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Nagesh VK, Pulipaka SP, Bhuju R, Martinez E, Badam S, Nageswaran GA, Tran HHV, Elias D, Mansour C, Musalli J, Bhattarai S, Shobana LS, Sethi T, Sethi R, Nikum N, Trivedi C, Jarri A, Westman C, Ahmed N, Philip S, Weissman S, Weinberger J, Bangolo AI. Management of gastrointestinal bleed in the intensive care setting, an updated literature review. World J Crit Care Med 2025; 14:101639. [DOI: 10.5492/wjccm.v14.i1.101639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2024] [Revised: 11/08/2024] [Accepted: 12/02/2024] [Indexed: 12/11/2024] Open
Abstract
Gastrointestinal (GI) bleeding is a critical and potentially life-threatening condition frequently observed in the intensive care unit (ICU). This literature review consolidates current insights on the epidemiology, etiology, management, and outcomes of GI bleeding in critically ill patients. GI bleeding remains a significant concern, especially among patients with underlying risk factors such as coagulopathy, mechanical ventilation, and renal failure. Managing GI bleeding in the ICU requires a multidisciplinary approach, including resuscitation, endoscopic intervention, pharmacologic therapy, and sometimes surgical procedures. Even with enhanced management strategies, GI bleeding in the ICU is associated with considerable morbidity and mortality, particularly when complicated by multi-organ failure. This review reiterates the need for adequate resuscitation and interventions in managing GI bleeding in critically ill patients, aiming to enhance survival rates and improve the quality of care within the ICU setting.
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Affiliation(s)
- Vignesh K Nagesh
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Sai Priyanka Pulipaka
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Ruchi Bhuju
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Emelyn Martinez
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Shruthi Badam
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Gomathy Aarthy Nageswaran
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
| | - Hadrian Hoang-Vu Tran
- Department of Internal Medicine, Hackensack Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Daniel Elias
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Charlene Mansour
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Jaber Musalli
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Sanket Bhattarai
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Lokeash Subramani Shobana
- Department of Internal Medicine, Hackensack Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Tannishtha Sethi
- Department of Internal Medicine, Hackensack Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Ritvik Sethi
- Department of Internal Medicine, Hackensack Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Namrata Nikum
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Chinmay Trivedi
- Department of Gastroenterology, Hackensack University Medical Center, Hackensack, NJ 07061, United States
| | - Amer Jarri
- Department of Pulmonology and Critical Care, HCA Florida Bayonet Point Hospital, Hudson, FL 34667, United States
| | - Colin Westman
- Department of Gastroenterology, Hackensack University Medical Center, Hackensack, NJ 07061, United States
| | - Nazir Ahmed
- Department of Gastroenterology, Hackensack University Medical Center, Hackensack, NJ 07061, United States
| | - Shawn Philip
- Department of Gastroenterology, Hackensack University Medical Center, Hackensack, NJ 07061, United States
| | - Simcha Weissman
- Department of Internal Medicine, Hackensack Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Jonathan Weinberger
- Department of Gastroenterology, Hackensack University Medical Center, Hackensack, NJ 07061, United States
| | - Ayrton I Bangolo
- Department of Hematology & Oncology, John Theurer Cancer Center at Hackensack University Medical Center, Hackensack, NJ 07601, United States
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Zhan JY, Chen J, Yu JZ, Xu FP, Xing FF, Wang DX, Yang MY, Xing F, Wang J, Mu YP. Prognostic model for esophagogastric variceal rebleeding after endoscopic treatment in liver cirrhosis: A Chinese multicenter study. World J Gastroenterol 2025; 31:100234. [DOI: 10.3748/wjg.v31.i2.100234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2024] [Revised: 09/28/2024] [Accepted: 10/25/2024] [Indexed: 12/18/2024] Open
Abstract
BACKGROUND Rebleeding after recovery from esophagogastric variceal bleeding (EGVB) is a severe complication that is associated with high rates of both incidence and mortality. Despite its clinical importance, recognized prognostic models that can effectively predict esophagogastric variceal rebleeding in patients with liver cirrhosis are lacking.
AIM To construct and externally validate a reliable prognostic model for predicting the occurrence of esophagogastric variceal rebleeding.
METHODS This study included 477 EGVB patients across 2 cohorts: The derivation cohort (n = 322) and the validation cohort (n = 155). The primary outcome was rebleeding events within 1 year. The least absolute shrinkage and selection operator was applied for predictor selection, and multivariate Cox regression analysis was used to construct the prognostic model. Internal validation was performed with bootstrap resampling. We assessed the discrimination, calibration and accuracy of the model, and performed patient risk stratification.
RESULTS Six predictors, including albumin and aspartate aminotransferase concentrations, white blood cell count, and the presence of ascites, portal vein thrombosis, and bleeding signs, were selected for the rebleeding event prediction following endoscopic treatment (REPET) model. In predicting rebleeding within 1 year, the REPET model exhibited a concordance index of 0.775 and a Brier score of 0.143 in the derivation cohort, alongside 0.862 and 0.127 in the validation cohort. Furthermore, the REPET model revealed a significant difference in rebleeding rates (P < 0.01) between low-risk patients and intermediate- to high-risk patients in both cohorts.
CONCLUSION We constructed and validated a new prognostic model for variceal rebleeding with excellent predictive performance, which will improve the clinical management of rebleeding in EGVB patients.
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Affiliation(s)
- Jun-Yi Zhan
- Cell Biology Laboratory, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
- Institute of Liver Diseases, Shanghai Academy of Chinese Medicine, Shanghai 201203, China
- Clinical Key Laboratory of Traditional Chinese Medicine of Shanghai, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
- Key Laboratory of Liver and Kidney Disease of the Ministry of Education, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Jie Chen
- Department of Gastroenterology and Hepatology, Zhongshan Hospital Affiliated to Fudan University, Shanghai 200032, China
- Shanghai Institute of Liver Disease, Fudan University, Shanghai 200032, China
- Evidence-Based Medicine Center, Fudan University, Shanghai 200032, China
| | - Jin-Zhong Yu
- Department of Gastrointestinal Endoscopy, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Fei-Peng Xu
- Cell Biology Laboratory, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
- Institute of Liver Diseases, Shanghai Academy of Chinese Medicine, Shanghai 201203, China
- Clinical Key Laboratory of Traditional Chinese Medicine of Shanghai, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
- Key Laboratory of Liver and Kidney Disease of the Ministry of Education, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Fei-Fei Xing
- Cell Biology Laboratory, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
- Institute of Liver Diseases, Shanghai Academy of Chinese Medicine, Shanghai 201203, China
- Clinical Key Laboratory of Traditional Chinese Medicine of Shanghai, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
- Key Laboratory of Liver and Kidney Disease of the Ministry of Education, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - De-Xin Wang
- Cell Biology Laboratory, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
- Institute of Liver Diseases, Shanghai Academy of Chinese Medicine, Shanghai 201203, China
- Clinical Key Laboratory of Traditional Chinese Medicine of Shanghai, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
- Key Laboratory of Liver and Kidney Disease of the Ministry of Education, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Ming-Yan Yang
- Cell Biology Laboratory, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
- Institute of Liver Diseases, Shanghai Academy of Chinese Medicine, Shanghai 201203, China
- Clinical Key Laboratory of Traditional Chinese Medicine of Shanghai, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
- Key Laboratory of Liver and Kidney Disease of the Ministry of Education, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Feng Xing
- Department of Hepatology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Jian Wang
- Department of Gastroenterology and Hepatology, Zhongshan Hospital Affiliated to Fudan University, Shanghai 200032, China
- Shanghai Institute of Liver Disease, Fudan University, Shanghai 200032, China
| | - Yong-Ping Mu
- Cell Biology Laboratory, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
- Institute of Liver Diseases, Shanghai Academy of Chinese Medicine, Shanghai 201203, China
- Clinical Key Laboratory of Traditional Chinese Medicine of Shanghai, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
- Key Laboratory of Liver and Kidney Disease of the Ministry of Education, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
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3
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Liu L, Ye S, Nie Y, Zhu X. Comparative efficacy of endoscopic variceal ligation versus non-selective beta-blockers in primary prevention of gastroesophageal varix type 2: an IPTW-adjusted study. Surg Endosc 2025; 39:332-340. [PMID: 39542889 DOI: 10.1007/s00464-024-11396-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2024] [Accepted: 10/29/2024] [Indexed: 11/17/2024]
Abstract
BACKGROUND Practice guidelines recommend non-selective beta-blockers (NSBB) and endoscopic variceal ligation (EVL) for primary prevention in cirrhosis patients with esophageal varices. However, there is no clear recommendation for primary prevention strategies for gastric varices, particularly GOV-2. Our objective is to investigate the incidence of initial bleeding and liver-related complications when NSBB and EVL are used for primary prevention in GOV-2. METHODS A retrospective analysis was conducted on data from patients with GOV-2 gastric varices. Patients were divided into the NSBB group or the EVL group. Differences in the incidence of initial bleeding within 1 year, as well as the occurrence of complications such as hepatic encephalopathy and ascites, were compared between the two groups before and after adjustment for Inverse Probability of Treatment Weighting (IPTW). A Cox proportional hazards model was used to identify independent risk factors for the first bleeding event. RESULTS There were 60 patients in the NSBB group and 66 patients in the EVL group. Before IPTW adjustment, there were differences between the two groups in sex, portal hypertensive gastropathy, esophageal variceal diameter, red signs, FIB-4, and MELD scores. After IPTW adjustment, these differences were balanced, with standardized mean differences (SMDs) within acceptable ranges. Kaplan-Meier survival analysis showed no difference in bleeding rates between the two groups before or after IPTW adjustment. After IPTW adjustment, Cox regression analysis identified esophageal variceal diameter (HR:5.59 (2.03-15.39), p < 0.001) and MELD score (HR:1.17 (1.01-1.23), p = 0.042) were independent risk factors for bleeding. NSBB treatment did not reduce the incidence of liver-related complications within one year compared to EVL. CONCLUSION For primary prevention of bleeding in cirrhotic patients with GOV-2, EVL does not significantly reduce initial bleeding episodes or liver-related complications compared to NSBB.
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Affiliation(s)
- Linxiang Liu
- Department of Gastroenterology, Jiangxi Provincial Key Laboratory of Digestive Diseases, Jiangxi Clinical Research Center for Gastroenterology, Jiangxi Medical College, Digestive Disease Hospital, The First Affiliated Hospital, Nanchang University, No.17, Yongwaizhengjie Road, Donghu District, Nanchang, 330006, Jiangxi, China
| | - Shenfeng Ye
- Department of Gastroenterology, Jiangxi Provincial Key Laboratory of Digestive Diseases, Jiangxi Clinical Research Center for Gastroenterology, Jiangxi Medical College, Digestive Disease Hospital, The First Affiliated Hospital, Nanchang University, No.17, Yongwaizhengjie Road, Donghu District, Nanchang, 330006, Jiangxi, China
| | - Yuan Nie
- Department of Gastroenterology, Jiangxi Provincial Key Laboratory of Digestive Diseases, Jiangxi Clinical Research Center for Gastroenterology, Jiangxi Medical College, Digestive Disease Hospital, The First Affiliated Hospital, Nanchang University, No.17, Yongwaizhengjie Road, Donghu District, Nanchang, 330006, Jiangxi, China
| | - Xuan Zhu
- Department of Gastroenterology, Jiangxi Provincial Key Laboratory of Digestive Diseases, Jiangxi Clinical Research Center for Gastroenterology, Jiangxi Medical College, Digestive Disease Hospital, The First Affiliated Hospital, Nanchang University, No.17, Yongwaizhengjie Road, Donghu District, Nanchang, 330006, Jiangxi, China.
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4
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Hoover JM. Letter to the Editor: Utilization of beta-blockers in patients with portal hypertension and peripheral artery disease. Hepatology 2025; 81:E4. [PMID: 38985973 DOI: 10.1097/hep.0000000000001008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 05/07/2024] [Indexed: 07/12/2024]
Affiliation(s)
- Jon M Hoover
- Department of Pharmacy, VA Medical Center University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Protopapas AA, Tsankof A, Papagiouvanni I, Kaiafa G, Skoura L, Savopoulos C, Goulis I. Outpatient management after hospitalisation for acute decompensation of cirrhosis: A practical guide. World J Hepatol 2024; 16:1377-1394. [DOI: 10.4254/wjh.v16.i12.1377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Revised: 10/24/2024] [Accepted: 11/20/2024] [Indexed: 11/29/2024] Open
Abstract
Acute decompensation in cirrhotic patients signifies the onset of clinically evident events due to portal hypertension. The transition from compensated to decompensated cirrhosis involves hemodynamic changes leading to multiorgan dysfunction, managed predominantly in outpatient settings with regular monitoring. The mortality risk is elevated in decompensated patients. Therefore, diligent outpatient management should focus on regular medical follow-ups, medication adjustments, patient education, addressing emergent issues and evaluation for liver transplantation. The ultimate goal is to improve quality of life, prevent disease progression, reduce complications, and assess possible recompensation. This guide provides valuable recommendations for medical experts managing decompensated cirrhotic patients post-hospitalization.
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Affiliation(s)
- Adonis A Protopapas
- First Propaedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki 54636, Greece
| | - Alexandra Tsankof
- First Propaedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki 54636, Greece
| | - Ioanna Papagiouvanni
- Fourth Department of Internal Medicine, Aristotle University of Thessaloniki, Hippokration General Hospital, Thessaloniki 54642, Greece
| | - Georgia Kaiafa
- First Propaedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki 54636, Greece
| | - Lemonia Skoura
- Department of Microbiology, Aristotle University οf Thessaloniki, AHEPA University Hospital, Thessaloniki 54636, Greece
| | - Christos Savopoulos
- First Propaedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki 54636, Greece
| | - Ioannis Goulis
- Fourth Department of Internal Medicine, Aristotle University of Thessaloniki, Hippokration General Hospital, Thessaloniki 54642, Greece
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6
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Fortea JI, Alvarado-Tapias E, Simbrunner B, Ezcurra I, Hernández-Gea V, Aracil C, Llop E, Puente A, Roig C, Reiberger T, García-Pagan JC, Calleja JL, Ferrero-Gregori A, Mandorfer M, Villanueva C, Crespo J. Carvedilol vs. propranolol for the prevention of decompensation and mortality in patients with compensated and decompensated cirrhosis. J Hepatol 2024:S0168-8278(24)02772-7. [PMID: 39701300 DOI: 10.1016/j.jhep.2024.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2024] [Revised: 12/04/2024] [Accepted: 12/05/2024] [Indexed: 12/21/2024]
Abstract
BACKGROUND AND AIMS Data on the effectiveness of classical non-selective beta-blockers (cNSBB, i.e., propranolol and nadolol) versus carvedilol in patients with cirrhosis are scarce. The present study aimed to compare their potential for preventing decompensation and mortality in patients with compensated and decompensated cirrhosis. METHODS Multicenter retrospective study including compensated and decompensated cirrhotic patients with clinically significant portal hypertension, undergoing measurement of hepatic venous pressure gradient (HVPG) to assess acute hemodynamic response to intravenous propranolol (i.e., HVPG decrease≥10% from baseline value) prior to primary prophylaxis for variceal bleeding. Outcomes were adjusted using Inverse Probability of Treatment Weighting (IPTW) in a competitive risk framework. RESULTS A total of 540 patients with cirrhosis were included, 256 compensated (cNSBB n=111; carvedilol n=145) and 284 decompensated (cNSBB n=134; carvedilol n=150). Median follow-up was 36.3 (IQR 16.9-61.0) months and 30.7 (IQR 13.1-52.2) months, respectively. After covariate balancing with IPTW, carvedilol, compared to cNSBB, significantly reduced the risk of a first decompensation in compensated patients (SHR 0.61; 95% CI 0.41-0.92; p=0.019) and a combined endpoint of further decompensation/death in decompensated patients (SHR 0.57; 95% CI 0.42-0.77; p<0.0001). A second HVPG was conducted on 176 (68.8%, compensated) and 177 patients (62.3%, decompensated). Acute non-responders, both compensated (11.1% vs. 29.4%; p=0.422) and decompensated (16.0% vs. 43.6%: p=0.0247) patients, showed a higher likelihood of achieving a chronic hemodynamic response with carvedilol. The safety profile of each type of NSBB was comparable in both cohorts. CONCLUSIONS Our data endorse the current recommendation favoring the use of carvedilol in the prevention of a first decompensation of cirrhosis and suggest extending the recommendation for its preferential use to patients with decompensated cirrhosis without recurrent or refractory ascites. IMPACT AND IMPLICATIONS This study addresses a gap in the comparative effectiveness of classical non-selective beta-blockers (e.g., propranolol and nadolol) versus carvedilol in managing cirrhosis in both compensated and decompensated stages. Our results support the preferential use of carvedilol in both settings due to its superior efficacy in reducing first and further decompensation. However, the retrospective nature of the study and inherent selection biases advise caution against broadly applying these findings to patients with decompensated cirrhosis who exhibit signs of circulatory dysfunction or recurrent/refractory ascites.
