Several scoring systems predict mortality in alcohol-associated hepatitis (AH), including the Maddrey discriminant function (mDF) and model for end-stage liver disease (MELD) score developed in the ...United States, Glasgow alcoholic hepatitis score in the United Kingdom, and age, bilirubin, international normalized ratio, and creatinine score in Spain. To date, no global studies have examined the utility of these scores, nor has the MELD-sodium been evaluated for outcome prediction in AH. In this study, we assessed the accuracy of different scores to predict short-term mortality in AH and investigated additional factors to improve mortality prediction.
Patients admitted to hospital with a definite or probable AH were recruited by 85 tertiary centers in 11 countries and across 3 continents. Baseline demographic and laboratory variables were obtained. The primary outcome was all-cause mortality at 28 and 90 days.
In total, 3,101 patients were eligible for inclusion. After exclusions (n = 520), 2,581 patients were enrolled (74.4% male, median age 48 years, interquartile range 40.9-55.0 years). The median MELD score was 23.5 (interquartile range 20.5-27.8). Mortality at 28 and 90 days was 20% and 30.9%, respectively. The area under the receiver operating characteristic curve for 28-day mortality ranged from 0.776 for MELD-sodium to 0.701 for mDF, and for 90-day mortality, it ranged from 0.773 for MELD to 0.709 for mDF. The area under the receiver operating characteristic curve for mDF to predict death was significantly lower than all other scores. Age added to MELD obtained only a small improvement of AUC.
These results suggest that the mDF score should no longer be used to assess AH's prognosis. The MELD score has the best performance in predicting short-term mortality.
Beyond conventional physical examination in hepatology: POCUS Velarde-Ruiz Velasco, J.A.; Tapia Calderón, D.K.; Llop Herrera, E. ...
Revista de Gastroenterología de México (English Edition),
2023 Oct-Dec, 2023-10-00, 2023-10-01, Letnik:
88, Številka:
4
Journal Article
Recenzirano
Odprti dostop
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.
La ecografía en el punto de atención (POCUS) se refiere a la utilización del ultrasonido (US) mediante dispositivos ultrasonográficos de bolsillo, al pie de la cama del paciente, con el objetivo de establecer un diagnóstico o dirigir un procedimiento y responder a una cuestión clínica de forma inmediata, su finalidad es ampliar la exploración física, no sustituir la evaluación ultrasonográfica convencional. POCUS ha evolucionado como un complemento del examen físico siendo adoptado por distintas especialidades médicas, incluyendo la hepatología. Se elaboró una síntesis de evidencia narrativa sobre las aplicaciones de POCUS en hepatología, describiendo la utilidad de POCUS en el diagnóstico de cirrosis hepática, enfermedad hepática esteatósica asociada a disfunción metabólica (MASLD, por sus siglas en inglés), cirrosis descompensada y el diagnóstico de hipertensión portal, así como las más recientes aplicaciones de POCUS en la evaluación hemodinámica del paciente con cirrosis hepática en estado crítico, otras enfermedades hepáticas y guía ultrasonográfica de procedimientos.
POCUS podría formar parte de la práctica clínica diaria de gastroenterólogos y hepatólogos, simplificando la evaluación inicial de los pacientes y optimizando el manejo clínico. Su accesibilidad, facilidad de uso y bajo perfil de efectos adversos la hacen una herramienta útil para el médico propiamente entrenado en el escenario clínico adecuado, por lo que el objetivo de esta revisión fue describir la evidencia que existe sobre la utilidad de POCUS en la práctica clínica diaria de gastroenterólogos y hepatólogos.
Alcoholic liver disease (ALD) is a clinical-pathologic entity caused by the chronic excessive consumption of alcohol. The disease includes a broad spectrum of anomalies at the cellular and tissual ...level that can cause acute-on-chronic (alcoholic hepatitis) or chronic (fibrosis, cirrhosis, hepatocellular cancer) injury, having a great impact on morbidity and mortality worldwide. Alcohol is metabolized mainly in the liver. During alcohol metabolism, toxic metabolites, such as acetaldehyde and oxygen reactive species, are produced. At the intestinal level, alcohol consumption can cause dysbiosis and alter intestinal permeability, promoting the translocation of bacterial products and causing the production of inflammatory cytokines in the liver, perpetuating local inflammation during the progression of ALD. Different study groups have reported systemic inflammatory response disturbances, but reports containing a compendium of the cytokines and cells involved in the pathophysiology of the disease, from the early stages, are difficult to find. In the present review article, the role of the inflammatory mediators involved in ALD progression are described, from risky patterns of alcohol consumption to advanced stages of the disease, with the aim of understanding the involvement of immune dysregulation in the pathophysiology of ALD.
