AASLD Practice Guidance on risk stratification and management of portal hypertension and varices in cirrhosis

Visualizing global progress and challenges in esophagogastric variceal bleeding

BACKGROUND

Esophageal and gastric variceal bleeding is a catastrophic complication of portal hypertension, most commonly caused by cirrhosis of various etiologies. Although a considerable body of research has been conducted in this area, the complexity of the disease and the lack of standardized treatment strategies have led to fragmented findings, insufficient information, and a lack of systematic investigation. Bibliometric analysis can help clarify research trends, identify core topics, and reveal potential future directions. Therefore, this study aims to use bibliometric methods to conduct an in-depth exploration of research progress in this field, with the expectation of providing new insights for both clinical practice and scientific research.

AIM

To evaluate research trends and advancements in esophagogastric variceal bleeding (EGVB) over the past twenty years.

METHODS

Relevant publications on EGVB were retrieved from the Web of Science Core Collection. VOSviewer, Pajek, CiteSpace, and the bibliometrix package were then employed to perform bibliometric visualizations of publication volume, countries, institutions, journals, authors, keywords, and citation counts.

RESULTS

The analysis focused on original research articles and review papers. From 2004 to 2023, a total of 2097 records on EGVB were retrieved. The number of relevant publications has increased significantly over the past two decades, especially in China and the United States. The leading contributors in this field, in terms of countries, institutions, authors, and journals, were China, Assistance Publique-Hôpitaux de Paris, Bosch Jaime, and World Journal of Gastroenterology, respectively. Core keywords in this field include portal hypertension, management, liver cirrhosis, risk, prevention, and diagnosis. Future research directions may focus on optimizing diagnostic methods, personalized treatment, and multidisciplinary collaboration.

CONCLUSION

Using bibliometric methods, this study reveals the developmental trajectory and trends in research on EGVB, underscoring risk assessment and diagnostic optimization as the core areas of current focus. The study provides an innovative and systematic perspective for this field, indicating that future research could center on multidisciplinary collaboration, personalized treatment approaches, and the development of new diagnostic tools. Moreover, this work offers practical research directions for both the academic community and clinical practice, driving continued advancement in this domain.

Nomogram for predicting survival after transjugular intrahepatic portosystemic shunt in portal hypertension patients with bleeding

BACKGROUND

Portal hypertension (PHT) is a life-threatening complication of cirrhosis, often resulting in gastrointestinal bleeding that requires transjugular intrahepatic portosystemic shunt (TIPS). While TIPS effectively reduces portal pressure, predicting long-term survival remains challenging due to the multifactorial nature of patient outcomes. Accurate survival prediction tools are lacking, and existing models often omit critical factors such as portal vein diameter. This study aimed to develop and validate a nomogram incorporating key clinical and biochemical variables to predict 1-year and 2-year survival following TIPS in PHT patients. We hypothesized that this model would provide improved risk stratification and guide clinical decisions.

AIM

To develop and validate a nomogram for predicting 1-year and 2-year survival in PHT patients post-TIPS.

METHODS

This retrospective cohort study included 848 TIPS-treated PHT patients with gastrointestinal bleeding from two tertiary hospitals (2013-2021). Mortality was the primary endpoint. Predictive variables were selected using least absolute shrinkage and selection operator regression, and a nomogram was developed with Cox regression to predict 1-year and 2-year survival. Model performance was evaluated through receiver operating characteristic curves, calibration plots, and decision curve analysis.

RESULTS

The mean age of the included (848) patients was 53.00 years ± 12.51, where 69.58% were men. Results showed that portal vein diameter, serum creatinine, potassium, and alpha-fetoprotein were the independent predictors of post-TIPS survival. Besides, the model showed strong discriminatory ability (C-index, 0.816 in the training set; 0.827 in the validation set) and good calibration. The area under the curve for 1-year and 2-year survival in the training set were 0.890 [95% confidence interval (CI): 0.802-0.948] and 0.838 (95%CI: 0.803-0.869), respectively. The area under the curve for 1-year and 2-year survival in the validation set were 0.934 (95%CI: 0.815-0.987) and 0.864 (95%CI: 0.811-0.907), respectively.

CONCLUSION

The developed nomogram could reliably predict 1-year and 2-year survival in patients undergoing TIPS for PHT-induced gastrointestinal bleeding.

Identification of Clinically Significant Portal Hypertension in cACLD Individuals With Spleen Stiffness Measurement

BACKGROUND AND AIMS

The Baveno VII consensus recommends spleen stiffness measurement (SSM) for the detection of clinically significant portal hypertension (CSPH) in patients with compensated advanced chronic liver disease (cACLD). We aimed to evaluate the performance of SSM-based algorithms.

METHODS

Consecutive cACLD individuals who underwent hepatic venous pressure gradient measurement, liver stiffness measurement (LSM), and SSM measured with the dedicated 100-Hz probe by vibration-controlled transient elastography were prospectively enrolled.

RESULTS

From July 2021 to August 2024, a total of 395 patients were screened, and 185 cACLD cases were enrolled, of which 101 patients had CSPH. An SSM > 50 kPa demonstrated a positive predictive value (PPV) of 98.0% and a specificity of 98.8% for ruling in CSPH, correctly identifying 47.5% (48/101) of CSPH cases. Sensitivity analysis revealed that in 60 patients with aetiology removal or suppression, SSM > 50 kPa achieved both a PPV and specificity of 100%. Among the 125 patients with ongoing aetiologies, the PPV and specificity were 96.4% and 98.3%, respectively. Across HBV (with or without viral suppression) and non-HBV subgroups, the PPV and specificity consistently exceeded 90%. In decision curve analysis, SSM > 50 kPa provided the highest net benefit compared with other elastography-based algorithms when threshold probabilities exceeded 0.8.

CONCLUSIONS

We prospectively validated that SSM > 50 kPa, measured using the spleen-dedicated probe, is sufficient for identifying CSPH in individuals with cACLD.

TRIAL REGISTRATION

NCT04820166.

