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Velarde-Ruiz Velasco JA, Tapia Calderón DK, Llop Herrera E, Castro Narro G, García Jiménez ES, Cerda Reyes E, Higuera de la Tijera F, Cano Contreras AD, Moreno Alcántar R, Chávez Ramírez RM, Calleja Panero JL. Beyond conventional physical examination in hepatology: POCUS. Rev Gastroenterol Mex (Engl Ed) 2023; 88:381-391. [PMID: 37833134 DOI: 10.1016/j.rgmxen.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 07/26/2023] [Indexed: 10/15/2023]
Abstract
Point-of-care ultrasound (POCUS) refers to the use of ultrasound imaging through pocket-sized sonographic devices at the patient's bedside, to make a diagnosis or direct a procedure and immediately answer a clinical question. Its goal is to broaden the physical examination, not to replace conventional ultrasound studies. POCUS has evolved as a complement to physical examination and has been adopted by different medical specialties, including hepatology. A narrative synthesis of the evidence on the applications of POCUS in hepatology was carried out, describing its usefulness in the diagnosis of cirrhosis of the liver, metabolic dysfunction-associated steatotic liver disease (MASLD), decompensated cirrhosis, and portal hypertension. The review also encompasses more recent applications in the hemodynamic evaluation of the critically ill patient with cirrhosis of the liver, patients with other liver diseases, as well as in the ultrasound guidance of procedures. POCUS could make up part of the daily clinical practice of gastroenterologists and hepatologists, simplifying the initial evaluation of patients and optimizing clinical management. Its accessibility, ease of use, and low adverse event profile make POCUS a useful tool for the properly trained physician in the adequate clinical setting. The aim of this review was to describe the available evidence on the usefulness of POCUS in the daily clinical practice of gastroenterologists and hepatologists.
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Affiliation(s)
- J A Velarde-Ruiz Velasco
- Servicio de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico; Departamento de Clínicas Médicas, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - D K Tapia Calderón
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Puerta de Hierro, IDIPHISA, Ciberhd, Majadahonda, Madrid, Spain.
| | - E Llop Herrera
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Puerta de Hierro, IDIPHISA, Ciberhd, Majadahonda, Madrid, Spain
| | - G Castro Narro
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - E S García Jiménez
- Servicio de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | - E Cerda Reyes
- Servicio de Gineco-Obstetricia, Hospital Central Militar, Mexico City, Mexico
| | - F Higuera de la Tijera
- Servicio de Gastroenterología, Hospital General de México Dr. Eduardo Liceaga, Mexico City, Mexico
| | - A D Cano Contreras
- Instituto de Investigaciones Médico-Biológicas, Universidad Veracruzana, Veracruz, Mexico
| | - R Moreno Alcántar
- Unidad Médica de Alta Especialidad Hospital de Especialidades CMN SXXI, Mexico City, Mexico
| | - R M Chávez Ramírez
- Unidad de Cuidados Intensivos, Hospital de Ginecoobstetricia, UMAE CMNO IMSS, Guadalajara, Jalisco, Mexico
| | - J L Calleja Panero
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Puerta de Hierro, IDIPHISA, Ciberhd, Majadahonda, Madrid, Spain
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2
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Romero-Gómez M. Non-alcoholic steatohepatitis. Med Clin (Barc) 2022; 159:388-395. [PMID: 36075749 DOI: 10.1016/j.medcli.2022.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 06/05/2022] [Accepted: 06/08/2022] [Indexed: 10/14/2022]
Abstract
Non-alcoholic steatohepatitis belongs to the spectrum of metabolic-associated fatty liver diseases characterized by steatosis linked to obesity, diabetes, metabolic syndrome, dyslipidemia and immune-mediated disorders. The main features of MAFLD include high prevalence, heterogeneity, complexity and dynamic disease. Pruritus and asthenia are the main clinical manifestation that impact on quality of life and patient-reported outcomes. Biochemical or imagen-based non-invasive test have been implemented in the diagnostic process. Liver biopsy remains as the gold standard. Therapeutic options included life-style intervention. Mediterranean hypocaloric Diet to lose weight, exercise to fight sarcopenia and alcohol abstinence. In non-responders, drug-therapy focusing on obesity, diabetes and fibrosis using sequentially or combined to promote steatosis, inflammation and fibrosis regression.
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Affiliation(s)
- Manuel Romero-Gómez
- Servicio de Aparato Digestivo, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERHD), Departamento de Medicina, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (HUVR/CSIC/US), Universidad de Sevilla, Sevilla, España.