La enfermedad hepática alcohólica (EHA) es una entidad clínico-patológica, ocasionada por el consumo excesivo y crónico de alcohol. La enfermedad incluye un amplio espectro de anomalías a nivel celular y tisular que pueden causar daño agudo sobre crónico (hepatitis alcohólica) o crónico (fibrosis, cirrosis, cáncer hepatocelular), teniendo un gran impacto en la morbilidad y mortalidad a nivel mundial. El alcohol es metabolizado principalmente en el hígado. Durante el metabolismo del alcohol son generados metabolitos tóxicos como el acetaldehído y las especies reactivas de oxígeno. A nivel intestinal, el consumo de alcohol puede producir disbiosis y alteración de la permeabilidad intestinal, promoviendo la translocación de productos bacterianos, y provocando la producción de citocinas proinflamatorias en el hígado, lo cual perpetua la inflamación local durante la evolución de la EHA. Diferentes grupos de estudio han reportado alteraciones de la respuesta inflamatoria a nivel sistémico, sin embargo, es difícil encontrar reportes que contengan un compendio de las células y citocinas involucradas en la fisiopatología de la enfermedad desde sus etapas tempranas. En este trabajo de revisión se describe el papel de los mediadores inflamatorios involucrados en la progresión de la EHA, desde los patrones de consumo de riesgo hasta etapas avanzadas de la enfermedad, con la finalidad de comprender la implicación de la desregulación inmunológica en la fisiopatología de esta enfermedad.
Background and Aims
Data regarding outcome of COVID‐19 in patients with autoimmune hepatitis (AIH) are lacking.
Approach and Results
We performed a retrospective study on patients with AIH and ...COVID‐19 from 34 centers in Europe and the Americas. We analyzed factors associated with severe COVID‐19 outcomes, defined as the need for mechanical ventilation, intensive care admission, and/or death. The outcomes of patients with AIH were compared to a propensity score–matched cohort of patients without AIH but with chronic liver diseases (CLD) and COVID‐19. The frequency and clinical significance of new‐onset liver injury (alanine aminotransferase > 2 × the upper limit of normal) during COVID‐19 was also evaluated. We included 110 patients with AIH (80% female) with a median age of 49 (range, 18‐85) years at COVID‐19 diagnosis. New‐onset liver injury was observed in 37.1% (33/89) of the patients. Use of antivirals was associated with liver injury (P = 0.041; OR, 3.36; 95% CI, 1.05‐10.78), while continued immunosuppression during COVID‐19 was associated with a lower rate of liver injury (P = 0.009; OR, 0.26; 95% CI, 0.09‐0.71). The rates of severe COVID‐19 (15.5% versus 20.2%, P = 0.231) and all‐cause mortality (10% versus 11.5%, P = 0.852) were not different between AIH and non‐AIH CLD. Cirrhosis was an independent predictor of severe COVID‐19 in patients with AIH (P < 0.001; OR, 17.46; 95% CI, 4.22‐72.13). Continuation of immunosuppression or presence of liver injury during COVID‐19 was not associated with severe COVID‐19.
Conclusions
This international, multicenter study reveals that patients with AIH were not at risk for worse outcomes with COVID‐19 than other causes of CLD. Cirrhosis was the strongest predictor for severe COVID‐19 in patients with AIH. Maintenance of immunosuppression during COVID‐19 was not associated with increased risk for severe COVID‐19 but did lower the risk for new‐onset liver injury during COVID‐19.
The sofosbuvir-velpatasvir (SOF/VEL) combination is a direct-acting antiviral therapy that is authorized and available in Mexico, making the performance of a real-world multicenter study that ...evaluates the sustained virologic response at 12 weeks post-treatment a relevant undertaking.
A retrospective review of the case records of 241 patients seen at 20 hospitals in Mexico was conducted to assess hepatitis C treatment with the SOF/VEL combination (n = 231) and the sofosbuvir/velpatasvir/ribavirin (SOF/VEL/RBV) combination (n = 10). The primary efficacy endpoint was the percentage of patients that achieved SVR at 12 weeks after the end of treatment.
Overall SVR was 98.8% (95% CI 97.35-100%). Only three patients did not achieve SVR, two of whom had cirrhosis and a history of previous treatment with peg-IFN. Of the subgroups analyzed, all the patients with HIV coinfection, three patients with genotype 3, and the patients treated with the SOF/VEL/RBV combination achieved SVR. The subgroups with the lower success rates were patients that were treatment-experienced (96.8%) and patients with F1 fibrosis (95.5%). The most frequent adverse events were fatigue, headache, and insomnia. No serious adverse events were reported.
Treatments with SOF/VEL and SOF/VEL/RBV were highly safe and effective, results coinciding with those of other international real-world studies.
Management of the patient with cirrhosis of the liver that requires surgical treatment has been relatively unexplored. In Mexico, there is currently no formal stance or expert recommendations to ...guide clinical decision-making in this context.
