Muscle fat content correlates with postoperative survival of viral-related cirrhosis patients after the TIPS: a retrospective study

PURPOSE

Early prediction of the prognosis of viral-related cirrhosis patients after transjugular intrahepatic portosystemic shunt (TIPS) is beneficial for clinical decision-making. The aim of this study is to explore a comprehensive prognostic assessment model for evaluating the survival outcomes of patients post-TIPS.

MATERIALS AND METHODS

A total of 155 patients treated with TIPS were included in the study. The data were collected from electronic records. The nutritional status of the patient is evaluated using imaging examinations measuring by the axial CT images from the L3 vertebral level. The primary endpoint was set as death within 1 year after TIPS. Multivariate Cox regression was performed to determine the factors associated with mortality.

RESULTS

The Cox regression analysis revealed that the lower PMFI was associated with a lower risk of all-cause mortality after TIPS (hazard ratio [HR] 1.159, 95% confidence interval [CI] 1.063-1.263, p = 0.001). Furthermore, subgroup analyses according to gender revealed the PMFI was associated with postoperative death both in male (HR 2.125, 95% CI, 1.147-3.936, p = 0.017) and female patients (HR 1.070, 95% CI, 1.001-1.144, p = 0.047). The area under the curve (AUC) for predicting death within 1 year was 0.807. The clinical impact curve analysis showed that PMFI had higher levels of risk threshold probability and a smaller gap between actual and predicted curves.

CONCLUSIONS

In viral-related cirrhosis patients with portal hypertension, increased muscle fat content might be a potential prognostic marker and associated with postoperative death after TIPS.

Distinct clusters of bacterial and fungal microbiota in end-stage liver cirrhosis correlate with antibiotic treatment, intestinal barrier impairment, and systemic inflammation

Decompensated liver cirrhosis (dLC) is associated with intestinal dysbiosis, however, underlying reasons and clinical consequences remain largely unexplored. We investigated bacterial and fungal microbiota, their relation with gut barrier integrity, inflammation, and cirrhosis-specific complications in dLC-patients. Competing-risk analyses were performed to investigate clinical outcomes within 90 days. Samples were prospectively collected from 95 dLC-patients between 2017 and 2022. Quantitative metagenomic analyses clustered patients into three groups (G1-G3) showing distinct microbial patterns. G1 (n = 39) displayed lowest diversity and highest Enterococcus abundance, G2 (n = 24) was dominated by Bifidobacteria, G3 (n = 29) was most diverse and clustered most closely with healthy controls (HC). Of note, bacterial concentrations were significantly lower in cirrhosis compared with HC, especially for G1 that also showed the lowest capacity to produce short chain fatty acids and secondary bile acids. Consequently, fungal overgrowth, dominated by Candida spp. (51.63%), was observed in G1. Moreover, G1-patients most frequently received antibiotics (n = 33; 86.8%), had highest plasma-levels of Zonulin (p = 0.044) and a proinflammatory cytokine profile along with numerically higher incidences of subsequent infections (p = 0.09). In conclusion, distinct bacterial clusters were observed at qualitative and quantitative levels and correlated with fungal abundances. Antibiotic treatment significantly contributed to dysbiosis, which translated into intestinal barrier impairment and systemic inflammation.

Oxidative stress and inflammation in hemodialysis: a comparison of patients with or without advanced nonalcoholic fatty liver disease (NAFLD)

Nonalcoholic fatty liver disease (NAFLD) and chronic kidney disease are global public health issues associated with high morbidity and mortality. Both diseases are also interlinked. Little is known about the meaning of NAFLD in hemodialysis (HD) patients. Therefore, the aim of our study was to investigate the difference in oxidative stress and inflammation in HD patients with or without advanced NAFLD. Seventy-seven HD patients were included (65.14 ± 12.34 years, 59.2% male) and divided according to abdominal ultrasound and two-dimensional shear wave elastography (2D-SWE) measurements into two groups: 1) no NAFLD or no advanced NAFLD (2D-SWE <9 kPa) and 2) advanced NAFLD (2D-SWE ≥9 kPa). Medical history data and blood results were collected. HD patients with advanced NAFLD had significantly higher levels of 8-hydroxy-2'-deoxyguanosine (8-OHdG; p = 0.025), tumor necrosis factor-alpha (TNF-α; p = 0.023), and intercellular adhesion molecule 1 (ICAM-1; p = 0.015) in comparison to HD patients without advanced NAFLD. Interleukin 6 (IL-6) was higher in the advanced NAFLD group, but the difference was of borderline significance (p = 0.054). There was no significant difference in high-sensitivity C-reactive protein (hs-CRP), and vascular cell adhesion molecule 1 (VCAM-1) between groups. In binary logistic regression analysis, advanced NAFLD was significantly associated with 8-OHdG and ICAM-1. In conclusion, higher oxidative stress and inflammation levels are present in HD patients with advanced NAFLD.

Gut microbiota in hepatocellular carcinoma immunotherapy: immune microenvironment remodeling and gut microbiota modification

Hepatocellular carcinoma (HCC) remains a leading cause of cancer-related mortality, with limited treatment options at advanced stages. The gut microbiota, a diverse community of microorganisms residing in the gastrointestinal tract, plays a pivotal role in regulating immune responses through the gut-liver axis. Emerging evidence underscores its impact on HCC progression and the efficacy of immunotherapy. This review explores the intricate interactions between gut microbiota and the immune system in HCC, with a focus on key immune cells and pathways involved in tumor immunity. Additionally, it highlights strategies for modulating the gut microbiota - such as fecal microbiota transplantation, dietary interventions, and probiotics - as potential approaches to enhancing immunotherapy outcomes. A deeper understanding of these mechanisms could pave the way for novel therapeutic strategies aimed at improving patient prognosis.

Application of combi-elastography for follow-up after pediatric liver transplantation: A prospective study

OBJECTIVE

To investigate the use of combi-elastography in children after liver transplantation.

METHODS

Thirty-five children who underwent liver transplantation at our hospital were prospectively selected. Donor livers were divided into fatty liver and nonfatty liver groups according to the degree of fatty liver. Recipients were categorized into groups with (10 patients) and without complications (25 patients) according to the presence or absence of complications within 6 months after surgery. Combi-elastography was performed on each donor liver, and each patient underwent combi-elastography at the time of surgery and at 1 day, 7 days, 1 month, 3 months, and 6 months after surgery; the results of liver function tests were recorded at the same time points.

RESULTS

Despite the rapid recovery of liver function in the group without complications, the combi-elastography indices were still high in the early stage and gradually stabilized after 3 months but were still higher than those of the donor liver at 6 months. In the fatty liver group, the postoperative 1-day combi-elastography values were significantly higher than those in the nonfatty liver group, and in the group with complications, the postoperative 1-day combi-elastography values were significantly higher than those in the group without complications. The receiver operating characteristic (ROC) curve analysis revealed that the areas under the curves (AUCs) of the combi-elastography values for predicting complications in children at 6 months after liver transplantation were 8.41 kPa for Young's modulus (E) (with a sensitivity of 90 % (9/10 and a specificity of 76 % (19/25)) 1.26 for the F-index (FI) value (sensitivity 80 %(8/10), specificity 80 % (20/25)), and 1.05 kPa for the A-index (AI) value (sensitivity 80 %(8/10), specificity 72 % (18/25)).

CONCLUSIONS

Combi-elastography is useful for assessing changes in liver stiffness in the early period after liver transplantation and should therefore be considered for the follow-up of children who undergo liver transplantation.

Non-cirrhotic portal hypertension in pregnancy due to schistosomiasis: A case series

The presence of non-cirrhotic portal hypertension in pregnancy poses a challenging clinical scenario as it predisposes women to several life-threatening complications such as variceal haemorrhage, splenic artery aneurysm, pulmonary hypertension and bacterial peritonitis. The haemodynamic changes in pregnancy along with the demands of a growing fetus may worsen the severity of pre-existing non-cirrhotic portal hypertension. In this case series, we discuss four cases of non-cirrhotic portal hypertension in pregnancy in a low to middle income setting and review the literature related to this condition.

Percutaneous recanalization of non-cirrhotic extrahepatic portal vein obstruction in children: technical considerations in a preliminary cohort

OBJECTIVES

Portal hypertension resulting from non-cirrhotic extrahepatic portal vein obstruction (EHPVO) in children has been primarily managed with the Meso-Rex bypass, but only a few patients have a viable Rex recessus, required by surgery. This study reports a preliminary series of patients who underwent interventional radiology attempts at portal vein recanalization (PVR), with a focus on technical aspects and safety.

METHODS

A retrospective review of consecutive patients with severe portal hypertension due to non-cirrhotic EHPVO at a single institution from 2022, who underwent percutaneous attempts at PVR, was performed. Technical and clinical data including fluoroscopy time, radiation exposure, technical and clinical success, complications and follow-up were recorded.

