Randomized controlled trial of rivaroxaban versus warfarin in the management of acute non-neoplastic portal vein thrombosis

BACKGROUND AND AIM

Anticoagulation therapy is the main line of treatment for acute portal vein thrombosis (PVT) in the absence of cirrhosis. However, the use of this therapy in cirrhotic PVT is still with doubtful evidence. We aimed to evaluate the efficacy and safety of rivaroxaban compared to warfarin for the management of acute non-neoplastic PVT in Hepatitis C virus (HCV)-related compensated cirrhosis.

METHODS

Out of 578 patients with chronic HCV infection, 80 patients with acute PVT who had undergone splenectomy due to hypersplenism and 4 patients with acute PVT due to portal pyemia were selected. The patients were randomly assigned (1:1) to the study group (n = 40), in which the patients received rivaroxaban 10 mg/12 h, or the control group (n = 40), in which the patients received warfarin.

RESULTS

In the rivaroxaban group, the resolution of PVT was achieved in 34 patients (85%) within 2.6 ± 0.4 months and delayed, partial recanalization after 6.7 ± 1.2 months (n = 6.15%). Complications such as major bleeding, abnormal liver functions, death, or recurrence did not occur during treatment, and patients in this group showed improved short-term survival rate (20.4 ± 2.2 months) compared to the survival rate in the control group (10.6 ± 1.8 months) in which warfarin achieved complete resolution in 45% of patients. Complications such as severe upper GI tract bleeding (43.3%), hepatic decompensation (22.5%), progression to mesenteric ischemia (12.5%), recurrence (10%), and death (20%) were observed in the control group. The duration until complete resolution of thrombus correlated with age, the extent of the thrombus, creatinine level, and MELD score. The recurrence after complete resolution of thrombus correlated with age, the extent of the thrombus, thrombogenic gene polymorphism, and the use of warfarin.

CONCLUSION

Rivaroxaban was effective and safe in acute HCV-related non-neoplastic PVT with improved short-term survival rate; ClinicalTrials.gov Identifier: NCT03201367.

Endoscopic management of refractory gastroesophageal reflux disease

OBJECTIVE

Despite the therapeutic and surgical interventions for the management of gastroesophageal reflux disease (GERD), yet the high cost and the post-operative complications had led to a significant socioeconomic burden. The aim was to evaluate the safety and efficacy of endoscopic band ligation (EBL) in the management of refractory GERD.

METHODS

A total of 150 patients with refractory GERD were assigned to an EBL group (banding was done at four quadrants just at the gastroesophageal junction (GEJ) (n = 75) or to a control group (optimized dose of PPI, n = 75). Follow-up for both groups by upper GI endoscopy to evaluate the site of the Z line from the incisors, the width of the GEJ and the coaptation of GEJ around the endoscope on retroflection. PH monitoring was performed every 3 months with GERD- QoL assessment monthly for 1 year.

RESULTS

In EBL group; 58 patients (77.3%) needed 1 session, 17 patients (22.7%) needed 2 sessions. 4 rubber bands were utilized in 44 patients (58.7%), 3 rubber bands in 31 patients (41.3%). Follow-up for 1 year revealed a highly significant improvement of the GERD- QoL score, the site of Z line with significant reduction of reflux episodes and symptom index when compared to the medical treatment group. In EBL group; there were no major adverse events including bleeding, post band ulcers, stenosis at one year follow up.

CONCLUSION

The current study provides a novel endoscopic intervention to treat refractory GERD, which is safe, cost-effective, with no major adverse effects at one year follow up.

Rescue therapy for chronic hepatitis C virus infection after repeated treatment failures: Impact on disease progression and risk of hepatocellular carcinoma

AIM

Retreatment after previous failure of direct-acting antivirals for hepatitis C virus (HCV) infection is a challenging decision. The importance of achieving viral eradication on modification of disease progression and outcome, including the risk of hepatocellular carcinoma (HCC), remains a critical issue to be evaluated.