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Affiliation(s)
- Jose Ignacio Fortea
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, Santander, Spain
| | - Edilmar Alvarado-Tapias
- Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (UAB), Departament de Medicina UAB, Barcelona, Spain; Centre for Biomedical Research in Liver and Digestive Diseases Network (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Benedikt Simbrunner
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Hepatic Hemodynamic Lab, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Iranzu Ezcurra
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, Santander, Spain
| | - Virginia Hernández-Gea
- Centre for Biomedical Research in Liver and Digestive Diseases Network (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-RARE-LIVER), Barcelona, Spain
| | - Carles Aracil
- Centre for Biomedical Research in Liver and Digestive Diseases Network (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Digestive Diseases Unit, Hospital Arnau de Vilanova, Lleida, Spain
| | - Elba Llop
- Centre for Biomedical Research in Liver and Digestive Diseases Network (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Department of Gastroenterology and Hepatology, Puerta de Hierro University Hospital, Puerta de Hierro Health Research Institute (IDIPHIM), Universidad Autonoma de Madrid, Majadahonda, Spain
| | - Angela Puente
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, Santander, Spain
| | - Cristina Roig
- Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (UAB), Departament de Medicina UAB, Barcelona, Spain; Centre for Biomedical Research in Liver and Digestive Diseases Network (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Hepatic Hemodynamic Lab, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Juan Carlos García-Pagan
- Centre for Biomedical Research in Liver and Digestive Diseases Network (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-RARE-LIVER), Barcelona, Spain
| | - José Luis Calleja
- Centre for Biomedical Research in Liver and Digestive Diseases Network (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Department of Gastroenterology and Hepatology, Puerta de Hierro University Hospital, Puerta de Hierro Health Research Institute (IDIPHIM), Universidad Autonoma de Madrid, Majadahonda, Spain
| | - Andreu Ferrero-Gregori
- Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (UAB), Departament de Medicina UAB, Barcelona, Spain
| | - Matthias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Hepatic Hemodynamic Lab, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Candid Villanueva
- Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (UAB), Departament de Medicina UAB, Barcelona, Spain; Centre for Biomedical Research in Liver and Digestive Diseases Network (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Javier Crespo
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, Santander, Spain
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Zhao N, Shi A, Huang W, He J, Wang D, Zhang Y, Guo H, Zhou B, Gan H, Pang P. Three-dimensional volumetric CT image fusion and trans-abdominal US: Adjunct guidance to portal vein cannulation for TIPS. Eur J Radiol 2024; 183:111875. [PMID: 39671727 DOI: 10.1016/j.ejrad.2024.111875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2024] [Revised: 11/11/2024] [Accepted: 12/03/2024] [Indexed: 12/15/2024]
Abstract
PURPOSE To describe portal vein cannulation under adjunct guidance for transjugular intrahepatic portosystemic shunts (TIPS). METHODS Medical records of 86 patients who underwent TIPS, including conventional TIPS, 3D volumetric CT image fusion (CT-fluoroscopy image fusion)-guided TIPS, and trans-abdominal ultrasound (US)-guided TIPS at our institute from March 2016 to June 2024 were reviewed. Baseline characteristics, clinical outcomes, and procedural data were analyzed. RESULTS Technical success was achieved in 35 conventional TIPS patients (92.11 %), 20 CT-fluoroscopy image fusion-guided TIPS patients (95.24 %), and 26 transabdominal US-guided TIPS patients (96.30 %). Among patients who underwent a successful procedure, the procedural time and contrast usage were lower in the CT-fluoroscopy image fusion-guided and trans-abdominal US-guided TIPS groups than in the conventional group. There was a statistical significance in the cumulative fluoroscopic time between CT-fluoroscopy image fusion-guided TIPS and conventional TIPS groups (43.19 ± 14.92 vs 63.05 ± 30.33 min, p = 0.012). No immediate experienced complications were observed. Furthermore, the incidence of post-procedural complications among the three groups was not statistically different during follow-up. CONCLUSIONS CT-fluoroscopy image fusion and trans-abdominal US-guided portal vein cannulation are feasible, safe, and effective adjunct methods for patients undergoing TIPS. These methods provide shorter procedural time and lower contrast usage for TIPS placement.
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Affiliation(s)
- Ni Zhao
- Center for Interventional Medicine, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China
| | - Anya Shi
- Center for Interventional Medicine, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China
| | - Weile Huang
- Center for Interventional Medicine, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China
| | - Jianan He
- Center for Interventional Medicine, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China
| | - Dashuai Wang
- Center for Interventional Medicine, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China
| | - Yongyu Zhang
- Center for Interventional Medicine, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China
| | - Hui Guo
- Center for Interventional Medicine, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China
| | - Bin Zhou
- Center for Interventional Medicine, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China; Guangdong Provincial Engineering Research Center of Molecular Imaging, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China.
| | - Hairun Gan
- Center for Interventional Medicine, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China; Guangdong Provincial Engineering Research Center of Molecular Imaging, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China.
| | - Pengfei Pang
- Center for Interventional Medicine, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China; Guangdong Provincial Engineering Research Center of Molecular Imaging, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China
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8
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Mak LY, Liu K, Chirapongsathorn S, Yew KC, Tamaki N, Rajaram RB, Panlilio MT, Lui R, Lee HW, Lai JCT, Kulkarni AV, Premkumar M, Lesmana CRA, Hsu YC, Huang DQ. Liver diseases and hepatocellular carcinoma in the Asia-Pacific region: burden, trends, challenges and future directions. Nat Rev Gastroenterol Hepatol 2024; 21:834-851. [PMID: 39147893 DOI: 10.1038/s41575-024-00967-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/10/2024] [Indexed: 08/17/2024]
Abstract
Globally, nearly half of deaths from cirrhosis and chronic liver diseases (CLD) and three-quarters of deaths from hepatocellular carcinoma (HCC) occur in the Asia-Pacific region. Chronic hepatitis B is responsible for the vast majority of liver-related deaths in the region. Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most common form of CLD, affecting an estimated 30% of the adult population. Compared with people of European descent, people from the Asia-Pacific region carry more genetic variants associated with MASLD and its progression. Alcohol is a fast-growing cause of CLD and HCC in Asia as a result of the rising per-capita consumption of alcohol. Drug-induced liver injury is under-recognized and probably has a high prevalence in this region. The epidemiological and outcome data of acute-on-chronic liver failure are heterogeneous, and non-unified definitions across regions contribute to this heterogeneity. CLDs are severely underdiagnosed, and effective treatments and vaccinations are underutilized. In this Review, we highlight trends in the burden of CLD and HCC in the Asia-Pacific region and discuss the rapidly changing aetiologies of liver disease. We examine the multiple gaps in the care cascade and propose mitigating strategies and future directions.
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Affiliation(s)
- Lung-Yi Mak
- The University of Hong Kong, Hong Kong, China
| | - Ken Liu
- The University of Sydney, Sydney, Australia
| | | | | | | | | | | | - Rashid Lui
- The Chinese University of Hong Kong, Hong Kong, China
| | - Hye Won Lee
- Yonsei University College of Medicine, Seoul, Korea
| | | | - Anand V Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Madhumita Premkumar
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Yao Chun Hsu
- Department of Medical Research, E-Da Hospital, Kaohsiung, Taiwan; School of Medicine and Graduate Institute of Medicine, I-Shou University, Kaohsiung, Taiwan
- School of Medicine and Graduate Institute of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Daniel Q Huang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
- Division of Gastroenterology and Hepatology, National University Hospital, Singapore, Singapore.
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Celaj S, Estevez J, Novelli P, Orons P, Al-Khafaji A, Jonassaint NL, Cruz RJ, Malik SM. Challenges and Opportunities in the Adoption of p-TIPS for Acute Variceal Bleeding: Insights from a US Tertiary Center. Dig Dis Sci 2024:10.1007/s10620-024-08745-7. [PMID: 39586926 DOI: 10.1007/s10620-024-08745-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2024] [Accepted: 11/06/2024] [Indexed: 11/27/2024]
Abstract
BACKGROUND AND AIMS Since the overwhelmingly positive results of the 'early use of TIPS' published in 2010, studies in Europe and Asia have confirmed early/pre-emptive transjugular intrahepatic portosystemic shunt (p-TIPS) in high-risk patients with acute variceal bleed (AVB) reduces treatment failure and mortality compared to standard of care (SOC). There are no studies evaluating p-TIPS in a US cohort. METHODS A review of patients with cirrhosis from June 2010 to June 2020 with AVB was conducted from a single large US center. RESULTS Of 745 cirrhotic patients with AVB, 18% met criteria for p-TIPS. Alcohol and HCV accounted for 75% of etiology; 13% MASLD. The mean MELD-Na score in our cohort was 24, which is ten points higher than reported in the literature for over 600 p-TIPS cases. Only 9 patients underwent p-TIPS. Patients undergoing p-TIPS were less likely to have MASLD, more likely to be female and less likely to have PSE at baseline. One-year mortality in the SOC group (including patients undergoing 'rescue TIPS') was 53% versus 0% for p-TIPS (p = 0.01). CONCLUSION Our observation suggests hesitancy among providers to recommend p-TIPS, likely due to concerns regarding a 'sicker' patient population. The current SOC in high-risk patients remain suboptimal. Limited data, including our own, suggest that p-TIPS may confer a survival benefit even in patients with high MELD. However, the recommendation of p-TIPS in such patients necessitates validation of its safety and efficacy. Consequently, we advocate for a RCT in the US to conclusively assess the utility of p-TIPS in this context. Until such evidence is established, it is likely that underutilization of this life-saving intervention will persist.
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Affiliation(s)
- Stela Celaj
- Division of Gastroenterology, Hepatology & Nutrition, University of Pittsburgh Medical Center, 200 Lothrop Street, Kaufmann Building, Suite 201, Pittsburgh, PA, 15213, USA
| | - J Estevez
- Division of Gastroenterology, Hepatology & Nutrition, University of Pittsburgh Medical Center, 200 Lothrop Street, Kaufmann Building, Suite 201, Pittsburgh, PA, 15213, USA
| | - Paula Novelli
- Department of Interventional Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Philip Orons
- Department of Interventional Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ali Al-Khafaji
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Naudia L Jonassaint
- Division of Gastroenterology, Hepatology & Nutrition, University of Pittsburgh Medical Center, 200 Lothrop Street, Kaufmann Building, Suite 201, Pittsburgh, PA, 15213, USA
| | - Ruy J Cruz
- Department of Transplant Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Shahid M Malik
- Division of Gastroenterology, Hepatology & Nutrition, University of Pittsburgh Medical Center, 200 Lothrop Street, Kaufmann Building, Suite 201, Pittsburgh, PA, 15213, USA.
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10
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Singh S, Chandan S, Vinayek R, Aswath G, Facciorusso A, Maida M. Comprehensive approach to esophageal variceal bleeding: From prevention to treatment. World J Gastroenterol 2024; 30:4602-4608. [PMID: 39575399 PMCID: PMC11572636 DOI: 10.3748/wjg.v30.i43.4602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2024] [Revised: 10/02/2024] [Accepted: 10/18/2024] [Indexed: 10/31/2024] Open
Abstract
Esophageal variceal bleeding is a severe complication often associated with portal hypertension, commonly due to liver cirrhosis. Prevention and treatment of this condition are critical for patient outcomes. Preventive strategies focus on reducing portal hypertension to prevent varices from developing or enlarging. Primary prophylaxis involves the use of non-selective beta-blockers, such as propranolol or nadolol, which lower portal pressure by decreasing cardiac output and thereby reducing blood flow to the varices. Endoscopic variceal ligation (EVL) may also be employed as primary prophylaxis to prevent initial bleeding episodes. Once bleeding occurs, immediate treatment is essential. Initial management includes hemodynamic stabilization followed by pharmacological therapy with vasoactive drugs such as octreotide or terlipressin to control bleeding. Endoscopic intervention is the cornerstone of treatment, with techniques such as EVL or sclerotherapy applied to directly manage the bleeding varices. In cases where bleeding is refractory to endoscopic treatment, transjugular intrahepatic portosystemic shunt may be considered to effectively reduce portal pressure. Long-term management after an acute bleeding episode involves secondary prophylaxis using beta-blockers and repeated EVL sessions to prevent rebleeding, complemented by monitoring and managing liver function to address the underlying disease. In light of new scientific evidence, including the findings of the study by Peng et al, this editorial aims to review available strategies for the prevention and treatment of esophageal varices.
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Affiliation(s)
- Sahib Singh
- Department of Internal Medicine, Sinai Hospital, Baltimore, MD 21215, United States
| | - Saurabh Chandan
- Center for Interventional Endoscopy, Advent Health, Orlando, FL 32803, United States
| | - Rakesh Vinayek
- Department of Gastroenterology, Sinai Hospital of Baltimore, Baltimore, MD 21215, United States
| | - Ganesh Aswath
- Division of Gastroenterology and Hepatology, State University of New York Upstate Medical University, Syracuse, NY 13210, United States
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia 71122, Italy
| | - Marcello Maida
- Department of Medicine and Surgery, University of Enna ‘Kore’, Enna 94100, Sicilia, Italy
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11
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Xiao QA, Zhao WJ, Yu J, Qin L, Zhang XL, Yu J. Identification of novel drug targets for liver cirrhosis and its potential side-effects by human plasma proteome. Sci Rep 2024; 14:28884. [PMID: 39572673 PMCID: PMC11582803 DOI: 10.1038/s41598-024-80483-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Accepted: 11/19/2024] [Indexed: 11/24/2024] Open
Abstract
Liver cirrhosis, a common liver disease, currently lacks specific targeted therapies. This study investigates the potential therapeutic effects of serum circulating proteins on cirrhosis from a genetic perspective, and identified six associated plasma proteins (SERPINA1, PSG5, NCAN, APOE, ADH1B, GM2A). To search for therapeutic drugs associated with circulating proteins, databases such as DrugBank and DGIdb are utilized. Phenome-wide Mendelian Randomization analysis of the six significantly associated proteins revealed that GM2A exhibited no notable side effects as a therapeutic target for cirrhosis, SERPINA1 may offer additional therapeutic benefits for cholelithiasis and emphysema. ADH1B serves as a potential drug target that could simultaneously reduce the risk of alcohol-related disorders and hypertension. Furthermore, PSG5 and APOE might increase the risk of cardiovascular and neurological diseases, and NCAN has the potential to additionally reduce the risk of developing non-alcoholic fatty liver disease NAFLD. In conclusions, this study substantiates, from a genetic perspective, the potential therapeutic target role of six plasma proteins in cirrhosis, while comprehensively evaluating their side effects.