Preventing the progression of cirrhosis to decompensation and death

Two main stages are differentiated in patients with advanced chronic liver disease (ACLD), one compensated (cACLD) with an excellent prognosis, and the other decompensated (dACLD), defined by the appearance of complications (ascites, variceal bleeding and hepatic encephalopathy) and associated with high mortality. Preventing the progression to dACLD might dramatically improve prognosis and reduce the burden of care associated with ACLD. Portal hypertension is a major driver of the transition from cACLD to dACLD, and a portal pressure of ≥10 mmHg defines clinically significant portal hypertension (CSPH) as the threshold from which decompensating events may occur. In recent years, innovative studies have provided evidence supporting new strategies to prevent decompensation in cACLD. These studies have yielded major advances, including the development of noninvasive tests (NITs) to identify patients with CSPH with reasonable confidence, the demonstration that aetiological therapies can prevent disease progression and even achieve regression of cirrhosis, and the finding that non-selective β-blockers can effectively prevent decompensation in patients with cACLD and CSPH, mainly by reducing the risk of ascites, the most frequent decompensating event. Here, we review the evidence supporting new strategies to manage cACLD to prevent decompensation and the caveats for their implementation, from patient selection using NITs to ancillary therapies.

Future of Endoscopy in Surveillance of Esophageal Varices

PURPOSE OF REVIEW

tTo assess the evolving role of endoscopy assessment for esophageal varices in cirrhosis.

RECENT FINDINGS

The approach to screening endoscopy for varices has significantly changed in the last 10 years with the refinement of non-diagnostic tests. Non-invasive diagnostic methods have reduced the need of upper endoscopies for variceal screening in patients with compensated cirrhosis, focusing primarily on those with ambiguous risk assessments or contraindications to non-selective beta-blockers (NSBBs). In contrast, decompensated cirrhosis patients require more frequent endoscopic evaluations due to their heightened risk of complications and the potential benefit of combination therapy (NSBBs + variceal ligation). In patients with hepatocellular carcinoma (HCC) the performance of non-invasive tests is suboptimal and most patients require endoscopy. Emerging applications of artificial intelligence (AI) can assist in patient triage and the interpretation of endoscopic findings, potentially improving care. Further research is essential to validate these technologies within clinical practice and optimize their integration into patient management strategies.

Effect of portal pressure gradient reduction on outcomes after transjugular intrahepatic portosystemic shunt in portal hypertension patients

BACKGROUND

Portal hypertension (PHT), a complication of liver cirrhosis, is sometimes managed with transjugular intrahepatic portosystemic shunt (TIPS) to reduce portal pressure. Although effective, TIPS poses risks, including hepatic encephalopathy (HE). This study investigates whether a significant reduction in the portal pressure gradient (PPG) after TIPS improves outcomes in PHT patients.

AIM

To evaluate the impact of post-TIPS PPG reduction on clinical outcomes and explore the relationship between PPG reduction and portal vein diameter.

METHODS

This retrospective cohort study included 815 patients with PHT who underwent TIPS at two tertiary hospitals between 2014 and 2022. Patients were categorized based on whether they achieved a 50% reduction in PPG. Propensity score matching was applied to balance baseline characteristics. Kaplan-Meier analysis assessed clinical outcomes, including rebleeding, HE, liver failure, and hepatocellular carcinoma. Cox regression identified risk factors, and Spearman correlation analyzed the relationship between PPG reduction and portal vein diameter.

RESULTS

Patients with a PPG reduction > 50% had significantly lower risks of rebleeding (P = 0.004), shunt dysfunction (P = 0.002), and mortality (P = 0.024) compared to those with a PPG reduction ≤ 50%. However, these patients faced higher risks of HE (P < 0.001) and liver failure (P = 0.003). A significant negative correlation was observed between the percentage of PPG reduction and portal vein diameter (ρ = -0.632, P < 0.001), suggesting that patients with smaller portal vein diameters may achieve greater PPG reductions.

CONCLUSION

A significant PPG reduction following TIPS is associated with improved clinical outcomes, including reduced risks of rebleeding, shunt dysfunction, hepatocellular carcinoma, and mortality, though it increases HE and liver failure risks. The observed correlation between portal vein diameter and PPG reduction highlights the potential role of portal vein anatomy in predicting TIPS efficacy, warranting further investigation.

Management of gastrointestinal bleed in the intensive care setting, an updated literature review

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.

Long-term liver outcomes after metabolic surgery in compensated cirrhosis due to metabolic dysfunction-associated steatohepatitis

No therapy has been shown to reduce the risk of major adverse liver outcomes (MALO) in patients with cirrhosis due to metabolic dysfunction-associated steatohepatitis (MASH). The Surgical Procedures Eliminate Compensated Cirrhosis In Advancing Long-term (SPECCIAL) observational study compared the effects of metabolic surgery and nonsurgical treatment in patients with obesity and compensated histologically proven MASH-related cirrhosis. Using a doubly robust estimation methodology to balance key baseline characteristics between groups, the time-to-incident MALO was compared between 62 patients (68% female) who underwent metabolic surgery and 106 nonsurgical controls (71% female), with a mean follow-up of 10.0 ± 4.5 years. The 15 year cumulative incidence of MALO was 20.9% (95% confidence interval (CI), 2.5-35.9%) in the surgical group compared with 46.4% (95% CI, 25.6-61.3%) in the nonsurgical group, with an adjusted hazard ratio of 0.28 (95% CI, 0.12-0.64), P = 0.003. The 15 year cumulative incidence of decompensated cirrhosis was 15.6% (95% CI, 0-31.3%) in the surgical group compared with 30.7% (95% CI, 12.9-44.8%) in the nonsurgical group, with an adjusted hazard ratio of 0.20 (95% CI, 0.06-0.68), P = 0.01. Among patients with compensated MASH-related cirrhosis and obesity, metabolic surgery, compared with nonsurgical management, was associated with a significantly lower risk of incident MALO. In the absence of approved medical therapies for compensated MASH-related cirrhosis, metabolic surgery may represent a safe and effective therapeutic option to influence the trajectory of cirrhosis.

Trans-splenic anterograde coil-assisted transvenous occlusion (TACATO) of bleeding gastric varices associated with gastrorenal shunts in cirrhosis

Background & Aims

There is a lack of consensus on the optimal management of fundal gastric varices (GVs) in patients with cirrhosis due to varied anatomy and hemodynamics. In this study, we evaluate the safety and efficacy of trans-splenic anterograde coil-assisted transvenous occlusion (TACATO) for preventing recurrent bleeding in fundal GVs associated with gastrorenal shunt (GRS).

Methods

In this 4-year study, patients with cirrhosis with GRS-associated GV bleeding, without prior esophageal variceal bleeding, ascites, or portal vein thrombosis, were eligible for TACATO. Trans-splenic access was achieved by puncturing a splenic venous branch using ultrasound/fluoroscopic guidance. A microcatheter was inserted into the varices for embolization with detachable microcoils and possibly N-butyl-cyanoacrylate-Lipiodol. Technical success was assessed by venography. All patients underwent follow-up endoscopy and decompensating events were recorded. A retrospective external control group of patients with cirrhosis and similar GRS-associated GVs treated by retrograde transvenous obliteration was enrolled as a comparative group.

