Prognostic value of S100A4 and Glypican-3 in hepatocellular carcinoma in cirrhotic HCV patients

AIMS

Both S100A4 and Glypican-3 have been known to be engaged in HCC development and progression. This study aimed to evaluate both S100A4 and GPC3 expression in HCC tissues as a prognostic markers.

METHODS

Tissues from 70 patients of HCC in cirrhotic HCV patients were evaluated by immunohistochemistry using antibodies against SA100A4 and GPC3 and compared with tumor-adjacent tissue (controls). All cases were followed for 40 months.

RESULTS

GPC3 was more expressed in HCC (79%) than S100A4 (21%). S100A4 was more significantly expressed in cases showing metastasis, microscopic vascular emboli, necrosis, and grade III tumors. There was no relationship between overall survival and both S100A4 and GPC3. The only significant independent predictor for recurrence was decompensation (OR 3.037), while metastasis was significantly predicted by S100A4 expression (OR 9.63) and necrosis (OR 8.33).

CONCLUSION

S100A4 might be used as a prognostic marker for HCC, while GPC3 is a reliable marker of HCC diagnosis.

The Use of Albumin-to-bilirubin Score in Predicting Variceal Bleed: A Pilot Study from Pakistan

Variceal hemorrhage is a serious consequence of patients having chronic liver disease (CLD). Various scores exist that predict the outcome for non-variceal bleed. However, only a few scores evaluate patients with variceal bleed. We, in our study, evaluated 48 cirrhotics who presented with variceal gastrointestinal (GI) bleed over a period of 3 months. Majority of these were males and the most common etiology was hepatitis C infection. The main presenting complaints were hematemesis seen in 39.6% followed by hematemesis and melena in 31.25%. Most bleeding episodes were secured via banding in 62.5% followed by injection of histoacryl in 12.5%. Finally, Child-Turcotte-Pugh (CTP), model for end-stage liver disease (MELD), albumin-to-bilirubin (ALBI), and the ABC score were applied and none correlated with the presence of esophageal varices. However, the ALBI score did correlate with the presence of tachycardia in our study, a pertinent sign of upper GI bleed.

How to cite this article

Majid Z, Khan SA, Akbar N, et al. The Use of Albumin-to-bilirubin Score in Predicting Variceal Bleed: A Pilot Study from Pakistan. Euroasian J Hepato-Gastroenterol 2022;12(2):77-80.

Temporary pacemaker protected transjugular intrahepatic portosystemic shunt in a patient with acute variceal bleeding and bradyarrhythmia: A case report

BACKGROUND

Esophagogastric varices are a common complication of cirrhosis with portal hypertension and endoscopic treatment has been recognized as a primary preventive and therapeutic option for such patients; however, it should be noted that bradyarrhythmia is regarded as one of the contraindications to endoscopic examination. Meanwhile, acute variceal bleeding may result in a high mortality rate in cirrhotic patients with portal hypertension accompanied by bradyarrhythmia. At present, there is an absence of reports concerning the treatment of such group of patients who underwent transjugular intrahepatic portosystemic shunt (TIPS). The present report details the case of a cirrhotic patient with acute variceal bleeding accompanied by bradyarrhythmia who underwent TIPS under temporary pacemaker protection.

CASE SUMMARY

We report the case of a 64-year-old male patient who was confirmed with bradyarrhythmia by ambulatory electrocardiogram 24 h before the operation. The patient was successfully treated by TIPS under temporary pacemaker protection.

CONCLUSION

In terms of cirrhotic patients with abnormal cardiac electrophysiological conduction, TIPS may be effective in reducing the complications of portal hypertension following the exclusion of severe pulmonary hypertension and heart failure, showing moderate feasibility in clinical applications.

Value of virtual touch tissue quantification in evaluating therapeutic effects of transjugular intrahepatic portosystemic stent shunt

BACKGROUND

Virtual touch tissue quantification (VTQ) is a new ultrasonic technology which can quantitatively analyze the elastic hardness of tissue. It is convenient, noninvasive, and repeatable. In the present study, the changes of tissue hardness of the liver and spleen after transjugular intrahepatic portosystemic stent shunt (TIPSS) were analyzed quantitatively to assess the clinical therapeutic effects, with an aim to provide a valuable imaging method for the evaluation of therapeutic effects of TIPSS.