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Affiliation(s)
- Qing-Ao Xiao
- Department of Interventional Radiology, the First College of Clinical Medical Science, China Three Gorges University, Yichang, 443003, Hubei Province, China
- Department of Interventional Radiology, Yichang Central People's Hospital, Yichang, 443003, Hubei Province, China
| | - Wen-Jiang Zhao
- Department of Interventional Radiology, the First College of Clinical Medical Science, China Three Gorges University, Yichang, 443003, Hubei Province, China
- Department of Interventional Radiology, Yichang Central People's Hospital, Yichang, 443003, Hubei Province, China
| | - Jing Yu
- Department of Interventional Radiology, the First College of Clinical Medical Science, China Three Gorges University, Yichang, 443003, Hubei Province, China
- Department of Interventional Radiology, Yichang Central People's Hospital, Yichang, 443003, Hubei Province, China
| | - Lei Qin
- Department of Interventional Radiology, the First College of Clinical Medical Science, China Three Gorges University, Yichang, 443003, Hubei Province, China
- Department of Interventional Radiology, Yichang Central People's Hospital, Yichang, 443003, Hubei Province, China
| | - Xiao-Lin Zhang
- Department of Interventional Radiology, the First College of Clinical Medical Science, China Three Gorges University, Yichang, 443003, Hubei Province, China.
- Department of Interventional Radiology, Yichang Central People's Hospital, Yichang, 443003, Hubei Province, China.
| | - Jin Yu
- Department of Interventional Radiology, the First College of Clinical Medical Science, China Three Gorges University, Yichang, 443003, Hubei Province, China
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12
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Tao K, Shan X, He B, Zeng Q, Wu M, Jie L, Yuan W, Dan H, Tao Z. Sequential endoscopic treatment for esophageal and gastric variceal bleeding significantly reduces patient mortality and rebleeding rates. Therap Adv Gastroenterol 2024; 17:17562848241299743. [PMID: 39553446 PMCID: PMC11565611 DOI: 10.1177/17562848241299743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Accepted: 10/28/2024] [Indexed: 11/19/2024] Open
Abstract
Background Esophageal-gastric variceal bleeding (EGVB) is a serious complication in patients with liver cirrhosis, characterized by high mortality and rebleeding rates. The effect of sequential endoscopic therapy on patient mortality and rebleeding rates remains unclear. Objectives This study aimed to evaluate the effects of sequential endoscopic therapy on mortality and rebleeding rates in patients with EGVB. Design In this single-center retrospective study, 373 hospitalized cases of EGVB caused by liver cirrhosis, collected between November 2019 and November 2023, were divided into four groups according to different treatment methods: a sequential endoscopy group, emergency endoscopy group, emergency endoscopy plus transjugular intrahepatic portosystemic shunt (TIPS) group and control group. Methods Mortality and rebleeding rates were compared among the four groups using statistical analyses. Results The mortality and rebleeding rates of the sequential endoscopy group (3.7% and 19%, respectively) were significantly lower than those of the emergency endoscopy (22% and 36%, respectively), emergency endoscopy plus TIPS (33% and 28%, respectively), and control groups (33% and 51%, respectively) (p = 0.013 and p = 0.013, respectively). Conclusion Sequential endoscopic therapy may significantly reduce the mortality and rebleeding rates of patients with EGVB compared to other conventional treatment strategies. The findings of the study could help develop approaches benefiting EGVB treatment.
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Affiliation(s)
- Kong Tao
- Department of Gastroenterology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Renmin South Road, Shunqing District, Nanchong City, Sichuan 637000, China
| | - Xu Shan
- Department of Gastroenterology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, China
| | - Binbo He
- Department of Gastroenterology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, China
| | - Qingyu Zeng
- Department of Gastroenterology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, China
| | - Meirong Wu
- Nanchong Hospital of Traditional Chinese Medicine, Nanchong, China
| | - Liu Jie
- Department of Gastroenterology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, China
| | - Wenfeng Yuan
- Department of Gastroenterology, Yingshan County Hospital of Traditional Chinese Medicine, Nanchong, China
| | - Hu Dan
- Department of Gastroenterology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, China
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13
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Gumm AJ, Rand EB. Fontan-Associated Liver Disease. J Pediatr 2024; 277:114389. [PMID: 39510163 DOI: 10.1016/j.jpeds.2024.114389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2024] [Revised: 10/15/2024] [Accepted: 10/29/2024] [Indexed: 11/15/2024]
Affiliation(s)
- Alexis J Gumm
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Wisconsin, Milwaukee, WI.
| | - Elizabeth B Rand
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA
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14
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Shafiq M, Khan MA, Khan S. Clinical Outcomes of Transjugular Intrahepatic Portosystemic Shunt Among Cirrhosis Patients With Recurrent Esophageal Variceal Bleeding. Cureus 2024; 16:e73101. [PMID: 39651005 PMCID: PMC11621572 DOI: 10.7759/cureus.73101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2024] [Indexed: 12/11/2024] Open
Abstract
Background Transjugular intrahepatic portosystemic shunt (TIPS) has been shown to reduce the risk of rebleeding among patients with recurrent esophageal variceal bleeding. However, the impact of TIPS on survival remains uncertain. This study took on this challenge to determine if TIPS has any impact on all-cause inpatient mortality during the hospitalization in which it is performed and if it impacts all-cause 30-day readmission rates when compared to patients who only undergo esophageal variceal banding (EVB) for recurrent esophageal variceal bleeding. Methods This was a retrospective cohort study using the Healthcare Cost and Utilization Project - National Readmission Database 2019. All adult patients who had a diagnosis of cirrhosis, were hospitalized once for esophageal variceal bleeding requiring EVB in 2019, and then were hospitalized again later in the year for recurrent esophageal variceal bleeding requiring either TIPS or EVB were included. This second hospitalization in which patients either received TIPS or EVB only was considered as the index hospitalization. Patients with missing data and patients who were discharged in December were excluded. The primary outcome was all-cause 30-day readmission rates among patients who either received TIPS or EVB only. The secondary outcomes included: (i) incidence of all-cause inpatient mortality; and (ii) length of hospital stay during index hospitalization. Patients who underwent TIPS were matched with patients who underwent EVB only on age, sex, and baseline comorbidities. After propensity score matching, survival analysis was performed to compare the all-cause 30-day readmission rates after the index hospitalization, between patients who either received TIPS or EVB only during the index hospitalization. χ2 test was used to compare the inpatient mortality. As the data did not have a normal distribution, the Wilcoxon signed-rank test was used to compare the length of index hospitalization between patients who either received TIPS or EVB only. The alpha criterion was set at 0.05 for all statistical tests. Results This study found no difference in all-cause 30-day readmission rates between patients who underwent either TIPS or EVB only for recurrent esophageal variceal bleeding (hazard ratio: 1.24, 95%CI: 0.73-2.12, P = 0.4). In the exploratory analysis, it was noted that the rate of recurrent esophageal variceal bleeding, among patients who were readmitted within 30 days was lower in the TIPS group (13.3%) when compared to the EVB group (50%) with a risk ratio of 0.27 (95%CI: 0.10-0.72, P = 0.003). Although it was not statistically significant, the inpatient mortality rate during the index hospitalization appeared to be lower in the TIPS group when compared to the EVB group (4.2% vs 10.08%, respectively). Patients who underwent TIPS were hospitalized three days longer than patients who underwent EVB only. Conclusion TIPS does not reduce all-cause 30-day readmission rates but is associated with reduced 30-day readmission rates secondary to recurrent esophageal variceal bleeding. TIPS shows a modest survival advantage during index hospitalization when compared to EVB only.
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Affiliation(s)
- Muhammad Shafiq
- Internal Medicine, University of Kansas Medical Center, Kansas City, USA
| | | | - Shahryar Khan
- Internal Medicine, University of Kansas Medical Center, Kansas City, USA
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15
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Chalasani N, Vilar-Gomez E, Loomba R, Yates KP, Diehl AM, Neuschwander-Tetri BA, Dasarathy S, Kowdley KV, Terrault N, Wilson LA, Tonascia J, Sanyal AJ. PNPLA3 rs738409, age, diabetes, sex, and advanced fibrosis jointly contribute to the risk of major adverse liver outcomes in metabolic dysfunction-associated steatotic liver disease. Hepatology 2024; 80:1212-1226. [PMID: 38652636 DOI: 10.1097/hep.0000000000000896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 03/18/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND AND AIMS The patatin-like phospholipase domain-containing protein 3 ( PNPLA3 ) rs738409 variant is associated with steatotic liver disease and its progression. We examined the association between PNPLA3 and the development of major adverse liver outcomes (MALOs) and how nonmodifiable and modifiable conditions modify this relationship. APPROACH AND RESULTS A total of 2075 adults with biopsy-confirmed metabolic dysfunction-associated steatotic liver disease (MASLD) were enrolled in the metabolic dysfunction-associated steatohepatitis Clinical Research Network (MASH CRN) studies and followed prospectively until death, transplant, or withdrawal of consent. One hundred four MALOs were recorded during an average of 4.3 years. PNPLA3 G-allele (Adj. sub-hazard ratio (sHR): 1.4, 95% CI: 1.07-1.8), advanced fibrosis (AF) (Adj. sHR: 7.8, 95% CI: 4.4-13.8), age >60 years (Adj. sHR: 2.9, 95% CI: 1.3-6.8), and type 2 diabetes mellitus (Adj. sHR: 2.8, 95% CI: 1.8-4.2) were associated with MALO. Among participants with AF, those carrying the G-allele displayed the highest cumulative incidence of MALO (85%) versus noncarriers (53%), p =0.03, and p -value for interaction <0.01. The strength of the association between PNPLA3 and MALO was statistically significantly greater among older than 60 years (sHR: 2.1, 95% CI: 1.5-2.8), women (sHR: 1.4, 95% CI: 1.1-1.9), and those with AF (sHR: 1.9, 95% CI: 1.5-2.4) or type 2 diabetes mellitus (sHR: 2.1, 95% CI: 1.5-2.8) as compared with their counterparts, p -value for interaction between PNPLA3 and each factor<0.01. CONCLUSIONS The deleterious effects of PNPLA3 rs738409 on the risk of MALO are significantly worsened by AF, age, type 2 diabetes mellitus, and sex.
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Affiliation(s)
- Naga Chalasani
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine Indiana University Health, Indianapolis, Indiana, USA
| | - Eduardo Vilar-Gomez
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine Indiana University Health, Indianapolis, Indiana, USA
| | - Rohit Loomba
- Division of Gastroenterology and Hepatology, Department of Medicine, MASLD Research Center, University of California, San Diego School of Medicine, La Jolla, California, USA
| | - Katherine P Yates
- Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland
| | - Anna Mae Diehl
- Division of Gastroenterology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | | | - Srinivasan Dasarathy
- Division of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Norah Terrault
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, University of Southern California, Los Angeles, California, USA
| | - Laura A Wilson
- Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland
| | - James Tonascia
- Department of Biostatistics and Epidemiology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Arun J Sanyal
- Division of Gastroenterology and Hepatology, Department of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
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16
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Redinger JW, Johnson KM, Slawski BA. Perioperative Liver and Kidney Diseases. Med Clin North Am 2024; 108:1119-1134. [PMID: 39341617 DOI: 10.1016/j.mcna.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2024]
Abstract
Perioperative risks associated with acute hepatitis, cirrhosis, and chronic kidney disease are substantial and prevalence of underlying chronic kidney or liver disease is rising; surgeries in these populations have accordingly become more common. Optimal perioperative management in both cases is paramount; this article focuses on understanding disease pathophysiology, a targeted preoperative evaluation, accurate estimation of perioperative risk, and anticipation and management of common postoperative complications.
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Affiliation(s)
- Jeffrey W Redinger
- Division of General Internal Medicine, Department of Medicine, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, USA; Hospital and Specialty Medicine, VA Puget Sound Healthcare System, 1660 South Columbian Way (S-111-MED), Seattle, WA 98108, USA.
| | - Kay M Johnson
- Division of General Internal Medicine, Department of Medicine, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, USA; Hospital and Specialty Medicine, VA Puget Sound Healthcare System, 1660 South Columbian Way (S-111-MED), Seattle, WA 98108, USA
| | - Barbara A Slawski
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, The Hub for Collaborative Medicine, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA
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17
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Goldberg D, Wilder J, Terrault N. Health disparities in cirrhosis care and liver transplantation. Nat Rev Gastroenterol Hepatol 2024:10.1038/s41575-024-01003-1. [PMID: 39482363 DOI: 10.1038/s41575-024-01003-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/02/2024] [Indexed: 11/03/2024]
Abstract
Morbidity and mortality from cirrhosis are substantial and increasing. Health disparities in cirrhosis and liver transplantation are reflective of inequities along the entire spectrum of chronic liver disease care, from screening and diagnosis to prevention and treatment of liver-related complications. The key populations experiencing disparities in health status and healthcare delivery include racial and ethnic minority groups, sexual and gender minorities, people of lower socioeconomic status and underserved rural communities. These disparities lead to delayed diagnosis of chronic liver disease and complications of cirrhosis (for example, hepatocellular carcinoma), to differences in treatment of chronic liver disease and its complications, and ultimately to unequal access to transplantation for those with end-stage liver disease. Calling out these disparities is only the first step towards implementing solutions that can improve health equity and clinical outcomes for everyone. Multi-level interventions along the care continuum for chronic liver disease are needed to mitigate these disparities and provide equitable access to care.
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Affiliation(s)
- David Goldberg
- Division of Digestive Health and Liver Diseases, University of Miami, Miami, FL, USA
| | - Julius Wilder
- Division of Gastroenterology, Duke University, Durham, NC, USA
| | - Norah Terrault
- Division of GI and Liver Diseases, University of Southern California, Los Angeles, CA, USA.