Results

Twenty patients with cirrhosis underwent TACATO (17 GOV2, 6 IGV1 - median GRS size 23 mm, range 15-32 mm). Median occlusion of the shunt was 90% (complete in 14/20); complications included local abdominal pain and partial splanchnic thrombosis in two patients. Over a median follow-up of 23 (range 10-31) months, no rebleeding or further decompensation occurred; liver function remained stable and endoscopy showed reduced or resolved fundal GVs without worsening esophageal varices in all patients. The comparative group (18 patients - median GRS diameter 14 mm, range 6-23 mm) reported no rebleeding but worsening varices in two and ascites progression in two.

Conclusions

TACATO is a viable option for secondary prophylaxis of bleeding from GVs associated with GRS and may reduce hepatic decompensation risk. Further studies are needed to validate these results and determine TACATO's broader role in GV management.

Impact and implications

Gastric varices (GVs) affect 20% of patients with cirrhosis, with a 2-year bleeding risk of 25%. Fundal GVs, which account for 70% of cases, are associated with mortality rates of up to 55%, posing management challenges due to their complex anatomy and hemodynamics. Transjugular intrahepatic portosystemic shunt placement often fails to address fundal GV hemodynamics, leaving patients at a high risk of rebleeding. Balloon-occluded retrograde transvenous obliteration, while effective, is limited by complexity, logistical hurdles, and complications. TACATO (trans-splenic anterograde coil-assisted transvenous occlusion) provides effective secondary prophylaxis for fundal GV bleeding linked to gastrorenal shunts. It matches the efficacy of retrograde and anterograde techniques while offering faster execution, minimal side effects, and no need for specialized equipment or gastrorenal shunt size restrictions. Trans-splenic access ensured safe and straightforward access to the portal system and fundal GVs in all patients treated with TACATO.

Noninvasive liver disease assessment to identify portal hypertension: Systematic and narrative reviews supporting the AASLD Practice Guideline

BACKGROUND AND AIMS

Portal hypertension is a serious complication of cirrhosis, which leads to life-threatening complications. HVPG, a surrogate of portal pressure, is the reference standard test to assess the severity of portal hypertension. However, since HVPG is limited by its invasiveness and availability, noninvasive liver disease assessments to assess portal pressure, especially clinically significant portal hypertension (CSPH), are needed.

APPROACH AND RESULTS

We conducted a systematic review of Ovid MEDLINE(R) Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus from each database's inception to April 22, 2022. We included only studies in English that examined ≥50 patients in single liver disease etiologies, which compared noninvasive tests (blood and/or imaging) to HVPG for predicting clinically significant portal hypertension (CSPH; defined as HVPG ≥ 10 mm Hg) in patients with chronic liver disease. Outcomes included measures of diagnostic test accuracy. Additionally, a narrative review of studies not eligible for the systematic review is also provided. Nine studies with 2492 patients met the inclusion criteria. There was substantial heterogeneity with regard to liver disease studied and cutoff values used to detect CSPH. Blood-based tests, including aspartate-to-platelet ratio index (APRI) (56% sensitivity and 68% specificity) and FIB-4 (54% sensitivity and 73% specificity) had low accuracy measures. Imaging-based tests (transient elastography and shear wave elastography detection of liver stiffness measurement [LSM]) had better accuracy but also had substantial variation; at 15 kPa, TE sensitivity was 90%-96% and specificity was 48%-50%, while at 25 kPa, its sensitivity and specificity were 57%-85% and 82%-93%, respectively. The narrative review suggested that imaging-based tests are the best available noninvasive liver disease assessment to detect CSPH; CSPH is highly unlikely to be present at an LSM ≤15 kPa and likely to be present at an LSM ≥25 kPa.

CONCLUSIONS

While imaging-based noninvasive liver disease assessment appeared to have higher accuracy than blood-based tests to detect CSPH, only 9 studies fit the a priori established inclusion criteria for the systematic review. In addition, there was substantial study heterogeneity and variation in cutoffs for LSM to detect CSPH, limiting the ability to establish definitive cutoffs to detect CSPH.

Liver-Secreted Extracellular Vesicles Promote Cirrhosis-Associated Skeletal Muscle Injury Through mtDNA-cGAS/STING Axis

Skeletal muscle atrophy (sarcopenia) is a serious complication of liver cirrhosis, and chronic muscle inflammation plays a pivotal role in its pathologenesis. However, the detailed mechanism through which injured liver tissues mediate skeletal muscle inflammatory injury remains elusive. Here, it is reported that injured hepatocytes might secrete mtDNA-enriched extracellular vesicles (EVs) to trigger skeletal muscle inflammation by activating the cGAS-STING pathway. Briefly, injured liver secreted increased amounts of EVs into circulation, which are then engulfed primarily by macrophages in skeletal muscle and subsequently induce cGAS-STING signaling and its-mediated inflammatory response in muscles. In contrast, suppression of hepatic EV secretion or STING signaling significantly alleviated cirrhosis-induced skeletal muscle inflammation and muscle atrophy in vivo. Circulating EVs from cirrhotic patients showed higher levels of mtDNA, and the levels of EV-mtDNA positively correlated with the severity of liver injury. In injured hepatocytes, mitochondrial damage promoted the release of cytosolic mtDNA and the subsequent secretion of mtDNA-enriched EVs. This study reveals that injured hepatocyte-derived EVs induce skeletal muscle inflammation via the mtDNA‒STING axis, while targeted blockade of liver EV secretion or STING signaling represents a potential therapeutic approach for preventing cirrhosis-associated skeletal muscle atrophy.

Limitations and enhancement opportunities for variceal rebleeding prediction model in patients with cirrhosis

A multicenter study recently published introduced a novel prognostic model for predicting esophagogastric variceal rebleeding after endoscopic treatment in patients with cirrhosis. The model incorporated six readily available clinical variables—albumin level, aspartate aminotransferase level, white blood cell count, ascites, portal vein thrombosis, and bleeding signs—and demonstrated promising predictive performance. However, limitations, including the retrospective design and exclusion of patients with hepatocellular carcinoma, may affect the generalizability of the model. Additionally, further improvement is needed in the model’s discrimination between intermediate- and high-risk groups in external. Prospective validation and inclusion of additional variables are recommended to enhance predictive accuracy across diverse clinical scenarios.