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3
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Tafur Sánchez CN, Durá Gil M, Alemán Domínguez Del Río A, Hernández Pérez CM, Mora Cuadrado N, de la Cuesta SG, Primo Martín D, de Luis Román D, de la Fuente RA. The practical utility of non-invasive indices in metabolic hepatic steatosis. ENDOCRINOL DIAB NUTR 2022; 69:418-425. [PMID: 35787355 DOI: 10.1016/j.endien.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 08/10/2021] [Indexed: 06/15/2023]
Abstract
BACKGROUND Metabolic hepatic steatosis (metHS) is the most frequent cause of chronic liver disease in our environment. The "gold standard" for its diagnosis continues to be liver biopsy, but this is an invasive technique, is not risk-free, and has great interobserver variability, so noninvasive diagnostic methods are necessary. OBJECTIVE To determine the diagnostic accuracy of non-invasive methods based on clinical and analytical data compared to liver biopsy, and to analyse their concordance with each other in the overall cohort and in subpopulations at risk of metHS. METHODS Prospective observational study of 245 patients aged 19-80 years diagnosed with metHS by liver biopsy. Steatosis indices were calculated: FLI (Fatty Liver Index), LAP (Liver Accumulation Product), HSI-(Hepatitis Score Index) and fibrosis indices: Non-alcoholic fatty liver disease fibrosis score (NFS), fibrosis-4 index (FIB-4) and Hepamet Fibrosis Score (HFS). RESULTS The non-invasive steatosis indices showed high sensitivity, and those of fibrosis, high specificity. To assess steatosis, FLI was the most sensitive index in all subpopulations (89-97%), except in women. To assess fibrosis, HFS offers maximum sensitivity in diabetics (86.7%) and is the index with the highest negative predictive value overall. The COR curves for non-invasive indices in steatosis and fibrosis compared to liver biopsy showed greater areas under the curve for the fibrosis indices, with NFS and HFS offering greater diagnostic accuracy (area > 0.8, p < 0.05). HFS also offers high diagnostic sensitivity in the diabetic population. CONCLUSIONS Non-invasive indices of steatosis are more sensitive and those of fibrosis more specific than liver biopsy. NFS and HFS offer the highest diagnostic accuracy, with HFS having the highest negative predictive value.
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Affiliation(s)
| | - Miguel Durá Gil
- Servicio de Aparato Digestivo, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | | | | | - Natalia Mora Cuadrado
- Servicio de Aparato Digestivo, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | | | - David Primo Martín
- Servicio de Aparato Digestivo, Hospital Clínico Universitario de Valladolid, Valladolid, Spain; Facultad de Medicina, Universidad de Valladolid, Valladolid, Spain; Centro de Investigación de Endocrinología y Nutrición, Valladolid, Spain
| | - Daniel de Luis Román
- Servicio de Aparato Digestivo, Hospital Clínico Universitario de Valladolid, Valladolid, Spain; Facultad de Medicina, Universidad de Valladolid, Valladolid, Spain; Centro de Investigación de Endocrinología y Nutrición, Valladolid, Spain
| | - Rocío Aller de la Fuente
- Servicio de Aparato Digestivo, Hospital Clínico Universitario de Valladolid, Valladolid, Spain; Facultad de Medicina, Universidad de Valladolid, Valladolid, Spain; Centro de Investigación de Endocrinología y Nutrición, Valladolid, Spain; Grupo de Investigación Biomédica en Medicina Crítica (BioCritic), Valladolid, Spain
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4
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Marciano S, Dirchwolf M, Torres MC, Allevato J, García Dans C, García B, Pollarsky F, Gaite L, Sirotinsky E, Rios B, Anselmo MN, Peche M, Hurtado E, Haddad L, Narvaez A, Mauro E, Martinez A, Bellizzi C, Ratusnu N, D'Amico C, Arora S, Gadano A. Fibrosis assessment in patients with nonalcoholic fatty liver disease: Adherence to proposed algorithms and barriers to complying with them. Rev Gastroenterol Mex (Engl Ed) 2021; 87:4-12. [PMID: 34690105 DOI: 10.1016/j.rgmxen.2021.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 08/24/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION AND AIMS Fibrosis staging in patients with nonalcoholic fatty liver disease (NAFLD) is carried out through the application of stepwise algorithms but there is little real-world data on their use. Our aim was to calculate the number of patients with NAFLD and indeterminate or high risk for fibrosis, assessed through noninvasive scores, that consequently underwent further staging evaluation. MATERIALS AND METHODS A cross-sectional multicenter cohort study was conducted on patients with NAFLD evaluated by hepatologists within the time frame of June 1 and July 31, 2018. The FIB-4 and NAFLD fibrosis scores were calculated in all the patients, and if at least one of the scores suggested indeterminate or high risk for fibrosis, we believed the patient should have undergone additional fibrosis staging assessment. RESULTS The study included 238 patients. The median time interval from NAFLD diagnosis and inclusion in the analysis was 12.2 months (IQR 3.0-36.5). A total of 128 (54%) patients had at least one noninvasive score that suggested indeterminate or high risk for fibrosis but studies to confirm the fibrosis grade (elastography, biopsy, etc.) were performed on only 72 (56%). The main barriers encountered by the physicians for applying the staging algorithms were related to health insurance coverage and imaging study costs. CONCLUSIONS A high percentage of patients with NAFLD were at indeterminate or high risk for fibrosis, according to noninvasive scores, but additional studies were carried out on only half of them, showing low adherence to current recommendations.