RESULTS

Eleven patients (6 males and 5 females; median age 7 years, range 1-14) underwent 15 percutaneous transhepatic (n = 1), transplenic (n = 11), or simultaneous transhepatic/transplenic (n = 3) procedures. Rex recessus was patent in 4/11 (36%). Fluoroscopy resulted in a high median total dose area product (DAP) of 123 Gycm2 (range 17-788 Gycm2) per procedure. PVR was achieved in 5/11 patients (45%), 3/5 with obliterated Rex recessus. Two adverse events of grade 2 and grade 3 occurred without sequelae. After angioplasty, 4/5 patients required stenting to obtain sustained patency, as demonstrated by colour-Doppler ultrasound in all PVR after a median follow-up of 6 months (range 6-14).

CONCLUSION

Our preliminary experience suggests that 45% of children with non-cirrhotic EHPVO can restore portal flow even with obliterated Rex recessus. In non-cirrhotic EHPVO, PVR may be an option, if a Meso-Rex bypass is not feasible, although the radiation exposure deserves attention.

CLINICAL RELEVANCE STATEMENT

Innovative percutaneous procedures may have the potential to be an alternative option to the traditional surgical approach in the management of non-cirrhotic EHPVO and its complications in children not eligible for Meso-Rex bypass surgery.

KEY POINTS

Non-cirrhotic portal hypertension in children has been traditionally managed by surgery with Meso-Rex bypass creation. Percutaneous PVR may restore the patency of the native portal system even when the Rex recessus is obliterated and surgery has been excluded. Interventional radiological techniques may offer a minimally invasive solution in complex cases of EHPVO in children when Meso-Rex bypass is not feasible.

Effects of Probiotics on Liver Diseases: Current In Vitro and In Vivo Studies

Various types of liver or hepatic diseases cause the death of about 2 million people worldwide every year, of which 1 million die from the complications of cirrhosis and another million from hepatocellular carcinoma and viral hepatitis. Currently, the second most common solid organ transplant is the liver, and the current rate represents less than 10% of global transplant requests. Hence, finding new approaches to treat and prevent liver diseases is essential. In liver diseases, the interaction between the liver, gut, and immune system is crucial, and probiotics positively affect the human microbiota. Probiotics are a non-toxic and biosafe alternative to synthetic chemical compounds. Health promotion by lowering cholesterol levels, stimulating host immunity, the natural gut microbiota, and other functions are some of the activities of probiotics, and their metabolites, including bacteriocins, can exert antimicrobial effects against a broad range of pathogenic bacteria. The present review discusses the available data on the results of preclinical and clinical studies on the effects of probiotic administration on different types of liver diseases.

Clinical Trial: A Multicentre Randomised Controlled Trial of Carvedilol Versus Variceal Band Ligation in Primary Prevention of Variceal Bleeding in Liver Cirrhosis (CALIBRE Trial)

BACKGROUND

The superior efficacy of non-selective beta-blockers (NSBB) compared with variceal band ligation (VBL) in the primary prevention of variceal bleeding is uncertain.

AIM

To compare carvedilol versus VBL for primary prevention of variceal bleeding.

METHODS

CALIBRE was an investigator-initiated, multicentre, randomised, controlled, open-label trial. Participants were randomly assigned to 12.5 mg carvedilol once daily or VBL. Inclusion criteria were cirrhosis and medium to large oesophageal varices that had not bled. The primary outcome is any variceal bleeding within 1 year of randomisation. Secondary outcomes include survival, other complications of cirrhosis, quality of life, cost-effectiveness and adverse events. Recruitment closed early, mainly due to the impact of the pandemic.

RESULTS

265 participants (10% of the intended sample size) from 52 sites were randomised to carvedilol (n = 133) or VBL (n = 132) between 22 January 2019 and 31 August 2022. 5/133 participants (3.8%) in the carvedilol arm vs. 10/132 participants (7.6%) in the VBL arm experienced variceal bleeding (risk ratio 0.50 (95% confidence interval [CI]; 0.17-1.41); risk difference - 0.038 (95% CI; -0.094-0.017)). Serious adverse events occurred in one participant in each treatment arm, with no treatment-related deaths. Of the secondary outcomes, there were no statistically significant differences. Carvedilol was cheaper and resulted in slightly more quality-adjusted life years than VBL.

CONCLUSIONS

The early terminated and, thus, underpowered CALIBRE trial showed no difference between carvedilol and VBL in the primary prevention of variceal bleeding in patients with cirrhosis and medium-to large-sized oesophageal varices. No untoward safety concerns were noted.

TRIAL REGISTRATION

ISRCTN73887615.

Non-Invasive Stratification of Portal Hypertension in Patients With BCR::ABL1-Negative Myeloproliferative Neoplasms

BACKGROUND & AIMS

The course of BCR::ABL1-negative myeloproliferative neoplasms (MPN) is frequently complicated by thromboembolic events in the splanchnic venous system, resulting in portal hypertension (PH). Therefore, the introduction of spleen stiffness measurement (SSM) might improve the diagnosis of PH. The aim of this study was to evaluate the clinical utility of SSM (performed by using the 100 Hz probe) in non-invasive stratification of PH in these patients.

METHODS

We performed a retrospective, monocentric, cross-sectional analysis including consecutive patients with BCR::ABL1-negative MPN attending the haematological outpatient clinic at the Medical University of Vienna with available liver stiffness (LSM)/SSM from 10/2023 to 09/2024. LSM/SSM were linked to signs and events of PH.

RESULTS

Fifty-five patients were included (mean age 57.9 ± 14.2 years, 69% females, polycythaemia vera as main entity). One fourth of patients had splanchnic vein thrombi. Nineteen patients (34.5%) had specific and 29 patients (52.7%) had unspecific signs of PH. Twelve patients (21.8%) experienced PH events prior to study inclusion. SSM correlated with disease severity (i.e., JAK2 V617F allele frequency). LSM/SSM adequately stratified patients with vs. without PH. While SSM was strongly linked with splenomegaly, it yielded independent information regarding PH on top of splenomegaly. The implementation of sequential LSM (< 5 & ≥ 15 kPa) and SSM (< 21 & ≥ 50 kPa) for ruling in and out PH reduced the grey zone (24%) with adequate sensitivity/specificity.

CONCLUSIONS

While SSM is strongly correlated with splenomegaly and disease severity, it is independently associated with PH in patients with BCR::ABL1-negative MPN. Implementation of LSM/SSM might improve patient management.

Safety of Anticoagulant Treatment in Patients With Splanchnic Vein Thrombosis and History of Portal Hypertension-Related Bleeding

Splanchnic vein thrombosis (SVT) can be associated with liver cirrhosis or prothrombotic conditions, including myeloproliferative disorders, intra-abdominal inflammation, solid cancers or surgery. While anticoagulation therapy improves outcomes in noncirrhotic patients and reduces all-cause mortality in cirrhotic populations, its safety in patients with a history of portal hypertension (PH)-related bleeding is less clear. This systematic review examines the impact of anticoagulant therapy on rebleeding risk in SVT patients with a history of PH-related bleeding. A systematic review and meta-analysis were conducted according to PRISMA guidelines. A comprehensive search of PubMed, Web of Science and Scopus was performed for studies published up to September 2024. Studies were included if they compared SVT patients with a history of PH-related bleeding receiving anticoagulant therapy versus those not receiving anticoagulants. The primary outcome was the cumulative incidence of PH-related rebleedings. Of 2853 identified studies, five (186 participants) met the inclusion criteria: two randomised controlled trials (RCTs) and three observational studies. The cumulative incidence of PH-related rebleeding was significantly lower in the anticoagulant group at 17.10% [95% CI 17.02, 17.19] compared to the control group at 40.00% [95% CI 39.90, 40.09]. The overall odds ratio (OR) from observational studies was 0.15 [95% CI 0.04, 0.52], indicating a reduced bleeding risk, while the OR from RCTs was 0.84 [95% CI 0.31, 2.32], showing a nonsignificant trend. Anticoagulant therapy may reduce rebleeding risk in SVT patients with a history of PH-related bleeding, but further high-quality studies are needed.

Real-world effectiveness and safety of bulevirtide monotherapy for up to 96 weeks in patients with HDV-related cirrhosis

BACKGROUND & AIMS

Bulevirtide (BLV) 2 mg/day is EMA approved for the treatment of compensated chronic HDV infection; however, real-world data in large cohorts of patients with cirrhosis are lacking.

METHODS

Consecutive HDV-infected patients with cirrhosis starting BLV 2 mg/day from September 2019 were included in a European retrospective multicenter real-world study (SAVE-D). Patient characteristics before and during BLV treatment were collected. Virological, biochemical, combined responses, adverse events and liver-related events (hepatocellular carcinoma [HCC], decompensation, liver transplant) were assessed.

RESULTS

A total of 244 patients with HDV-related cirrhosis receiving BLV monotherapy for a median of 92 (IQR 71-96) weeks were included: at BLV start, median (IQR) age was 49 (40-58) years and 61% were men; median ALT, LSM and platelet count were 80 (55-130) U/L, 18.3 (13.0-26.3) kPa, and 94 (67-145) x103/mm3, respectively; 54% had esophageal varices, 95% Child-Pugh A cirrhosis, and 10% HIV coinfection; 92% were on nucleos(t)ide analogues; median HDV RNA and HBsAg were 5.4 (4.1-6.5) log10 IU/ml and 3.8 (3.4-4.1) log10 IU/ml, respectively. At weeks 48 and 96, virological, biochemical and combined responses were observed in 65% and 79%, 61% and 64%, 44% and 54% of patients, respectively. AST, GGT, albumin, IgG and LSM values significantly improved throughout treatment. Serum bile acid levels increased in most patients, but only 10% reported mild and transient pruritus, which was independent of bile acid levels. The week 96 cumulative risks of de novo HCC and decompensation were 3.0% (95% CI 2-6%) and 2.8% (95% CI 1-5%), respectively. Thirteen (5%) patients underwent liver transplantation (n = 11 for HCC, n = 2 for decompensation).