Pharmacological Treatment of Ascites: Challenges and Controversies

Ascites is the most common complication from cirrhosis related to portal hypertension and depicts the onset of hepatic decompensation. Ranging from uncomplicated to refractory ascites, the progression carries prognostic value by reflecting the deterioration of underlying cirrhosis and portal hypertension. Diuretics have been the mainstay of treatment to control ascites, but the side effects heighten when the dosage is escalated. Non-selective beta-blockers (NSBBs) are widely used nowadays to prevent hepatic decompensation and variceal hemorrhage. However, with worsening systemic vasodilation and inflammation when ascites progresses, patients on NSBBs are at risk of hemodynamic collapse leading to renal hypoperfusion and thus hepatorenal syndrome. Long-term albumin infusion was studied to prevent the progression of ascites. However, the results were conflicting. Sodium-glucose cotransporter-2 inhibitors are under investigation to control refractory ascites. With that, patients with refractory ascites may require regular large-volume paracentesis. With an aging population, more patients are put on anti-thrombotic agents and their risks in decompensated cirrhosis and invasive procedures have to be considered. In general, decompensated cirrhosis with ascites poses multiple issues to pharmacological treatment. In the present review, we discuss the challenges and controversies in the pharmacological treatment of ascites.

Which patients benefit the most? An update on transjugular intrahepatic portosystemic shunt

This is a narrative review in which the advances in technical aspects, the main indications, limitations and clinical results of the transjugular intrahepatic portosystemic shunt (TIPS) in portal hypertension (PH) are addressed. With the emergence of the coated prosthesis, a better shunt patency, a lower incidence of hepatic encephalopathy (HE) and better survival when compared to TIPS with the conventional prosthesis are demonstrated. The main indications for TIPS are refractory ascites, acute variceal bleeding unresponsive to pharmacological/endoscopic therapy and, lastly, patients considered at high risk for rebleeding preemptive TIPS (pTIPS). Absolute contraindications to the use of TIPS are severe uncontrolled HE, systemic infection or sepsis, congestive heart failure, severe pulmonary arterial hypertension, and biliary obstruction. The control of hemorrhage due to variceal rupture can reach up to 90%-100% of cases, and 55% in refractory ascites. Despite evidences regarding pTIPS in patients at high risk for rebleeding, less than 20% of eligible patients are treated. TIPS may also decrease the incidence of future decompensation in cirrhosis and increase survival in selected patients. In conclusion, TIPS is an essential treatment for patients with PH, but is often neglected. It is important for the hepatologist to form a multidisciplinary team, in which the role of the radiologist with experience in interventional procedures is prominent.

Liver diseases: epidemiology, causes, trends and predictions

As a highly complex organ with digestive, endocrine, and immune-regulatory functions, the liver is pivotal in maintaining physiological homeostasis through its roles in metabolism, detoxification, and immune response. Various factors including viruses, alcohol, metabolites, toxins, and other pathogenic agents can compromise liver function, leading to acute or chronic injury that may progress to end-stage liver diseases. While sharing common features, liver diseases exhibit distinct pathophysiological, clinical, and therapeutic profiles. Currently, liver diseases contribute to approximately 2 million deaths globally each year, imposing significant economic and social burdens worldwide. However, there is no cure for many kinds of liver diseases, partly due to a lack of thorough understanding of the development of these liver diseases. Therefore, this review provides a comprehensive examination of the epidemiology and characteristics of liver diseases, covering a spectrum from acute and chronic conditions to end-stage manifestations. We also highlight the multifaceted mechanisms underlying the initiation and progression of liver diseases, spanning molecular and cellular levels to organ networks. Additionally, this review offers updates on innovative diagnostic techniques, current treatments, and potential therapeutic targets presently under clinical evaluation. Recent advances in understanding the pathogenesis of liver diseases hold critical implications and translational value for the development of novel therapeutic strategies.

Coil or plug-assisted retrograde transvenous obliteration (CARTO/PARTO) for treating portal hypertensive variceal bleeding: A multicenter, real-world 10-year retrospective study

BACKGROUND AND AIMS

Coil-assisted retrograde transvenous obliteration (CARTO) and plug-assisted retrograde transvenous obliteration (PARTO) are well-accepted treatments for gastric variceal bleeding. However, long-term (>2 y) clinical outcomes have yet to be studied. In this study, we investigated long-term clinical outcomes, including overall survival (OS) in 10 years.

APPROACH AND RESULTS

We performed a multinational, multicenter, retrospective study of CARTO/PARTO in gastric varices treatments between May 2012 and July 2024. The primary study outcomes were a long-term OS and prognostic factors of CARTO/PARTO. The secondary outcomes were long-term clinical/technical success, complications, and clinical changes including portal hypertensive symptoms. A total of 311 patients (41% female; 69% CARTO) from 13 centers in 5 countries were included. The cumulative 1-, 3-, 5-, 7-, and 10-year OS rates were 98%, 80%, 68%, 52%, and 33%, respectively, with a median OS of 99 months. Prophylactic CARTO/PARTO showed a better OS than CARTO/PARTO for active bleeding ( p =0.00035). The independent prognostic factors of OS were having high pre-MELD, concurrent HCC, treating GOV2, history of esophageal variceal bleeding, high pre-TBili, and ammonia levels. Notably, a high pre-MELD score >27 had a significantly higher mortality rate (92.6%) than a lower pre-MELD score ( p <0.001). The overall cumulative 1-, 3-, 5-, 7-, and 10-year recurrent gastric varices bleeding rates were 0.9%, 3.2%, 4.0%, 4.5%, and 5.4%, respectively. The overall technical and clinical success rates were 96.5% and 95.3%, respectively, with a 4.5% major complication rate over 10 years.

CONCLUSIONS

CARTO and PARTO have excellent long-term survival and clinical outcomes. However, these are negatively affected by high MELD scores, concomitant HCC, and coexisting esophageal varices.

Optimal Management of the Inpatient With Decompensated Cirrhosis

Over the past several years, there has been a wealth of new data pertaining to the management of complications of cirrhosis, resulting in several important updates to best practices and consensus guidelines. Despite these advancements and numerous recent targeted quality initiatives, hospitalizations resulting from complications of cirrhosis remain frequent, costly and associated with poor patient outcomes. An emphasis on evidence-based management of hospitalized patients with decompensated cirrhosis has the potential to decrease readmission rates and length of stay while improving overall patient outcomes. Herein, we provide an updated, evidence-based overview of the optimal inpatient management of the most frequently encountered complications associated with cirrhosis.

