Latin American Association for the study of the liver (ALEH) practice guidance for the diagnosis and treatment of non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) currently represents an epidemic worldwide. NAFLD is the most frequently diagnosed chronic liver disease, affecting 20-30% of the general population. Furthermore, its prevalence is predicted to increase exponentially in the next decades, concomitantly with the global epidemic of obesity, type 2 diabetes mellitus (T2DM), and sedentary lifestyle. NAFLD is a clinical syndrome that encompasses a wide spectrum of associated diseases and hepatic complications such as hepatocellular carcinoma (HCC). Moreover, this disease is believed to become the main indication for liver transplantation in the near future. Since NAFLD management represents a growing challenge for primary care physicians, the Asociación Latinoamericana para el Estudio del Hígado (ALEH) has decided to organize this Practice Guidance for the Diagnosis and Treatment of Non-Alcoholic Fatty Liver Disease, written by Latin-American specialists in different clinical areas, and destined to general practitioners, internal medicine specialists, endocrinologists, diabetologists, gastroenterologists, and hepatologists. The main purpose of this document is to improve patient care and awareness of NAFLD. The information provided in this guidance may also be useful in assisting stakeholders in the decision-making process related to NAFLD. Since new evidence is constantly emerging on different aspects of the disease, updates to this guideline will be required in future.

Comparison of different prognostic scores for patients with cirrhosis hospitalized with SARS-CoV-2 infection

INTRODUCTION AND OBJECTIVES

Viral infections have been described to increase the risk of decompensation in patients with cirrhosis. We aimed to determine the effect of SARS-CoV-2 infection on outcome of hospitalized patients with cirrhosis and to compare the performance of different prognostic models for predicting mortality.

PATIENTS

We performed a prospective cohort study including 2211 hospitalized patients with confirmed SARS-CoV-2 infection from April 15, 2020 through October 1, 2020 in 38 Hospitals from 11 Latin American countries. We registered clinical and laboratory parameters of patients with and without cirrhosis. All patients were followed until discharge or death. We evaluated the prognostic performance of different scoring systems to predict mortality in patients with cirrhosis using ROC curves.

RESULTS

Overall, 4.6% (CI 3.7-5.6) subjects had cirrhosis (n = 96). Baseline Child-Turcotte-Pugh (CTP) class was assessed: CTP-A (23%), CTP-B (45%) and CTP-C (32%); median MELD-Na score was 19 (IQR 14-25). Mortality was 47% in patients with cirrhosis and 16% in patients without cirrhosis (P < .0001). Cirrhosis was independently associated with death [OR 3.1 (CI 1.9-4.8); P < .0001], adjusted by age, gender, and body mass index >30. The areas under the ROC curves for performance evaluation in predicting 28-days mortality for Chronic Liver Failure Consortium (CLIF-C), North American Consortium for the Study of End-Stage Liver Disease (NACSELD), CTP score and MELD-Na were 0.85, 0.75, 0.69, 0.67; respectively (P < .0001).

CONCLUSIONS

SARS-CoV-2 infection is associated with elevated mortality in patients with cirrhosis. CLIF-C had better performance in predicting mortality than NACSELD, CTP and MELD-Na in patients with cirrhosis and SARS-CoV-2 infection. Clinicaltrials.gov:NCT04358380.

[Autoimmune hepatitis induced by isotretionine]

We describe a case of a teenage patient with the diagnosis of drug induced autoimmune hepatitis. The patient is a 16 years old female, with the past medical history of Hashimoto’s hypothyroidism controlled with levothyroxine, who started treatment with Isotretionin (®Accutane) 20 mg q/12 hours for a total of 3 months for the treatment of severe acne. The physical examination was within normal limits and the results of the laboratory exams are: Baseline values of ALT 28 U/L, AST 28 U/L. Three months later: AST 756 U/L, ALT 1199U/L, alkaline phosphatase 114 U/L, with normal bilirrubin levels throughout the process. The serology studies were negative for all viral hepatitis; ANA titers were positive (1/160) and igG levels were also elevated. A liver biopsy was performed, and was compatible with the diagnosis of autoimmune hepatitis. Corticosteroid therapy was started with Prednisone 40 mg per day one week after stopping the treatment with isotretionin, observing an improvement in the laboratory values. We describe this case and review the world literature since there are no reported cases of Isotretinoin-induced autoimmune hepatitis.

[Incidence and associated factors in ulcer bleeding recurrence post inyectotherapy with adrenaline]

AIM

To determine the incidence and associated factors with upper gastrointestinal bleeding after injection therapy with adrenaline in a general hospital.