CONCLUSION

BLV 2 mg/day monotherapy for up to 96 weeks was safe and effective in patients with HDV-related cirrhosis. Virological and clinical responses increased over time, while the incidence of liver-related complications was low.

IMPACT AND IMPLICATIONS

Bulevirtide 2 mg/day is EMA approved for the treatment of compensated chronic hepatitis delta; however, real-world data in large cohorts of patients with cirrhosis are lacking. Bulevirtide 2 mg/day monotherapy for up to 96 weeks was safe and effective (week 96: 79% virological, 64% biochemical and 54% combined response) in a large real-world cohort of patients with HDV-related cirrhosis, including patients with clinically significant portal hypertension. Liver function tests and liver stiffness improved, suggesting a potential clinical benefit in patients with advanced liver disease, while the incidence of de novo liver-related events (hepatocellular carcinoma and decompensation) was low during the 96-week study period.

Inferior vena cava-splenic vein shunt for the treatment of complete portal trunk occlusion and portal cavernoma in liver cirrhosis

OBJECTIVES

The transjugular intrahepatic portosystemic shunt procedure remains technically challenging in cases involving occlusion of the portal trunk. This study aimed to evaluate the feasibility, efficacy, and safety of utilizing the inferior vena cava-splenic vein shunt (IVCSS) as a new treatment option in cirrhotic patients with complete portal trunk occlusion and portal cavernoma.

METHODS

The IVCSS procedure was performed on twelve patients, involving the creation of a shunt using a covered stent between the inferior vena cava and the proximal end of the splenic vein to reduce distal portal pressure.

RESULTS

Technical success was achieved in all patients, with a mean procedure duration of 71.7 ± 44.2 min. The portosystemic gradient was reduced by a mean of 11.0 ± 5.6 mmHg after the procedure. After a median follow-up of 6.7 [2.8-11.4] months, clinical symptoms improved in all patients. Stent dysfunction occurred in 1 patient, the recurrence rates for variceal bleeding and ascites were 8.3% and 16.7%, respectively. One patient (8.3%) experienced a procedure-related complication of retroperitoneal hemorrhage. Three patients (25%) had an episode of hepatic encephalopathy, which improved after conservative treatment.

CONCLUSION

IVCSS effectively reduced distal portal pressure, which contributed to an improvement of the patients' clinical symptoms with an acceptable procedure-related complication rate. IVCSS may serve as an alternative strategy to manage symptomatic portal hypertension for patients with complete portal trunk occlusion and portal cavernoma.

KEY POINTS

Question What is an alternative treatment for cirrhotic patients with symptomatic portal hypertension caused by chronic portal vein occlusion other than TIPS? Findings Inferior vena cava-splenic vein shunt (IVCSS) is feasible for reducing distal portal pressure and effectively improving clinical symptoms. Clinical relevance For cirrhotic patients with complete portal trunk occlusion and portal cavernoma, the IVCSS approach seemed to be a promising alternative treatment for symptomatic portal hypertension.

Patients with cirrhosis have a disbalance between coagulation and fibrinolysis resulting in a prothrombotic phenotype

BACKGROUND

Patients with cirrhosis develop multiple hemostatic alterations. Although fibrinolysis is also affected by liver disease, studies have produced conflicting results, highlighting the need for a reliable fibrinolysis assay. Assessing the kinetics of plasmin generation (PG) is a new method to study the fibrinolytic state of cirrhosis patients.

OBJECTIVES

This study aimed to compare fibrinolysis between patients with cirrhosis and healthy subjects.

METHODS

This single-center cohort study included cirrhosis patients from the Padova University Hospital. Fibrinolysis and hemostasis were assessed with PG, thrombin generation (TG), and clot lysis time. To quantify malalignment between TG and PG, ratios were calculated.

RESULTS

In total, 101 patients with cirrhosis (Child-Pugh A/B/C: 36/24/41) and 20 healthy subjects were included. Compared with healthy subjects, patients showed a significantly lower endogenous plasmin potential and plasmin peak. The PG capacity decreased with liver disease severity. The lag time to PG was prolonged in patients. No differences in endogenous thrombin potential and lag time were found when comparing TG profiles. Patients had a shorter clot lysis time. Increased TG/PG ratios for the endogenous plasmin potential and plasmin peak were found in patients compared with that in controls. TG/PG ratios increased with liver disease severity.

CONCLUSION

Patients with cirrhosis have a complex fibrinolytic profile, with a delayed and decreased capacity to generate plasmin and a more rapid clot lysis. A disbalance was found between coagulation and fibrinolysis, with a normal-to-increased TG capacity and a decreased PG capacity. These results support the theory that cirrhosis patients are in a prothrombotic state.

Liver bypass in the development of pathogen-associated pulmonary vascular disease: contribution of mesocaval and portosystemic shunts

Portosystemic and mesocaval shunts are aberrant vascular connections that bypass hepatic detoxification process, directly linking the portal to the systemic circulation. These shunts, whether congenital or acquired, might play a pivotal role in the pathogenesis of systemic inflammatory diseases, such as schistosomiasis-associated pulmonary hypertension (Sch-PH) by facilitating the dissemination of pathogen-derived eggs and antigens from the gut and mesentery into the lungs. Beyond the translocation of Schistosoma mansoni eggs, emerging evidence implicates that gut-lung microbiome dysbiosis contributes to the development of pulmonary hypertension (PH) in the preclinical animal model of Sch-PH. Sch-PH emerges as a chronic complication of schistosomiasis and evolves silently, progressively increasing the mean pulmonary arterial pressure and vascular resistance, leading to right heart hypertrophy, failure, and significant morbidity and mortality. Chronic schistosomiasis is often linked to the development of portal hypertension, which significantly contributes to the formation of the porto/mesocaval shunt as a compensatory response that can have far-reaching implications on pulmonary vascular physiology. In addition, portal hypertension compromises the integrity of the intestinal barrier, exacerbating peritoneal and mesenteric inflammation, potentially facilitating microbial and metabolite entrance into the systemic circulation. This article briefly discusses the mechanisms by which porto/mesocaval shunts contribute to PH, especially Group I PH, focusing on the interplay between portosystemic shunting, microbial translocation, and systemic dissemination of proinflammatory metabolites.

Transjugular mesenteric-caval shunt for portal vein cavernous transformation with recurrent variceal bleeding: preliminary results

OBJECTIVES

This study aimed to evaluate the feasibility, safety, and efficacy of the transjugular mesenteric-caval shunt (TMCS) as a treatment for the cavernous transformation of the portal vein (CTPV) and recurrent variceal bleeding.

METHODS

This retrospective case series was conducted with approval from the institutional review board. It involved seven patients diagnosed with CTPV and recurrent variceal bleeding who underwent the TMCS procedure. We analyzed the rate of procedural complications, incidents of rebleeding, stent stenosis, hepatic encephalopathy, and overall survival to assess treatment outcomes.

RESULTS

The TMCS was successfully performed in all seven patients without any life-threatening complications. Postoperatively, one patient developed a lung infection and pleural effusion, which resolved with appropriate treatment. Additionally, two patients experienced an increase in total bilirubin levels, but there was no further deterioration in liver function. The median portal pressure gradient significantly decreased from a preoperative value of 27 mmHg (range 20-36 mmHg) to a postoperative value of 6 mmHg (range 4-11 mmHg). A notable improvement was observed in one cirrhotic patient, with liver function progressing from Child-Pugh class B (score 9) to class A (score 6). Over a median follow-up period of 14 months (range 7-18 months), none of the patients encountered rebleeding, stent stenosis, hepatic encephalopathy, or mortality.

CONCLUSION

The TMCS appears to be a viable and effective alternative for managing CTPV with recurrent variceal bleeding. Its long-term outcome requires further evaluation.

CLINICAL RELEVANCE STATEMENT

TMCS provides a promising treatment for patients with life-threatening CTPV complications when occluded portal vein cannot be recanalized and portal vein recanalization TIPS is not an option.

KEY POINTS

Performing TIPS in patients with portal vein cavernoma is complex due to the requirement for recanalization of the occluded portal vein. Creating a mesenteric-caval shunt through a transjugular approach is a feasible technique. Establishing a TMCS provides a means to manage life-threatening complications arising from portal vein cavernoma.

Visual prediction models for predicting rebleeding events after the first esophageal variceal ligation

BACKGROUND

Sequential endoscopic variceal ligation (EVL) is a standard therapy for esophageal variceal bleeding, yet poor compliance often compromises its efficacy. This study aimed to identify high-risk factors for rebleeding after initial EVL and establish a visual predictive model to improve patient follow-up and education.