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Affiliation(s)
- S Marciano
- Sección Hepatología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Departamento de Investigación, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | - M Dirchwolf
- Sección Hepatología, Hospital Privado de Rosario, Rosario, Argentina
| | - M C Torres
- Sección Hepatología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - J Allevato
- Unidad de Diagnóstico y Tratamiento para Enfermedades Hepáticas de Neuquén, Neuquén, Argentina
| | - C García Dans
- Sección Hepatología, Hospital Zonal Bariloche Dr. Ramón Carrillo, Bariloche, Argentina
| | - B García
- Sección Hepatología, Centro de Estudios Digestivos de Mendoza, Mendoza, Argentina
| | - F Pollarsky
- Sección Hepatología, Hospital Dr. Carlos Bonorino Udaondo, Buenos Aires, Argentina
| | - L Gaite
- Sección Hepatología, Clínica de Nefrología, Santa Fe, Argentina
| | - E Sirotinsky
- Centro de Estudios Digestivos, Comodoro Rivadavia, Argentina
| | - B Rios
- Hepatología, Centro de Investigación, Neuquén, Argentina
| | - M N Anselmo
- Sección Gastroenterología y Hepatología, Hospital Zonal Esquel, Esquel, Argentina
| | - M Peche
- Hospital López Lima Gral Roca, Rio Negro, Argentina
| | - E Hurtado
- Hospital Municipal Coronel Suárez, Buenos Aires, Argentina
| | - L Haddad
- Sección Hepatología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - A Narvaez
- Sección Hepatología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - E Mauro
- Sección Hepatología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - A Martinez
- Sección Gastroenterología, Hospital Juan A. Fernández, Buenos Aires, Argentina
| | - C Bellizzi
- Sección Gastroenterología, Hospital Juan A. Fernández, Buenos Aires, Argentina
| | - N Ratusnu
- Hospital Regional de Ushuaia, Ushuaia, Tierra del Fuego, Argentina
| | - C D'Amico
- Hepatología, CEMA - Centro de Especialidades Médicas Ambulatoria, Mar del Plata, Argentina
| | - S Arora
- Project ECHO, School of Medicine, University of New Mexico, Albuquerque, New Mexico, United States
| | - A Gadano
- Sección Hepatología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Departamento de Investigación, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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5
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Marciano S, Dirchwolf M, Torres MC, Allevato J, García Dans C, García B, Pollarsky F, Gaite L, Sirotinsky E, Rios B, Anselmo MN, Peche M, Hurtado E, Haddad L, Narvaez A, Mauro E, Martinez A, Bellizzi C, Ratusnu N, D Amico C, Arora S, Gadano A. Fibrosis assessment in patients with nonalcoholic fatty liver disease: Adherence to proposed algorithms and barriers to complying with them. Rev Gastroenterol Mex (Engl Ed) 2021; 87:S0375-0906(21)00015-X. [PMID: 33773856 DOI: 10.1016/j.rgmx.2020.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 08/13/2020] [Accepted: 08/24/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION AND AIMS Fibrosis staging in patients with nonalcoholic fatty liver disease (NAFLD) is carried out through the application of stepwise algorithms but there is little real-world data on their use. Our aim was to calculate the number of patients with NAFLD and indeterminate or high risk for fibrosis, assessed through noninvasive scores, that consequently underwent further staging evaluation. MATERIALS AND METHODS A cross-sectional multicenter cohort study was conducted on patients with NAFLD evaluated by hepatologists within the time frame of June 1 and July 31, 2018. The FIB-4 and NAFLD fibrosis scores were calculated in all the patients, and if at least one of the scores suggested indeterminate or high risk for fibrosis, we believed the patient should have undergone additional fibrosis staging assessment. RESULTS The study included 238 patients. The median time interval from NAFLD diagnosis and inclusion in the analysis was 12.2months (IQR 3.0-36.5). A total of 128 (54%) patients had at least one noninvasive score that suggested indeterminate or high risk for fibrosis but studies to confirm the fibrosis grade (elastography, biopsy, etc.) were performed on only 72 (56%). The main barriers encountered by the physicians for applying the staging algorithms were related to health insurance coverage and imaging study costs. CONCLUSIONS A high percentage of patients with NAFLD were at indeterminate or high risk for fibrosis, according to noninvasive scores, but additional studies were carried out on only half of them, showing low adherence to current recommendations.