The present position paper reviews the existing evidence on risks, prognoses, precautions, special care, and specific management or procedures for patients with cirrhosis that require surgical interventions or invasive procedures. Our aim is to provide recommendations by an expert panel, based on the best published evidence, and consequently ensure timely, quality, efficient, and low-risk care for this specific group of patients.
Twenty-seven recommendations were developed that address preoperative considerations, intraoperative settings, and postoperative follow-up and care.
The assessment and care of patients with cirrhosis that require major surgical or invasive procedures should be overseen by a multidisciplinary team that includes the anesthesiologist, hepatologist, gastroenterologist, and clinical nutritionist. With respect to decompensated patients, a nephrology specialist may be required, given that kidney function is also a parameter involved in the prognosis of these patients.
El terreno del paciente con cirrosis que requiere de una intervención quirúrgica ha sido poco explorado. En México, a la fecha no contamos con un posicionamiento formal o recomendaciones de expertos que ayuden a la toma de decisiones clínicas en este contexto.
Revisar la evidencia existente sobre el riesgo, pronóstico, precauciones, cuidados especiales y manejo o proceder específico para los pacientes con cirrosis que requieren ser intervenidos quirúrgicamente o mediante procedimientos invasivos, para emitir recomendaciones por un panel experto, basadas en la mejor evidencia publicada para la atención oportuna, de calidad, eficiente y con el menor riesgo posible en este grupo específico de pacientes.
Se obtuvieron 27 recomendaciones, en donde se abordan el terreno preoperatorio, el escenario transoperatorio y el seguimiento y cuidados postoperatorios.
La valoración y cuidado del paciente con cirrosis que requiere un procedimiento quirúrgico o invasivo mayor, debe estar a cargo de un equipo multidisciplinario que brinde soporte al cirujano, durante todo el perioperatorio, este equipo debe incluir al anestesiólogo, hepatólogo, gastroenterólogo, nutriólogo clínico. En el paciente descompensado, puede ser necesario involucrar especialistas en nefrología ya que la función renal es un parámetro implicado también en el pronóstico de estos pacientes.
Primary biliary cholangitis (PBC) is characterized by the presence of specific antimitochondrial autoantibodies (AMA), antinuclear autoantibodies (ANA), or documented by liver biopsy, treatment with ...ursodeoxycholic acid (UDCA) has implication in disease progression and survival without a liver transplant. This study aimed to know the clinical characteristics of patients with PBC.
Observational, descriptive, longitudinal and retrospective study, case series study. It included patients aged 18 to 80 years seen in the Liver Clinic consultation with a diagnosis of PBC in the Hospital General de Mexico from 2015 to 2022.
Sixty patients were evaluated; 95% were women, the most frequent age of presentation was between the fifth and sixth decade of life, the prevalence of AMA was 95%, the other 5% were diagnosed by liver biopsy or specific ANA, the presence of other antibodies was 26% of which the most frequent, were ANA. Transitional elastography was performed in 68% of the patients and documented significant fibrosis in 68% and some degree of steatosis in 30%. The association with autoimmune diseases is 33%; Sjögren's syndrome and scleroderma are the most representative. Overlap with autoimmune hepatitis was documented in 25%. Osteometabolic disease was present in up to 35%. The response to treatment to AUDC, as measured by the Paris II Score, was 31%.
The clinical characteristics are similar to those described in the literature. The low response rate to UDCA is striking, which is a factor implicated in the progression of the disease, which correlate with the high degree of documented fibrosis.
The resources used in this study were from the hospital without any additional financing
The authors declare no potential conflicts of interest.
A hepatic abscess (HA) accumulates purulent material in the liver parenchyma and can be of bacterial, parasitic, fungal, or mixed origin. The incidence ranges from 2.3 to 22 per 100,000 people. In ...Mexico, the annual incidence of amoebic liver abscess is 6.7 per 100,000 population.
To determine the clinical, biochemical, and imaging characteristics in patients diagnosed with amoebic and bacterial liver abscess.
Research design: Descriptive, cross-sectional/prevalence.
We analyzed medical records of patients admitted during 2019 with a diagnosis of liver abscess and who had an amoeba PCR test. The qualitative variables were expressed in frequencies and percentages; the numerical variables were mean and standard deviation. We use X2, Fisher's exact, Student's t, and Mann-Whitney U to compare groups as appropriate.