METHODS

In this retrospective study, we enrolled patients who underwent first-time EVL for esophageal variceal bleeding at Xiangya Hospital, Central South University, between January 2017 and January 2023. Patients were allocated to training and validation cohorts. Clinical data were systematically collected, and rebleeding incidence rates within 6 weeks and 6 months post-EVL were analyzed. Logistic regression was used to explore high-risk factors influencing postoperative rebleeding and to establish visual models, evaluated with a validation set.

RESULTS

The study involved 629 patients in the training set and 312 in the validation set. Rebleeding occurred in 34.8% (219/629) and 80.1% (504/629) of patients within 6 weeks and 6 months after initial EVL, respectively. Esophageal variceal severity and platelet count emerged as shared independent risk factors for both 6-week and 6-month rebleeding. The nomogram models demonstrated robust predictive accuracy in the validation cohort, with areas under the curve (AUC) of 0.942 (95% CI 0.901-0.983) for 6-week rebleeding risk and 0.852 (95% CI 0.759-0.945) for 6-month rebleeding risk.

CONCLUSION

This study proposes a visual prediction model designed to assess the risk of rebleeding following initial EVL in patients with esophageal variceal hemorrhage to optimize clinical decision-making and improve patient management strategies.

Noninvasive Evaluation of Prolonged-Release Pirfenidone in Compensated Liver Cirrhosis. ODISEA Study, a Randomised Trial

BACKGROUND

Advanced liver fibrosis (ALF) predicts an adverse prognosis in chronic liver disease. In addition to etiological treatment, a new approach to stop or reverse residual fibrosis is desirable.

OBJECTIVE

To assess the efficacy and safety of prolonged-release pirfenidone (PR-PFD) versus placebo in compensated cirrhosis.

METHODS

180 patients with ALF (F4) were randomly assigned to: placebo, 1200 mg/d, and 1800 mg/d PR-PFD, plus standardised care, for 24mo. Frequency of lab tests: (3mo), liver stiffness measurement (LSM), FibroTest, ultrasound (US) (6mo), and endoscopy (annually).

RESULTS

Fibrosis evolution estimated from LSM was significantly lower only in the 1200 compared to placebo and 1800 groups (24.2 ± 2.4 vs. 15.4 ± 2.4; 27.6 ± 2.4 vs. 24.6 ± 2.4; 24.4 ± 2.3 vs. 23.3 ± 2.3 kPa, respectively, p < 0.001), in intergroup analysis, meeting the primary endpoint. Fibrotest was significantly lower only in the 1200 mg/d group, compared to baseline values (0.86 ± 0.02 vs. 0.83 ± 0.02 units, p < 0.001). Liver function test (LFT's) also improved as well as Model for End-Stage Liver Disease (MELD) score and quality of life (QoL). Decompensations occurred in 19 patients: 12 ascites (more frequent in placebo, p = 0.003), 5 variceal bleeding, 4 encephalopathies, 4 hepatocarcinomas. Adverse events were mainly mild gastrointestinal (n = 35, 48 and 46, p = 0.010) and cutaneous (n = 12, 15, and 22, p = 0.0001) in placebo, 1200 and 1800 mg/day, respectively.

CONCLUSION

PR-PFD at a dose of 1200 mg significantly decreased non-invasive liver fibrosis markers at 24 months and induced improvement in LFT's, MELD, and QoL in compensated cirrhosis, without safety concerns.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01046474.

Understanding acute kidney injury in cirrhosis: Current perspective

Acute kidney injury (AKI) is present in 30%-40% of hospitalized patients with cirrhosis. Its incidence is higher in patients with severe alcoholic hepatitis, spontaneous bacterial peritonitis, and acute-on-chronic-liver failure (ACLF). Kidney injury is an important landmark event in the natural history of cirrhosis as it is associated with higher mortality. Overwhelming systemic vasodilation, cardiac dysfunction, hypoperfusion, endotoxemia, and direct nephrotoxicity predispose patients with cirrhosis to kidney injury. Infection is present in 25% of patients with decompensated cirrhosis and 35%-40% of patients with ACLF. Advanced cirrhosis with portal hypertension leads to a sluggish portal flow, leading to increased gut congestion, altered gut permeability and bacterial translocations. They drive infection and endotoxemia in such patients. Pathogen-associated molecular patterns activate inflammatory cascades, which leads to further deterioration in hemodynamics and reduced glomerular filtration rate. Infections and pro-inflammatory cytokines like interleukin 6 (IL-6), IL-1, and tumor necrosis factor alpha may directly cause kidney parenchymal injury. The combined effect of dysfunctional albumin and systemic and splanchnic vasodilatation leads to low effective blood volume, activating the renin-angiotensin-aldosterone system. This causes renal vasoconstriction, water retention, and ascites, which progresses to hepatorenal physiology and AKI development. Vasoconstriction and volume expansion effectively improve arterial blood volume and systemic hemodynamics, thereby improving renal blood flow. It is of paramount importance to predict, detect, and treat AKI in its early state, as progressive renal dysfunction is invariably associated with higher mortality in patients with decompensated cirrhosis and ACLF. This comprehensive review will focus on the recent evolving concepts of the pathophysiology, diagnosis, and management of AKI in patients with cirrhosis.

A model predicting the 6-year all cause mortality of patients with advanced schistosomiasis after discharge: Derived from a large population-based cohort study

BACKGROUND

Advanced schistosomiasis imposed a heavy economic burden on society and had a high rate of mortality and disability. However, methods for assessing its long-term prognosis were currently insufficient, and there was a lack of predictive tools to aid clinical decision-making and personalized follow-up plans for patients. We sought to determine risk factors associated with six-year all-cause mortality in advanced schistosomiasis, deriving and validating a six-year all-cause mortality prediction model through a retrospective cohort study based on a large population-based cohort.

METHODOLOGY

We collected information from 4,136 patients with advanced schistosomiasis who were discharged between December 2014 and January 2015. After excluding 17 patients with the less common subtypes of colonic tumoroid proliferation and dwarfism, as well as 92 patients who were lost to follow-up or had incomplete information, data from 4,027 patients were included in the study. These patients were randomly assigned to the derivation cohort and the external validation cohort in a 7:3 ratio, with 1,400 patients randomly selected from the derivation cohort for internal validation. Sixteen candidate variables were collected: age, gender, nutritional status, splenectomy history, presence of other conditions (such as cardiovascular and digestive diseases), clinical classification, disease duration, ascites occurrence frequency, levels of serum total bilirubin (TBil), direct bilirubin (DBil), aspartate aminotransferase (AST), alanine aminotransferase (ALT), albumin (ALB), alkaline phosphatase (ALP), Hepatitis B surface antigen (HBsAg), and alpha-fetoprotein (AFP). High-risk factors associated with the 6-year mortality outcome were identified through univariate and multivariate Cox proportional hazards regression analyses. The predictive value of different models was evaluated and compared using the receiver operating characteristic (ROC) curves, Akaike information criterion (AIC), net reclassification improvement (NRI), C statistic, and integrated discrimination improvement (IDI).

FINDINGS

The derivation cohort comprised 2819 patients and we randomly selected 1400 cases from this cohort for internal validation. The external cohort consisted of 1208 patients. The mortality rate for three groups was around 27%-28%. We identified ten variables associated with increased risk of death, including age, course of disease, frequence of ascites, hepatitis B co-infection, and levels of DBil, ALT, AST, ALP, ALB, and AFP at baseline. Using these variables, we developed a ten-variable model and three simpler models. In the derivation cohort, the ten-variable model showed the highest C statistic (0.759; 95% CI, 0.739-0.778) and the lowest AIC (2834.2). ROC curves indicated an AUC of 0.759 for the ten-variable model, outperforming the simpler models. External validation also demonstrated superior performance of the ten-variable model with a higher C statistic (0.774; 95% CI, 0.749-0.797). This model consistently showed better results in ROC curves, IDI, continuous NRI, and categorical NRI analyses compared to the reduced models in external validation cohort.

CONCLUSIONS

This study developed a multivariate model to predict the 6-year all-cause mortality rate in patients with advanced schistosomiasis, which demonstrated good performance. This convenient tool may potentially assist clinicians in formulating patient follow-up plans.

A novel noninvasive assessment of portal pressure from computational biofluid mechanics in patients with portal hypertension

BACKGROUND AND AIMS

To introduce and assess a novel method for portal pressure measurement based on biofluid mechanics in portal hypertensive patients undergoing surgery.

METHODS

The research was a multi-center, retrospective study, conducted on patients who underwent surgery and measurement of free portal pressure (FPP). There were 118 patients included and 21 patients excluded due to the failure or poor results of Doppler ultrasound, and 97 patients were screened. We used patients' CT images, Doppler ultrasound results of the portal system, blood density and viscosity to reconstruct their portal system and simulate its internal blood flow. According to the patient's physical property, geometry, and boundary conditions, the Navier-Stokes equations were solved by FLUENT software, and virtual free portal pressure (vFPP) was calculated. Finally, the Bland-Altman Limits of Agreement, intraclass correlation coefficient (ICC), and the Lin's concordance correlation coefficient were performed to evaluate the numerical correlation between the vFPP and FPP.