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Affiliation(s)
- S Marciano
- Sección Hepatología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Departamento de Investigación, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | - M Dirchwolf
- Sección Hepatología, Hospital Privado de Rosario, Rosario, Argentina
| | - M C Torres
- Sección Hepatología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - J Allevato
- Unidad de Diagnóstico y Tratamiento para Enfermedades Hepáticas de Neuquén, Neuquén, Argentina
| | - C García Dans
- Sección Hepatología, Hospital Zonal Bariloche Dr. Ramón Carrillo, Bariloche, Argentina
| | - B García
- Sección Hepatología, Centro de Estudios Digestivos de Mendoza, Mendoza, Argentina
| | - F Pollarsky
- Sección Hepatología, Hospital Dr. Carlos Bonorino Udaondo, Buenos Aires, Argentina
| | - L Gaite
- Sección Hepatología, Clínica de Nefrología, Santa Fe, Argentina
| | - E Sirotinsky
- Centro de Estudios Digestivos, Comodoro Rivadavia, Argentina
| | - B Rios
- Hepatología, Centro de Investigación, Neuquén, Argentina
| | - M N Anselmo
- Sección Gastroenterología y Hepatología, Hospital Zonal Esquel, Esquel, Argentina
| | - M Peche
- Hospital López Lima Gral Roca, Rio Negro, Argentina
| | - E Hurtado
- Hospital Municipal Coronel Suárez, Buenos Aires, Argentina
| | - L Haddad
- Sección Hepatología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - A Narvaez
- Sección Hepatología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - E Mauro
- Sección Hepatología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - A Martinez
- Sección Gastroenterología, Hospital Juan A. Fernández, Buenos Aires, Argentina
| | - C Bellizzi
- Sección Gastroenterología, Hospital Juan A. Fernández, Buenos Aires, Argentina
| | - N Ratusnu
- Hospital Regional de Ushuaia, Ushuaia, Tierra del Fuego, Argentina
| | - C D Amico
- Hepatología, CEMA - Centro de Especialidades Médicas Ambulatoria, Mar del Plata, Argentina
| | - S Arora
- Project ECHO, School of Medicine, University of New Mexico, Albuquerque, New Mexico, Estados Unidos de América
| | - A Gadano
- Sección Hepatología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Departamento de Investigación, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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Vieira J, Amorim J, Martí-Bonmatí L, Alberich-Bayarri Á, França M. Quantifying steatosis in the liver and pancreas with MRI in patient with chronic liver disease. Radiologia (Engl Ed) 2020; 62:222-228. [PMID: 31932016 DOI: 10.1016/j.rx.2019.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 09/08/2019] [Accepted: 11/04/2019] [Indexed: 12/13/2022]
Abstract
AIM To compare pancreatic and hepatic steatosis quantified by proton density fat fraction (PDFF) on magnetic resonance imaging (MRI) in patients with chronic liver disease. MATERIAL AND METHODS This cross-sectional study included 46 adult patients who underwent liver biopsy for chronic viral hepatitis (n=19) or other chronic non-alcoholic liver diseases (NALD) (n=27). Liver biopsy was used as the gold standard for diagnosing and grading hepatic steatosis. All patients underwent clinical evaluation and MRI with a multi-echo chemical shift-encoded (MECSE) gradient-echo sequence for liver and pancreas PDFF quantification. We used Spearman's correlation coefficient to determine the degree of association between hepatic PDFF and steatosis grade, and between pancreatic PDFF and steatosis grade and hepatic PDFF. To compare the chronic viral hepatitis group and the NALD group, we used t-tests for continuous or ordinal variables and chi-square tests for categorical variables. RESULTS Hepatic PDFF measurements correlated with steatosis grades (RS=0.875, p<0.001). Pancreatic PDFF correlated with hepatic steatosis grades (RS=0.573, p<0.001) and hepatic PDFF measurements (RS=0.536, p<0.001). In the subgroup of patients with chronic NALD, the correlations remained significant between pancreatic PDFF and hepatic PDFF (RS=0.632, p<0.001) and between pancreatic PDFF and liver steatosis (RS=0.608, p<0.001); however, in the subgroup of patients with viral hepatitis these correlations were no longer significant. CONCLUSION Pancreatic fat deposition correlates with hepatic steatosis in patients with chronic NALD, but not in those with chronic viral hepatitis.
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Affiliation(s)
- J Vieira
- Instituto de Ciências Biomédicas de Abel Salazar (ICBAS), Universidad de Oporto, Oporto, Portugal.
| | - J Amorim
- Departamento de Diagnóstico por la Imagen, Centro Hospitalar do Porto, Oporto, Portugal; Escola de Medicina, Universidade do Minho, Braga, Portugal; ICVS/3B's, Instituto de Investigación de Ciencias de la Vida y la Salud, Universidade do Minho, Braga, Portugal
| | - L Martí-Bonmatí
- Departamento de Radiología y Grupo de Investigación Biomédica en Imagen GIBI2(30). Hospital Universitario y Politécnico La Fe e Instituto de Investigación Sanitaria La Fe, Valencia, España
| | - Á Alberich-Bayarri
- Departamento de Radiología y Grupo de Investigación Biomédica en Imagen GIBI2(30). Hospital Universitario y Politécnico La Fe e Instituto de Investigación Sanitaria La Fe, Valencia, España; Quantitative Imaging Biomarkers in Medicine (QUIBIM), Valencia, España
| | - M França
- Instituto de Ciências Biomédicas de Abel Salazar (ICBAS), Universidad de Oporto, Oporto, Portugal; Departamento de Diagnóstico por la Imagen, Centro Hospitalar do Porto, Oporto, Portugal; i3S, Instituto de Investigacão e Inovação em Saúde, IBMC, Instituto de Biología Molecular y Celular, Oporto, Portugal
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7
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Velarde-Ruiz Velasco JA, García-Jiménez ES, García-Zermeño KR, Morel-Cerda EC, Aldana-Ledesma JM, Castro-Narro GE, Cerpa-Cruz S, Tapia-Calderón DK, Mercado-Jauregui LA, Contreras-Omaña R. Extrahepatic complications of non-alcoholic fatty liver disease: Its impact beyond the liver. Rev Gastroenterol Mex (Engl Ed) 2019; 84:472-481. [PMID: 31488310 DOI: 10.1016/j.rgmx.2019.05.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Revised: 04/20/2019] [Accepted: 05/02/2019] [Indexed: 12/12/2022]
Abstract
Non-alcoholic fatty liver disease (NAFLD) is currently one of the main causes of chronic liver disease in Western countries, with a 25% prevalence reported in the general population worldwide. Visceral adiposity and liver fat promote a state of systemic inflammation, predisposing individuals with NAFLD to the extrahepatic pathologies of cardiovascular disease (the most common cause of death in patients with NAFLD), diabetes mellitus, chronic kidney disease, hypothyroidism, polycystic ovary syndrome, obstructive sleep apnea, and an increased risk for presenting with gastrointestinal and extraintestinal neoplasias. Different mechanisms between NAFLD and its association with extrahepatic diseases have been reported, and lipotoxicity is the main cause of inflammatory pathway activation that results in extrahepatic tissue damage.