METHODS

One hundred patients with repeated failure of sofosbuvir and ribavirin or triple therapy with sofosbuvir, ribavirin, and daclatasvir were divided into a study group (n = 50) given rescue therapy (sofosbuvir, daclatasvir, simeprevir, and ribavirin) or a control group (n = 50) matched for age, sex, and pretreatment variables (Child-Turcotte-Pugh score and Fibrosis-4 score). Follow-up was undertaken after the last non-response to detect serious adverse events, such as hepatic decompensation and development of HCC.

RESULTS

The study group achieved sustained virologic response (SVR) in 47 of 50 (94%) patients. The control group had significantly higher HCC rates than the study group (7 vs. 1 patients), with an odds ratio of 5.44. The rescue therapy was associated with significantly longer time to the occurrence of adverse events. Repeated treatment failures were associated with progression of FibroScan values in the control group (21 ± 4.5 vs. 10 ± 1.5 kPa, P = 0.001); achieving SVR in the study group stopped fibrosis progression despite non-significant increase from baseline (13.2 ± 3.2 vs. 10.6 ± 0.6, P = 0.12).

CONCLUSIONS

Rescue treatment for HCV infection was highly effective in achieving SVR, less expensive than the newer agents, and is associated with diminished risk of serious adverse events, mainly HCC in these patients.

Challenges in COVID-19 drug treatment in patients with advanced liver diseases: A hepatology perspective

The global incidence of coronavirus disease 2019 (COVID-19) continues to increase despite health care efforts. The disease is caused by coronavirus 2 with high transmission and mortality rates. Little is known about the management of COVID-19 in advanced liver disease. The aim of work was to propose a plan for management of this drastic disease in case of this specific population with review of medications that could be suitable for advanced liver disease. All the guidelines and medications available for treatment of COVID-19 were reviewed with selection of the less toxic medications that could be used in advanced liver disease. Drugs suitable to manage COVID-19 in patients with liver disease might include remdesivir intravenously, nitazoxanide + sofosbuvir, ivermectin, tocilizumab, convalescent plasma, and low molecular weight heparin in certain situations. Advanced liver disease is associated with portal hypertension and splenomegaly with reduction of blood elements and immune dysfunction and impaired T cell function. Thus, when confronted by cytokine storm as an immune response to COVID-19, there may be an increase in the mortality rate of these patients. Through this review, a plan to treat COVID-19 in this special group of patients with advanced cirrhosis is proposed.

Management of different types of gastric varices with band ligation: a 3-year experience

BACKGROUND AND AIM

Gastric varices (GVs) occur with an incidence of 20% in patients with portal hypertension. The aim of this study was to evaluate the efficacy of endoscopic band ligation (BL) as an option in the management of small-to-moderate nonbleeding GVs in cirrhotic patients.

PATIENTS AND METHODS

A total of 50 patients (GOV2; n=6, IGV1; n=34, IGV2; n=10) with nonbleeding small-to-moderate-sized GVs without local risk signs of bleeding, such as large size, red-colored elevated areas or red wales, and systemic factors of bleeding risk such as an international normalized ratio of at least 2 and a platelet count of 80 000/µl or less were subjected to endoscopic BL. The patients were followed up every 2 weeks for 1 month and then every 1.5 months for 6 months. The primary outcome was GV eradication, detection of complications such as postprocedural bleeding ulceration and mortality.

RESULTS

The mean number of BL sessions was 2.2±0.8; post-BL ulceration occurred in two (4%) patients (n=2 in IGV1, P=0.61), bleeding occurred in one (2%) patient (n=1 in IGV1, P=0.79), and epigastric pain occurred in six (12%, n=4 in GOV2, n=2 in IGV1) patients. There was no mortality reported among patients treated with BL.

CONCLUSION

Endoscopic BL resulted in better outcome and a lower incidence of complications when used to treat small-to-medium-sized nonbleeding GVs. Further, early eradication can save effort and cost, thus avoiding the future risk of treatment of large or risky GVs with sclerotherapy.

