Introduction

Sarcopenia defined as having low muscle mass, muscle strength and if combined with low performance indicate severe sarcopenia¹. It is associated with adverse outcomes in cirrhosis, including hepatic encephalopathy, ascites, infection, and increased hospitalisation. Sarcopenia is measured using cross-sectional CT scanning. Thigh ultrasound (TUS) may be a low-cost tool to identify sarcopenia in cirrhosis.

Aims & Methods

We aim to validate TUS for measurement of total-muscle-thickness (TMT) and superficial fat thickness (SF) in cirrhosis using bioelectrical impedance analysis (BIA) as a standard. Cirrhotic patients were recruited from a tertiary-hepatology-clinic for this prospective cross-sectional study. Using TUS at right thigh, average readings on B-mode at one-half of the total distance from the top-of-the-patella to the iliac crest were recorded. BIA was performed as the validation standard (SECA mBCA 525) using Sergi-sarcopenia-equation². Validated functional muscle metrics (gait speed, handgrip, and sit-to-stand) and liver-frailty-index (LFI)³ were recorded. Statistical analysis was performed using Stata version 17.0.

Results

Total of 124 individuals were recruited. 80 patients {56% (n=45) alcohol-liver-disease, 19% (n=15) non-alcoholic steatohepatitis, 5% (n=4) viral, 4% (n=3) autoimmune, 12% (n=10) combination of above and 4% (n=3) other aetiologies} were included. 44 healthy controls (HC) were included. Most patients were male (n=45, 56%), with mean age 59 years old (SD=10), mean Child-Pugh score 6 (IQR=5-7) and MELD 11 (IQR=7-12). 14 patients (18%) had clinical ascites and 27% (n=19) were actively drinking alcohol. Of cirrhotic, 15 (33%) male and 2 (6%) female were sarcopenic.
Using TUS, TMT was lower in cirrhotic cohort vs HC (female: 17.9 vs 29 mm and male: 32 vs 43.7 mm, SD 7 and 9 respectively, p < 0.001). BIA height adjusted appendiceal muscle mass (ASMI) correlates strongly with TMT (r=0.46, P <0.001). BIA height-adjusted skeletal muscle mass (SMI) also strongly correlated with TUS-measured TMT (male r=0.71 and female r=0.43, P<0.001). it was found that TMT significantly predicted SMI both in male and female patient ( β= 0.39 vs 0.2 with P <0.001 and P=0.02 respectively).
TMT ≥ 3.66 cm in men would exclude sarcopenia (sensitivity=71%, specificity=82%) with likelihood ratio of 3.92 and AUROC 0.85. Intra-rater and Inter-rater reliability for TMT was good (p<0.001). SF measured through TUS strongly correlated with height-adjusted fat mass via BIA (r = 0.58, P< 0.001).
Using functional testing, HCs were walking faster (3.11 vs 4.25 secs, p <0.001). Sit-to-stand time was lower in HCs (8.94 vs 13.4 secs, p =0.001) and hand-grip strength higher in HC (p< 0.001). 13% (n=6) of male and 26% (n=9) of female were frail and frailty scores negatively correlated with TMT (r=-0.3, p=0.005).

Conclusion

TUS is a rapid, valid point-of-care test which can identify high-risk patients with systemic sarcopenia in cirrhosis. Furthermore, lower TMT is associated with increased frailty and reduced muscle function in cirrhosis. Further prospective studies are required to determine if this can be used with other biomarkers to identify patients who would benefit from intensive nutrition intervention.

References

1. Alfonso J Cruz-Jentoft et al. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing 2019 Jan 1;48(1):16-31
2. Giuseppe Sergi et al. Assessing appendicular skeletal muscle mass with bioelectrical impedance analysis in free-living Caucasian older adults. Clin Nutr. 2015 Aug; 34(4):667-73
3.Jennifer C Lai et al. Development of a novel frailty index to predict mortality in patients with end-stage liver disease Hepatology 2017 Aug;66(2): 564-574

Introduction

Gastroesophageal reflux disease (GERD) is associated with an increased risk of esophageal adenocarcinoma, but whether patients with non-erosive GERD, i.e., GERD symptoms without esophageal mucosal abnormalities, are at an increased risk is unknown.

Aims & Methods

This population-based cohort study included all 486,556 patients who underwent endoscopy for GERD in Finland, Denmark, or Sweden from 1987-2019. Non-erosive GERD was defined by an absence of esophagitis and any other esophageal diagnosis within 12 months of the endoscopy, while erosive GERD was defined by the presence of esophagitis at endoscopy. Standardized incidence ratios (SIR) with 95% confidence intervals (95%CI) were calculated by dividing the observed number of esophageal adenocarcinomas in the non-erosive and erosive GERD cohorts, analyzed separately, by the expected number, derived from the general populations in Finland, Denmark, and Sweden of the corresponding age, sex, and calendar period.

Results

Among 285,811 patients with non-erosive GERD, 228 developed esophageal adenocarcinomas during 2,081,051 person-years of follow-up. The overall risk of esophageal adenocarcinoma was similar to that of the background population (SIR 1.04, 95%CI 0.91-1.18), and did not increase with longer follow-up. Patients with erosive esophagitis at endoscopy (200,745 patients, 1,750,249 person-years, and 542 esophageal adenocarcinomas) had a notable increased overall risk of esophageal adenocarcinoma (SIR 2.36, 95%CI 2.17-2.57), which became more pronounced with longer follow-up.

Conclusion

Patients with non-erosive GERD seem to have a similar risk of esophageal adenocarcinoma compared to the corresponding background population. This finding is relieving for the majority of GERD patients with normal endoscopy and may guide follow-up strategies.