RESULTS

All patients enrolled in this study underwent the surgery, and the FPP of patients was measured during the surgery, with a mean FPP of 22.8 ± 3.3 mmHg (range: 13-33 mmHg). Meanwhile, according to computational biofluid mechanics, all patients' vFPP was calculated. Then, we further explored whether there was a close relationship between vFPP and FPP in the whole population. For the analysis of Bland-Altman Limits of Agreement, the mean value of difference was - 0.1569 (95% CI: - 0.4305 to 0.1167); lower limit of agreement: - 2.8176 (95% CI: - 3.2868 to - 2.3484); upper limit of agreement: 2.5038 (95% CI: 2.0346 to 2.9730). The ICC was 0.9215 (95% CI: 0.8848 to 0.9468). Furthermore, the Lin's concordance correlation coefficient showed a numerical correlation between the vFPP and FPP, which was 0.9205 (95% CI: 0.8840 to 0.9459). All these results confirmed that our vFPP model could provide an accurate prediction of FPP in patients.

CONCLUSIONS

The vFPP of patients calculated by computational biofluid mechanics was significantly correlated with the FPP of portal hypertensive patients, which would be a novel, non-invasive, and accurate method for the assessment of portal pressure in surgical patients.

Etiology and Risk Factors for Splanchnic Vein Thrombosis in Non-Cirrhotic, Non-Neoplastic Patients: A Narrative Review

Splanchnic vein thrombosis (SVT) is a heterogeneous group of disorders affecting the portal, mesenteric, splenic, and hepatic veins. While frequently associated with liver cirrhosis and malignancy, SVT also occurs in non-cirrhotic, non-neoplastic patients. This narrative review evaluates the epidemiology and risk factors for SVT in this population. The prevalence and incidence of SVT in non-cirrhotic, non-neoplastic patients remain incompletely characterized, with estimates varying widely across studies. The clinical significance of SVT relates to potential complications, including intestinal ischemia, portal hypertension, and a possible underlying systemic disorder. Risk factors for SVT can be categorized into local abdominal conditions, thrombophilias, and systemic disorders. Local factors include inflammatory bowel disease, pancreatitis, abdominal surgery, and trauma. Thrombophilias, both inherited and acquired, are significant contributors to SVT risk. Systemic conditions associated with SVT include autoimmune disorders, pregnancy, hematological diseases, and infections. The complex interplay of these risk factors highlights the need for a comprehensive evaluation of SVT patients. Early recognition and management of these conditions can prevent potentially life-threatening complications and guide decisions regarding anticoagulation and long-term follow-up.

The diagnostic value of two-dimensional shear-wave elastography in identifying malignant lesions in lymph nodes: a prospective study

This study evaluates the diagnostic performance of two-dimensional shear wave elastography (2D-SWE) in differentiating between benign, metastatic lymph nodes (LNs) and lymphomas. From May 2022 to February 2023, a total of 137 patients who presented with unexplained LN enlargement were examined at the Ultrasound Medical Department of Union Hospital of Huazhong University of Science and Technology. The conventional ultrasound recorded the location, longitudinal diameter, transverse diameter, L/T ratio, blood supply mode, lymphatic hilum and 2D-SWE calculated the average elasticity (E) of LN. Histopathology was the diagnostic gold standard. A total of 124 patients with 159 superficial LNs were included (32 benign, 70 metastatic, 57 lymphoma). Malignant LNs had significantly higher E values than benign ones (49.38 ± 29.96 kPa vs. 25.00 ± 14.42 kPa, P < 0.001). When E > 25.46 kPa, the AUC, sensitivity, specificity, PPV, NPV and accuracy were 0.807, 0.787, 0.750, 0.926, 0.471 and 0.780, respectively, in identifying malignant LNs. For distinguishing benign LNs from lymphoma, the E cutoff was 25.03 kPa, with the AUC, sensitivity, specificity, PPV, NPV and accuracy of 0.727, 0.754, 0.719, 0.827, 0.622 and 0.742, respectively. To differentiate benign from metastatic LNs, an E cutoff of 36.97 kPa yielded an AUC, sensitivity, specificity, PPV, NPV and accuracy of 0.872, 0.757, 0.875, 0.930, 0.622 and 0.794, respectively. Comparing lymphoma and metastatic LNs, the E cutoff was 42.57 kPa. And the AUC, sensitivity, specificity, PPV, NPV and accuracy were 0.787, 0.700, 0.860, 0.860, 0.700 and 0.772, respectively. 2D-SWE parameter (the average elasticity) can effectively evaluate benign, metastatic LNs and lymphoma, which provides valuable information for preoperative evaluation of superficial LNs.

Cyanoacrylate injection assisted by endosonographic mini-probe in the management of gastric varices: a single-center, retrospective cohort study

BACKGROUND

Gastric varices (GV) pose the potential risk of massive bleeding. Endoscopic ultrasound (EUS) guided real-time delivery of adhesives and devices has emerged as a promising therapeutic modality for GV but was limited in its generalizability due to the unavailability and lack of expertise of linear echoendoscopy. Therefore, we utilized the more readily available EUS mini-probe (EMP) in assisting cyanoacrylate (CYA) injection in the management of GV.

METHODS

This is a retrospective cohort study from a single tertiary medical center. One hundred and thirty-three eligible patients were divided into three groups based on the treatment modalities including EMP-guided CYA injection via a dual-channel gastroscope (EMP-D group), EMP-guided injection via a single-channel gastroscope (EMP-S group) and direct endoscopic injection (DEI group). The clinical characteristics, procedural parameters, outcomes, adverse events and follow-up data were analyzed.

RESULTS

An overall statistical significance was achieved in the number of puncture site (p < 0.001), the number of instant blood return upon puncture (p = 0.001), cyanoacrylate dose (p = 0.004), late rebleeding rate (p = 0.018), post-injection ulcer (p = 0.005), and non-rebleeding interval (p = 0.026) among the three groups. Patients in EMP-D group exhibited a lower rate of post-injection ulcer than those in DEI group (p = 0.009). Procedural time of EMP-D was shorter than that of EMP-S (p < 0.001). Less amount of cyanoacrylate was needed per reinjection session in EMP-D than in DEI (p = 0.002).

CONCLUSIONS

EMP-guided cyanoacrylate injection exhibited superior effectiveness and safety to DEI, while use of the dual-channel gastroscope further enhanced the precision and efficiency.

The burden of ascites in cirrhosis

OBJECTIVES

Liver cirrhosis is a leading cause of morbidity and mortality worldwide, with complications such as ascites, spontaneous bacterial peritonitis (SBP), and hepatorenal syndrome (HRS) significantly worsening prognosis. This paper aims to review the pathophysiology, diagnostic approaches, and management strategies for ascites and the complication of it, emphasizing the role of portal hypertension.

METHODS

We conducted a comprehensive review of the literature on liver cirrhosis, portal hypertension, ascites formation, and related complications. Existing evidence was evaluated and ranked using the GRADE system: A (high) to D (verly low). Recommendation strength was graded 1 (strong) or 2 (weak).

RESULTS

Portal hypertension is the key factor in ascites development. Non-invasive tools such as liver stiffness measurement (LSM) have proven to be effective in identifying patients at risk for clinically significant portal hypertension (CSPH), thus guiding treatment decisions. Carvedilol, recommended over propranolol, offers superior efficacy in reducing portal pressure. Diuretics, in combination with a moderate sodium-restricted diet, are the first-line treatment for ascites. However, refractory ascites requires advanced interventions. Spontaneous bacterial peritonitis (SBP) remains a major complication in patients with ascites, while hepatorenal syndrome - acute kidney injury (HRS-AKI) demands early recognition and timely vasoconstrictor therapy.

CONCLUSIONS

Liver cirrhosis and the complication of it significantly impact patient quality of life and survival. Portal hypertension is a critical driver of ascites and other complications, making early identification through non-invasive diagnostic methods essential for appropriate management. Medical treatments, including non-selective beta-blockers (NSBBs), diuretics, and advanced procedures, offer substantial benefits in controlling ascites and preventing further decompensation.

Preliminary Evaluation of Plasma circ_0009910, circ_0027478, and miR-1236-3p as Diagnostic and Prognostic Biomarkers in Hepatocellular Carcinoma

Circular RNAs (circRNAs) are increasingly recognized as significant regulators in multiple cancers, such as hepatocellular carcinoma (HCC), frequently affecting microRNA (miRNA) expression. The diagnostic and prognostic roles of circRNAs, specifically circ_0009910 and circ_0027478, in conjunction with miR-1236-3p, in HCC, have not yet been fully investigated. In this pilot study, we assessed the expression levels of circ_0009910, circ_0027478, and miR-1236-3p in plasma samples from 100 patients diagnosed with HCC and 50 healthy controls through reverse transcriptase-quantitative polymerase chain reaction (RT-qPCR). The diagnostic performance was evaluated using receiver operating characteristic (ROC) curve analysis, and correlations with clinicopathological features were examined. Circ_0009910 and circ_0027478 exhibited significant upregulation in patients with HCC (p < 0.05), whereas miR-1236-3p demonstrated downregulation (p < 0.05). Circ_0009910 demonstrated significant diagnostic accuracy (area under the curve [AUC] = 0.90), effectively differentiating HCC from controls and showing a correlation with tumor size, metastasis, and alpha-fetoprotein (AFP) levels (p < 0.05). Both circ_0009910 and circ_0027478 exhibited a positive correlation with clinicopathological features, whereas miR-1236-3p demonstrated an inverse correlation. Logistic regression validated the diagnostic and prognostic capabilities of these biomarkers. The results indicate that circ_0009910, circ_0027478, and miR-1236-3p, in conjunction with AFP three, present a promising diagnostic and prognostic profile for HCC. Additional validation in larger cohorts is required to establish their clinical utility.