Development of a Novel Classification for Gastric Antral Vascular Ectasia Based on Upper Gastrointestinal Endoscopy Findings in Patients With Gastrointestinal Bleeding and Anemia

BACKGROUND AND AIM

Upper GI endoscopy (UGIE) identifies diverse findings in GI bleeding (GIB) patients. Gastric antral vascular ectasia (GAVE), a notable GIB cause, lacks a comprehensive classification. Besides, a detailed photographic data bank is crucial for training novice endoscopists and developing artificial intelligence (AI)-driven neural networks. This study aims to compile a databank of UGIE findings in GIB patients and propose a novel GAVE classification.

MATERIALS AND METHODS

A retrospective analysis of prospectively collected data was manually performed. Case records were evaluated, including video and photographic UGIE findings and indications for GIB patients. Fully and partially completed records were included; grossly incomplete ones were excluded. Data on common findings, indications, laboratory parameters, and risk factors were analyzed and classified. A novel classification of GAVE was developed.

RESULTS

Of 1821 records, 430 were analyzed. The mean patient age was 44.5 ± 16.8 years (range 10-85), with males comprising 251 (58.4%). The primary indication for UGIE was anemia (388, 90.2%), followed by hematemesis (57, 13.3%). The most frequent endoscopic findings were varices (139, 32.3%) and portal hypertensive gastropathy (131, 30.5%). GAVE was present in 22 (5.1%). Key risk factors included non-vegetarian diet (102, 23.7%) and alcohol consumption (101, 23.5%).

CONCLUSIONS

This study highlights the most common indications, findings, and risk factors for UGIE in GIB patients, such as anemia, varices, and non-vegetarian diet, respectively. It provides a novel classification of GAVE and establishes a resourceful photographic data bank for beginner training and AI applications, enhancing diagnostic and therapeutic approaches in GIB.

Health disparities in cirrhosis care and liver transplantation

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.

Three-dimensional volumetric CT image fusion and trans-abdominal US: Adjunct guidance to portal vein cannulation for TIPS

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.

Comparing serial and current liver stiffness measurements to predict decompensation in compensated advanced chronic liver disease patients

BACKGROUND AND AIMS

The utility of serial liver stiffness measurements (LSM) to predict decompensation in patients with compensated advanced chronic liver disease (cACLD) remains unclear. We aimed to validate whether comparing serial LSM is superior to using the current LSM to predict liver-related events (LRE) in patients with cACLD.

APPROACH AND RESULTS

In this retrospective analysis of an international registry, patients with cACLD and serial LSM were followed up until index LRE. We compared the performance of both the dynamic LSM changes and the current LSM in predicting LRE using Cox regression analysis, considering time zero of follow-up as the date of latest liver stiffness measurement. Overall, 480 patients with cACLD with serial LSM were included from 5 countries. The commonest etiology of cACLD was viral (53%) and MASLD (34%). Over a median follow-up of 68 (IQR: 45-92) months, 32% experienced a LSM decrease to levels below 10kPa (resolved cACLD) and 5.8% experienced LRE. Resolved cACLD were more likely to be non-diabetic and had better liver function. While a higher value of the current LSM was associated with higher LREs, LSM changes over time (LSM slope) were not associated with LRE. In multivariable Cox regression, neither the prior LSM nor the LSM slope added predictive value to latest liver stiffness measurement.

CONCLUSIONS

Once the current LSM is known, previous LSM values do not add to the prediction of LREs in patients with cACLD.

Efficacy and safety of anticoagulation in asymptomatic cirrhotic patients with portal vein thrombosis: a systematic review and meta-analysis

BACKGROUND

The role of anticoagulation in asymptomatic cirrhotic patients with portal vein thrombosis (PVT) remains unclear. This study aims to evaluate the efficacy and safety of anticoagulation in this patient population.

METHODS

We systematically searched PubMed, Web of Science, Cochrane Library, and Embase up to August 2024. The primary outcomes analyzed were PVT recanalization, progression of PVT, bleeding events, and mortality. Odds ratios (OR) with 95% confidence intervals (CI) were calculated for dichotomous variables.

RESULTS

Seventeen studies, including randomized controlled trials (RCTs) and observational studies, were included in the analysis. Compared to no intervention, anticoagulation significantly increased the PVT recanalization rate (OR = 3.89, p < .001) and decreased the PVT progression rate (OR = 0.28, p < .001) as well as overall mortality (OR = 0.66, p = .008). Importantly, anticoagulation did not significantly increase the bleeding rate (OR = 1.21, p = .41). Subgroup analysis revealed a greater benefit in PVT recanalization within the short-term treatment subgroup (≤ 6 months) compared to long-term treatment subgroup (> 6 months), and in the Asian subgroup compared to the European or United States of America (USA) subgroup. In the Warfarin subgroup, while the total bleeding rate increased significantly, there was no significant rise in major bleeding events. Additionally, a downward trend in variceal bleeding was observed in the Asian subgroup (OR = 0.44; 95% CI: 0.19-1.04; p = .06).

CONCLUSION

Anticoagulation is both safe and effective for asymptomatic cirrhotic patients with PVT. It not only treats PVT and reduces all-cause mortality, but also does so without significantly increasing the risk of bleeding events.

MELD-Lactate as a predictor of in-hospital mortality in patients with variceal gastrointestinal bleeding

INTRODUCTION

Variceal upper gastrointestinal bleeding is a common cause of decompensation in patients with liver cirrhosis. While mortality data, which are from 10 to 15%, are available, there are no validated scales to predict in-hospital mortality in this patient population.

OBJECTIVE

To determine whether the MELD-Lactate (MELD-LA) level is associated with in-hospital mortality in patients with chronic liver disease who are admitted for variceal bleeding.

MATERIAL AND METHODS

A prospective, observational, and analytical study was conducted that included 120 patients. The MELD-LA cut-off point was obtained, and in-hospital mortality was obtained using conventional prognostic scales that had the highest sensitivity and specificity for comparison purposes. Additionally, a survival analysis was performed using the MELD-LA cut-off point obtained.

RESULTS

In our cohort, 6 (5.0%) patients died during hospitalization. Patients who died had a mean MELD-LA value of 20.0 (±4.97) as opposed to those who did not die, 13.62 (±3.29), (p<0.001). The MELD-LA cut-off point of >14.0, with a sensitivity of 100%, a specificity of 71.0%, a positive predictive value of 15.4%, a negative predictive value of 100.0%, and an AUC (area under the curve) of 0.886, was most well correlated with higher in-hospital mortality. Survival was 71.1% in patients with MELD-LA levels>14.0 versus 100.0% in those with lower levels (p=0.001) during hospitalization.