AIM

To explore the clinical value of VTQ in evaluating the therapeutic effects of TIPSS.

METHODS

Fifty-two cirrhotic patients with portal hypertension were selected as subjects. The shear wave velocity (SWV) of the liver and spleen was measured by VTQ one day before operation and one month after operation, and the changes of SWV of the liver and spleen were compared.

RESULTS

The velocities of the portal vein and splenic vein after TIPSS increased significantly compared with those before TIPSS (P < 0.05). The diameter of the portal vein after TIPSS decreased significantly compared with that before TIPSS (P < 0.05). The SWV of the liver and spleen after TIPSS decreased significantly compared with those before TIPSS (P < 0.05).

CONCLUSION

VTQ is a noninvasive method to measure the SWV of the liver and spleen, which can effectively monitor the therapeutic effect of TIPSS.

In silico analysis excavates potential biomarkers by constructing miRNA-mRNA networks between non-cirrhotic HCC and cirrhotic HCC

Background

Mounting evidences have demonstrated that HCC patients with or without cirrhosis possess different clinical characteristics, tumor development and prognosis. However, few studies directly investigated the underlying molecular mechanisms between non-cirrhotic HCC and cirrhotic HCC.

Methods

The clinical information and RNA-seq data were downloaded from The Cancer Genome Atlas (TCGA) database. Differentially expressed genes (DEGs) of HCC with or without cirrhosis were obtained by R software. Functional annotation and pathway enrichment analysis were performed by Enrichr. Protein-protein interaction (PPI) network was established through STRING and mapped to Cytoscape to identify hub genes. MicroRNAs were predicted through miRDB database. Furthermore, correlation analysis between selected genes and miRNAs were conducted via starBase database. MiRNAs expression levels between HCC with or without cirrhosis and corresponding normal liver tissues were further validated through GEO datasets. Finally, expression levels of key miRNAs and target genes were validated through qRT-PCR.

Results

Between 132 non-cirrhotic HCC and 79 cirrhotic HCC in TCGA, 768 DEGs were acquired, mainly involved in neuroactive ligand-receptor interaction pathway. According to the result from gene expression analysis in TCGA, CCL19, CCL25, CNR1, PF4 and PPBP were renamed as key genes and selected for further investigation. Survival analysis indicated that upregulated CNR1 correlated with worse OS in cirrhotic HCC. Furthermore, ROC analysis revealed the significant diagnostic values of PF4 and PPBP in cirrhotic HCC, and CCL19, CCL25 in non-cirrhotic HCC. Next, 517 miRNAs were predicted to target the 5 key genes. Correlation analysis confirmed that 16 of 517 miRNAs were negatively regulated the key genes. By detecting the expression levels of these key miRNAs from GEO database, we found 4 miRNAs have high research values. Finally, potential miRNA-mRNA networks were constructed based on the results of qRT-PCR.

Conclusion

In silico analysis, we first constructed the miRNA-mRNA regulatory networks in non-cirrhotic HCC and cirrhotic HCC.

Daclatasvir Plasma Levels in a Cohort of Patients with Hepatitis C Virus Infection Taking Methadone: A Prospective Analysis

Backround: The effect of methadone (MET) during therapy with novel direct-acting antiviral agents is still not fully understood. Currently, no data are available about the influence of MET on daclatasvir (DCV) plasma levels in patients affected by chronic hepatitis C (CHC). The aim of this study was to assess the DCV plasma concentrations in patients treated with sofosbuvir (SOF) plus DCV, with or without ribavirin (RBV) and with or without MET.

METHODS

In this analysis, 47 patients were included, treated consecutively with SOF + DCV ± RBV for 24 weeks, from May to October 2015; 22 (46.8%) received MET substitutive therapy.