CT-Derived spleen volume accurately diagnoses severe portal hypertension at HVPG thresholds of 16 mmhg

To investigate the diagnostic utility of a noninvasive method based on spleen volume for the accurate diagnosis of severe portal hypertension (PH). We enrolled 260 patients undergoing hepatic venous pressure gradient (HVPG) assessment and enhanced CT at Tianjin Third Central Hospital (December 2019-July 2023), with clinical data collected. Patients were stratified by HVPG levels: ≥16 mmHg (severe PH group) and < 16 mmHg (non-severe PH group). We included 120 cirrhotic patients who met the inclusion criteria. Splenic volume exhibited a linear correlation with HVPG (r = 0.364, p < 0.001). Univariate and multivariate logistic regression analyses identified spleen volume, age, and serum albumin as independent risk factors for severe PH (p < 0.05). Accordingly, a clinical diagnostic model was developed, named the "S-HVPG" score. The area under the curve (AUC) for the "S-HVPG" score was 0.803, with an optimal threshold of 0.694, achieving sensitivity, specificity, positive predictive value(PPV), and negative predictive value (NPV) of 78.8%, 74.3%, 88.2%, and 59.1%, respectively. The spleen volume-based "S-HVPG" scoring system introduces a novel, straightforward, noninvasive approach for diagnosing severe PH. A cutoff value of 0.694 for the S-HVPG score effectively distinguishes patients with severe PH from those with cirrhosis.

How I manage major hemorrhage

ABSTRACT

Acute hemorrhage can be a life-threatening emergency that is complex in its management and affects many patient populations. The past 15 years has seen the introduction of comprehensive massive hemorrhage protocols, wider use of viscoelastic testing, new coagulation factor products, and the publication of robust randomized controlled trials in diverse bleeding patient populations. Although gaps continue to exist in the evidence base for several aspects of patient care, there is now sufficient evidence to allow for an individualized hemostatic response based on the type of bleeding and specific hemostatic defects. We present 3 clinical cases that highlight some of the challenges in acute hemorrhage management, focusing on the importance of interprofessional communication, rapid provision of hemostatic resuscitation, repeated measures of coagulation, immediate administration of tranexamic acid, and prioritization of surgical or radiologic control of hemorrhage. This article provides a framework for the clear and collaborative conversation between the bedside clinical team and the consulting hematologist to achieve prompt and targeted hemostatic resuscitation. In addition to providing consultations on the hemostatic management of individual patients, the hematology service must be involved in setting hospital policies for the prevention and management of patients with major hemorrhage.

The Gut Microbiome in Hepatocellular Carcinoma: Proliferation, Inhibition, Diagnosis, and Immunotherapy

Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related death worldwide. Major causes of HCC include hepatitis B and C viral infections, alcoholic hepatitis, and liver cirrhosis. Additionally, conditions such as obesity, diabetes, and metabolic syndrome have been identified as contributing factors to HCC development. In recent years, research on gut microbiota has expanded significantly, resulting in numerous studies exploring the relationship between HCC and gut microbiota. Thus, in this review, we highlight the association between gut microbiota and HCC, focusing on microbiota-related proliferation, inhibition, diagnosis, and immunotherapy. The gut microbiota is proposed to play a crucial role in both the diagnosis and treatment of HCC, paving the way for the development of novel diagnostic and therapeutic approaches for this disease.

Role of liver transient elastography in detecting cirrhosis with esophageal and gastric varices and evaluating variceal severity

OBJECTIVE

To explore the application and clinical value of liver transient elastography (TE) in diagnosing and assessing the degree of liver cirrhosis combined with esophageal and gastric varices (EGV).

METHODS

We chose 136 patients with cirrhosis and EGV admitted to the Liver Disease Department of our hospital from December 2022 to December 2024. The patients were divided into mild EGV (n = 71), moderate EGV (n = 40), and severe EGV (n = 25) based on the gastroscopic results, and another 50 cases of healthy physical examination at the same period were admitted into the control group. All cases underwent liver TE, biochemical parameters, and immune parameters examination to observe the diagnostic efficacy of liver TE in cirrhosis combined with EGV and the degree of varices.

RESULTS

The differences in TBIL, ALT, AST, PTA, and other biochemical parameters between all of groups were not statistically significant (P > 0.05). The differences were not statistically significant for the four groups of IgM, IgG, and other immune indices (P > 0.05). There was no significant difference in blood flow among these groups (P > 0.05). The interior diameter (ID) of the portal vein, blood flow velocity, and liver stiffness values were significant (P < 0.05). Portal vein ID, blood velocity, and liver stiffness values showed well diagnostic efficacy in cirrhosis with EGV, and liver stiffness values were the best in evaluating cirrhosis with EGV (P < 0.05). Liver stiffness values were more effective in assessing the degree of varices in cirrhosis combined with EGV and the best in diagnosing cirrhosis combined with severe EGV (P < 0.05).

CONCLUSION

The application of liver TE has a high value in diagnosing cirrhosis combined with EGV and their degree of varices, especially in identifying severe curves, which has good clinical value.

Effects of the COVID-19 Pandemic and Post-Pandemic Changes on the Diagnosis, Treatment, and Mortality of Hepatocellular Carcinoma in a Tertiary Center in Western Romania

BACKGROUND/OBJECTIVES

Access to healthcare services was significantly restricted during the COVID-19 pandemic, leading to changes in the management of hepatocellular carcinoma (HCC). However, limited research has examined how these changes evolved post-pandemic. This study evaluated the impact of the pandemic at a tertiary center in Romania, focusing on diagnosis rates, treatments, and survival outcomes.

METHODS

A retrospective study conducted at Timișoara County Hospital divided patients into three equal cohorts of 23 months each: the pre-pandemic period (PreP: 1 May 2018-31 March 2020), the pandemic period (PandP: 1 April 2020-28 February 2022), and the post-pandemic period (PostP: 1 March 2022-31 January 2024). Newly diagnosed HCC cases were evaluated for the tumor stage, biological markers, and treatment received during each period. A survival census was conducted nine months after the diagnosis.

RESULTS

During the PandP and PostP periods, the numbers of newly diagnosed HCC cases decreased to 58 cases (p < 0.001) and 64 cases (p < 0.005), respectively, representing reductions of 38.3% and 31.9% compared to the PreP period, which had 94 cases. The proportion of patients in the BCLC-B stage increased from 31.9% in the PreP period to 50% during the PandP period (p = 0.0401), with fewer BCLC-A-0 cases (17% vs 5.1%; p = 0.059) during PandP. The tumor characteristics, BCLC classification, and TNM staging showed no significant differences between the PreP and PostP periods. Systemic therapy was the most commonly used treatment (39.7-50%). No significant differences were observed across treatment types when comparing all three periods (p > 0.05). The median follow-up times in the PreP, PandP, and PostP periods were 157.5, 159.5, and 183.5 days, respectively, with no statistically significant differences. The survival curve showed no statistically significant differences in survival between the groups at the nine-month follow-up (p > 0.05).

CONCLUSIONS

The COVID-19 pandemic decreased HCC diagnoses, with only a partial rebound in the PostP period that did not reach PreP levels. While the PandP period showed worsening BCLC staging and an increase in tumor numbers, the tumor stage and treatment in the PostP period were similar to those in the PreP period. Similarly, the nine-month survival rates remained similar across all three periods.

Endovascular management of acute superior mesenteric vein thrombosis: a retrospective study on thrombolysis outcomes

BACKGROUND

Acute superior mesenteric vein thrombosis (ASMVT) is a rare but life-threatening condition associated with high morbidity and mortality. While anticoagulation remains the standard treatment, endovascular therapies such as thrombolysis, thrombectomy, and angioplasty are increasingly utilized in selected cases. However, evidence on their outcomes remains limited. This study retrospectively reports the clinical outcomes of ASMVT patients treated with endovascular combination therapies.

METHODS

Between August 2019 and May 2024, 12 patients (males = 9; mean age, 52.33 ± 12.51 years) were diagnosed with ASMVT. The study collected comprehensive data on demographic details, presenting symptoms, etiology, treatment modalities, response to treatment, and follow-up outcomes. Computed Tomography (CT) was available from diagnosis, and an average of 6.3 CT scans with a median follow-up of 3 months (IQR: 2-20 months).