Multifocal fatty liver disease, insulin resistance and carotid atherosclerosis: exploring the interrelated relationship

Introduction: Multifocal fatty liver infiltrations are not uncommon ultrasonographic finding; they are explained by the presence of aberrant vascular supply independent of the portal circulation or insulin resistance. Aim: To study the significance of this ultrasonographic finding. Methods: A study group (n = 96) with multifocal fatty liver and two control groups: healthy subjects (n = 100) and patients with diffuse fatty liver disease (n = 100) were enrolled. They were tested for fasting blood glucose, lipid profile, transaminases, serum insulin, glycated hemoglobin, Homeostatic Model Assessment of Insulin Resistance, high-sensitivity C-reactive protein and liver stiffness in Fibroscan. Results: Patients with multifocal fatty liver showed a statistically significant higher values of serum transaminases, markers of insulin resistance, high-sensitivity C-reactive protein, and neutrophil lymphocyte ratio (p <0.05). Lipid profile parameters were significantly higher (p <0.05). Mean liver stiffness (9.8 ± 1.2 kPa) and carotid intima media thickness (1.16 ± 0.2 mm) were significantly higher when compared to healthy subjects and patients with diffuse fatty liver disease. Independent predictors of insulin resistance and premature carotid atherosclerosis in patients with multifocal fatty liver disease were: serum gamma-glutamyl transferase (odds ratio 1.69), high-sensitivity C-reactive protein (odds ratio 1.62), uric acid (odds ratio 1.55), very low-density lipoprotein (odds ratio 1.74), total cholesterol/high-density lipoprotein (odds ratio 1.58) and severity of liver stiffness measured by Fibroscan (odds ratio 1.9). Conclusions: Multifocal fatty liver is an aggressive form of nonalcoholic fatty liver disease and should be considered a radiological sign of insulin resistance that needs special attention and management. Introduction: Multifocal fatty liver infiltrations are not uncommon ultrasonographic finding; they are explained by the presence of aberrant vascular supply independent of the portal circulation or insulin resistance. Aim: To study the significance of this ultrasonographic finding. Methods: A study group (n = 96) with multifocal fatty liver and two control groups: healthy subjects (n = 100) and patients with diffuse fatty liver disease (n = 100) were enrolled. They were tested for fasting blood glucose, lipid profile, transaminases, serum insulin, glycated hemoglobin, Homeostatic Model Assessment of Insulin Resistance, high-sensitivity C-reactive protein and liver stiffness in Fibroscan. Results: Patients with multifocal fatty liver showed a statistically significant higher values of serum transaminases, markers of insulin resistance, high-sensitivity C-reactive protein, and neutrophil lymphocyte ratio (p <0.05). Lipid profile parameters were significantly higher (p <0.05). Mean liver stiffness (9.8 ± 1.2 kPa) and carotid intima media thickness (1.16 ± 0.2 mm) were significantly higher when compared to healthy subjects and patients with diffuse fatty liver disease. Independent predictors of insulin resistance and premature carotid atherosclerosis in patients with multifocal fatty liver disease were: serum gamma-glutamyl transferase (odds ratio 1.69), high-sensitivity C-reactive protein (odds ratio 1.62), uric acid (odds ratio 1.55), very low-density lipoprotein (odds ratio 1.74), total cholesterol/high-density lipoprotein (odds ratio 1.58) and severity of liver stiffness measured by Fibroscan (odds ratio 1.9). Conclusions: Multifocal fatty liver is an aggressive form of nonalcoholic fatty liver disease and should be considered a radiological sign of insulin resistance that needs special attention and management.

Management of a Portal Hypertensive Polyp: Case Report of a Rare Entity

Portal hypertensive polyposis is a rare finding represented in about 2.5% of all patients with portal hypertension. The diagnostic criteria are not yet clearly defined. It has been mentioned in a few case reports; its distribution was mainly duodenal and less frequently gastric. Here, a patient with type 2 diabetes and liver cirrhosis was hospitalized for vomiting, abdominal pain, and melena. The patient was admitted to the intensive care unit for stabilization and urgent esophagogastroduodenoscopy (EGD). EGD revealed a single antral polyp occluding the pyloric ring which was the cause of gastric outlet obstruction. Complete debulking by argon plasma was done which improved gastric outlet obstruction and melena. We conclude that argon plasma coagulation is a safe, rapid, and effective method for treating portal hypertensive polyposis.