STUDY DESIGN

longitudinal and analytic. Clinical records of patients with upper gastrointestinal bleeding who received injection therapy with adrenalin during 2005 and 2011 in Daniel Alcides Carrion Hospital, Peru were reviewed. Rebleeding and pre-endoscopic and endoscopic associated factors were sought. A bivariate (Chi Square, Fisher Exact test and RR) and multivariate analysis were performed.

RESULTS

A total of 111 patients were included. Rebleeding rate was 20.7%. Multivariate analysis showed active bleeding (p=0.002) and anticoagulant drugs (p=0.035) were associated with rebleeding.

CONCLUSION

Rebleeding rate was 20.7% and active bleeding as well as anticoagulant drugs use were associated factors.

[Celiac disease: descriptive study at the Anglo American clinic]

BACKGROUND

Celiac disease (CD) is a condition in which gluten intake develops an autoimmune response generating intestinal villous atrophy, causing malabsorption. Prevalence worldwide is approximately 1%, in our country it is not known.

MATERIAL AND METHODS

Retrospective, descriptive, observational study in Anglo American Clinic between September 2004 and February 2012. We reviewed the medical charts, upper GI endoscopy reports and duodenal biopsy reports of all patients with positive anti TTG results, who were older than 18 years of age.

RESULTS

We studied 39 cases, 26 (66.7%) women and 13 (33.3%) men. Mean age was 61.25 years. The symptoms were chronic diarrhea in 32 (82.1%), abdominal pain in 22 (56.4%), abdominal distention in 14 (35.9%), and others in lower frequency. Eight (20.5%) patients had anemia. Just 5 (12.8%) had upper endoscopy findings consistent with CD, and Marsh classification was: 0: 5 (12.7%), I: 1 (2.6%), II: 0 (0%), IIII A: 20 (51.3%), III B: 12 (30.8%) y III C: 1 (2.6%).

CONCLUSIONS

CD should be considered as a differential diagnosis of patients with non-specific long-term gastrointestinal symptoms, extraintestinal symptoms should also be taken into account. Diagnosis should be made with anti TTG as the initial test and posteriorly with a duodenal biopsy for staging.

[Cameron lesions: clinical experience]

Cameron lesions are becoming an increasingly important diagnosis in the evaluation of patients with iron deficiency anemia. We describe the demographic data, clinico-pathologic features and therapeutic outcome of a group of patients with Cameron lesions at a single private practice clinic in Lima, Peru. Twelve patients (9 men) were included in the report Median age at diagnosis was 71 years (range 49-91). Five patients had anemia and one of them had severe anemia. 91.7% of our patients presented with large hiatal| hernias. There were 5 patients with anemia and large hernias. Two patients tested positive for H. pylori. Two patients reported chronic NSAIDs use.

CONCLUSIONS

Cameron lesions are not an uncommon cause of chronic gastrointestinal bleeding and should be kept in mind in the study of patients with iron deficiency anemia.

[Autoimmune hepatitis with elevation of CA 19-9 and normalization with immunosuppressant [corrected]treatment: case report and review of the literature]

We describe the case of an 81 year old woman that presented with jaundice, bile duct dilation, hepatic liver tests abnormalities and elevated levels of CA-19-9 (741 UI). Intestinal and pancreatic neoplasia were ruled out. Hepatic biopsy revealed chronic inflammation, cirrhosis and findings consistent with autoimmune hepatitis. The patient was given a course of corticoids and the disease as well as levels of CA-19-9 returned to normal levels.

[Propofol in combination with meperidine and midazolam in colonoscopy and upper endoscopy: first prospective study in private practice in Peru]

INTRODUCTION

There is currently a vast experience reported in the literature with respect to Propofol utilization as a single agent and in combination with narcotics and/or benzodiazepines in endoscopic procedures, without the presence of an anesthesiologist in the endoscopy suite. Over 200 thousand reported procedures have demonstrated safety and excellent acceptance by patients.

OBJECTIVES

To report the experience in a private endoscopy center in Lima utilizing propofol in combination with Meperidine and Midazolam in colonoscopies and upper endoscopies, administered by a nurse supervised by a trained gastroenterologist without the presence of an anesthesiologist.

PATIENTS AND METHODS

We included adult patients with low or moderate risk for sedation, subjected to colonoscopy and / or upper endoscopy between November 2006 and September 2007 in the Gastroenterology Service at the Clinica Anglo Americana in Lima. Meperidine 25 mg IV was administered for colonoscopy and 50 mg IV for upper endoscopy and Midazolam 1.5 mg for both procedures as premedication. All the patients received Oxygen 2 L/min per nasal cannula throughout the procedure. After the above mentioned premedication, an initial bolus of propofol (10 - 30 mg) was administered, according to the general condition of the patient and the level of sedation achieved by the premedication, according to the judgement made by the gastroenterologist and the nurse. We registered the following variables: sex, age, average dose of propofol according to sex, age and procedure. We also registered adverse events such as desaturation < 90%, hypotension, bradycardia, need for assisted ventilation or hospitalization.