RESULTS AND CONCLUSION

We found a significant difference in DCV levels at 2 weeks and 1 month: 150 ng/mL in patients without MET and 313 ng/mL with MET at 2 weeks (p < 0.001), 149 and 279 ng/mL at 1 month (p = 0.006). DCV levels were lower in cirrhotic patients (p < 0.001); among cirrhotic patients we also evidenced higher DCV concentrations in patients receiving MET at 2 weeks, 1 and 2 months (p < 0.001, p = 0.005, and p = 0.031, respectively). In multivariate analysis, the only predictive factor associated with DCV plasma levels was the presence of MET. The reason for this increased DCV exposure is unclear; on the clinical side, we have not observed significant adverse events related to the reduction or increase of MET plasma levels. The administration of MET in patients with advanced fibrosis or cirrhosis leads to an early increase of DCV plasma level without significant clinical effects or toxicity.

Safety and Feasibility of a Laparoscopy-Assisted Non-Anatomic Resection Technique for Hepatocellular Carcinoma Located at Right Posterior Segments in Cirrhotic Patients: A Case-Controlled Study with Propensity Score Matching

PURPOSE

The aim of this study was to compare the short- and long-term outcomes of laparoscopy-assisted resection for right posterior segment (LAR-RPS) with open resection (OR-RPS) performed by experienced hepatobiliary surgeons.

METHODS

This was a prospective comparative nonrandomized study.

RESULTS

The groups were comparable in terms of baseline demographics and clinicopathological data. Reduced operative time (254.88 ± 78.56 vs. 347.95 ± 82.56 min; p = 0.04) and estimated blood loss (477 ± 756 vs. 712 ± 836 mL; p = 0.03) were observed in LAR-RPS. Also, significant less duration of hospital stay (7.53 ± 2.68 vs. 12.57 ± 3.21 days; p < 0.001) was associated with LAR-RPS compared to OR-RPS. Long-term oncologic outcomes were comparable in 2 groups, in terms of both the overall and disease-free survival rates (p = 0.450 and 0.463, respectively).

CONCLUSIONS

This study confirms that laparoscopic-assisted resection is a safe and effective operative procedure in those cirrhotic patients with a lesion in the right posterior section of the liver. When compared to the open approach, the laparoscopic-assisted approach reduces operative time and blood loss, as well as the length of hospital stay.

Treatment with daclatasvir and sofosbuvir for 24 weeks without ribavirin in cirrhotic patients who failed first-generation protease inhibitors

BACKGROUND

Treatment of patients with chronic hepatitis C who failed the triple therapy with first generation of protease inhibitors is not still defined. The combined use of sofosbuvir (SOF) and daclatasvir (DCV) seems to be promising due to higher genetic barrier, good tolerance and effectiveness.

METHODS

We described the treatment with this drug combination in a real-life cohort of 20 cirrhotic patients with genotype 1 who failed the triple therapy.

RESULTS

18 of them (90%) with Child-Pugh A, 11 (55%) with genotype 1a, 17 (85%) with more than 1 and 8 (40%) with more than 2 previous failed treatment; all patients had at baseline NS3 resistance-associated variants related to triple therapy failure. RBV was not administered due to anemia in previous treatments. The sustained virological response was 100%.

CONCLUSION

Treatment with SOF + DCV without RBV for 24 weeks is safe and effective in cirrhotic patients who failed triple therapy with the first generation of protease inhibitors.

Impact of long-term gastric acid suppression on spontaneous bacterial peritonitis in patients with advanced decompensated liver cirrhosis

OBJECTIVE

Recent studies have presented conflicting results on the association between gastric acid suppression and spontaneous bacterial peritonitis (SBP). The long-term effects of gastric acid suppression on SBP in cirrhotic patients remain unclear. This study evaluated the risk of SBP in advanced decompensated cirrhotic patients with long-term gastric acid suppression.

METHODS

Using the Taiwan National Health Insurance Research Database, we identified 4788 patients with decompensated cirrhosis from 1998 to 2011. The SBP incidence rate was compared among proton pump inhibitor (PPI), H2-receptor antagonist (H2RA), and control cohorts. Multivariate Cox proportional hazards regressions analysis was conducted to confirm the association between gastric acid suppression and SBP.