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Affiliation(s)
- J A Velarde-Ruiz Velasco
- Servicio de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, México.
| | - E S García-Jiménez
- Servicio de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, México
| | - K R García-Zermeño
- Servicio de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, México
| | - E C Morel-Cerda
- Servicio de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, México
| | - J M Aldana-Ledesma
- Servicio de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, México
| | - G E Castro-Narro
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - S Cerpa-Cruz
- Servicio de Reumatología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, México
| | - D K Tapia-Calderón
- Servicio de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, México
| | - L A Mercado-Jauregui
- Servicio de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, México
| | - R Contreras-Omaña
- Centro de Investigación en Enfermedades Hepáticas y Gastroenterología (CIEHG), Pachuca, Hidalgo, México
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8
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Caballeria L, Augustin S, Broquetas T, Morillas RM, Vergara M, Virolés S, Hernández MR, Serra I, Goday A, Vila L, Siso-Almirall A, Solans R, Fernández-Real JM, Carrión JA, Graupera I, Ginès P. Recommendations for the detection, diagnosis and follow-up of patients with non-alcoholic fatty liver disease in primary and hospital care. Med Clin (Barc) 2019; 153:169-177. [PMID: 31178295 DOI: 10.1016/j.medcli.2019.01.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 01/22/2019] [Accepted: 01/24/2019] [Indexed: 12/18/2022]
Abstract
Non-alcoholic fatty liver disease (NAFLD) is one of the most common chronic liver diseases, with a prevalence of 20-30% in the general population and 60-80% in at-risk populations. In a not negligible percentage of patients, NAFLD progresses from steatosis to different stages of fibrosis and cirrhosis. Due to its high prevalence, NAFLD has become a significant health problem that requires specific action in detection, diagnosis, follow-up and treatment. Furthermore, given that NAFLD presents an increased risk of cardiovascular morbidity and mortality, a multidisciplinary approach is required for its treatment and follow-up. Patients with early stages of the disease, without fibrosis, can be diagnosed and receive treatment in the Primary Care setting, while those with more advanced liver disease benefit from specialised follow-up in the hospital setting to prevent and treat liver complications. This consensus document, prepared by the Catalan Societies of Digestology, Primary Care, Endocrinology, Diabetes and Internal Medicine, arises from the need to design strategies to guide patient flows between Primary and Hospital Care in order to offer patients with NAFLD the best care according to the stage of their disease. The consensus document describes the most commonly used non-invasive diagnostic methods for patient diagnosis and two algorithms have been designed for patient management in both Primary Care and Hospital Care.
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Affiliation(s)
- Llorenç Caballeria
- Unitat de Suport a la Recerca Metropolitana Nord, Institut Universitari d'Investigació en Atenció Primària Jordi Gol, Mataró, Barcelona, España; Societat Catalana de Medicina Familiar i Comunitària (CAMFIC), Barcelona, España; Grupo de trabajo sobre «Hígado graso no alcohólico» de la Societat Catalana de Digestologia, Barcelona, España
| | - Salvador Augustin
- Servei de Medicina Interna - Hepatologia, Hospital Universitari Vall d'Hebron, Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) Instituto de Salud Carlos III, España; Grupo de trabajo sobre «Hígado graso no alcohólico» de la Societat Catalana de Digestologia, Barcelona, España
| | - Teresa Broquetas
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) Instituto de Salud Carlos III, España; Sección de Hepatología, Servicio de Digestivo, Hospital del Mar, Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Universitat Autònoma de Barcelona (UAB), Barcelona, España; Grupo de trabajo sobre «Hígado graso no alcohólico» de la Societat Catalana de Digestologia, Barcelona, España
| | - Rosa Maria Morillas
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) Instituto de Salud Carlos III, España; Secció de Hepatologia, Servei Aparell Digestiu, Hospital Germans Trias i Pujol, Badalona, Universitat Autònoma de Barcelona, España; Grupo de trabajo sobre «Hígado graso no alcohólico» de la Societat Catalana de Digestologia, Barcelona, España
| | - Mercè Vergara
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) Instituto de Salud Carlos III, España; Unidad de Hepatología, Servicio Digestivo, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, España; Grupo de trabajo sobre «Hígado graso no alcohólico» de la Societat Catalana de Digestologia, Barcelona, España