Efficacy of low dose capecitabine and sorafenib in patients with advanced alfa-fetoprotein secreting hepatocellular carcinoma: a 1 year experience

BACKGROUND

There is no global consensus for the optimal management of HCC. Most of patients at the time of diagnosis are not candidate for potentially curative therapy. The study aimed to evaluate the efficacy of low dose capecitabine combined with sorafenib in subset of Egyptian HCV patients presented with advanced HCC unfit for surgical or locoregional therapies.

METHODS

15 patients with advanced HCC, unfit for surgical or locoregional intervention, with PS <2 recieved Capecitabine 500 mg/day with sorafeneb 200 mg twice daily till normalization of AFP then the treatment was modified to capecitabine 250 mg every other day and sorafenib 400 mg once daily. They were followed every 3 months for size, number of focal masses and AFP. 30 patients were selected as a control group, they received supportive therapy (n = 15) or sorafenib only (n = 15).

RESULTS

After 10 months of therapy, 6 patients showed complete response (40 %) with complete recanalization of portal vein (n = 2) and treatment was stopped and the others (n = 4) showed partial portal vein recanalization so, treatment is continued till now. 1 patient (6.7 %) showed recurrence of the disease and died after 1 month, 8 patients showed partial response (53.3 %) and still on treatment. The control groups showed a highly significant reduction in survival when compared to patients who received capecitabine and sorafenib (12.9 ± 2.1, 7.9 ± 0.9, 4.5 ± 1.3 months, p = 0.000).

CONCLUSIONS

Combined low dose capecitabine and sorafenib proved to be safe with low toxicity profile and deserves further attention as a convenient, outpatient-based chemotherapy in patients with advanced HCC.

Novel markers of endothelial dysfunction in hepatitis C virus-related cirrhosis: More than a mere prediction of esophageal varices

BACKGROUND

Hepatitis C virus (HCV) infection may affect lipid metabolism by enhancing the circulating levels of inflammatory cytokines, together with its impact on endothelial function.

AIM

To evaluate the potential correlation of changes in lipid profile, carotid intima-media thickness (CIMT), and ankle-brachial index with the severity of fibrosis, grades of esophageal varices (EVs), and fibrosis indices.

METHODS

The study included 240 subjects who were divided into 3 groups; group 1 (n = 90, HCV-related cirrhotic patients with EVs), group 2 (n = 90, HCV-related cirrhotic patients without EVs), and group 3 (n = 60, served as the healthy control group). All patients underwent routine laboratory tests, including a lipid profile assay. Low-density lipoproteins (LDL)/platelet count and platelet/splenic diameter ratios were calculated. Abdominal ultrasonography, CIMT by carotid Doppler, bedside ankle-brachial index (ABI), liver stiffness measurement, and upper gastrointestinal endoscopy were performed.

RESULTS

Multivariate logistic regression revealed that very-low-density lipoprotein (VLDL) (β = 0.988, odds ratio 2.5, P = 0.001), LDL/platelet count ratio (β = 1.178, odds ratio 3.24, P = 0.001), CIMT (β = 1.37, odds ratio 3.9, P = 0.001), and ABI (β = 2.3, odds ratio 5.9, P = 0.001) were the key variables associated with significant fibrosis, EVs and endothelial dysfunction. CIMT and LDL/platelet count ratio were predictive of advanced fibrosis and EVs at cutoff values of 1.1 mm and 1 mm, respectively, with an area under the curve (AUC) of 0.966 and 0.960 (P = 0.001), while VLDL and ABI at a cutoff of 16.5 mg/dL and 0.94 were predictive of advanced fibrosis and EVs with an AUC of 0.891 and 0.823, respectively (P = 0.001).

CONCLUSION

CIMT, ABI, VLDL, LDL/platelet count ratio are good non-invasive predictors of advanced fibrosis, presence of EVs, and endothelial dysfunction in liver cirrhosis.