RESULTS

Totally, 4788 patients were analyzed: 1870 in the PPI cohort, 1728 in the H2RA cohort, and 1190 in the control cohort. The overall incidences of SBP were 16.8, 11.9, and 9.80 per 1000 person-years in the PPI, H2RA, and control cohorts, respectively. The adjusted hazard ratio (aHR) of SBP during the follow-up period was 1.16- (95% confidence interval [CI], 0.72-1.86) and 1.00-fold (95% CI, 0.63-1.57) higher in the PPI and H2RA cohorts, respectively, than in the control cohort; the result was non-significant. Compared with the control cohort, patients with >180days of PPI therapy had significantly higher risks of SBP, with an aHR of 2.28 (95% CI, 1.37-3.78).

CONCLUSIONS

Long-term PPI use is associated with a high risk of SBP in advanced decompensated cirrhotic patients. Well-designed prospective studies are necessary to evaluate the safety of long-term PPI use in such patients.

Management of colorectal cancer in patients with cirrhosis: A retrospective, case-matched study of short- and long-term outcomes

BACKGROUND

Few studies have assessed access to postoperative chemotherapy and survival in cirrhotic patients with colorectal cancer. Aim of this study was to analyse short and long-term outcomes in these patients compared to non-cirrhotics.

METHODS

A retrospective, single-centre, comparative, case-matched study comparing 40 cirrhotic patients who had undergone colorectal resection between January 2006 and January 2014, and a matched cohort of 80 non-cirrhotic patients. Data collection included rate of postoperative outcomes, chemotherapy regimen, overall and disease-free 3-year survival.

RESULTS

Cirrhotics had more major postoperative complications than non-cirrhotics (57.5% vs. 26.5%, respectively; p=0.002) but no difference in anastomotic leakage (p=0.1); a higher mortality rate (p=0.0006) was observed in Child-Pugh class B patients. Cirrhotics had no difference in adjuvant chemotherapy rate compared to non-cirrhotics (55% vs. 65%, respectively p=0.8); 3-year overall survival was 71% in the Child A group vs. 92% in non-cirrhotics (p=0.03).

CONCLUSION

Despite a higher postoperative complication rate and a lower overall survival of cirrhotic patients compared to non-cirrhotics, cirrhosis had no impact on oncological outcomes and access/tolerance to postoperative chemotherapy. Thus cirrhosis should not be considered as a contraindication to curative treatment of colon cancer.

Portal hypertensive gastropathy: A systematic review of the pathophysiology, clinical presentation, natural history and therapy

AIM: To describe the pathophysiology, clinical presentation, natural history, and therapy of portal hypertensive gastropathy (PHG) based on a systematic literature review.

METHODS: Computerized search of the literature was performed via PubMed using the following medical subject headings or keywords: “portal” and “gastropathy”; or “portal” and “hypertensive”; or “congestive” and “gastropathy”; or “congestive” and “gastroenteropathy”. The following criteria were applied for study inclusion: Publication in peer-reviewed journals, and publication since 1980. Articles were independently evaluated by each author and selected for inclusion by consensus after discussion based on the following criteria: Well-designed, prospective trials; recent studies; large study populations; and study emphasis on PHG.

RESULTS: PHG is diagnosed by characteristic endoscopic findings of small polygonal areas of variable erythema surrounded by a pale, reticular border in a mosaic pattern in the gastric fundus/body in a patient with cirrhotic or non-cirrhotic portal hypertension. Histologic findings include capillary and venule dilatation, congestion, and tortuosity, without vascular fibrin thrombi or inflammatory cells in gastric submucosa. PHG is differentiated from gastric antral vascular ectasia by a different endoscopic appearance. The etiology of PHG is inadequately understood. Portal hypertension is necessary but insufficient to develop PHG because many patients have portal hypertension without PHG. PHG increases in frequency with more severe portal hypertension, advanced liver disease, longer liver disease duration, presence of esophageal varices, and endoscopic variceal obliteration. PHG pathogenesis is related to a hyperdynamic circulation, induced by portal hypertension, characterized by increased intrahepatic resistance to flow, increased splanchnic flow, increased total gastric flow, and most likely decreased gastric mucosal flow. Gastric mucosa in PHG shows increased susceptibility to gastrotoxic chemicals and poor wound healing. Nitrous oxide, free radicals, tumor necrosis factor-alpha, and glucagon may contribute to PHG development. Acute and chronic gastrointestinal bleeding are the only clinical complications. Bleeding is typically mild-to-moderate. Endoscopic therapy is rarely useful because the bleeding is typically diffuse. Acute bleeding is primarily treated with octreotide, often with concomitant proton pump inhibitor therapy, or secondarily treated with vasopressin or terlipressin. Nonselective β-adrenergic receptor antagonists, particularly propranolol, are used to prevent bleeding after an acute episode or for chronic bleeding. Iron deficiency anemia from chronic bleeding may require iron replacement therapy. Transjugular-intrahepatic-portosystemic-shunt and liver transplantation are highly successful ultimate therapies because they reduce the underlying portal hypertension.