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18
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Tahata Y, Hikita H, Mochida S, Enomoto N, Kawada N, Ido A, Miki D, Kurosaki M, Yoshiji H, Sakamori R, Kuroda H, Yatsuhashi H, Yamashita T, Hiasa Y, Kato N, Miyaaki H, Ueno Y, Itoh Y, Matsuura K, Takami T, Asahina Y, Suda G, Akuta N, Tateishi R, Nakamoto Y, Kakazu E, Terai S, Shimizu M, Miyazaki M, Nozaki Y, Sobue S, Yano H, Miyaki T, Moriuchi A, Hori T, Shirai K, Murai K, Saito Y, Kodama T, Tatsumi T, Yamada T, Takehara T. Factors involved in gastroesophageal varix-related events in patients with hepatitis C virus-related compensated and decompensated cirrhosis after direct-acting antiviral therapy. Hepatol Res 2024. [PMID: 39470448 DOI: 10.1111/hepr.14131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Revised: 09/24/2024] [Accepted: 10/11/2024] [Indexed: 10/30/2024]
Abstract
AIM The incidence of and factors involved in gastroesophageal varix-related events in hepatitis C virus-related cirrhosis patients, including decompensated cirrhosis, after direct-acting antiviral therapy are unclear. METHODS We conducted a multicenter study using prospective data from 478 hepatitis C virus-related cirrhosis patients treated with direct-acting antiviral therapy from February 2019 to December 2021 at 33 Japanese hospitals. Gastroesophageal varices were classified as F1 (small-caliber), F2 (moderately enlarged), or F3 (markedly enlarged) according to the Japanese criteria. Patients without varix or with F1 without red color signs were defined as low-risk varix, and patients with ≥F2 or red color signs or a history of rupture were defined as high-risk varix. Varix-related events were defined as prophylactic treatment or rupture of gastroesophageal varix. RESULTS The median age was 70 years, 43% of patients had decompensated cirrhosis, and 16% had high-risk varices (13% in compensated and 33% in decompensated, p < 0.001). Sustained virologic response rates were 94.9% for compensated cirrhosis and 91.3% for decompensated cirrhosis (p = 0.120). Across 35.7 months, 25 patients received prophylactic treatment, and four experienced varix rupture. The 3-year incidence rate of varix-related events was 6.2% (3.5% in compensated and 9.9% in decompensated, p = 0.001). In the multivariate analysis, high-risk varix (p < 0.001), high baseline gamma-glutamyl transpeptidase levels (p < 0.001), and virologic failure (p = 0.004) were significantly involved in varix-related events. CONCLUSIONS The cumulative incidence rate of varix-related events was significantly higher in decompensated cirrhosis than in compensated cirrhosis. Baseline varix status, baseline gamma-glutamyl transpeptidase levels, and virologic response were related to varix-related events after direct-acting antiviral therapy.
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Affiliation(s)
- Yuki Tahata
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hayato Hikita
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Satoshi Mochida
- Department of Gastroenterology and Hepatology, Saitama Medical University, Saitama, Japan
| | - Nobuyuki Enomoto
- First Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Norifumi Kawada
- Department of Hepatology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Akio Ido
- Digestive and Lifestyle Diseases, Department of Human and Environmental Sciences, Kagoshima University Graduate School of Medicine and Dental Sciences, Kagoshima, Japan
| | - Daiki Miki
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masayuki Kurosaki
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, Tokyo, Japan
| | - Hitoshi Yoshiji
- Department of Gastroenterology, Nara Medical University, Nara, Japan
| | - Ryotaro Sakamori
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hidekatsu Kuroda
- Division of Hepatology, Department of Internal Medicine, Iwate Medical University, Yahaba, Iwate, Japan
| | - Hiroshi Yatsuhashi
- Clinical Research Center, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Taro Yamashita
- Department of Gastroenterology, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
| | - Yoichi Hiasa
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Naoya Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hisamitsu Miyaaki
- Department of Gastroenterology and Hepatology, Nagasaki University of Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yoshiyuki Ueno
- Department of Gastroenterology, Faculty of Medicine, Yamagata University, Yamagata, Japan
| | - Yoshito Itoh
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kentaro Matsuura
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Taro Takami
- Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Yasuhiro Asahina
- Department of Gastroenterology and Hepatology, Department of Liver Disease Control, Tokyo Medical and Dental University, Tokyo, Japan
| | - Goki Suda
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Norio Akuta
- Department of Hepatology, Toranomon Hospital, Tokyo, Japan
| | - Ryosuke Tateishi
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yasunari Nakamoto
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Eiji Kakazu
- The Research Center for Hepatitis and Immunology, National Center for Global Health and Medicine, Chiba, Japan
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Graduate School of Medicine and Dental Sciences, Niigata University, Niigata, Japan
| | - Masahito Shimizu
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | | | - Yasutoshi Nozaki
- Department of Gastroenterology, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Satoshi Sobue
- Department of Gastroenterology, Kasugai Municipal Hospital, Kasugai, Japan
| | - Hiroki Yano
- Department of Gastroenterology, Oshima Hospital, Kagoshima, Japan
| | - Tomokatsu Miyaki
- Department of Gastroenterology, Toyokawa City Hospital, Toyokawa, Japan
| | - Akihiro Moriuchi
- Department of Gastroenterology, National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan
| | - Takeshi Hori
- Department of Gastroenterology, Kagoshima City Hospital, Kagoshima, Japan
| | - Kumiko Shirai
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Kazuhiro Murai
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yoshinobu Saito
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Takahiro Kodama
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Tomohide Tatsumi
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Tomomi Yamada
- Department of Medical Innovation, Osaka University Hospital, Suita, Osaka, Japan
| | - Tetsuo Takehara
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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Mossie GY, Nur AM, Ayalew ZS, Azibte GT, Berhane KA. Platelet counts to spleen diameter ratio: A promising noninvasive tool for predicting esophageal varices in cirrhosis patients. World J Hepatol 2024; 16:1357-1367. [DOI: 10.4254/wjh.v16.i10.1357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Revised: 08/21/2024] [Accepted: 09/06/2024] [Indexed: 11/22/2024] Open
Abstract
BACKGROUND Liver cirrhosis is the end stage of progressive liver fibrosis as a consequence of chronic liver inflammation, wherein the standard hepatic architecture is replaced by regenerative hepatic nodules, which eventually lead to liver failure. Cirrhosis without any symptoms is referred to as compensated cirrhosis. Complications such as ascites, variceal bleeding, and hepatic encephalopathy indicate the onset of decompensated cirrhosis. Gastroesophageal varices are the hallmark of clinically significant portal hypertension.
AIM To determine the accuracy of the platelet count-to-spleen diameter (PC/SD) ratio to evaluate esophageal varices (EV) in patients with cirrhosis.
METHODS This retrospective observational study was conducted at Tikur Anbessa Specialized Hospital and Adera Medical Center from January 1, 2019, to December 30, 2023. Data were collected via chart review and direct patient interviews using structured questionnaires. The data were exported to the SPSS software version 26 for analysis and clearance. A receiver operating characteristic curve was plotted for splenic diameter, platelet count, and PC/SD ratio to obtain sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio.
RESULTS Of the 140 participants, 67% were men. Hepatitis B (38%) was the most common cause of cirrhosis, followed by cryptogenic cirrhosis (28%) and hepatitis C (16%). Approximately 83.6% of the participants had endoscopic evidence of EV, whereas 51.1% had gastric varices. Decompensated cirrhosis and PC were associated with the presence of EV with adjusted odds ratios of 12.63 (95%CI: 3.16-67.58, P = 0.001) and 0.14 (95%CI: 0.037-0.52, P = 0.004), respectively. A PC/SD ratio < 1119 had a sensitivity of 86.32% and specificity of 70% with area under the curve of 0.835 (95%CI: 0.736-0.934, P < 0.001).
CONCLUSION A PC/SD ratio < 1119 predicts EV in patients with cirrhosis. It is a valuable, noninvasive tool for EV risk assessment in resource-limited settings.
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Affiliation(s)
- Getnet Yigzaw Mossie
- Department of Internal Medicine, Addis Ababa University, Addis Ababa 1000, Ethiopia
| | - Abdulsemed Mohammed Nur
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa 1000, Ethiopia
| | | | | | - Kaleb Assefa Berhane
- Department of General Medicine, Adera Medical and Surgical Center, Addis Ababa 1000, Ethiopia
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20
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Mossie GY, Nur AM, Ayalew ZS, Azibte GT, Berhane KA. Platelet counts to spleen diameter ratio: A promising noninvasive tool for predicting esophageal varices in cirrhosis patients. World J Hepatol 2024; 16:1177-1187. [PMID: 39474572 PMCID: PMC11514619 DOI: 10.4254/wjh.v16.i10.1177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Revised: 08/21/2024] [Accepted: 09/06/2024] [Indexed: 10/21/2024] Open
Abstract
BACKGROUND Liver cirrhosis is the end stage of progressive liver fibrosis as a consequence of chronic liver inflammation, wherein the standard hepatic architecture is replaced by regenerative hepatic nodules, which eventually lead to liver failure. Cirrhosis without any symptoms is referred to as compensated cirrhosis. Complications such as ascites, variceal bleeding, and hepatic encephalopathy indicate the onset of decompensated cirrhosis. Gastroesophageal varices are the hallmark of clinically significant portal hypertension.
AIM To determine the accuracy of the platelet count-to-spleen diameter (PC/SD) ratio to evaluate esophageal varices (EV) in patients with cirrhosis.
METHODS This retrospective observational study was conducted at Tikur Anbessa Specialized Hospital and Adera Medical Center from January 1, 2019, to December 30, 2023. Data were collected via chart review and direct patient interviews using structured questionnaires. The data were exported to the SPSS software version 26 for analysis and clearance. A receiver operating characteristic curve was plotted for splenic diameter, platelet count, and PC/SD ratio to obtain sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio.
RESULTS Of the 140 participants, 67% were men. Hepatitis B (38%) was the most common cause of cirrhosis, followed by cryptogenic cirrhosis (28%) and hepatitis C (16%). Approximately 83.6% of the participants had endoscopic evidence of EV, whereas 51.1% had gastric varices. Decompensated cirrhosis and PC were associated with the presence of EV with adjusted odds ratios of 12.63 (95%CI: 3.16-67.58, P = 0.001) and 0.14 (95%CI: 0.037-0.52, P = 0.004), respectively. A PC/SD ratio < 1119 had a sensitivity of 86.32% and specificity of 70% with area under the curve of 0.835 (95%CI: 0.736-0.934, P < 0.001).
CONCLUSION A PC/SD ratio < 1119 predicts EV in patients with cirrhosis. It is a valuable, noninvasive tool for EV risk assessment in resource-limited settings.
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Affiliation(s)
- Getnet Yigzaw Mossie
- Department of Internal Medicine, Addis Ababa University, Addis Ababa 1000, Ethiopia
| | - Abdulsemed Mohammed Nur
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa 1000, Ethiopia
| | | | | | - Kaleb Assefa Berhane
- Department of General Medicine, Adera Medical and Surgical Center, Addis Ababa 1000, Ethiopia
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21
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Arab JP, Louvet A, Thiele M, Winder GS, Wong RJ, Singal AK. Alcohol-Associated Liver Disease: Managing the Dual Pathology of Liver Disease and of Alcohol Use Disorder. Gastroenterology 2024:S0016-5085(24)05593-8. [PMID: 39454893 DOI: 10.1053/j.gastro.2024.09.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Revised: 08/14/2024] [Accepted: 09/21/2024] [Indexed: 10/28/2024]
Affiliation(s)
- Juan Pablo Arab
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia; Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Alexandre Louvet
- Service des maladies de l'appareil digestif, University Hospital of Lille, Lille, France; Unite INSERM INFINITE, Lille, France
| | - Maja Thiele
- Center for Liver Research, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Gerald S Winder
- Departments of Psychiatry, Surgery, and Neurology, Michigan Medicine, Ann Arbor, Michigan
| | - Robert J Wong
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Gastroenterology Section, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
| | - Ashwani K Singal
- University of Louisville Health Sciences Center, Louisville, Kentucky; Trager Transplant Center at Jewish Hospital, Louisville, Kentucky; Robley Rex VA Medical Center, Louisville, Kentucky
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22
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Ma J, Ghabril M. Lowering Rebleeding Risk in Cardiofundal Gastric Varices: The Case for Combined Variceal Embolization and Endovascular Therapies? Clin Gastroenterol Hepatol 2024:S1542-3565(24)00944-3. [PMID: 39447946 DOI: 10.1016/j.cgh.2024.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2024] [Accepted: 09/17/2024] [Indexed: 10/26/2024]
Affiliation(s)
- Jiayi Ma
- Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Marwan Ghabril
- Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana.
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23
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Brujats A, Villanueva C. Examining the therapeutic landscape of beta-blockers in portal hypertension. Clin Mol Hepatol 2024; 30:1055-1059. [PMID: 38447532 PMCID: PMC11540378 DOI: 10.3350/cmh.2024.0144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 03/04/2024] [Accepted: 03/04/2024] [Indexed: 03/08/2024] Open
Affiliation(s)
- Anna Brujats
- Hospital Santa Creu and Sant Pau, Autonomous University of Barcelona, Hospital Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain
| | - Càndid Villanueva
- Hospital Santa Creu and Sant Pau, Autonomous University of Barcelona, Hospital Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain
- Centre for Biomedical Research in Liver and Digestive Diseases Network (CIBERehd), Barcelona, Spain
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24
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Fierro-Angulo OM, González-Regueiro JA, Pereira-García A, Ruiz-Margáin A, Solis-Huerta F, Macías-Rodríguez RU. Hematological abnormalities in liver cirrhosis. World J Hepatol 2024; 16:1229-1244. [PMID: 39351511 PMCID: PMC11438588 DOI: 10.4254/wjh.v16.i9.1229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 08/09/2024] [Accepted: 08/22/2024] [Indexed: 09/23/2024] Open
Abstract
Hematological abnormalities are common in cirrhosis and are associated with various pathophysiological mechanisms. Studies have documented a prevalence of thrombocytopenia, leukopenia, and anemia in patients with compensated cirrhosis of 77.9%, 23.5%, and 21.1%, respectively. These abnormalities carry significant clinical implications, including considerations for invasive procedures, infection risk, bleeding risk, and prognosis. Previously, cirrhosis was believed to predispose patients to bleeding due to alterations observed in classical coagulation tests such as prothrombin time, partial thromboplastin time, international normalized ratio, and thrombocytopenia. However, this understanding has evolved, and cirrhosis patients are now also acknowledged as being at a high risk for thrombotic events. Hemostasis in cirrhosis patients presents a complex phenotype, with procoagulant and anticoagulant abnormalities offsetting each other. This multifactorial phenomenon is inadequately reflected by routine laboratory tests. Thrombotic complications are more prevalent in decompensated cirrhosis and may correlate with disease severity. Bleeding is primarily associated with portal hypertension, endothelial dysfunction, mechanical vessel injury, disseminated intravascular coagulation, endotoxemia, and renal injury. This review comprehensively outlines hematologic index abnormalities, mechanisms of hemostasis, coagulation, and fibrinolysis abnormalities, limitations of laboratory testing, and clinical manifestations of bleeding and thrombosis in patients with liver cirrhosis.