CONCLUSION

The measurement of MELD-LA at admission seems to be a good complementary marker for the evaluation and prognosis of in-hospital mortality in patients with liver cirrhosis, and variceal upper gastrointestinal bleeding.

Prevalence and predictors of cirrhosis and portal hypertension in the United States

BACKGROUND AND AIMS

There is a paucity of data about the prevalence of cirrhosis and portal hypertension in the US general population.

APPROACH AND RESULTS

We used National Health and Nutrition Examination Surveys (NHANES 2017-2020) to estimate the prevalence of cirrhosis and clinically significant (CS)-portal hypertension in alcohol-associated liver disease (ALD), MetALD, viral hepatitis to include chronic hepatitis B (CHB) and chronic hepatitis C (CHC), and metabolic dysfunction-associated steatotic liver disease (MASLD). Cirrhosis was evaluated using liver stiffness measurement by transient elastography or FIB-4 score; CS-portal hypertension was defined through liver stiffness measurement and platelet count or the use of nonselective beta-blockers in the presence of cirrhosis.The prevalence of chronic liver disease etiologies was ALD 0.85%, MetALD 3.38%, CHB 0.23%, CHC 0.73%, ALD + viral hepatitis 0.16%, and MASLD 33.05%. In the general population, the prevalence of ALD-cirrhosis was 0.08%, MetALD-cirrhosis 0.19%, CHB-cirrhosis 0.01%, CHC-cirrhosis 0.10%, MASLD-cirrhosis 1.27%, ALD + viral hepatitis-cirrhosis 0.08%, and other cirrhosis 0.87%. The prevalence of CS-portal hypertension in chronic liver disease was 1.31% in MetALD, 1.60% in CHB, 4.73% in CHC, 2.00% in MASLD, and 0.35% in controls, to yield a population prevalence of 0.98%. In multivariate analysis, excessive alcohol use, CHC, male sex, obesity, type 2 diabetes, and hypertension were independently associated with an increased risk of cirrhosis (all p <0.05). Predictors of having CS-portal hypertension in chronic liver disease included CHC, obesity, and type 2 diabetes (all p <0.05).

CONCLUSIONS

The prevalence of cirrhosis in the United States is 2.6% while the prevalence of CS-portal hypertension is 0.98%. Individuals with MASLD comprise the majority of US residents with cirrhosis.

Machine learning prediction of hepatic encephalopathy for long-term survival after transjugular intrahepatic portosystemic shunt in acute variceal bleeding

BACKGROUND

Transjugular intrahepatic portosystemic shunt (TIPS) is an effective intervention for managing complications of portal hypertension, particularly acute variceal bleeding (AVB). While effective in reducing portal pressure and preventing rebleeding, TIPS is associated with a considerable risk of overt hepatic encephalopathy (OHE), a complication that significantly elevates mortality rates.

AIM

To develop a machine learning (ML) model to predict OHE occurrence post-TIPS in patients with AVB using a 5-year dataset.

METHODS

This retrospective single-center study included 218 patients with AVB who underwent TIPS. The dataset was divided into training (70%) and testing (30%) sets. Critical features were identified using embedded methods and recursive feature elimination. Three ML algorithms-random forest, extreme gradient boosting, and logistic regression-were validated via 10-fold cross-validation. SHapley Additive exPlanations analysis was employed to interpret the model's predictions. Survival analysis was conducted using Kaplan-Meier curves and stepwise Cox regression analysis to compare overall survival (OS) between patients with and without OHE.

RESULTS

The median OS of the study cohort was 47.83 ± 22.95 months. Among the models evaluated, logistic regression demonstrated the highest performance with an area under the curve (AUC) of 0.825. Key predictors identified were Child-Pugh score, age, and portal vein thrombosis. Kaplan-Meier analysis revealed that patients without OHE had a significantly longer OS (P = 0.005). The 5-year survival rate was 78.4%, with an OHE incidence of 15.1%. Both actual OHE status and predicted OHE value were significant predictors in each Cox model, with model-predicted OHE achieving an AUC of 88.1 in survival prediction.

CONCLUSION

The ML model accurately predicts post-TIPS OHE and outperforms traditional models, supporting its use in improving outcomes in patients with AVB.

Spleno-Mesenteric Venous Blood Flow Dynamics in Adult Patients with Chronic Portal Vein Thrombosis Analyzed by Sequential CT-Spleno- and Mesenterico-Portography

BACKGROUND

Portal vein thrombosis (PVT) leads to portal hypertension (PH) with its sequelae. Computed tomography spleno-mesenterico-portography (CT-SMPG) combines sequential CT spleno-portography and CT mesenterico-portography. CT-SMPG comprehensively illustrates the venous hemodynamic changes due to PH.

OBJECTIVE

To assess the effects of PV confluence thrombosis (PVCT) and liver cirrhosis on venous blood flow characteristics of patients with PVT.

METHOD

CT-SMPG was performed in 21 patients with chronic PVT. CT-SMPG was compared to standard contrast-enhanced CT (CECT) and gastroscopy concerning the patency of splanchnic veins, varices and venous congestion.

RESULTS

PVCT had a significant effect on perfusion patterns: in patients without PVCT, esophageal varices (EV) and gastric varices were supplied by either the splenic vein (SV), the superior mesenteric vein (SMV), or both. In patients with PVCT, EV and gastric varices were mostly supplied by the SV (p = 0.021, p = 0.016). In patients without PVCT, small bowel varices were fed by both systems or the SMV, while in patients with PVCT they were fed by the SMV (p = 0.031). No statistically significant changes were detected regarding gastropathy, colorectal varices and small bowel congestion. Liver cirrhosis had no statistically relevant effect on hemodynamics.

CONCLUSIONS

In CT-SMPG, patients with PVCT showed different venous hemodynamics to patients without PVCT, and this can serve as a basis for selecting therapy options.

Prognostic model for esophagogastric variceal rebleeding after endoscopic treatment in liver cirrhosis: A Chinese multicenter study

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.

Comparative efficacy of endoscopic variceal ligation versus non-selective beta-blockers in primary prevention of gastroesophageal varix type 2: an IPTW-adjusted study

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.

