The COVID-19 pandemic: Clinical practice advice for gastroenterologists, hepatologists, and liver transplant specialists

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a novel acute infectious disease that has rapidly reached staggering pandemic proportions. This review addresses gastroenterologists, hepatologists, liver transplant (LT) specialists, and health-care professionals working in the field of liver diseases and liver transplantation. It has been written based on a limited number of publications, recommendations of national and international liver and organ transplantation societies, and experiences of patients with COVID-19 around the world. The purpose of this review is to provide information addressing questions and concerns about COVID-19, to reveal the effects of the novel disease on patients with chronic liver disease and LT recipients, and to share information about ways in which this pandemic will affect clinical practices. We, the Turkish Association for the Study of the Liver (TASL), would like to remind you that this text is actually not a practical guide. It is imperative to act according to the standards set by health-care institutions and the Ministry of Health, Republic of Turkey.

Real-world efficacy and safety of Ledipasvir + Sofosbuvir and Ombitasvir/Paritaprevir/Ritonavir ± Dasabuvir combination therapies for chronic hepatitis C: A Turkish experience

BACKGROUND/AIMS

This study aimed to evaluate the real-life efficacy and tolerability of direct-acting antiviral treatments for patients with chronic hepatitis C (CHC) with/without cirrhosis in the Turkish population.

MATERIAL AND METHODS

A total of 4,352 patients with CHC from 36 different institutions in Turkey were enrolled. They received ledipasvir (LDV) and sofosbuvir (SOF)±ribavirin (RBV) orombitasvir/paritaprevir/ritonavir±dasabuvir (PrOD)±RBV for 12 or 24 weeks. Sustained virologic response (SVR) rates, factors affecting SVR, safety profile, and hepatocellular cancer (HCC) occurrence were analyzed.

RESULTS

SVR12 was achieved in 92.8% of the patients (4,040/4,352) according to intention-to-treat and in 98.3% of the patients (4,040/4,108) according to per-protocol analysis. The SVR12 rates were similar between the treatment regimens (97.2%-100%) and genotypes (95.6%-100%). Patients achieving SVR showed a significant decrease in the mean serum alanine transaminase (ALT) levels (50.90±54.60 U/L to 17.00±14.50 U/L) and model for end-stage liver disease (MELD) scores (7.51±4.54 to 7.32±3.40) (p<0.05). Of the patients, 2 were diagnosed with HCC during the treatment and 14 were diagnosed with HCC 37.0±16.0 weeks post-treatment. Higher initial MELD score (odds ratio [OR]: 1.92, 95% confidence interval [CI]: 1.22-2.38; p=0.023]), higher hepatitis C virus (HCV) RNA levels (OR: 1.44, 95% CI: 1.31-2.28; p=0.038), and higher serum ALT levels (OR: 1.38, 95% CI: 1.21-1.83; p=0.042) were associated with poor SVR12. The most common adverse events were fatigue (12.6%), pruritis (7.3%), increased serum ALT (4.7%) and bilirubin (3.8%) levels, and anemia (3.1%).

CONCLUSION

LDV/SOF or PrOD±RBV were effective and tolerable treatments for patients with CHC and with or without advanced liver disease before and after liver transplantation. Although HCV eradication improves the liver function, there is a risk of developing HCC.

Clinical and biochemical features and therapy responses in primary biliary cirrhosis and primary biliary cirrhosis-autoimmune hepatitis overlap syndrome

BACKGROUND/AIMS

Primary biliary cirrhosis and autoimmune hepatitis are two main immune-mediated liver diseases. Some patients display characteristics of both diseases, so called overlap syndrome. The aims of this study were to investigate and to compare the clinical and laboratory features and responses to therapy in primary biliary cirrhosis and overlap syndrome.

METHODOLOGY

Twenty-three patients with primary biliary cirrhosis (21 females, 2 males; median age: 50 years) and 20 with primary biliary cirrhosis-autoimmune hepatitis overlap syndrome (18 females, 2 males; median age: 44 years) were included in the study. All patients with primary biliary cirrhosis were treated with ursodeoxycholic acid. Of patients with overlap syndrome, 16 were treated with ursodeoxycholic acid and 4 with ursodeoxycholic acid plus prednisolone. Histological findings laboratory and clinical data were compared at the baseline and at the 2nd year of treatment.

RESULTS

Fatigue and pruritus were the most frequent and comparable symptoms in each group. Serum ALT, AST, gamma-glutamyl transpeptidase, total protein, globulin and gammaglobulin levels were higher in patients with overlap syndrome than those in patients with primary biliary cirrhosis. At the end of the 2nd year of the treatment, ALT normalization was achieved in 12 (52%), alkaline phosphatase in 7 (30%) patients with primary biliary cirrhosis. One of the non-responders to ursodeoxycholic acid therapy had the histological findings of overlap syndrome in her control biopsy. Fibrosis score deteriorated in 50% of the patients. Of ursodeoxycholic acid-treated overlap syndrome patients, 11 completed 2 years of treatment. Three patients were biochemically non-responsive and prednisolone was added to their regimen. Of the remaining 8 patients, 7 (64% of total patients) had normal ALT. Three patients had worse fibrosis score comparing the onset of the treatment. Six of 7 (86%) patients who were given ursodeoxycholic acid plus prednisolone including ursodeoxycholic acid-non-responsives had normal ALT and 2 of 6 biopsy-controlled patients display deterioration of their fibrosis score.

CONCLUSIONS

Biochemical tests tended to be higher in patients with overlap syndrome comparing to those with primary biliary cirrhosis. Response to ursodeoxycholic acid treatment in patients with overlap syndrome was comparable with that obtained in primary biliary cirrhosis. Therefore it should be the first-line treatment. Non-responsive patients may benefit from the use of ursodeoxycholic acid plus prednisolone combination.

Endoscopic injection therapy of bleeding Dieulafoy lesion of the stomach

BACKGROUND/AIMS

Dieulafoy's lesion is a rare cause of upper gastrointestinal bleeding and is potentially life threatening. The aim of this study is to determine the clinical features of these lesions and the efficacy of the endoscopic injection sclerotherapy in patients with Dieulafoy's lesion.

METHODOLOGY

Between January 1994 and December 2001, twenty-eight patients with upper gastrointestinal bleeding due to Dieulafoy's lesion were treated by endoscopic injection sclerotherapy. Efficacy of endoscopic therapy and clinical findings of these cases were analyzed.

RESULTS

The study group consisted of 22 male (78.5%) and 6 female (21.5%) patients with a mean age of 57 years (range 22-82 years). Significant comorbidity was present in 22 (78.5%) patients. Hemoglobin values of the patients ranged from 5.4-10.3 g/dL at hospitalization. The median transfusion requirement was 5 (range 0-12) units. Dieulafoy's lesion was observed in the proximal half of stomach in 25 cases (89.3%), in the antrum in 2 cases (7.1%) and in the angulus in 1 case (3.5%). Endoscopic injection sclerotherapy was successful in stopping the bleeding in 26 out of 28 patients (92.8%).

CONCLUSIONS

Dieulafoy's lesions mostly affect the proximal stomach and cause serious upper gastrointestinal bleeding. Endoscopic injection sclerotherapy is an effective and a safe therapeutic method for Dieulafoy's lesion.