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Affiliation(s)
- Oscar Manuel Fierro-Angulo
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico 14080, Mexico
| | - José Alberto González-Regueiro
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico 14080, Mexico
| | - Ariana Pereira-García
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico 14080, Mexico
| | - Astrid Ruiz-Margáin
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico 14080, Mexico
| | - Fernando Solis-Huerta
- Department of Hematology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico 14080, Mexico
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25
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Shalaby S, Nicoară-Farcău O, Perez-Campuzano V, Olivas P, Torres S, García-Pagán JC, Hernández-Gea V. Transjugular Intrahepatic Portosystemic Shunt (TIPS) for Treatment of Bleeding from Cardiofundal and Ectopic Varices in Cirrhosis. J Clin Med 2024; 13:5681. [PMID: 39407741 PMCID: PMC11476950 DOI: 10.3390/jcm13195681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 07/26/2024] [Accepted: 09/21/2024] [Indexed: 10/20/2024] Open
Abstract
Acute variceal bleeding in cirrhosis represents a critical clinical event that significantly impacts patient prognosis, with mortality rates increasing further after a second episode. This underscores the need for immediate intervention and optimal prophylaxis. The creation of a transjugular intrahepatic portosystemic shunt (TIPS) has been proven to be highly effective for managing esophageal variceal bleeding. However, the use of TIPS for managing cardiofundal gastric varices and ectopic varices remains debated due to their unique vascular anatomy and the limited data available. These varices, although less prevalent than esophageal varices, are complex and heterogeneous vascular shunts between the splanchnic venous system and the systemic veins. Indeed, while endoscopic therapy with tissue adhesives is widely endorsed for achieving hemostasis in active hemorrhage, there is no consensus regarding the optimal approach for secondary prophylaxis. Recent research emphasizes the efficacy of endovascular techniques over endoscopic treatments, such as TIPS and endovascular variceal embolization techniques. This review examines the use of TIPS in managing acute variceal bleeding in patients with cirrhosis, focusing specifically on cardiofundal gastric varices and ectopic varices, discussing optimal patient care based on the latest evidence, aiming to improve outcomes for this challenging subset of patients.
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Affiliation(s)
- Sarah Shalaby
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Fundació de Recerca Clínic Barcelona (FRCB-IDIABPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-RareLiver), 08036 Barcelona, Spain
| | - Oana Nicoară-Farcău
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Hepatology Department, Regional Institute of Gastroenterology and Hepatology “Octavian Fodor”, “Iuliu Hatieganu” University of Medicine and Pharmacy, 3rd Medical Clinic, 400394 Cluj-Napoca, Romania
| | - Valeria Perez-Campuzano
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Fundació de Recerca Clínic Barcelona (FRCB-IDIABPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-RareLiver), 08036 Barcelona, Spain
| | - Pol Olivas
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Fundació de Recerca Clínic Barcelona (FRCB-IDIABPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-RareLiver), 08036 Barcelona, Spain
| | - Sonia Torres
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Fundació de Recerca Clínic Barcelona (FRCB-IDIABPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-RareLiver), 08036 Barcelona, Spain
| | - Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Fundació de Recerca Clínic Barcelona (FRCB-IDIABPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-RareLiver), 08036 Barcelona, Spain
- Departament de Medicina i Ciències de la Salut, Universitat de Barcelona, 08036 Barcelona, Spain
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Fundació de Recerca Clínic Barcelona (FRCB-IDIABPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-RareLiver), 08036 Barcelona, Spain
- Departament de Medicina i Ciències de la Salut, Universitat de Barcelona, 08036 Barcelona, Spain
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26
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Palle SK, Leung DH. Advanced cystic fibrosis liver disease: Endovascular, endoscopic, radiologic, and surgical considerations. Pediatr Pulmonol 2024; 59 Suppl 1:S115-S122. [PMID: 39105344 DOI: 10.1002/ppul.27174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 06/29/2024] [Accepted: 07/03/2024] [Indexed: 08/07/2024]
Abstract
Up to 90% of people with CF (pwCF) will have some form of hepatobiliary involvement. This manuscript aims to explore the different endovascular, endoscopic, radiological and surgical procedures available to diagnose and manage the most severe form of CF hepatobiliary involvement (CFHBI) known as advanced cystic fibrosis liver disease (aCFLD), seen in 10% of pwCF. These procedures and interventions include liver biopsy, hepatic venous pressure gradient measurement, gastrostomy tube placement to optimize nutrition, paracentesis, endoscopic variceal control of bleeding and portosystemic shunting before liver transplantation. By utilizing advanced diagnostic or surgical techniques, healthcare professionals of pwCF can more effectively manage patients with CFHBI and aCFLD and potentially improve patient outcomes.
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Affiliation(s)
- Sirish K Palle
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Daniel H Leung
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
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27
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Matsubara Y, Tsuboi A, Hirata I, Sumioka A, Takasago T, Tanaka H, Yamashita K, Hiyama Y, Takigawa H, Murakami E, Tsuge M, Urabe Y, Oka S. Predictive factors of portal hypertensive enteropathy exacerbations based on long-term outcomes. BMC Gastroenterol 2024; 24:287. [PMID: 39187770 PMCID: PMC11346274 DOI: 10.1186/s12876-024-03377-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 08/14/2024] [Indexed: 08/28/2024] Open
Abstract
BACKGROUND Portal hypertensive enteropathy (PHE) is a small-bowel lesion observed in patients with portal hypertension. The clinical significance of endoscopic findings in PHE remains unclear. We aimed to clarify the clinical significance and predictive factors of capsule endoscopic findings in patients with PHE based on long-term outcomes. METHODS This retrospective study enrolled 55 patients with PHE (33 males and 22 females; median age, 64 years; range, 23-87) followed for > 3 years using capsule endoscopy (CE) between February 2009 and May 2023. We evaluated the clinical factors affecting PHE exacerbations and the effects of PHE exacerbations on gastrointestinal bleeding by comparing exacerbated and unchanged PHE groups. RESULTS Overall, 3 (5%) patients showed improvement, 33 (60%) remained unchanged, and 19 (35%) showed exacerbation on follow-up CE. In the exacerbated group, the rates of worsened fibrosis-4 index, exacerbated esophageal varices, and exacerbated portal hypertensive gastropathy were significantly higher than those in the unchanged group (21%, 32%, and 42% vs. 3%, 6%, and 12%, respectively; P < 0.05), and the rate of splenectomy was significantly lower in the exacerbated group than in the unchanged group (5% vs. 39%, respectively; P < 0.01). In multivariate analysis, exacerbation of esophageal varices and absence of splenectomy were significantly associated with PHE exacerbation. The rate of gastrointestinal bleeding after follow-up CE was significantly high in the exacerbated group (log-rank, P = 0.037). CONCLUSIONS Exacerbation of esophageal varices and splenectomy were significantly associated with exacerbation of PHE. Exacerbated PHE requires specific attention to prevent gastrointestinal bleeding.
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Affiliation(s)
- Yuka Matsubara
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Akiyoshi Tsuboi
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
- Department of Gastroenterology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Issei Hirata
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Akihiko Sumioka
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Takeshi Takasago
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hidenori Tanaka
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Ken Yamashita
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuichi Hiyama
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hidehiko Takigawa
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Eisuke Murakami
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masataka Tsuge
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuji Urabe
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shiro Oka
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Singh S, Chandan S, Inamdar S, Kadkhodayan KS, Dhar J, Samanta J, Facciorusso A. EUS-Guided Vascular Interventions: Recent Advances. J Clin Med 2024; 13:4835. [PMID: 39200976 PMCID: PMC11355666 DOI: 10.3390/jcm13164835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2024] [Revised: 08/09/2024] [Accepted: 08/15/2024] [Indexed: 09/02/2024] Open
Abstract
Endoscopic ultrasound (EUS)-guided vascular interventions were first reported in 2000 in a study that evaluated the utility of EUS in sclerotherapy of esophageal varices. Currently, gastric variceal therapy and portosystemic pressure gradient (PPG) measurements are the most widely utilized applications. Ectopic variceal obliteration, splenic artery embolization, aneurysm/pseudoaneurysm treatment, portal venous sampling, and portosystemic shunt creation using EUS are some of the other emerging interventions. Since the release of the American Gastroenterological Association (AGA)'s commentary in 2023, which primarily endorses EUS-guided gastric variceal therapy and EUS-PPG measurement, several new studies have been published supporting the use of EUS for various vascular conditions. In this review, we present the recent advances in this field, critically appraising new studies and trials.
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Affiliation(s)
- Sahib Singh
- Department of Internal Medicine, Sinai Hospital of Baltimore, Baltimore, MD 21215, USA;
| | - Saurabh Chandan
- Center for Interventional Endoscopy (CIE), Advent Health, Orlando, FL 32803, USA; (S.C.); (K.S.K.)
| | - Sumant Inamdar
- Gastroenterology & Hepatology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA;
| | - Kambiz S. Kadkhodayan
- Center for Interventional Endoscopy (CIE), Advent Health, Orlando, FL 32803, USA; (S.C.); (K.S.K.)
| | - Jahnvi Dhar
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India; (J.D.); (J.S.)
| | - Jayanta Samanta
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India; (J.D.); (J.S.)
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy
- Clinical Effectiveness Research Group, Faculty of Medicine, Institute of Health and Society, University of Oslo, 0372 Oslo, Norway
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Singh J, Ebaid M, Saab S. Advances in the management of complications from cirrhosis. Gastroenterol Rep (Oxf) 2024; 12:goae072. [PMID: 39104730 PMCID: PMC11299547 DOI: 10.1093/gastro/goae072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 05/29/2024] [Accepted: 06/15/2024] [Indexed: 08/07/2024] Open
Abstract
Cirrhosis with complications of liver decompensation and hepatocellular carcinoma (HCC) constitute a leading cause of morbidity and mortality worldwide. Portal hypertension is central to the progression of liver disease and decompensation. The most recent Baveno VII guidance included revision of the nomenclature for chronic liver disease, termed compensated advanced chronic liver disease, and leveraged the use of liver stiffness measurement to categorize the degree of portal hypertension. Additionally, non-selective beta blockers, especially carvedilol, can improve portal hypertension and may even have a survival benefit. Procedural techniques with interventional radiology have become more advanced in the management of refractory ascites and variceal bleeding, leading to improved prognosis in patients with decompensated liver disease. While lactulose and rifaximin are the preferred treatments for hepatic encephalopathy, many alternative treatment options may be used in refractory cases and even procedural interventions such as shunt embolization may be of benefit. The approval of terlipressin for the treatment of hepatorenal syndrome (HRS) in the USA has improved the way in which HRS is managed and will be discussed in detail. Malnutrition, frailty, and sarcopenia lead to poorer outcomes in patients with decompensated liver disease and should be addressed in this patient population. Palliative care interventions can lead to improved quality of life and clinical outcomes. Lastly, the investigation of systemic therapies, in particular immunotherapy, has revolutionized the management of HCC. These topics will be discussed in detail in this review.
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Affiliation(s)
- Jasleen Singh
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Mark Ebaid
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Sammy Saab
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Siddiqi H, Huang DQ, Mittal N, Nourredin N, Bettencourt R, Madamba E, Amangurbanova M, Hernandez C, Sirlin C, Yin M, Loomba R. Repeatability of vibration-controlled transient elastography versus magnetic resonance elastography in patients with cirrhosis: A prospective study. Aliment Pharmacol Ther 2024; 60:484-491. [PMID: 38863232 PMCID: PMC11618574 DOI: 10.1111/apt.18118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 05/09/2024] [Accepted: 06/03/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND AND AIMS Magnetic resonance elastography (MRE) and vibration-controlled transient elastography (VCTE) have the potential to assess disease progression; however, repeatability data in people with cirrhosis are lacking. We aimed to assess the effect of disease severity on measurement variability and contribute to the evidentiary basis for the qualification of repeating liver stiffness measurements (LSM) in practice and research. METHODS This prospective study included 49 adult participants (58.3% female) with cirrhosis who underwent same-day repeat LSM examinations. The primary outcome was the same-day, same-operator repeatability coefficient% (RC%) and the within-case coefficient of variation (wCV) for each modality. Secondary outcomes include the intra-class correlation coefficient (ICC). The relationship between measurement variability (interquartile for VCTE, standard deviation for MRE) and disease severity (mean liver stiffness) was evaluated by linear regression with the coefficient of determination R2 reported. RESULTS Same-day repeat MRE and VCTE exams were prospectively conducted in 33 and 45 participants, respectively. The RC% appeared 82% higher for VCTE versus MRE (38% vs. 21%), with consistent findings in head-to-head analyses. The wCV for VCTE and MRE was 14% and 8% respectively, indicating VCTE has 75% higher within-subject measurement variation than MRE. ICC was excellent for LSM by VCTE (0.92) and MRE (0.96). Measurement variability increased with mean liver stiffness for VCTE (R2 = 0.78) and MRE (R2 = 0.93). CONCLUSION Both VCTE and MRE demonstrated increased measurement variability with disease severity. However, MRE outperformed VCTE in terms of technical repeatability in patients with cirrhosis. These repeatability estimates may improve the qualification of NITs in practice.
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Affiliation(s)
- Harris Siddiqi
- MASLD Research Center, Division of Gastroenterology. University of California at San Diego, La Jolla, CA, USA
| | - Daniel Q. Huang
- MASLD Research Center, Division of Gastroenterology. University of California at San Diego, La Jolla, CA, USA
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Nikita Mittal
- MASLD Research Center, Division of Gastroenterology. University of California at San Diego, La Jolla, CA, USA
| | - Nabil Nourredin
- MASLD Research Center, Division of Gastroenterology. University of California at San Diego, La Jolla, CA, USA
| | - Ricki Bettencourt
- MASLD Research Center, Division of Gastroenterology. University of California at San Diego, La Jolla, CA, USA
| | - Egbert Madamba
- MASLD Research Center, Division of Gastroenterology. University of California at San Diego, La Jolla, CA, USA
| | - Maral Amangurbanova
- MASLD Research Center, Division of Gastroenterology. University of California at San Diego, La Jolla, CA, USA
| | - Christie Hernandez
- MASLD Research Center, Division of Gastroenterology. University of California at San Diego, La Jolla, CA, USA
| | - Claude Sirlin
- Liver Imaging Group, University of California at San Diego, La Jolla, CA, USA
| | - Meng Yin
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Rohit Loomba
- MASLD Research Center, Division of Gastroenterology. University of California at San Diego, La Jolla, CA, USA
- Division of Gastroenterology and Hepatology, University of California at San Diego, La Jolla, CA, USA
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Garcia-Tsao G, Kaplan DE. Reply: On the use of nonselective beta blockers in cirrhosis. Hepatology 2024; 80:E35. [PMID: 38626347 DOI: 10.1097/hep.0000000000000889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 03/20/2024] [Indexed: 04/18/2024]
Affiliation(s)
- Guadalupe Garcia-Tsao
- Department of Medicine, Yale University, New Haven, Connecticut, USA
- Department of Medicine, VA-CT Healthcare System, West Haven, Connecticut, USA
| | - David E Kaplan
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
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Przybyszewski EM, Bhan I, Yarze JC. Letter to the Editor: On the use of nonselective beta-blockers in cirrhosis. Hepatology 2024; 80:E33-E34. [PMID: 38626348 DOI: 10.1097/hep.0000000000000888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 03/14/2024] [Indexed: 04/18/2024]
Affiliation(s)
- Eric M Przybyszewski
- Division of Gastroenterology and Hepatology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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Chen X, Huang M, Yu X, Chen J, Xu C, Jiang Y, Li Y, Zhao Y, Duan C, Luo Y, Zhang J, Lv W, Li Q, Luo J, Dong D, An T, Lu L, Fu S. Hepatic-associated vascular morphological assessment to predict overt hepatic encephalopathy before TIPS: a multicenter study. Hepatol Int 2024; 18:1238-1248. [PMID: 38833138 PMCID: PMC11297904 DOI: 10.1007/s12072-024-10686-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 04/21/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND To provide patients the chance of accepting curative transjugular intrahepatic portosystemic shunt (TIPS) rather than palliative treatments for portal hypertension-related variceal bleeding and ascites, we aimed to assess hepatic-associated vascular morphological change to improve the predictive accuracy of overt hepatic encephalopathy (HE) risks. METHODS In this multicenter study, 621 patients undergoing TIPS were subdivided into training (413 cases from 3 hospitals) and external validation datasets (208 cases from another 3 hospitals). In addition to traditional clinical factors, we assessed hepatic-associated vascular morphological changes using maximum diameter (including absolute and ratio values). Three predictive models (clinical, hepatic-associated vascular, and combined) were constructed using logistic regression. Their discrimination and calibration were compared to test the necessity of hepatic-associated vascular assessment and identify the optimal model. Furthermore, to verify the improved performance of ModelC-V, we compared it with four previous models, both in discrimination and calibration. RESULTS The combined model outperformed the clinical and hepatic-associated vascular models (training: 0.814, 0.754, 0.727; validation: 0.781, 0.679, 0.776; p < 0.050) and had the best calibration. Compared to previous models, ModelC-V showed superior performance in discrimination. The high-, middle-, and low-risk populations displayed significantly different overt HE incidence (p < 0.001). Despite the limited ability of pre-TIPS ammonia to predict overt HE risks, the combined model displayed a satisfactory ability to predict overt HE risks, both in the low- and high-ammonia subgroups. CONCLUSION Hepatic-associated vascular assessment improved the predictive accuracy of overt HE, ensuring curative chances by TIPS for suitable patients and providing insights for cirrhosis-related studies.