RESULTS

The average time from symptom onset to angiographic treatment initiation was 8.0 ± 4.71 days, preceded by anticoagulation with heparin from the time of diagnosis. Patients were treated with combination therapy involving endovascular thrombolysis, rheolytic thrombectomy, and balloon angioplasty via transjugular (n = 9, 75%) or percutaneous (n = 3, 25%) approaches. Thrombolysis was performed with an average recombinant tissue plasminogen activator (rt-PA) infusion duration of 2.75 ± 1.14 days and a total dose of 61.25 ± 18.48 mg rt-PA. Superior mesenteric vein (SMV) flow was initially restored almost completely in 58.3% and partially in 41.7% of patients. Complications observed were hepatic artery bleeding (n = 2, 16.7%), hepatic arteriovenous fistula (n = 1, 8.3%), hepatic parenchymal bleeding (n = 1, 8.3%), melena (n = 1, 8.3%), and nostril bleeding (n = 1, 8.3%). Two patients experienced worsening symptoms of post-intervention, leading to bowel resection revealing intestinal necrosis. SMV patency was almost complete in 25%, and partially in 25% of patients at follow-up.

CONCLUSION

Endovascular combination therapy with long-term thrombolysis and thrombectomy in patients with ASMVT demonstrated promising technical outcomes. In view of complications, individual indication for intervention needs to be confirmed in a multidisciplinary team.

Two-Year Mediterranean Diet Intervention Improves Hepatic Health in MASLD Patients

Background: Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) is one of the leading causes of chronic liver disease, affecting 30% of the global adult population and continuing to rise. Objective: We aimed to assess the effect of a two-year follow-up Mediterranean diet intervention on parameters of liver health in MASLD patients. Methods: Sixty-two people between 40 and 60 years of age, all diagnosed with MASLD, were enrolled in the two-year clinical trial, who were randomly assigned to one of three interventions following the Mediterranean diet pattern and the promotion of physical activity. After the intervention, the participants were categorized into two groups according to their progress in adhering to the Mediterranean diet (MedDiet), which was assessed at four follow-up time points, conducted at the start of this study and after 6, 12, and 24 months of intervention. A multivariate general linear model adjusted for age, sex, and intervention (diet and physical activity) was used. Bonferroni's post hoc test identified differences between groups and sessions within the same group. Results: Participants in the highly adherent group showed significantly stronger improvement in anthropometric measures, lipid profile, and liver enzyme levels during the follow-up period, along with a reduction in the Dietary Inflammatory Index, intrahepatic fat content, the fatty liver index, and plasma cytokeratin-18 levels compared to baseline. The progress observed in several parameters at 12 months came to a standstill, likely because of the COVID-19 pandemic at that time. At 24 months, following the COVID-19 pandemic, these parameters improved as a result of better adherence to the Mediterranean diet. Conclusions: Greater adherence to the Mediterranean diet, along with increased physical activity, significantly enhances liver health markers in individuals with MASLD. These findings support the Mediterranean lifestyle as an effective non-pharmacological strategy to improve liver health and prevent liver-related complications in MASLD patients, potentially reducing the future public health burden.

Prevalence of portal vein thrombosis in pediatric patients with cirrhosis and intrahepatic non-cirrhotic portal hypertension

INTRODUCTION

Portal vein thrombosis (PVT) has been increasingly diagnosed in pediatric patients owing to the widespread use of non-invasive radiological techniques. Although the prevalence of PVT in adults with cirrhosis and intrahepatic non-cirrhotic portal hypertension ranges from 0.6 to 26 % and 13 to 46 %, respectively, no available data exist in the pediatric population. The prevalence of PVT in children with cirrhotic and intrahepatic non-cirrhotic portal hypertension was evaluated in this study.

METHODS

This retrospective study included children with cirrhosis and intrahepatic non-cirrhotic portal hypertension, which consisted of congenital hepatic fibrosis (CHF) and idiopathic noncirrhotic portal hypertension (INCPH). Patients with extrahepatic portal venous obstruction were excluded from the study. The presence of PVT was evaluated using abdominal Doppler ultrasonography and/or CT. Etiological, clinical, and laboratory findings were compared between the groups.

RESULTS

One hundred and forty-two patients with cirrhosis (mean admission age: 64.6 months ± 66.4, mean follow-up duration: 46.8 months ± 45.6) and 41 patients with non-cirrhotic patients (CHF=16, INCPH = 25, mean admission age: 126 months ± 64.2) were enrolled in this study. The prevalence of PVT was not significantly different between cirrhotic (8.5 %) and non-cirrhotic (9.7 %) patients. The incidence of PVT was significantly higher in patients with biliary atresia than in those with other etiologies in the cirrhotic group (p = 0.022). The frequency of PVT was higher in patients who had Child-Pugh score ≥7 in the cirrhotic group, but the difference was not statistically significant (p = 0066). The PVT group required more liver transplantations than the non-PVT group (p = 0.038).

CONCLUSION

The prevalence of PVT was similar in pediatric patients with cirrhosis and intrahepatic non-cirrhotic portal hypertension in our cohort, which is compatible with adult studies. Biliary atresia is found to be an important risk factor for PVT in our pediatric population. It might be associated with rapid progression of the disease, ascending cholangitis, and embryological abnormalities. These patients should be routinely evaluated to identify portal vein complications and early warning signs during follow-up.

Portal vein recanalization-transjugular intrahepatic portosystemic shunt (PVR-TIPS) in liver transplant candidates with cirrhosis and complex portal anastomosis

BACKGROUND & AIMS

Portal vein (PV) thrombosis may represent a relative contraindication to liver transplantation (LT). Transjugular intrahepatic portosystemic shunt (TIPS) used in portal hypertension complications, may allow portal vein recanalization (PVR).

METHODS

We reported PVR-TIPS in patients who were candidates for LT for clinical conditions but deemed contraindicated because of PV anatomy. We included consecutive patients undergoing PVR-TIPS at our center from February 2014 to May 2024.

RESULTS

We identified 25 patients (19 males [76 %], mean age 56 years [IQR 51-62]) in which PVR-TIPS was offered because foreseen high complex PV anastomosis. Twelve (48 %) patients showed main PV thrombosis, 8 (32 %) had cavernoma and 5 (20 %) had PV with very small diameter. PVR-TIPS was successfully achieved in all but one patient. All patients were listed after PVR-TIPS, with a listing MELD-Na score higher than pre-PVR-TIPS values (19 [IQR 15-23] vs. 16 [IQR 13-18], p < 0.018). Overall, 3 patients (13 %) were delisted for clinical improvement, 2 (8 %) died on the waiting-list and 16 (66 %) underwent LT. LT was technically feasible in all patients, without immediate major vascular complication.

CONCLUSIONS

PVR-TIPS may be a strategy to enable LT in patients otherwise excluded due to PV anatomy. This needs high technical expertise and often at the expense of a worsening in liver function.

Efruxifermin in Compensated Liver Cirrhosis Caused by MASH

BACKGROUND

In phase 2 trials involving patients with stage 2 or 3 fibrosis caused by metabolic dysfunction-associated steatohepatitis (MASH), efruxifermin, a bivalent fibroblast growth factor 21 (FGF21) analogue, reduced fibrosis and resolved MASH. Data are needed on the efficacy and safety of efruxifermin in patients with compensated cirrhosis (stage 4 fibrosis) caused by MASH.

METHODS

In this phase 2b, randomized, placebo-controlled, double-blind trial, we assigned patients with MASH who had biopsy-confirmed compensated cirrhosis (stage 4 fibrosis) to receive subcutaneous efruxifermin (at a dose of 28 mg or 50 mg once daily) or placebo. The primary outcome was a reduction of at least one stage of fibrosis without worsening of MASH at week 36. Secondary outcomes included the same criterion at week 96.

RESULTS

A total of 181 patients underwent randomization and received at least one dose of efruxifermin or placebo. Of these patients, liver biopsy was performed in 154 patients at 36 weeks and in 134 patients at 96 weeks. At 36 weeks, a reduction in fibrosis without worsening of MASH occurred in 8 of 61 patients (13%) in the placebo group, in 10 of 57 patients (18%) in the 28-mg efruxifermin group (difference from placebo after adjustment for stratification factors, 3 percentage points; 95% confidence interval [CI], -11 to 17; P = 0.62), and in 12 of 63 patients (19%) in the 50-mg efruxifermin group (difference from placebo, 4 percentage points; 95% CI, -10 to 18; P = 0.52). At week 96, a reduction in fibrosis without worsening of MASH occurred in 7 of 61 patients (11%) in the placebo group, in 12 of 57 patients (21%) in the 28-mg efruxifermin group (difference from placebo, 10 percentage points; 95% CI, -4 to 24), and in 18 of 63 patients (29%) in the 50-mg efruxifermin group (difference from placebo, 16 percentage points; 95% CI, 2 to 30). Gastrointestinal adverse events were more common with efruxifermin; most events were mild or moderate.

CONCLUSIONS

In patients with compensated cirrhosis caused by MASH, efruxifermin did not significantly reduce fibrosis at 36 weeks. (Funded by Akero Therapeutics; SYMMETRY ClinicalTrials.gov number, NCT05039450.).