RESULTS

Four hundred procedures were performed, 315 colonoscopies (78.8%) and 85 upper endoscopies (21.3%). One hundred sixty one procedures (42.8%) were done in males and 229 (57.3%) in females. The average age was 60 years (22-91). The average propofol dose in general was 85.6 mg (10-330), 85.6, 87.7 mg in average for colonoscopies and 41.05 mg for upper endoscopies (p< 0.05). The average propofol dose for males was 78.4 mg and 91 mg for females (p<0.05). For patients younger than 70 years old (307) the average propofol dose was 91.6 mg and for patients older than 70 years old (93) it was 65.6 mg (p<0.05). We only registered one episode of oxygen desaturation to less than 90% (86%) responding to increase in the oxygen flow per nasal cannula and repositioning of the neck and chin. No patient required assisted ventilation or intubation, nor hospitalization for observation after the procedure. One hundred percent of the patients stated non having any discomfort whatsoever and expressed their satisfaction with the procedure.

CONCLUSIONS

Propofol combined with Meperine and Midazolam in endoscopic procedures is a safe agent administered by a trained gastroenterologist and nurse. Pacientes undergoing upper endoscopy, males and patients younger than 70 years old, required less doses of propofol compared with those subjected to colonoscopy, females and patients older than 70 years old respectively. We did not report complications or hospitalizations. Tolerance to endoscopic procedures with the above mentioned combination.

[Hereditary hemachromatosis: clinical case report and literature review]

Hemachromatosis is a hereditary condition, producing progressive iron overload as a result of the mutation in proteins that regulate intestinal iron absorption. It is a systemic disease with several manifestations including cirrhosis, diabetes mellitus, cardiomyopathy, joint disease and a proportion of asymptomatic patients. When it is diagnosed and treatment with phlebotomies is initiated before any organ damage is developed, the prognosis is very good, with normal survival free of manifestations. This condition is common in European populations. We report the case of a Peruvian patient of European ancestry who is asymptomatic, but has high levels of aminotransferases and elevated iron markers. Genetic testing confirmed the patient's diagnosis of hereditary hemachromatosis.

[Coexistence of Celiac Disease and autoimmune hepatitis case study and literature review]

The case of a patient who was initially diagnosed with Systemic Lupus Erythematosus, with subsequent documentation of Celiac Disease histologically and serologically is reported. The patient presented elevation of the aminotransferases, upon detection of the Celiac Disease which was initially attributed to the underlying disease. However, despite the complete resolution of her articular symptoms with a gluten-free diet, the liver chemistry abnormalities persisted. This led to consider an autoimmune hepatitis as the cause which was documented with a liver biopsy three months after the diagnosis of the celiac disease and under a strict gluten-free diet. Treatment with prednisone and azathioprine was initiated with complete normalization of aminotransferase levels. We present the sequence of events with the results and a review of the literature.

[Crohn's disease associated with focal pulmonare lesion]

40 year-old male recently diagnosed with Crohn's disease. A routine chest X ray showed a round, well defined opacity in right lung field. A chest CT scan confirmed the finding and also described bronchiectasis. Patient had no respiratory symptoms. He was prescribed with oral sulfasalazine and corticosteroids with rapid improvement of intestinal symptoms as well as resolution of the pulmonary opacity. We describe the clinical presentation of a male newly diagnosed with Crohn's disease who was found to have an asymptomatic pulmonary lesion on imaging studies. Pulmonary complications have been previously described in inflamatory bowel disease being more common in ulcerative colitis than in Crohn's disease; these can involve the lung parenchyma, the tracheobronchial tree, and the pleura. The true prevalence and etiology of these lesions is currently unknown and are not necessarily associated with bowel disease activity. Abnormal pulmonary functions test have been reported during inflammatory bowel disease exacerbations, and although pulmonary findings can present with a variety of symptoms, subclinical presentations have also been described. Pulmonary manifestations are usually steoid-responsive, as was the case in our patients.

[PRIMARY SCLEROSING CHOLANGITIS ASSOCIATED TO ULCERATIVECOLITIS AS A CAUSE OF CIRRHOSIS]

We report case of a peruvian patient with cirrhosis due to primary sclerosing cholangitis, associated with ulcerative colitis. The patient presented initially with intermittent diarrhea, manifesting features of chronic liver failure which progressed rapidly.Primary sclerosing cholangitis is a progressive diasease affecting intra and extrahepatic billary radicles, and is associated with ulcerative colitis in the majority of cases. The diagnosis is made by cholangiography, showing areas of stenosis, irregularity and dilatation of the biliary tree.In this article we report the clinical presentation and course of the patient, reviewing recent literature with emphasis in the association between primary sclerosing cholangitis and ulcerative colitis.