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Affiliation(s)
- Xiaoqiong Chen
- Zhuhai Interventional Medical Centre, Zhuhai Clinical Medical College of Jinan University (Zhuhai People's Hospital), No. 79 Kangning Road, Zhuhai, 519000, Guangdong Province, China
- Zhuhai Engineering Technology Research Center of Intelligent Medical Imaging, Zhuhai Clinical Medical College of Jinan University (Zhuhai People's Hospital), No. 79 Kangning Road, Zhuhai, 519000, Guangdong Province, China
| | - Mingsheng Huang
- Department of Interventional Radiology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Xiangrong Yu
- Zhuhai Engineering Technology Research Center of Intelligent Medical Imaging, Zhuhai Clinical Medical College of Jinan University (Zhuhai People's Hospital), No. 79 Kangning Road, Zhuhai, 519000, Guangdong Province, China
- Department of Radiology, Zhuhai Clinical Medical College of Jinan University (Zhuhai People's Hospital), Zhuhai, China
| | - Jinqiang Chen
- Zhuhai Interventional Medical Centre, Zhuhai Clinical Medical College of Jinan University (Zhuhai People's Hospital), No. 79 Kangning Road, Zhuhai, 519000, Guangdong Province, China
- Zhuhai Engineering Technology Research Center of Intelligent Medical Imaging, Zhuhai Clinical Medical College of Jinan University (Zhuhai People's Hospital), No. 79 Kangning Road, Zhuhai, 519000, Guangdong Province, China
| | - Chunchun Xu
- Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, China
| | - Yunzheng Jiang
- Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, China
| | - Yiting Li
- Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, China
| | - Yujie Zhao
- Zhuhai Interventional Medical Centre, Zhuhai Clinical Medical College of Jinan University (Zhuhai People's Hospital), No. 79 Kangning Road, Zhuhai, 519000, Guangdong Province, China
- Zhuhai Engineering Technology Research Center of Intelligent Medical Imaging, Zhuhai Clinical Medical College of Jinan University (Zhuhai People's Hospital), No. 79 Kangning Road, Zhuhai, 519000, Guangdong Province, China
| | - Chongyang Duan
- Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, China
| | - Yixin Luo
- Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, China
| | - Jiawei Zhang
- Zhuhai Interventional Medical Centre, Zhuhai Clinical Medical College of Jinan University (Zhuhai People's Hospital), No. 79 Kangning Road, Zhuhai, 519000, Guangdong Province, China
- Zhuhai Engineering Technology Research Center of Intelligent Medical Imaging, Zhuhai Clinical Medical College of Jinan University (Zhuhai People's Hospital), No. 79 Kangning Road, Zhuhai, 519000, Guangdong Province, China
| | - Weifu Lv
- Interventional Radiology Department, Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Qiyang Li
- Department of Interventional Radiology, Shenzhen People's Hospital, Shenzhen, China
| | - Junyang Luo
- Department of Interventional Radiology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Dandan Dong
- Zhuhai Engineering Technology Research Center of Intelligent Medical Imaging, Zhuhai Clinical Medical College of Jinan University (Zhuhai People's Hospital), No. 79 Kangning Road, Zhuhai, 519000, Guangdong Province, China
- Department of Radiology, Zhuhai Clinical Medical College of Jinan University (Zhuhai People's Hospital), Zhuhai, China
| | - Taixue An
- Department of Laboratory Medicine, Nanfang Hospital, Southern Medical University, No. 1023-1063 Shatai Road, Guangzhou, 510515, Guangdong Province, China.
| | - Ligong Lu
- Zhuhai Interventional Medical Centre, Zhuhai Clinical Medical College of Jinan University (Zhuhai People's Hospital), No. 79 Kangning Road, Zhuhai, 519000, Guangdong Province, China.
- Guangdong Provincial Key Laboratory of Tumor Interventional Diagnosis and Treatment, Zhuhai Institute of Translational Medicine, Zhuhai, China.
| | - Sirui Fu
- Zhuhai Interventional Medical Centre, Zhuhai Clinical Medical College of Jinan University (Zhuhai People's Hospital), No. 79 Kangning Road, Zhuhai, 519000, Guangdong Province, China.
- Zhuhai Engineering Technology Research Center of Intelligent Medical Imaging, Zhuhai Clinical Medical College of Jinan University (Zhuhai People's Hospital), No. 79 Kangning Road, Zhuhai, 519000, Guangdong Province, China.
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Garcia-Tsao G, Kaplan DE. Reply: Endoscopy for potential variceal bleeding within 12 hours-Not so fast! Hepatology 2024; 80:E36. [PMID: 38607742 DOI: 10.1097/hep.0000000000000881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 03/11/2024] [Indexed: 04/14/2024]
Affiliation(s)
- Guadalupe Garcia-Tsao
- Department of Medicine, Yale University, New Haven, Connecticut, USA
- Department of Medicine, VA-CT Healthcare System, West Haven, Connecticut, USA
| | - David E Kaplan
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
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Huang X, Zou D, Wang H, Chen W, Zhang L, Li F, Ma L, Zhang C, Chen Y, Chen S. Gastric variceal obstruction improves the efficacy of endoscopic management of esophageal variceal bleeding in GOV type I. Endosc Int Open 2024; 12:E940-E946. [PMID: 39131733 PMCID: PMC11309793 DOI: 10.1055/a-2360-4490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 06/27/2024] [Indexed: 08/13/2024] Open
Abstract
Background and study aims Limited data exist regarding endoscopic obstruction of type I gastroesophageal (GOV I) in managing bleeding from esophageal varices. In this multicenter retrospective cohort study, we aimed to access the efficacy of blocking gastric varices in management of bleeding from esophageal varices in patients with GOV1. Patients and methods Cirrhotic patients experiencing bleeding from esophageal varices and having GOV I gastric varices in four centers were screened. All included patients were followed up for 180 days, or until death. Results A total of 93 cirrhotic patients with GOV I and bleeding esophageal varices were included. Among them, 58 patients underwent endoscopic cyanoacrylate injection (ECI) for gastric varices in addition to treatment for esophageal varices (EV), while the remaining 35 patients received treatment for EV only. Kaplan-Meier analysis demonstrated that the cumulative 180-day rebleeding rate was significantly lower in the ECI plus EV treatment group (7.9%) compared with the EV treatment group (30.7%) ( P = 0.0031). The cumulative incidence of 180-day mortality was 1.9% in the ECI plus EV treatment group and 23.9% in the EV treatment group ( P = 0.0010). Multivariable Cox regression analysis revealed that concomitant ECI treatment was an independent protective factor against 180-day rebleeding and overall mortality. Conclusions In conclusion, obstruction of gastric varices in addition to endoscopic treatment for bleeding from esophageal varices in patients with GOV 1 proved superior to endoscopic treatment alone for esophageal variceal bleeding.
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Affiliation(s)
- Xiaoquan Huang
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, P.R.China
- Center of Evidence-Based Medicine, Fudan University,
| | - Detong Zou
- Department of Gastroenterology, Xinghua Renming Hospital, Jiangsu, P.R. China
| | - Huishan Wang
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, P.R.China
| | - Wei Chen
- Department of Gastroenterology and Hepatology, Minhang Hospital, Fudan University, Shanghai, P.R. China
| | - Lili Zhang
- Department of Gastroenterology, Xinghua Renming Hospital, Jiangsu, P.R. China
| | - Feng Li
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, P.R.China
| | - Lili Ma
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Chunqing Zhang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, P.R. China
| | - Ying Chen
- Department of Gastroenterology and Hepatology, Minhang Hospital, Fudan University, Shanghai, P.R. China
| | - Shiyao Chen
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, P.R.China
- Center of Evidence-Based Medicine, Fudan University,
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
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Jaan A, Razzak IA, Chaudhary AJ, Farooq U, Khan AM, Sheikh LF, Dhawan A, Cryer B. Malnutrition Severity Predicts Clinical Outcomes in Alcoholic Hepatitis: Evidence from National Data. JOURNAL OF THE AMERICAN NUTRITION ASSOCIATION 2024:1-7. [PMID: 39073449 DOI: 10.1080/27697061.2024.2383403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Revised: 07/08/2024] [Accepted: 07/17/2024] [Indexed: 07/30/2024]
Abstract
OBJECTIVE Alcoholic hepatitis (AH) represents a severe manifestation of alcoholic liver disease (ALD) associated with a wide severity spectrum. ALD is linked to nutritional deficiencies, with the gravity of malnutrition escalating as alcohol abuse and ALD progress. This study aims to delve into the impact of malnutrition on the clinical trajectory of AH. METHODS We identified adult patients admitted with AH using the National Readmission Database (NRD) 2016-2020. We further classified AH patients based on the severity of malnutrition. We compared the outcomes of AH hospitalizations using a multivariate regression model. RESULTS We included 82,367 AH patients, of whom 15,693 (19.00%) had malnutrition. 4,243 (5.15%) patients exhibited mild to moderate malnutrition, 5,862 (7.07%) patients had severe malnutrition, and 5,588 (6.78%) patients had unspecified severity of malnutrition. We found that adjusted in-hospital mortality due to AH was higher in patients with malnutrition, corresponding to the severity of malnutrition (adjusted odds ratio [aOR] 1.62 and 3.14 in mild-moderate malnutrition and severe malnutrition, respectively; p < .01). Additionally, patients with malnutrition had progressively elevated odds of septic shock, vasopressor requirement, mechanical ventilation, and intensive care unit (ICU) admission with escalating intensity of malnutrition. Liver-related complications, such as spontaneous bacterial peritonitis, coagulopathy, hepatorenal syndrome, and hepatic encephalopathy, were also found to have an increased likelihood in the presence of malnutrition. Furthermore, resource utilization showed a progressive increase with increasing severity of malnutrition. CONCLUSION Our findings indicate that malnutrition is a common comorbidity in AH patients, with varying degrees of severity, which correlates with higher mortality rates, emphasizing the critical role of nutritional status in the prognosis of AH. These findings underscore the importance of addressing and managing malnutrition in patients with AH, not only for its potential contribution to mortality but also because of its association with a spectrum of complications and increased healthcare resource utilization.
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Affiliation(s)
- Ali Jaan
- Department of Internal Medicine, Rochester General Hospital, NY, USA
| | - Iyiad Alabdul Razzak
- Department of Internal Medicine, St. Elizabeth's Medical Center, Tufts School of Medicine, Boston, MA, USA
| | | | - Umer Farooq
- Department of Gastroenterology, Saint Louis University, MO, USA
| | - Abdul Moiz Khan
- Department of Internal Medicine, Ayub Medical college, Pakistan
| | | | - Ashish Dhawan
- Department of Internal Medicine, Gian Sagar Medical College and Hospital, Punjab, India
| | - Byron Cryer
- Department of Gastroenterology, Baylor University Medical Center, Dallas, USA
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Huang DQ, Wilson LA, Behling C, Amangurbanova M, Kleiner DE, Kowdley KV, Dasarathy S, Terrault NA, Diehl AM, Chalasani N, Neuschwander-Tetri BA, Sanyal AJ, Tonascia J, Loomba R. Liver stiffness progression in biopsy-proven metabolic dysfunction-associated steatotic disease among people with diabetes versus people without diabetes: A prospective multicenter study. Hepatology 2024:01515467-990000000-00969. [PMID: 39028908 DOI: 10.1097/hep.0000000000001015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 06/29/2024] [Indexed: 07/21/2024]
Abstract
BACKGROUND AND AIMS There are limited data on the progression of liver stiffness measurement (LSM) by vibration-controlled transient elastography (VCTE) in people with type 2 diabetes mellitus (T2DM) versus those without T2DM in biopsy-proven metabolic dysfunction-associated steatotic liver disease. We examined LSM progression in participants with T2DM versus those without T2DM in a large, prospective, multicenter cohort study. APPROACH AND RESULTS This study included 1231 adult participants (62% female) with biopsy-proven metabolic dysfunction-associated steatotic liver disease who had VCTEs at least 1 year apart. LSM progression and regression were defined by a ≥20% increase and an upward or downward change, respectively, in the LSM category in the Baveno VII categories for compensated advanced chronic liver disease, compared between participants with T2DM (n = 680) versus no T2DM (n = 551) at baseline. The mean (±SD) age and body mass index were 51.8 (±12.0) years and 34.0 (±6.5) kg/m 2 , respectively. The median (IQR) time between the first and last VCTE measurements was 4.1 (2.5-6.5) years. Participants with T2DM had higher LSM progression at 4 years (12% vs. 10%), 6 years (23% vs. 16%), and 8 years (50% vs. 39%), p = 0.04. Using a multivariable Cox proportional hazards model adjusted for multiple confounders, the presence of T2DM remained an independent predictor of LSM progression (adjusted HR: 1.35, 95% CI: 1.01-1.81, p = 0.04). T2DM was not associated with LSM regression ( p = 0.71). Mean HbA1c was significantly associated with LSM progression ( p = 0.003) and regression ( p = 0.02). CONCLUSIONS Using serial VCTE data from a multicenter study of participants with biopsy-proven metabolic dysfunction-associated steatotic liver disease, we demonstrate that T2DM and HbA1c are associated with LSM progression.