EASL Clinical Practice Guidelines on the management of hepatitis B virus infection

The updated EASL Clinical Practice Guidelines on the management of hepatitis B virus (HBV) infection provide comprehensive, evidence-based recommendations for its management. Spanning ten thematic sections, the guidelines address diagnostics, treatment goals, treatment indications, therapeutic options, hepatocellular carcinoma surveillance, management of special populations, HBV reactivation prophylaxis, post-transplant care, HBV prevention strategies, and finally address open questions and future research directions. Chronic HBV remains a global health challenge, with over 250 million individuals affected and significant mortality due to cirrhosis and hepatocellular carcinoma. These guidelines emphasise the importance of early diagnosis, risk stratification based on viral and host factors, and tailored antiviral therapy. Attention is given to simplified algorithms, vaccination, and screening to support global HBV elimination targets. The guidelines also discuss emerging biomarkers and evolving definitions of functional and partial cure. Developed through literature review, expert consensus, and a Delphi process, the guidelines aim to equip healthcare providers across disciplines with practical tools to optimise HBV care and outcomes worldwide.

EASL Clinical Practice Guidelines on extrahepatic abdominal surgery in patients with cirrhosis and advanced chronic liver disease

Extrahepatic surgery in patients with cirrhosis of the liver represents a growing clinical challenge due to the increasing prevalence of chronic liver disease and improved long-term survival of these patients. The presence of cirrhosis significantly increases the risk of perioperative morbidity and mortality following abdominal surgery. Advances in preoperative risk stratification, surgical techniques, and perioperative care have led to better outcomes, yet integration of these improvements into routine clinical practice is needed. These clinical practice guidelines provide comprehensive recommendations for the assessment and perioperative management of patients with cirrhosis undergoing extrahepatic surgery. An individualised patient-centred risk assessment by a multidisciplinary team including hepatologists, surgeons, anaesthesiologists, and other support teams is essential.

EASL Clinical Practice Guidelines on the management of autoimmune hepatitis

Autoimmune hepatitis (AIH) is a chronic liver disease of unknown aetiology which may affect any patient irrespective of age, sex, and ethnicity. At baseline, the clinical spectrum of the disease varies largely from asymptomatic cases to acute liver failure with massive hepatocyte necrosis. The aim of these EASL guidelines is to provide updated guidance on the diagnosis and management of AIH both in adults and children. Updated guidance on the management of patients with variants and specific forms of AIH is also provided, as is detailed guidance on the management of AIH-associated cirrhosis, including surveillance for portal hypertension and hepatocellular carcinoma, as well as liver transplantation in decompensated cirrhosis.

Abnormal gastroesophageal flap valve: A predictor of recurrent variceal hemorrhage

BACKGROUND AND STUDY AIMS

Esophageal variceal bleeding is affected by various risk factors. We hypothesized that increased exposure to gastric acid in patients with abnormal gastroesophageal flap valve (GEFV) might increase esophageal variceal bleeding. The aim of this study is to investigate the relationship between GEFV and esophageal variceal bleeding episodes.

PATIENTS AND METHODS

In this cross-sectional study, 300 consecutive patients with esophageal varices and a documented GEFV during esophagogastroduodenoscopy were included. Patients were divided into two groups according to: the Hill's grade of flap valve (grade 1,2- normal and grade 3,4- abnormal), size of varices - large (>5 mm) and small (<5 mm) and the number of bleeding episodes into: Group A with ≤ 1 and Group B with ≥ 2 bleeding episodes. We compared GEFV and various other factors to the number of variceal bleeding episodes.

RESULTS

224 patients (74.60 %) had a normal and 76 (25.40 %) had an abnormal GEFV. Clinical variables were statistically significant in the abnormal GEFV group (P < 0.0.5). Propensity score matching was done to reduce the significant differences in the clinical background at baseline between the 2 groups. 152 patients (76 in each group) were analysed after propensity score matching. A significant difference between the two groups disappeared except for number of bleeding episodes. Binary logistic Cox regression analysis was applied using the clinical variables to assess their role in predicting recurrent variceal bleeding. On univariate analysis, abnormal GEFV and large varices were significantly associated with recurrent esophageal variceal bleed (P = 0.001). On Multivariate analysis, abnormal GEFV (OR 7.25, 95 % CI 3.27- 16.08, P = 0.001), History of EVL (OR 6.21, 95 % CI 1.98- 12.22, P = 0.03) and large varices (OR 5.70, 95 % CI 2.45- 13.20, P = 0.001) were independent predictors for recurrent esophageal variceal bleeding.

CONCLUSION

Abnormal GEFV, History of EVL and large varices are independent risk factors for recurrent esophageal variceal haemorrhage.

Noncirrhotic portal hypertension: current trends and future directions

PURPOSE OF REVIEW

Noncirrhotic portal hypertension (NCPH) comprises a diverse group of vascular liver disorders characterized by elevated portal pressure without cirrhosis. Due to overlapping clinical features, distinguishing NCPH from cirrhosis and porto-sinusoidal vascular disorder (PSVD) remains challenging. This review explores recent advancements in diagnosis, differentiation, and evolving treatment strategies.

RECENT FINDINGS

NCPH is characterized by preserved liver function and near-normal hepatic venous pressure gradients (HVPG). It shares risk factors with PSVD, including infections, drugs, toxins, and prothrombotic conditions. Diagnostic advancements, such as liver stiffness measurement (LSM) and splenic stiffness measurement (SSM), offer noninvasive differentiation from cirrhosis, while liver biopsy remains crucial for confirming PSVD and noncirrhotic portal fibrosis (NCPF). Imaging is reliable for diagnosing extrahepatic portal vein obstruction (EHPVO). Transjugular intrahepatic portosystemic shunts (TIPS) for refractory variceal bleeding or ascites, achieving rebleeding control in 72-80% of cases. Surgical shunts and splenectomy remain essential for uncontrolled bleeding and portal biliopathy, demonstrating excellent variceal control (93-95%).

SUMMARY

NCPH requires a high index of suspicion for diagnosis. Differentiation from cirrhosis and PSVD relies on clinical, histological, and hemodynamic assessments. Management focuses on endoscopic, interventional, and surgical strategies tailored to disease severity. Future research should standardize diagnostic criteria, explore targeted therapies, and refine prognostic tools to improve outcomes.

Reduced Mastication Is Associated With Dynapenia Markers in Patients With Cirrhosis: A Cross-Sectional Study

Background and Aim: Dental diseases are common in patients with cirrhosis. In these patients, reduced mastication might interfere with protein intake and contribute to malnutrition. We addressed the relationship between reduced mastication and dynapenia in patients with cirrhosis. Methods: This cross-sectional study involved patients with cirrhosis treated in a Brazilian center. Trained dentists performed oral examinations and tested the patients for nutritional parameters such as handgrip strength (HGS) and gait speed test (GST). Reduced mastication was presumed when a patient had molar edentulism (≥ 3 teeth), bad dental occlusion, or ill-fitting denture. Associations between mastication status and malnutrition were evaluated using multivariate linear regression analysis for continuous measures and adjusted prevalence ratio (PR (95% confidence interval)) for binary measures. Results: We included 149 patients with cirrhosis (60 ± 13 years old, 76% men, 64% Child A, 60% due to alcoholism only). Reduced mastication affected 107 patients (72%), low muscle strength (decreased HGS) occurred in 45 (30%), and decreased GST was observed in 58 (41%, among 143 patients able to walk). Thirty-one out of 143 (22%) presented decreased HGS and GST, characterizing dynapenia. Reduced mastication was associated either with decreased HGS [PR = 2.28 (1.08-4.81), p = 0.030; reduced mastication decreases the HGS mean by 12.5 kg for men (p < 0.001) and 8.1 kg for women (p = 0.065)] or with decreased GST [PR 1.97 (1.09-3.55), p = 0.024; reduced mastication increased the time of GST by 1.1 s on average (p = 0.005)], adjusting for age, alcoholic etiology, and Child-Pugh classification. Conclusions: Reduced mastication is associated with dynapenia markers in patients with cirrhosis. Further studies are needed to assess whether oral rehabilitation can change the curse of malnutrition in this population.

Expert of Experts Verification and Alignment (EVAL) Framework for Large Language Models Safety in Gastroenterology

Large language models generate plausible text responses to medical questions, but inaccurate responses pose significant risks in medical decision-making. Grading LLM outputs to determine the best model or answer is time-consuming and impractical in clinical settings; therefore, we introduce EVAL (Expert-of-Experts Verification and Alignment) to streamline this process and enhance LLM safety for upper gastrointestinal bleeding (UGIB). We evaluated OpenAI's GPT-3.5/4/4o/o1-preview, Anthropic's Claude-3-Opus, Meta's LLaMA-2 (7B/13B/70B), and Mistral AI's Mixtral (7B) across 27 configurations, including zero-shot baseline, retrieval-augmented generation, and supervised fine-tuning. EVAL uses similarity-based ranking and a reward model trained on human-graded responses for rejection sampling. Among the employed similarity metrics, Fine-Tuned ColBERT achieved the highest alignment with human performance across three separate datasets (ρ = 0.81-0.91). The reward model replicated human grading with 87.9% of cases across temperature settings and significantly improved accuracy through rejection sampling by 8.36% overall. EVAL offers scalable potential to assess accuracy for high-stakes medical decision-making.