Management Outcomes of Variceal Bleeding in Northern Tanzania: Insights From a Single-Center Retrospective Analysis

Aims

Due to the expensiveness and unavailability of endoscopy management in Tanzania, the management outcomes of variceal bleeding are unknown. The objective of this study was to assess the management outcomes of patients with variceal bleeding.

Methods

This was a retrospective study conducted between April 2012 and April 2022. The study enrolled all patients diagnosed with variceal bleeding aged 18 years and older. Socio-demographic and clinic characteristics, treatment modalities, and outcomes were collected. Statistical analysis was done using a chi-square test. Multivariable logistic regression was used to determine factors associated with rebleeding and mortality. A p-value of ≤ 0.05 was considered statistically significant.

Results

A total of 534 patients were enrolled based on diagnostic endoscopy findings. Esophageal varices were identified in 88.9% of patients, gastric varices in 0.9%, and 10.1% had both. Conservative treatment was given to 77.5% of patients, and endoscopic treatment was performed in 22.5%: endoscopic variceal ligation (17.6%), endoscopic injection sclerotherapy (4.3%), and both (0.6%). Rebleeding occurred in 40.1%, and factors associated with rebleeding were patients without insurance (p = 0.037), without comorbidities (p = 0.042), with non-communicable diseases (p = 0.039), and with chronic infections (p = 0.035). In-hospital mortality was 8.1%, and factors associated with mortality were a shorter length of stay (p = 0.045), patients without comorbidities (p = 0.041), and grade II esophageal varices (p = 0.043).

Conclusion

This study shows a high rate of variceal bleeding among patients treated conservatively. Mortality and rebleeding rates in our setting remain high, which appears to be due to the expensiveness and unavailability of endoscopic treatment. Available endoscopic interventions will be vital in improving the outcomes of patients with variceal bleeding.

Management of Refractory Esophageal Variceal Bleeding when TIPSS Is Not Possible: Review of a Challenging Case

Introduction

Esophageal variceal bleeding (EVB) is a common complication of portal hypertension. Guidelines recommend initiation of vasoactive agents in combination with antimicrobial therapy prior to endoscopic variceal ligation. In cases of refractory EVB, trans-jugular intrahepatic portosystemic shunt (TIPSS) is recommended; however, it is contraindicated in up to 35% of cases.

Case Presentation

We report a case of a 61-year-old male newly diagnosed with hepatocellular carcinoma and extensive portal vein thrombosis. The patient developed a refractory EVB failing medical and endoscopic therapies which was successfully treated with transcutaneous left gastric vein embolization (LGVE).

Conclusion

LGVE could be contemplated in instances where anatomical complexities or contraindications to TIPSS arise.

Challenges and Opportunities in the Adoption of p-TIPS for Acute Variceal Bleeding: Insights from a US Tertiary Center

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.

Outpatient management after hospitalisation for acute decompensation of cirrhosis: A practical guide

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.

Carvedilol vs. propranolol for the prevention of decompensation and mortality in patients with compensated and decompensated cirrhosis

BACKGROUND & AIMS

Data on the effectiveness of classical non-selective beta-blockers (cNSBBs, i.e., propranolol and nadolol) vs. carvedilol in patients with cirrhosis are scarce. In the present study, we aimed to compare their potential for preventing decompensation and mortality in patients with compensated and decompensated cirrhosis.

METHODS

We performed a multicenter retrospective study including patients with compensated and decompensated cirrhosis 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 in a competitive risk framework.

RESULTS

A total of 540 patients were included, 256 with compensated (cNSBBs n = 111; carvedilol n = 145) and 284 with decompensated (cNSBBs n = 134; carvedilol n = 150) cirrhosis. Median follow-up was 36.3 (IQR 16.9-61.0) and 30.7 (IQR 13.1-52.2) months, respectively. After covariate balancing, compared to cNSBBs, carvedilol significantly reduced the risk of a first decompensation in compensated patients (subdistribution hazard ratio 0.61; 95% CI 0.41-0.92; p = 0.019) and a combined endpoint of further decompensation/death in decompensated patients (subdistribution hazard ratio 0.57; 95% CI 0.42-0.77; p <0.0001). A second HVPG was conducted on 176 (68.8%, compensated) and 177 (62.3%, decompensated) patients. 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 for the prevention of a first decompensation of cirrhosis and suggest extending the recommendation 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) vs. 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, owing to the retrospective nature of the study and inherent selection biases, we advise against broadly applying these findings to patients with decompensated cirrhosis who exhibit signs of circulatory dysfunction or recurrent/refractory ascites.

Validation and expansion of Baveno VII criteria for cACLD and CSPH based on liver stiffness and platelet count: Correlation with risk of hepatic decompensation and death

BACKGROUND AND AIMS

Recently proposed "Rule-of-Five" criteria define compensated advanced chronic liver disease (cACLD) and clinically significant portal hypertension (CSPH) using liver stiffness (LS) and platelet count. We aimed to validate these criteria by determining whether they are associated with risk of adverse outcomes.

APPROACH AND RESULTS

Patients without prior hepatic decompensation or HCC who underwent LS and platelet measurements (n = 17,076) were categorized as follows: no cACLD (LS: 2.5-9.9 kPa); probable cACLD (LS: 10-14.9 kPa); certain cACLD-no CSPH (LS: 15-19.9 kPa and platelets ≥110,000/µL or LS 20-24.9 kPa and platelets ≥150,000/µL); probable CSPH (LS 15-19.9 kPa and platelets <110,000/µL or LS 20-24.9 and platelets <150,000/µL); and certain CSPH (LS ≥25 kPa), which we further subdivided into 25-49.9 and 50-75 kPa.During a median follow-up of 2.82 years, each increase in the "Rule-of-Five" category was associated linearly with higher risks of death (HR: 1.22, 95% CI: 1.18-1.25) and decompensation (HR: 1.52, 95% CI: 1.46-1.58). Compared to patients with LS 25-49.9 kPa, those with LS 50-75 kPa ("critical" CSPH) had approximately double the risk of decompensation (11.24 vs. 4.20 per 100 patient-years) and death (9.85 vs. 6.98 per 100 patient-years).

CONCLUSIONS

The Baveno VII "Rule-of-Five" criteria provide a valid system for stratifying risks of death and hepatic decompensation and should be used routinely in patients with chronic liver disease. Among patients with CSPH (LS ≥25 kPa), the subgroup with LS 50-75 kPa ("critical" CSPH) has approximately double the risk of death and hepatic decompensation than LS 25-49.9 kPa.