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Affiliation(s)
- Daniel Q Huang
- Division of Gastroenterology, MASLD Research Center, Department of Medicine, University of California at San Diego, La Jolla, California, USA
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Health System, Singapore
| | - Laura A Wilson
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Cynthia Behling
- Department of Pathology, University of California San Diego School of Medicine, San Diego, California, USA
| | - Maral Amangurbanova
- Division of Gastroenterology, MASLD Research Center, Department of Medicine, University of California at San Diego, La Jolla, California, USA
| | - David E Kleiner
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | | | | | - Norah A Terrault
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Anna Mae Diehl
- Division of Gastroenterology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | - Arun J Sanyal
- Division of Gastroenterology and Hepatology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - James Tonascia
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Rohit Loomba
- Division of Gastroenterology, MASLD Research Center, Department of Medicine, University of California at San Diego, La Jolla, California, USA
- Division of Epidemiology, Department of Family Medicine and Public Health, University of California at San Diego, San Diego, California, USA
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Biswas S, Vaishnav M, Gamanagatti S, Swaroop S, Arora U, Aggarwal A, Elhence A, Gunjan D, Kedia S, Mahapatra SJ, Mishra AK, Shalimar. Endoscopic Glue Injection vs Glue Plus BRTO or TIPSS for Preventing Gastric Variceal Bleeding: A Randomized Controlled Trial. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00593-7. [PMID: 38969074 DOI: 10.1016/j.cgh.2024.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 06/18/2024] [Accepted: 06/18/2024] [Indexed: 07/07/2024]
Abstract
BACKGROUND AND AIMS The study sought to compare the efficacy of endoscopic injection sclerotherapy with cyanoacrylate glue (EIS-CYA) vs EIS-CYA plus a radiologic intervention (RI) (either transjugular intrahepatic portosystemic shunt or balloon-occluded retrograde transvenous obliteration) for secondary prophylaxis in patients with liver cirrhosis who presented with acute variceal bleeding from cardiofundal varices. Primary outcome measure was gastric varix (GV) rebleed rates at 1 year. METHODS Consecutive cirrhosis patients with acute variceal bleeding from cardiofundal varices were randomized into 2 arms (45 in each) after primary hemostasis by EIS-CYA. In the endoscopic intervention (EI) arm, EIS-CYA was repeated at regular intervals (1, 3, 6, and 12 months), while in the RI arm, patients underwent transjugular intrahepatic portosystemic shunt or balloon-occluded retrograde transvenous obliteration followed by endoscopic surveillance. RESULTS GV rebleed rates at 1 year were higher in the EI arm compared with the RI arm: 11 (24.4%; 95% confidence interval [CI], 12.9%-39.5%) vs 1 (2.2%; 95% CI, 0.1%-11.8%) (P = .004; absolute risk difference: 22.2%; 95% CI, 8.4%-36.6%). GV rebleed-related mortality in the EI arm (8 [17.8%; 95% CI, 8.0%-32.1%]) was significantly higher than in the RI arm (1 [2.2%; 0.1%-11.8%]) (P = .030; absolute risk difference: 15.6; 95% CI, 2.9%-29.2%); however, there was no difference in all-cause mortality between the 2 groups (12 [26.7%; 95% CI, 14.6%-41.9%] vs 7 [15.6%; 95% CI, 6.5%-29.5%]). The number needed to treat to prevent 1 GV-related rebleed at 1 year was 4.5. CONCLUSIONS RI for secondary prophylaxis reduces rebleeding from GV and GV rebleeding-related mortality in patients with GV hemorrhage. (CTRI/2021/02/031396).
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Affiliation(s)
- Sagnik Biswas
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Manas Vaishnav
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Shivanand Gamanagatti
- Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Shekhar Swaroop
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Umang Arora
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Arnav Aggarwal
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Anshuman Elhence
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Gunjan
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh Kedia
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Soumya Jagannath Mahapatra
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Ashwani Kumar Mishra
- National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, Delhi, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India.
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Laine L, Barkun AN, Leontiadis GI. Letter to the Editor: Endoscopy for potential variceal bleeding within 12 hours-Not so fast! Hepatology 2024; 80:E15-E16. [PMID: 38607699 DOI: 10.1097/hep.0000000000000876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 12/11/2023] [Indexed: 04/14/2024]
Affiliation(s)
- Loren Laine
- Yale School of Medicine, New Haven, Connecticut, USA
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
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Forte E, Sanders JM, Pla I, Kanchustambham VL, Hollas MAR, Huang CF, Sanchez A, Peterson KN, Melani RD, Huang A, Polineni P, Doll JM, Dietch Z, Kelleher NL, Ladner DP. Top-Down Proteomics Identifies Plasma Proteoform Signatures of Liver Cirrhosis Progression. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.06.19.599662. [PMID: 38948836 PMCID: PMC11212939 DOI: 10.1101/2024.06.19.599662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Cirrhosis, advanced liver disease, affects 2-5 million Americans. While most patients have compensated cirrhosis and may be fairly asymptomatic, many decompensate and experience life-threatening complications such as gastrointestinal bleeding, confusion (hepatic encephalopathy), and ascites, reducing life expectancy from 12 to less than 2 years. Among patients with compensated cirrhosis, identifying patients at high risk of decompensation is critical to optimize care and reduce morbidity and mortality. Therefore, it is important to preferentially direct them towards specialty care which cannot be provided to all patients with cirrhosis. We used discovery Top-down Proteomics (TDP) to identify differentially expressed proteoforms (DEPs) in the plasma of patients with progressive stages of liver cirrhosis with the ultimate goal to identify candidate biomarkers of disease progression. In this pilot study, we identified 209 DEPs across three stages of cirrhosis (compensated, compensated with portal hypertension, and decompensated), of which 115 derived from proteins enriched in the liver at a transcriptional level and discriminated the three stages of cirrhosis. Enrichment analyses demonstrated DEPs are involved in several metabolic and immunological processes known to be impacted by cirrhosis progression. We have preliminarily defined the plasma proteoform signatures of cirrhosis patients, setting the stage for ongoing discovery and validation of biomarkers for early diagnosis, risk stratification, and disease monitoring.
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Affiliation(s)
- Eleonora Forte
- Proteomics Center of Excellence, Northwestern University, Evanston, IL, 60208, USA
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, 60611, USA
| | - Jes M. Sanders
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, 60611, USA
| | - Indira Pla
- Proteomics Center of Excellence, Northwestern University, Evanston, IL, 60208, USA
| | | | - Michael A. R. Hollas
- Proteomics Center of Excellence, Northwestern University, Evanston, IL, 60208, USA
| | - Che-Fan Huang
- Proteomics Center of Excellence, Northwestern University, Evanston, IL, 60208, USA
| | - Aniel Sanchez
- Proteomics Center of Excellence, Northwestern University, Evanston, IL, 60208, USA
| | - Katrina N. Peterson
- Proteomics Center of Excellence, Northwestern University, Evanston, IL, 60208, USA
| | - Rafael D. Melani
- Proteomics Center of Excellence, Northwestern University, Evanston, IL, 60208, USA
| | - Alexander Huang
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, 60611, USA
| | - Praneet Polineni
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, 60611, USA
| | - Julianna M. Doll
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, 60611, USA
| | - Zachary Dietch
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, 60611, USA
| | - Neil L. Kelleher
- Proteomics Center of Excellence, Northwestern University, Evanston, IL, 60208, USA
- Department of Chemistry, Northwestern University, Evanston, IL, 60208, USA
- Department of Biochemistry and Molecular Genetics, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - Daniela P. Ladner
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, 60611, USA
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Ostojic A, Mahmud N, Reddy KR. Surgical risk stratification in patients with cirrhosis. Hepatol Int 2024; 18:876-891. [PMID: 38472607 DOI: 10.1007/s12072-024-10644-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 01/15/2024] [Indexed: 03/14/2024]
Abstract
Individuals with cirrhosis experience higher morbidity and mortality rates than the general population, irrespective of the type or scope of surgery. This increased risk is attributed to adverse effects of liver disease, encompassing coagulation dysfunction, altered metabolism of anesthesia and sedatives, immunologic dysfunction, hemorrhage related to varices, malnutrition and frailty, impaired wound healing, as well as diminished portal blood flow, overall hepatic circulation, and hepatic oxygen supply during surgical procedures. Therefore, a frequent clinical dilemma is whether surgical interventions should be pursued in patients with cirrhosis. Several risk scores are widely used to aid in the decision-making process, each with specific advantages and limitations. This review aims to discuss the preoperative risk factors in patients with cirrhosis, describe and compare surgical risk assessment models used in everyday practice, provide insights into the surgical risk according to the type of surgery and present recommendations for optimizing those with cirrhosis for surgical procedures. As the primary focus is on currently available risk models, the review describes the predictive value of each model, highlighting its specific advantages and limitations. Furthermore, for models that do not account for the type of surgical procedure to be performed, the review suggests incorporating both patient-related and surgery-related risks into the decision-making process. Finally, we provide an algorithm for the preoperative assessment of patients with cirrhosis before elective surgery as well as guidance perioperative management.
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Affiliation(s)
- Ana Ostojic
- Division of Gastroenterology, Department of Internal Medicine, University Hospital Center Zagreb, Kispaticeva 12, Zagreb, 10000, Croatia
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology, University of Pennsylvania, 2 Dulles, 3400 Spruce Street, HUP, Philadelphia, PA, 19104, USA
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, 2 Dulles, 3400 Spruce Street, HUP, Philadelphia, PA, 19104, USA.
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McGrath MS, Wentworth BJ. The Renin-Angiotensin System in Liver Disease. Int J Mol Sci 2024; 25:5807. [PMID: 38891995 PMCID: PMC11172481 DOI: 10.3390/ijms25115807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Revised: 05/23/2024] [Accepted: 05/25/2024] [Indexed: 06/21/2024] Open
Abstract
The renin-angiotensin system (RAS) is a complex homeostatic entity with multiorgan systemic and local effects. Traditionally, RAS works in conjunction with the kidney to control effective arterial circulation, systemic vascular resistance, and electrolyte balance. However, chronic hepatic injury and resulting splanchnic dilation may disrupt this delicate balance. The role of RAS in liver disease, however, is even more extensive, modulating hepatic fibrosis and portal hypertension. Recognition of an alternative RAS pathway in the past few decades has changed our understanding of RAS in liver disease, and the concept of opposing vs. "rebalanced" forces is an ongoing focus of research. Whether RAS inhibition is beneficial in patients with chronic liver disease appears to be context-dependent, but further study is needed to optimize clinical management and reduce organ-specific morbidity and mortality. This review presents the current understanding of RAS in liver disease, acknowledges areas of uncertainty, and describes potential areas of future investigation.
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Affiliation(s)
- Mary S. McGrath
- Department of Medicine, School of Medicine, University of Virginia, Charlottesville, VA 22903, USA;
| | - Brian J. Wentworth
- Division of Gastroenterology & Hepatology, School of Medicine, University of Virginia, Charlottesville, VA 22903, USA
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Majid Z, Abrar G. Reinforcing the management of type 1 gastric esophageal varices. World J Gastroenterol 2024; 30:2615-2617. [PMID: 38817659 PMCID: PMC11135417 DOI: 10.3748/wjg.v30.i19.2615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Revised: 04/22/2024] [Accepted: 04/25/2024] [Indexed: 05/20/2024] Open
Abstract
Variceal bleed represents an important complication of cirrhosis, with its presence reflecting the severity of liver disease. Gastric varices, though less frequently seen than esophageal varices, present a distinct clinical challenge due to its higher intensity of bleeding and associated mortality. Based upon the Sarin classification, GOV1 is the most common subtype of gastric varices seen in clinical practice.
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Affiliation(s)
- Zain Majid
- Department of Gastroenterology, Sindh Institute of Urology and Transplantation, Karachi 75500, Pakistan
| | - Ghazi Abrar
- Department of Gastroenterology, Sindh Institute of Urology and Transplantation, Karachi 75500, Pakistan
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Selvanderan SP, Lam E, Shahidi N. Endohepatology: Arrival at the frontier of interventional endosonography. World J Gastroenterol 2024; 30:2397-2401. [PMID: 38764768 PMCID: PMC11099394 DOI: 10.3748/wjg.v30.i18.2397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 03/16/2024] [Accepted: 04/19/2024] [Indexed: 05/11/2024] Open
Abstract
Endohepatology describes the emerging field where diagnostic and therapeutic endoscopic ultrasound (EUS) are used for the diagnosis and management of liver disease and its sequelae. In this editorial we comment on the article by Gadour et al. The spectrum of EUS-guided procedures includes liver parenchymal and lesional biopsy, abscess drainage, treatment of focal liver lesions, diagnosis of portal hypertension and management of gastric varices. The data suggest that the application of EUS to hepatology is technically feasible and safe, heralding the arrival at a new frontier for EUS. More data, specifically randomised trials comparing EUS to interventional radiology techniques, and continued partnership between endoscopy and hepatology are required to see this field establish itself outside expert tertiary centres.
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Affiliation(s)
- Shane P Selvanderan
- Department of Medicine, University of British Columbia, Vancouver V6Z 1Y6, BC, Canada
| | - Eric Lam
- Department of Medicine, University of British Columbia, Vancouver V6Z 1Y6, BC, Canada
| | - Neal Shahidi
- Department of Medicine, University of British Columbia, Vancouver V6Z 1Y6, BC, Canada
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Obeidat M, Teutsch B, Floria DE, Veres DS, Hegyi P, Erőss B. Early nutrition is safe and does not increase complications after upper gastrointestinal bleeding-a systematic review and meta-analysis of randomized controlled trials. Sci Rep 2024; 14:10725. [PMID: 38730079 PMCID: PMC11087503 DOI: 10.1038/s41598-024-61543-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 05/07/2024] [Indexed: 05/12/2024] Open
Abstract
Despite a lack of evidence, patients are often not fed for 48-96 h after upper gastrointestinal bleeding (UGIB); however, many trials have demonstrated the benefits of early nutrition (EN). We conducted a meta-analysis of randomized controlled trials (RTCs) to evaluate the outcomes of EN compared to delayed nutrition (DN) after UGIB. The protocol was registered on PROSPERO (CRD42022372306). PubMed, Embase, CENTRAL, Scopus, and Web of Science were searched on the 27th of April 2024 to identify eligible RCTs. The primary outcomes were early (within 7 days) and late (within 30-42 days) mortality and rebleeding. Pooled risk ratios (RR), mean differences (MD), and corresponding 95% confidence intervals (CI) were calculated using a random-effects model. A total of 10 trials with 1051 patients were included in the analysis. Early mortality was not significantly different between the two groups (RR 1.20, CI 0.85-1.71, I2 = 0%), whereas late mortality was reduced to a clinically relevant extent in the EN group (RR 0.61, CI 0.35-1.06, I2 = 0%). When comparing the two groups, we found no significant difference in terms of early and late rebleeding (RR 1.04, CI 0.66-1.63, I2 = 0% and RR 1.16, CI 0.63-2.13, I2 = 0%, respectively). Our analysis also showed that the length of hospital stay was reduced in the EN group compared to the DN group (MD -1.22 days, CI: -2.43 to -0.01, I2 = 94%). In conclusion, compared with DN, EN (within 24 h) appears to be a safe intervention and could reduce the length of hospital stay without increasing the risk of complications after UGIB.