| | - Silvia Virolés
- Unitat de Digestiu, Servei Medicina Interna, Hospital de Figueres, Institut d'Investigació Biomèdica de Girona (IDIBGI), Girona, España; Grupo de trabajo sobre «Hígado graso no alcohólico» de la Societat Catalana de Digestologia, Barcelona, España
| | - Mª Rosario Hernández
- Societat Catalana de Medicina Familiar i Comunitària (CAMFIC), Barcelona, España; Centre Atenció Primària-La Marina, SAP Esquerre Barcelona, Institut Català de la Salut, Barcelona, España; Grupo de trabajo sobre «Hígado graso no alcohólico» de la Societat Catalana de Digestologia, Barcelona, España
| | - Isabel Serra
- Departament d'Hepatologia, Hospital Dr. Josep Trueta, Girona, España; Grupo de trabajo sobre «Hígado graso no alcohólico» de la Societat Catalana de Digestologia, Barcelona, España
| | - Alberto Goday
- Servicio de Endocrinología, Hospital del Mar, Barcelona, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, España; Centro de Investigación Biomédica en Red de Enfermedades de la Obesidad y Nutrición (CiberOBN), Instituto de Salud Carlos III, España; Associació Catalana de Diabetes, Barcelona, España
| | - Lluis Vila
- Servei d'Endocrinologia i Nutrició, Hospital de Sant Joan Despí Moisès Broggi, Sant Joan Despí, Barcelona, España; Societat Catalana d'Endocrinologia i Nutrició, Barcelona, España
| | | | - Rosa Solans
- Societat Catalano-Balear de Medicina Interna (SCBMI) de l'Acadèmia de Ciències Mèdiques de Catalunya i Balears (ACMCB), Barcelona, España
| | - Jose Manuel Fernández-Real
- Centro de Investigación Biomédica en Red de Enfermedades de la Obesidad y Nutrición (CiberOBN), Instituto de Salud Carlos III, España; Servei d'Endocrinologia i Nutrició, Hospital de Girona «Dr. Josep Trueta». Institut d'Investigació Biomèdica de Girona (IdIbGi), Departament de Ciències Mèdiques, Facultat de Medicina, Universitat de Girona, Girona, España; Grupo de trabajo sobre «Hígado graso no alcohólico» de la Societat Catalana de Digestologia, Barcelona, España
| | - Jose Antonio Carrión
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) Instituto de Salud Carlos III, España; Sección de Hepatología, Servicio de Digestivo, Hospital del Mar, Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Universitat Autònoma de Barcelona (UAB), Barcelona, España; Grupo de trabajo sobre «Hígado graso no alcohólico» de la Societat Catalana de Digestologia, Barcelona, España
| | - Isabel Graupera
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) Instituto de Salud Carlos III, España; Servei d'Hepatologia, Hospital Clínic, Universitat de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, España; Grupo de trabajo sobre «Hígado graso no alcohólico» de la Societat Catalana de Digestologia, Barcelona, España.
| | - Pere Ginès
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) Instituto de Salud Carlos III, España; Servei d'Hepatologia, Hospital Clínic, Universitat de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, España; Grupo de trabajo sobre «Hígado graso no alcohólico» de la Societat Catalana de Digestologia, Barcelona, España
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Aller R, Fernández-Rodríguez C, Lo Iacono O, Bañares R, Abad J, Carrión JA, García-Monzón C, Caballería J, Berenguer M, Rodríguez-Perálvarez M, Miranda JL, Vilar-Gómez E, Crespo J, García-Cortés M, Reig M, Navarro JM, Gallego R, Genescà J, Arias-Loste MT, Pareja MJ, Albillos A, Muntané J, Jorquera F, Solà E, Hernández-Guerra M, Rojo MÁ, Salmerón J, Caballería L, Diago M, Molina E, Bataller R, Romero-Gómez M. Consensus document. Management of non-alcoholic fatty liver disease (NAFLD). Clinical practice guideline. Gastroenterol Hepatol 2018; 41:328-349. [PMID: 29631866 DOI: 10.1016/j.gastrohep.2017.12.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 09/11/2017] [Accepted: 12/01/2017] [Indexed: 02/07/2023]
Abstract
Non-alcoholic fatty liver disease (NAFLD) is the main cause of liver diseases in Spain and the incidence is raising due to the outbreak of type 2 diabetes and obesity. This CPG suggests recommendation about diagnosis, mainly non-invasive biomarkers, and clinical management of this entity. Life-style modifications to achieve weight loss is the main target in the management of NAFLD. Low caloric Mediterranean diet and 200 minutes/week of aerobic exercise are encouraged. In non-responders patients with morbid obesity, bariatric surgery or metabolic endoscopy could be indicated. Pharmacological therapy is indicated in patients with NASH and fibrosis and non-responders to weight loss measures. NAFLD could influence liver transplantation, as a growing indication, the impact of steatosis in the graft viability, de novo NAFLD rate after OLT and a raised cardiovascular risk that modify the management of this entity. The current CPG was the result of the First Spanish NAFLD meeting in Seville.