CONCLUSION: PHG is important to recognize in patients with cirrhotic or non-cirrhotic portal hypertension because it can cause acute or chronic GI bleeding that often requires pharmacologic therapy.

Biopsy Diagnosis of Inherited Liver Disease

Hepatic dysfunction during childhood can be due to acquired or inherited etiologies or a combination. The distinction can be difficult to make on liver biopsy, because the inherited disorders are rare and often lack pathognomonic light microscopic features. Recent progress in understanding the pathogenesis of these disorders has led to advances in molecular genetic screening and confirmatory tests. For a majority of these disorders, the liver biopsy continues to play a crucial role in primary diagnosis or confirmation. This article discusses algorithms that may aid pathologists in differential diagnosis of common inherited disorders of the liver, with emphasis on ancillary diagnostic tools and reference assays that are critical in establishing the diagnosis.

Clinical research on navel application of Shehuang Paste combined with Chinese herbal colon dialysis in treatment of refractory cirrhotic ascites complicated with azotemia

AIM: To explore the efficacy and mechanism of a novel therapeutic method of traditional Chinese medicine in patients with refractory cirrhotic ascites complicated with azotemia.

METHODS: Seventy-five cases of refractory cirrhotic ascites complicated with azotemia were randomly divided into 3 groups: comprehensive treatment (n = 29), simple treatment (n = 24), and control (n = 22). The basic treatment methods were the same in all groups, including liver protecting medicines, diuretics and supportive drugs. The control group underwent only the basic treatment. Shehuang Paste (SHP) was applied to the navels of the two treatment groups once a day for 30 d. Colon dialysis with Chinese herbs was administered to the comprehensive treatment group once every two days. Before and after treatment, we measured abdominal circumference, BUN, Cr, serum Na⁺, urine Na⁺/K⁺, liver function, endotoxin content, NO, and ET-1. Color Doppler ultrasonography was conducted to measure the portal vein blood flow.

RESULTS: The total effective rate for ascites was 72.4% in the comprehensive treatment group, 45.8% in the simple treatment, contrasting with 18.2% in the controls. Between the two treatment groups and the controls, there were significant differences in the effective rates (P < 0.01, and P < 0.05). There was also a significant difference (P < 0.05) between the two treatment groups. Measurements of Cr and BUN showed higher values for the treatment groups, with the comprehensive better than the simple group (P < 0.05). Sera Na, urine Na/K were different, P < 0.01 between pre- and post-treatment in the comprehensive group, and P < 0.05 in the simple group. The treatment groups’ endotoxin content was also significantly reduced (P < 0.01, and P < 0.05), with the comprehensive group better than the simple group (P < 0.05). Portal vein blood flow and NO content significantly reduced (P < 0.05), as did ET-1 content (P < 0.01). There were no significant changes in the control group (P > 0.05). The comprehensive treatment group’s pre- and post-treatment portal vein and splenic vein blood flows showed a positive correlation to NO, ET-1 and endotoxin contents.

CONCLUSION: When treating refractory cirrhotic ascites complicated with azotemia, Shehuang Paste combined with Chinese herbal dialysis is better than Shehuang Paste alone for ascites resolution, azotemia, and endotoxin elimination. However, both methods on their own were also effective for reducing portal and splenic vein blood flow, and lowering the contents of NO, ET-1 in the two treatment groups.