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Affiliation(s)
- Mahmoud Obeidat
- Centre for Translational Medicine, Semmelweis University, Budapest, 1085, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, 7623, Hungary
| | - Brigitta Teutsch
- Centre for Translational Medicine, Semmelweis University, Budapest, 1085, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, 7623, Hungary
| | - Diana-Elena Floria
- Centre for Translational Medicine, Semmelweis University, Budapest, 1085, Hungary
- Grigore T. Popa University of Medicine and Pharmacy, 700115, Iași, Romania
| | - Dániel Sándor Veres
- Centre for Translational Medicine, Semmelweis University, Budapest, 1085, Hungary
- Department of Biophysics and Radiation Biology, Semmelweis University, Budapest, 1085, Hungary
| | - Péter Hegyi
- Centre for Translational Medicine, Semmelweis University, Budapest, 1085, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, 7623, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest, 1083, Hungary
| | - Bálint Erőss
- Centre for Translational Medicine, Semmelweis University, Budapest, 1085, Hungary.
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, 7623, Hungary.
- Institute of Pancreatic Diseases, Semmelweis University, Budapest, 1083, Hungary.
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Tincopa MA, Anstee QM, Loomba R. New and emerging treatments for metabolic dysfunction-associated steatohepatitis. Cell Metab 2024; 36:912-926. [PMID: 38608696 DOI: 10.1016/j.cmet.2024.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/01/2024] [Accepted: 03/18/2024] [Indexed: 04/14/2024]
Abstract
Metabolic dysfunction-associated steatohepatitis (MASH) is a leading etiology of chronic liver disease worldwide, with increasing incidence and prevalence in the setting of the obesity epidemic. MASH is also a leading indication for liver transplantation, given its associated risk of progression to end-stage liver disease. A key challenge in managing MASH is the lack of approved pharmacotherapy. In its absence, lifestyle interventions with a focus on healthy nutrition and regular physical activity have been the cornerstone of therapy. Real-world efficacy and sustainability of lifestyle interventions are low, however. Pharmacotherapy development for MASH is emerging with promising data from several agents with different mechanisms of action (MOAs) in phase 3 clinical trials. In this review, we highlight ongoing challenges and potential solutions in drug development for MASH and provide an overview of available data from emerging therapies across multiple MOAs.
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Affiliation(s)
- Monica A Tincopa
- MASLD Research Center, Division of Gastroenterology and Hepatology, University of California, San Diego, La Jolla, CA 92103, USA
| | - Quentin M Anstee
- Translational & Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK; Newcastle NIHR Biomedical Research Center, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Rohit Loomba
- MASLD Research Center, Division of Gastroenterology and Hepatology, University of California, San Diego, La Jolla, CA 92103, USA; School of Public Health, University of California, San Diego, La Jolla, CA 92103, USA.
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Jachs M, Hartl L, Simbrunner B, Semmler G, Balcar L, Hofer BS, Schwarz M, Bauer D, Stättermayer AF, Pinter M, Trauner M, Reiberger T, Mandorfer M. Prognostic performance of non-invasive tests for portal hypertension is comparable to that of hepatic venous pressure gradient. J Hepatol 2024; 80:744-752. [PMID: 38218352 DOI: 10.1016/j.jhep.2023.12.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/08/2023] [Accepted: 12/20/2023] [Indexed: 01/15/2024]
Abstract
BACKGROUND & AIMS Non-invasive tests to assess the probability of clinically significant portal hypertension (CSPH) - including the ANTICIPATE±NASH models based on liver stiffness measurement and platelet count±BMI, and the von Willebrand factor antigen to platelet count ratio (VITRO) - have fundamentally changed the management of compensated advanced chronic liver disease (cACLD). However, their prognostic utility has not been compared head-to-head to the gold standard for prognostication in cACLD, i.e. the hepatic venous pressure gradient (HVPG). METHODS Patients with cACLD (liver stiffness measurement ≥10 kPa) who underwent advanced characterization via same-day HVPG/non-invasive test assessment from 2007-2022 were retrospectively included. Long-term follow-up data on hepatic decompensation was recorded. RESULTS Four hundred and twenty patients with cACLD of varying etiologies, with a CSPH prevalence of 67.6%, were included. The cumulative incidence of hepatic decompensation at 1 and 2 years was 4.7% and 8.0%, respectively. HVPG, VITRO, and ANTICIPATE±NASH-CSPH-probability showed similar time-dependent prognostic value (AUROCs 0.683-0.811 at 1 year and 0.699-0.801 at 2 years). In competing risk analyses adjusted for MELD score and albumin, HVPG (adjusted subdistribution hazard ratio [aSHR] 1.099 [95% CI 1.054-1.150] per mmHg; p <0.001), or VITRO (aSHR 1.134 [95% CI 1.062-1.211] per unit; p <0.001), or ANTICIPATE±NASH-CSPH-probability (aSHR 1.232 [95% CI 1.094-1.387] per 10%; p <0.001) all predicted first decompensation during follow-up. Previously proposed cut-offs (HVPG ≥10 mmHg vs. <10 mmHg, VITRO ≥2.5 vs. <2.5, and ANTICIPATE-CSPH probability ≥60% vs. <60%) all accurately discriminated between patients at negligible risk and those at substantial risk of hepatic decompensation. CONCLUSIONS The prognostic performance of ANTICIPATE±NASH-CSPH-probability and VITRO is comparable to that of HVPG, supporting their utility for identifying patients who may benefit from medical therapies to prevent first hepatic decompensation. IMPACT AND IMPLICATIONS Non-invasive tests have revolutionized the diagnosis and management of clinically significant portal hypertension in patients with compensated advanced chronic liver disease (cACLD). However, limited data exists regarding the prognostic utility of non-invasive tests in direct comparison to the gold standard for prognostication in cACLD, i.e. the hepatic venous pressure gradient. In our study including 420 patients with cACLD, the ANTICIPATE±NASH model and VITRO yielded similar AUROCs to hepatic venous pressure gradient for hepatic decompensation within 1 to 2 years. Thus, non-invasive tests should be applied and updated in yearly intervals in clinical routine to identify patients at short-term risk, thereby identifying patients who may benefit from treatment aimed at preventing hepatic decompensation.
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Affiliation(s)
- Mathias Jachs
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Hepatic Hemodynamic Lab, Division of Gatroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Lukas Hartl
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Hepatic Hemodynamic Lab, Division of Gatroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Benedikt Simbrunner
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Hepatic Hemodynamic Lab, Division of Gatroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | - Georg Semmler
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Hepatic Hemodynamic Lab, Division of Gatroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Lorenz Balcar
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Hepatic Hemodynamic Lab, Division of Gatroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Benedikt Silvester Hofer
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Hepatic Hemodynamic Lab, Division of Gatroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | - Michael Schwarz
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Hepatic Hemodynamic Lab, Division of Gatroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - David Bauer
- Hepatic Hemodynamic Lab, Division of Gatroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Department of Internal Medicine IV, Klinik Ottakring, Vienna, Austria
| | - Albert Friedrich Stättermayer
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Matthias Pinter
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Hepatic Hemodynamic Lab, Division of Gatroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.
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48
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Shung DL, Laine L. Review article: Upper gastrointestinal bleeding - review of current evidence and implications for management. Aliment Pharmacol Ther 2024; 59:1062-1081. [PMID: 38517201 DOI: 10.1111/apt.17949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/27/2023] [Accepted: 03/04/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Acute upper gastrointestinal bleeding (UGIB) is a common emergency requiring hospital-based care. Advances in care across pre-endoscopic, endoscopic and post-endoscopic phases have led to improvements in clinical outcomes. AIMS To provide a detailed, evidence-based update on major aspects of care across pre-endoscopic, endoscopic and post-endoscopic phases. METHODS We performed a structured bibliographic database search for each topic. If a recent high-quality meta-analysis was not available, we performed a meta-analysis with random effects methods and odds ratios with 95% confidence intervals. RESULTS Pre-endoscopic management of UGIB includes risk stratification, a restrictive red blood cell transfusion policy unless the patient has cardiovascular disease, and pharmacologic therapy with erythromycin and a proton pump inhibitor. Patients with cirrhosis should be treated with prophylactic antibiotics and vasoactive medications. Tranexamic acid should not be used. Endoscopic management of UGIB depends on the aetiology. For peptic ulcer disease (PUD) with high-risk stigmata, endoscopic therapy, including over-the-scope clips (OTSCs) and TC-325 powder spray, should be performed. For variceal bleeding, treatment should be customised by severity and anatomic location. Post-endoscopic management includes early enteral feeding for all UGIB patients. For high-risk PUD, PPI should be continued for 72 h, and rebleeding should initially be evaluated with a repeat endoscopy. For variceal bleeding, high-risk patients or those with further bleeding, a transjugular intrahepatic portosystemic shunt can be considered. CONCLUSIONS Management of acute UGIB should include treatment plans for pre-endoscopic, endoscopic and post-endoscopic phases of care, and customise treatment decisions based on aetiology and severity of bleeding.
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Affiliation(s)
| | - Loren Laine
- Yale School of Medicine, New Haven, Connecticut, USA
- West Haven Veterans Affairs Medical Center, West Haven, Connecticut, USA
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49
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Kim A, Sinn DH, Song BG, Goh MJ, Hwang SY, Ko RE, Chung CR, Park CM. Massive Transfusion Protocol and Outcome of Patients with Acute Variceal Bleeding. J Clin Med 2024; 13:2588. [PMID: 38731117 PMCID: PMC11084309 DOI: 10.3390/jcm13092588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Revised: 04/18/2024] [Accepted: 04/20/2024] [Indexed: 05/13/2024] Open
Abstract
Background/Aims: The massive transfusion protocol (MTP) can improve the outcomes of trauma patients with hemorrhagic shock and some patients with non-traumatic hemorrhagic shock. However, no information is available regarding whether MTP can improve the outcomes of acute variceal bleeding (AVB). This study aimed to determine the effects of MTP on the outcomes of patients with AVB. Methods: Consecutive patients (n = 218) with AVB who did not have current malignancy and visited the emergency room between July 2014 and June 2022 were analyzed. 42-day mortality and failure to control the bleeding were compared between patients with and without MTP activation. Additionally, propensity-score matching was conducted. Results: The amount of blood product transfused was higher in the MTP group. The 42-day mortality rate (42.1% vs. 1.5%, p < 0.001) and the rate of failure to control bleeding (36.8% vs. 0.5%, p < 0.001) were significantly higher in those who received blood transfusions by MTP. MTP was an independent factor associated with 42-day mortality in the multivariable-adjusted analysis (HR 21.05; 95% CI 3.07-144.21, p = 0.002, HR 24.04; 95% CI 3.41-169.31, p = 0.001). The MTP group showed consistently higher 42-day mortality and failure to control bleeding in all subgroup analyses, stratified by systolic blood pressure, hemoglobin level, and the model for end-stage liver disease score. The MTP group also showed higher 42-day mortality (42.9% vs. 0%, p = 0.001) and failure to control bleeding (42.9% vs. 0%, p = 0.001) in a propensity score-matched analysis (n = 52). Conclusions: MTP was associated with poor outcomes in patients with AVB. Further studies are needed to see whether MTP can be an option for patients with massive AVB.
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Affiliation(s)
- Aryoung Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang 10380, Republic of Korea
| | - Dong Hyun Sinn
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Byeong Geun Song
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Myung Ji Goh
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Sung Yeon Hwang
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Ryoung-Eun Ko
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Chi-Min Park
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
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50
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Celsa C, Veneziano M, Di Giorgio FM, Cannova S, Lombardo A, Errigo E, Landro G, Simone F, Sinagra E, Calvaruso V. Non-Invasive Diagnostic Tests for Portal Hypertension in Patients with HBV- and HCV-Related Cirrhosis: A Comprehensive Review. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:690. [PMID: 38792873 PMCID: PMC11123262 DOI: 10.3390/medicina60050690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 04/10/2024] [Accepted: 04/17/2024] [Indexed: 05/26/2024]
Abstract
Clinically significant portal hypertension (CSPH) in patients with compensated advanced chronic liver disease indicates an increased risk of decompensation and death. While invasive methods like hepatic venous-portal gradient measurement is considered the gold standard, non-invasive tests (NITs) have emerged as valuable tools for diagnosing and monitoring CSPH. This review comprehensively explores non-invasive diagnostic modalities for portal hypertension, focusing on NITs in the setting of hepatitis B and hepatitis C virus-related cirrhosis. Biochemical-based NITs can be represented by single serum biomarkers (e.g., platelet count) or by composite scores that combine different serum biomarkers with each other or with demographic characteristics (e.g., FIB-4). On the other hand, liver stiffness measurement and spleen stiffness measurement can be assessed using a variety of elastography techniques, and they can be used alone, in combination with, or as a second step after biochemical-based NITs. The incorporation of liver and spleen stiffness measurements, alone or combined with platelet count, into established and validated criteria, such as Baveno VI or Baveno VII criteria, provides useful tools for the prediction of CSPH and for ruling out high-risk varices, potentially avoiding invasive tests like upper endoscopy. Moreover, they have also been shown to be able to predict liver-related events (e.g., the occurrence of hepatic decompensation). When transient elastography is not available or not feasible, biochemical-based NITs (e.g., RESIST criteria, that are based on the combination of platelet count and albumin levels) are valid alternatives for predicting high-risk varices both in patients with untreated viral aetiology and after sustained virological response. Ongoing research should explore novel biomarkers and novel elastography techniques, but current evidence supports the utility of routine blood tests, LSM, and SSM as effective surrogates in diagnosing and staging portal hypertension and predicting patient outcomes.
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Affiliation(s)
- Ciro Celsa
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, 90127 Palermo, Italy; (M.V.); (F.M.D.G.); (S.C.); (A.L.); (E.E.); (G.L.); (F.S.); (V.C.)
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, London W12 0NN, UK
| | - Marzia Veneziano
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, 90127 Palermo, Italy; (M.V.); (F.M.D.G.); (S.C.); (A.L.); (E.E.); (G.L.); (F.S.); (V.C.)
| | - Francesca Maria Di Giorgio
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, 90127 Palermo, Italy; (M.V.); (F.M.D.G.); (S.C.); (A.L.); (E.E.); (G.L.); (F.S.); (V.C.)
| | - Simona Cannova
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, 90127 Palermo, Italy; (M.V.); (F.M.D.G.); (S.C.); (A.L.); (E.E.); (G.L.); (F.S.); (V.C.)
| | - Antonino Lombardo
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, 90127 Palermo, Italy; (M.V.); (F.M.D.G.); (S.C.); (A.L.); (E.E.); (G.L.); (F.S.); (V.C.)
| | - Emanuele Errigo
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, 90127 Palermo, Italy; (M.V.); (F.M.D.G.); (S.C.); (A.L.); (E.E.); (G.L.); (F.S.); (V.C.)
| | - Giuseppe Landro
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, 90127 Palermo, Italy; (M.V.); (F.M.D.G.); (S.C.); (A.L.); (E.E.); (G.L.); (F.S.); (V.C.)
| | - Fabio Simone
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, 90127 Palermo, Italy; (M.V.); (F.M.D.G.); (S.C.); (A.L.); (E.E.); (G.L.); (F.S.); (V.C.)
| | - Emanuele Sinagra
- Gastroenterology and Endoscopy Unit, Fondazione Istituto G. Giglio, 90015 Cefalù, Italy;
| | - Vincenza Calvaruso
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, 90127 Palermo, Italy; (M.V.); (F.M.D.G.); (S.C.); (A.L.); (E.E.); (G.L.); (F.S.); (V.C.)
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