Diagnostic accuracy of 2D-SWE ultrasound for liver fibrosis assessment in MASLD: A multilevel random effects model meta-analysis

BACKGROUND AND AIMS

Metabolic dysfunction-associated steatotic liver disease (MASLD) imposes significant health care burdens. Early detection of advanced fibrosis and cirrhosis in MASLD is essential due to their unfavorable outcomes. This multilevel random-effects meta-analysis aimed to provide the best evidence for the diagnostic accuracy of 2-dimensional shear wave elastography in detecting liver fibrosis in biopsy-proven MASLD.

APPROACH AND RESULTS

This study involves systematic search in PubMed/MEDLINE, Embase, Scopus, Web of Science, LILACS, and Cochrane Library electronic databases for full-text articles published in any language up to February 26, 2024. Included studies reported liver stiffness measurement by 2-dimensional shear wave elastography and used histological diagnosis as the gold standard. A linear mixed-effects multiple thresholds model was employed, and summary estimates for sensitivity, specificity (Sp), and summary area under the receiver operator characteristic curve were computed. Twenty observational studies (SuperSonic Imagine, General Electric Healthcare, and Canon Medical Systems) fulfilled the inclusion criteria, comprising 2223 participants with biopsy-proven MASLD. The prevalence of mild fibrosis (F1), significant fibrosis (F2), advanced fibrosis (F3), and cirrhosis (F4) was 30.0%, 18.5%, 17.9%, and 10.9%, respectively. The summary area under the receiver operator characteristic curve [95% CI] in detecting ≥F1, ≥F2, ≥F3, and F4 for all ultrasound machines considered together were 0.82 [0.16-0.98], 0.82 [0.76-0.88], 0.86 [0.77-0.93], and 0.89 [0.80-0.95], respectively. The optimal cutoff values were 6.432 kPa for ≥F1, 8.174 kPa for ≥F2, 9.418 kPa for ≥F3, and 11.548 kPa for F4, respectively.

CONCLUSIONS

Our meta-analysis identified optimized cutoffs for fibrosis staging by 2-dimensional shear wave elastography in etiology-specific chronic liver diseases (MASLD), with excellent diagnostic performance, underscoring the potential for standardizing cutoff values.

Nonalcohol-related Cirrhosis Leads to Higher 6-week Mortality After Acute Variceal Bleeding Than Alcohol-related Cirrhosis

BACKGROUND & AIMS

Acute variceal bleeding (AVB) portends significant 6-week mortality in patients with cirrhosis. It remains unclear if the correlation between liver prognostic scores and 6-week mortality are similar across different etiologies of liver cirrhosis, particularly alcohol-related liver disease (ALD) vs non-alcohol-related liver disease (non-ALD). This study aims to compare the 6-week mortality following AVB in these 2 patient populations.

METHODS

We assessed outcomes after AVB in 2 large multicenter cohorts from the United States and Singapore of patients with cirrhosis presenting with AVB. Using multivariable logistic regression, 6-week mortality between ALD and non-ALD cirrhosis was compared. Sensitivity analyses were performed with propensity-score matching analyses of the overall cohort.

RESULTS

A total of 1349 patients with AVB from the United States (n = 469) and Singapore (n = 880) cohorts were included. The aggregated cohort consisted of 379 patients (27.5%) with ALD cirrhosis. The overall 6-week mortality was 14.4%. Non-ALD cirrhosis was associated with a significantly higher 6-week mortality than ALD cirrhosis after accounting for Child-Turcotte-Pugh (CTP) score (adjusted odds ratio [aOR], 2.9; 95% confidence interval [CI], 1.5-5.3), Model of End-stage Liver Disease (MELD) score (aOR, 3.0; 95% CI, 1.6-5.6), and MELD 3.0 score (aOR, 3.3; 95% CI, 1.7-6.4). Addition of cirrhosis etiology (ALD vs non-ALD) to existing prognostic scores improved the prediction of 6-week mortality following AVB (MELD 3.0 c-statistic: 0.784 vs 0.770; P < .001). An etiology-adjusted updated MELD 3.0 model was the best prediction model for 6-week mortality after AVB.

CONCLUSION

Patients with non-ALD cirrhosis presenting with AVB had a higher risk of 6-week mortality, at each severity of liver disease by standard indices, than patients with ALD cirrhosis. Cirrhosis etiology (ALD vs non-ALD) should be incorporated into the risk stratification of patients with AVB.

Non-invasive tests for alcohol-associated liver disease

Alcohol consumption is a global phenomenon and a major contributor to alcohol-associated liver disease (ALD). Detecting individuals at risk of ALD has been challenging, with only a small fraction of patients being identified at early stages compared to other chronic liver diseases. In response to this challenge, non-invasive tests (NITs) have become essential tools for the detection of ALD, offering opportunities for early identification and intervention to mitigate the disease burden. Noninvasive alcohol consumption biomarkers are crucial in estimating individuals' recent alcohol intake, providing valuable insights into their drinking patterns. Various NITs have been investigated for the initial screening of asymptomatic individuals at risk of ALD, as well as for identifying specific stages of the disease. These NITs are applied in 2 main clinical scenarios: population-based stratification for identifying and predicting liver-related symptoms and diagnosing and prognosticating compensated cirrhosis or advanced chronic liver disease in secondary or tertiary care settings. Moreover, NITs play a significant role in the prognostic assessment of patients with various manifestations of ALD, including alcohol-associated hepatitis (AH), decompensated cirrhosis, and metabolic-associated and ALD. These tests guide appropriate treatment decisions and predict outcomes. In this review, various NITs for the early detection and monitoring of alcohol consumption were discussed. Additionally, the evaluation of NITs for screening and predicting ALD and liver complications was addressed comprehensively. Future perspectives of NITs for ALD were explored, alongside a thorough discussion of the opportunities and challenges associated with NITs for ALD screening.

Liver diseases and hepatocellular carcinoma in the Asia-Pacific region: burden, trends, challenges and future directions

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.

Comprehensive approach to esophageal variceal bleeding: From prevention to treatment

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.

Identification of novel drug targets for liver cirrhosis and its potential side-effects by human plasma proteome

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.

Sequential endoscopic treatment for esophageal and gastric variceal bleeding significantly reduces patient mortality and rebleeding rates

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.

Clinical Outcomes of Transjugular Intrahepatic Portosystemic Shunt Among Cirrhosis Patients With Recurrent Esophageal Variceal Bleeding

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.

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

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.

Perioperative Liver and Kidney Diseases

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.