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Affiliation(s)
- Rocío Aller
- Servicio de Gastroenterología, Hospital Clínico Universitario de Valladolid. Facultad de Medicina, Universidad de Valladolid. Centro de Investigación de Endocrinología y Nutrición, Facultad de Medicina, Universidad de Valladolid, Valladolid, España
| | - Conrado Fernández-Rodríguez
- Servicio de Gastroenterología, Hospital Universitario Fundación Alcorcón. Facultad de Medicina, Universidad Rey Juan Carlos, Alcorcón, Madrid, España
| | - Oreste Lo Iacono
- Servicio de Aparato Digestivo, Hospital del Tajo, Aranjuez, Madrid, España
| | - Rafael Bañares
- Servicio de Gastroenterología y Hepatología, Hospital Gregorio Marañón, Madrid, España
| | - Javier Abad
- Servicio de Gastroenterología y Hepatología, Hospital Puerta de Hierro, Madrid, España
| | | | | | - Joan Caballería
- Unidad de Hepatología, Hospital Clínic, IDIBAPS, CIBERehd, Barcelona, España
| | - Marina Berenguer
- Servicio de Medicina Digestiva, Hospital La Fe, Valencia, España
| | | | - José López Miranda
- Unidad de Trasplante Hepático, UGC de Aparato Digestivo, Hospital Reina Sofía, Córdoba, España
| | - Eduardo Vilar-Gómez
- UGC Aparato Digestivo, CIBERehd, Instituto de Biomedicina de Sevilla. Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla, España
| | - Javier Crespo
- Servicio Aparato Digestivo, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria. CIBERehd. Instituto de Investigación Valdecilla (IDIVAL), Santander, España
| | | | - María Reig
- Unidad de Hepatología, Hospital Clínic, IDIBAPS, CIBERehd, Barcelona, España
| | - José María Navarro
- Unidad de Hepatología, Servicio de Digestivo, Hospital Costa del Sol, Marbella, Málaga, España
| | - Rocío Gallego
- UGC Aparato Digestivo, CIBERehd, Instituto de Biomedicina de Sevilla. Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla, España
| | - Joan Genescà
- Servicio de Medicina Interna-Hepatología, Hospital Universitario Vall d'Hebron, Institut de Recerca Vall d'Hebron (VHIR), Universitat Autònoma de Barcelona, CIBERehd , Barcelona, España
| | - María Teresa Arias-Loste
- Servicio Aparato Digestivo, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria. CIBERehd. Instituto de Investigación Valdecilla (IDIVAL), Santander, España
| | | | - Agustín Albillos
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS). CIBERehd, Madrid, España
| | - Jordi Muntané
- UGC de Cirugía General y Aparato Digestivo, Hospital Universitario Virgen del Rocío/Instituto de Biomedicina de Sevilla/CSIC/Universidad de Sevilla. CIBERehd, Sevilla, España
| | - Francisco Jorquera
- Servicio de Aparato Digestivo, Complejo Asistencial Universitario de León, IBIOMED y CIBERehd, León, España
| | - Elsa Solà
- Unidad de Hepatología, Hospital Clínic, IDIBAPS, CIBERehd, Barcelona, España
| | | | - Miguel Ángel Rojo
- Servicio de Gastroenterología, Hospital Clínico Universitario de Valladolid. Facultad de Medicina, Universidad de Valladolid. Centro de Investigación de Endocrinología y Nutrición, Facultad de Medicina, Universidad de Valladolid, Valladolid, España
| | - Javier Salmerón
- UGC de Aparato Digestivo, Hospital San Cecilio, Granada, España
| | - Llorenc Caballería
- Unidad de Apoyo a la Investigación de la Atención Primaria en la Metropolitana Norte, Barcelona, España
| | - Moisés Diago
- Servicio de Aparato Digestivo, Hospital General de Valencia, Valencia, España
| | - Esther Molina
- Unidad de Hepatología, Servicio de Aparato Digestivo, Hospital Clínico-Xerencia de Xestión Integrada de Santiago de Compostela, Santiago de Compostela, La Coruña, España
| | - Ramón Bataller
- Liver Unit, University of Pittsburg Medical Center, Pittsburg, Pennsylvania, Estados Unidos
| | - Manuel Romero-Gómez
- UGC Aparato Digestivo, CIBERehd, Instituto de Biomedicina de Sevilla. Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla, España.
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10
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Stoopen-Rometti M, Encinas-Escobar ER, Ramirez-Carmona CR, Wolpert-Barraza E, Kimura-Hayama E, Sosa-Lozano LA, Favila R, Kimura-Fujikami Y, Saavedra-Abril JA, Loaeza-Del Castillo A. Diagnosis and quantification of fibrosis, steatosis, and hepatic siderosis through multiparametric magnetic resonance imaging. Rev Gastroenterol Mex 2017; 82:32-45. [PMID: 28089429 DOI: 10.1016/j.rgmx.2016.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 05/31/2016] [Accepted: 06/16/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND The presence of liver fibrosis is the common denominator in numerous chronic liver diseases that can progress to fibrosis and hepatocellular carcinoma. Most important, with respect to frequency, are viral hepatitis and non-alcoholic fatty liver disease, the prevalence of which is increasing in epidemic proportions. Liver biopsy, albeit imperfect, continues to be the criterion standard, but in many clinical situations tends to be replaced with noninvasive imaging methods. OBJECTIVES The aim of the present article was to describe our imaging department experience with magnetic resonance elastography and to analyze and discuss recently published results in gastroenterology, hepatology, and radiology from other authors in the literature, complemented with a PubMed search covering the last 10 years. RESULTS AND CONCLUSIONS Magnetic resonance elastography is an efficacious, noninvasive method with results that are concordant with liver biopsy. It is superior to ultrasound elastography because it evaluates a much greater volume of hepatic tissue and shows the often heterogeneous lesion distribution. The greatest advantage of the magnetic resonance protocol described is the fact that it quantifies fibrosis, fat content, and iron content in the same 25min examination specifically directed for that purpose, resulting in a favorable cost-benefit ratio for the patient and/or institution.
