbed production of intestinal antimicrobial peptides results in small intestinal bacterial overgrowth. The systemic inflammatory response leads to an increased leakiness of tight junctions further increasing gut permeability. Bacterial translocation contributes to an additional activation of the immune response with increased levels of cytokines (TNF) and reactive oxygen species (ROS), thereby forming a vicious cycle. LPS, lipopolysaccharide. Strnad, P. et al. (2016) Liver — guardian, modifier and target of sepsis Nat. Rev. Gastroenterol. Hepatol. doi:10.1038/nrgastro.2016.168