Of a total of 32 patients admitted with a liver abscess in Gastroenterology during 2019, 20 patients treated with drainage and PCR test for amoeba of the abscess fluid were included. Of these, 85%(17) were men with a mean age of 45.35±10.93 years, and 55%(11) were of bacterial etiology. Regarding the characteristics due to their etiology (amoebic vs. bacterial): 30%(6) were presented in segments VII and VIII; 33.3%(2/6) amoebic vs. 66.7%(4/6) bacterial. According to the number, they were multiple; 28.6%(2/7) amoebic vs 71.4%(5/7) bacterial, unique; 53.8%(7/13) amoebic vs 46.2%(6/13) bacterial, without significant difference (p = 0.37). 60%(12) presented with pleural effusion, and of these, 58.3%(7) were amoebic. 100% were drained, of which 50% were by catheter with a diameter of 14Fr. Regarding the laboratory studies: 80%(16) of those with amoebic etiology had cultures of the abscess fluid without development, the leukocytes were 18.65 ± 6.55mm3 with a range of 16.5 in the amoebians vs. 14.58±6.51mm3 with a range of 17.6 in bacteria, Hb of 12.10±1.93 gr/dl in amoebians vs. 12.18 ± 1.72 gr/dl in bacteria and with procalcitonin of 18.06±12.77 gr/dl in amoebic vs. 19.98±59.76 gr/dl in bacterial. According to the imaging studies: the USG diameter was 10.67±2.78cm in amoebians vs. 10.53±4.91cm in bacteria and with a volume of 375.08±263.95 with a range of 782.0cm3 in amebic vs. 441.80±393.90 with a range of 1362.1cm3 in bacterial.
Common etiologic agents for HA are E. histolytica (amoebic), bacterial (pyogenic), Mycobacterium tuberculosis, and various fungi. They tend to affect the younger population, especially men with immunosuppression, diabetes, and alcohol consumption. In developing countries, two-thirds are of amoebic origin and in need of puncture drainage. Our study observed that half had amoebic etiology corroborated by amoeba PCR, the majority unique, and almost all required drainage with diameters greater than 5cm by USG.
In the present work, we can show that half of the patients diagnosed with a liver abscess in the Gastroenterology Service are of amoebic origin and have similar characteristics to those described in the international bibliography.
The authors declare that there is no conflict of interest.
Portal vein thrombosis (PVT) refers to the formation of blood clots within the trunk of the portal vein (PV) or its main branches, which can spread to the superior mesenteric (SMV) and splenic (VE) ...veins. The natural history of liver cirrhosis is a complication with a "rebalanced" coagulation system that can promote bleeding or a thrombotic tendency. The prevalence in compensated cirrhotic is 1% in and 8-25% in decompensated patients.
To determine the prevalence and characteristics of PV recanalization in cirrhotic patients with PVT.
Descriptive, cross-sectional/prevalence.
We reviewed medical records of all cirrhotic patients admitted with PVT diagnosis from January 2019 to April 2021. We included patients with a diagnosis of PVT. Qualitative variables were expressed as frequencies and percentages. The numerical variables were expressed as means and standard deviations. We use X2, Fisher's exact, Student's t, and Mann-Whitney U to compare groups as appropriate.
Of 553 cirrhotic patients admitted from January 2019 to April 2021, 48(8.67%) patients with PVT diagnoses were included. Of these, 27(56.3%) were women, with a mean age of 59.37±12.67 years, 9(18%) with a diagnosis of cancer, of which 8(16.7%) were hepatocellular carcinoma, 2(33.3%) extended to the two arms, 6(12.5%) received treatment, 100% of the treatment was based on low molecular weight heparin. According to the degree of recanalization: 37(77.08%) recanalized, 27(56.3%) did so partially, of them, 24(88.9%) were spontaneous; 10(20.8%) recanalized utterly, of which 90% were without treatment, with no significant difference between recanalization to free progression vs. treatment (p=0.179) and 11(22.9%) did not recanalize. Regarding the characteristics of the thrombosis by imaging studies, 26(54.2%) were chronic, 28(58%) partial, only 9(18.8%) with cavernomatous transformation, 30(62.5%) were located in the main trunk, 6(12.5%) extended to the SLM and 11(22.9%) presented flow <15cm/s.
In cirrhotics with recent or partial occlusion (> 50% of the lumen) or thrombosis of the main PV or SMV, therapy should be considered. Anticoagulant or interventional therapy has no benefit complete chronic occlusion of the main PV or cavernomatous transformation. Spontaneous recanalization occurs in 40% in 3 months, and with therapy, it is 80%. Several cohort studies reported that near 50% recanalize partially or totally in the next three months, and up to 80% recanalize at 12 months. Clinical trial data are weak regarding the indications for treatment for PVT without ischemic symptoms. Our study showed that 77.08% of cirrhotic patients with PVT recanalized, most partially during follow-up and more than 80% spontaneously, and only a low percentage presented with cavernomatous transformation. In addition, more than 70% of the patients who recanalized have a low risk of re-thrombosis related to flow.
The prevalence of PVT in cirrhotic patients was relatively low (10%), complete or partial recanalization was very high, even spontaneously, there was no difference in the degree of recanalization with or without anticoagulation.
The authors declares that there is no conflict of interest
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