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Affiliation(s)
- M Stoopen-Rometti
- Departamento de Imagen, C.T. Scanner Lomas Altas, Ciudad de México, México.
| | - E R Encinas-Escobar
- Curso Universitario de Radiología, C.T. Scanner, Instituto Nacional de Cardiología Ignacio Chávez, Universidad Nacional Autónoma de México, Ciudad de México, México
| | | | - E Wolpert-Barraza
- Unidad de Gastroenterología y Hepatología, Clínica Lomas Altas, Ciudad de México, México
| | - E Kimura-Hayama
- Departamento de Imagen, C.T. Scanner Lomas Altas, Ciudad de México, México
| | - L A Sosa-Lozano
- Departamento de Imagen, C.T. Scanner de México, Ciudad de México, México
| | - R Favila
- General Electric Healthcare, Durango, México
| | - Y Kimura-Fujikami
- Departamento de Imagen, C.T. Scanner de México, Ciudad de México, México
| | - J A Saavedra-Abril
- Departamento de Imagen, C.T. Scanner Lomas Altas, Ciudad de México, México
| | - A Loaeza-Del Castillo
- Unidad de Gastroenterología y Hepatología, Clínica Lomas Altas, Ciudad de México, México
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11
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Segura Grau A, Valero López I, Díaz Rodríguez N, Segura Cabral JM. [Liver ultrasound: focal lesions and diffuse diseases]. Semergen 2014; 42:307-14. [PMID: 25523277 DOI: 10.1016/j.semerg.2014.10.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2014] [Revised: 07/20/2014] [Accepted: 10/20/2014] [Indexed: 12/25/2022]
Abstract
Liver ultrasound is frequently used as a first-line technique for the detection and characterization of the most common liver lesions, especially those incidentally found focal liver lesions, and for monitoring of chronic liver diseases. Ultrasound is not only used in the Bmode, but also with Doppler and, more recently, contrast-enhanced ultrasound. It is mainly used in the diagnosis of diffuse liver diseases, such as steatosis or cirrhosis. This article presents a practical approach for diagnosis workup, in which the different characteristics of the main focal liver lesions and diffuse liver diseases are reviewed.
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Affiliation(s)
- A Segura Grau
- Unidad de Ecografía San Francisco de Asís, Centro de Diagnóstico Ecográfico, Coordinadora del GTE en Madrid de Semergen, Madrid, España.
| | - I Valero López
- Centro de Salud Valleaguado. Centro de Diagnóstico Ecográfico. Miembro GTE en Madrid de Semergen, Madrid, España
| | | | - J M Segura Cabral
- Aparato Digestivo, Unidad de Ecografía San Francisco de Asís, Centro de Diagnóstico Ecográfico, Madrid, España
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12
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Bessone F, Poles N, Roma MG. Challenge of liver disease in systemic lupus erythematosus: Clues for diagnosis and hints for pathogenesis. World J Hepatol 2014; 6:394-409. [PMID: 25018850 PMCID: PMC4081614 DOI: 10.4254/wjh.v6.i6.394] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 03/08/2014] [Accepted: 05/14/2014] [Indexed: 02/06/2023] Open
Abstract
Systemic lupus erythematosus (SLE) encompass a broad spectrum of liver diseases. We propose here to classify them as follows: (1) immunological comorbilities (overlap syndromes); (2) non-immunological comorbilities associated to SLE; and (3) a putative liver damage induced by SLE itself, referred to as "lupus hepatitis". In the first group, liver injury can be ascribed to overlapping hepatopathies triggered by autoimmune mechanisms other than SLE occurring with higher incidence in the context of lupus (e.g., autoimmune hepatitis, primary biliary cirrhosis). The second group includes non-autoimmune liver diseases, such as esteatosis, hepatitis C, hypercoagulation state-related liver lesions, hyperplasic parenchymal and vascular lesions, porphyria cutanea tarda, and drug-induced hepatotoxicity. Finally, the data in the literature to support the existence of a hepatic disease produced by SLE itself, or the occurrence of a SLE-associated prone condition that increases susceptibility to acquire other liver diseases, is critically discussed. The pathological mechanisms underlying each of these liver disorders are also reviewed. Despite the high heterogeneity in the literature regarding the prevalence of SLE-associated liver diseases and, in most cases, lack of histopathological evidence or clinical studies large enough to support their existence, it is becoming increasingly apparent that liver is an important target of SLE. Consequently, biochemical liver tests should be routinely carried out in SLE patients to discard liver disorders, particularly in those patients chronically exposed to potentially hepatotoxic drugs. Diagnosing liver disease in SLE patients is always challenging, and the systematization of the current information carried out in this review is expected to be of help both to attain a better understanding of pathogenesis and to build an appropriate work-up for diagnosis.
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Affiliation(s)
- Fernando Bessone
- Fernando Bessone, Natalia Poles, Gastroenterology and Hepatology Department, University of Rosario School of Medicine, Rosario 2000, Argentina
| | - Natalia Poles
- Fernando Bessone, Natalia Poles, Gastroenterology and Hepatology Department, University of Rosario School of Medicine, Rosario 2000, Argentina
| | - Marcelo G Roma
- Fernando Bessone, Natalia Poles, Gastroenterology and Hepatology Department, University of Rosario School of Medicine, Rosario 2000, Argentina
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