The uncleared fundal pool in acute upper gastrointestinal bleeding: implications and outcomes

BACKGROUND

The implications and outcomes of patients with an uncleared fundal pool of blood found at emergent upper endoscopy are not well described.

METHODS

We reviewed the records of 484 consecutive patients who presented over a 12-month period to our medical center with acute upper gastrointestinal hemorrhage. All patients underwent upper endoscopy within 24 hours of their initial presentation. Patients with an uncleared fundal pool of blood at initial endoscopy were included in this study, and their findings and outcomes were compared with a randomly selected subgroup of these same patients who did not have residual gastric blood.

RESULTS

Sixty-one patients (13%) had uncleared fundal pools despite gastric lavage and patient positioning. Findings on initial endoscopy included esophageal varices in 29 (47%), gastric ulcer in 12 (20%), portal hypertensive gastropathy in 5 (8%), Mallory-Weiss tear in 5 (8%), duodenal ulcer in 5 (8%), gastric varices in 4 (7%), Dieulafoy's lesion in 2 (3%), and other in 7 (11%). Twelve of these 61 patients had multiple findings and 4 (7%) had no lesion identified. Thirty-two of the 61 patients (52%) had at least one follow-up endoscopy, with new fundal lesions identified in 13 (41%): portal hypertensive gastropathy in 8, gastric ulcer in 2, gastric varices in 2, and leiomyoma in 1. Of these 13 new findings, 5 (38%) were judged significant either by the presence of active bleeding or stigmata of recent hemorrhage. Of the 4 patients with no identifiable lesion on initial endoscopy, 3 had a follow-up endoscopy and 2 were found to have a significant new finding in the fundus. The control group had a statistically significant lower percentage of endoscopic findings related to portal hypertension. Recurrent bleeding during the index hospitalization occurred in 54% of the patients with uncleared fundal pools versus 11% of the control group (0 < 0.01). Length of stay, number of units of blood transfused, need for emergent surgery for bleeding, as well as overall and bleeding-related mortality were all significantly greater in the patients with the uncleared fundal pool than in the control patients.

CONCLUSIONS

The inability to clear a fundal pool of blood at emergent upper endoscopy is associated with significant morbidity and mortality. Further, new fundal lesions can be identified in 41% of patients on follow-up examination, with many being clinically significant. These data support the importance of clearing a fundal pool in patients undergoing endoscopy for upper gastrointestinal bleeding.

[Abdominal pain originated in nonvisceral structures]

In this paper causes of abdominal pain originated in non visceral structures are reviewed, focusing in clinical and anatomical aspects.

Small bowel push-type fiberoptic enteroscopy for patients with occult gastrointestinal bleeding or suspected small bowel pathology

OBJECTIVES

Endoscopic investigation of the small intestine remains the last frontier for gastroendoscopists. We evaluated the diagnostic efficacy and safety of two different push-type, fiberoptic enteroscopes in the investigation of patients with occult gastrointestinal bleeding or suspected small bowel pathology.

METHODS

Sixty-six patients (28 men, 38 women; mean age, 68) underwent push-type enteroscopy with either the SIF 10.5L (n = 17; scope length, 2495 mm) or the SIF 3000 (n = 49; length, 2995 mm) enteroscopes (Olympus America, Inc., Lake Success, New York). All patients enrolled had an indication of either occult gastrointestinal bleeding (n = 55) or suspected small bowel pathology (n = 11). Push-type enteroscopy was performed with an overtube and fluoroscopic guidance to better estimate the degree of insertion. Assessments of mucosal visualization, tip deflection, procedure tolerance, and complications were noted.

RESULTS

Visualization of the small bowel mucosa and tip deflection was rated excellent in all patients. The mean length of insertion past the ligament of Treitz for the SIF 10.5L was 90 cm and 113 cm for the SIF 3000. Only one complication, a pharyngeal tear, occurred with the SIF 3000. Lesions that may explain the occult GI bleeding were found in 35 out of 55 patients (64%). Twenty-one of these 35 patients (60%) had lesions proximal to the ligament of Treitz, and 14 patients (40%) had lesions distal to the ligament of Treitz. If only distal lesions were considered, the diagnostic yield was 25% (14/55) for occult GI bleeding and 73% (8/11) for suspected small bowel pathology. The most common lesions were arteriovenous malformations (34%), which were successfully cauterized.

CONCLUSION

With a relatively high diagnostic yield and therapeutic capability, push-type enteroscopy should play an important role in the investigation and treatment of lesions causing occult GI bleeding and small bowel pathology.