Introduction

Recurrence of common bile duct (CBD) stones after initial treatment is estimated to occur in 5%-20% of cases¹, requiring additional interventions and is associated with adverse patient outcomes. Previous small scale studies evaluated the role of UDCA in the prevention of CBD stone^2,3. We aimed to investigate whether UDCA is effective in preventing de-novo CBD stone formation.

Aims & Methods

This was a cohort analysis. We analyzed the electronic records of patients diagnosed with cholangitis or choledocholithiasis who underwent endoscopic retrograde cholangiopancreatography (ERCP) with evidence of complete common bile duct (CBD) stone removal. Due to the lack of consistent evidence, recommendations for using ursodeoxycholic acid (UDCA) to prevent stone recurrence varied among endoscopists. All patients were contacted and interviewed after providing informed consent. The follow-up period was defined as the time from the index ERCP to either evidence of CBD stone recurrence or the date of the patient interview. The primary outcome was a documented case of CBD stone recurrence. We compared baseline variables and outcomes between patients who were recommended to receive UDCA following ERCP and those who did not receive a UDCA recommendation. We performed univariate survival analysis using the log rank score to compare survival distributions between groups.

Results

Ninety-eight patients were included in the analysis and contacted. Of these, 50 patients received a recommendation for UDCA treatment, and 30 patients took UDCA. Additionally, 48 patients did not receive any recommendation for UDCA, contributing to a total of 68 patients who did not take UDCA. Comparison of baseline characteristics, index ERCP findings and outcomes between groups is presented in Table 1. There were no significant differences in patient ages and rate of major comorbidities. Most patients undergone cholecystectomy more than 24 months prior to the index ERCP. Previous sphincterectomy was more common in the UDCA treatment group (70% vs 17.6%; p<0.01). No marked differences were noted in regard to other index ERCP findings between the two groups including papillary anatomy, number, size, type of stones and technique of stone removal (Table 1). No significant difference in stone recurrence was between patients who took and did not take UDCA (recurrence in 8/30 patients [26.7%] and 22/68 [32.4%] respectively, P=0.75). There was no significant difference in survival without recurrence between the two groups (p=0.84).

Conclusion

Our findings do not suggest efficacy of UDCA in prevention of de-novo CBD stone recurrence after cholecystectomy and complete CBD clearance.

References

1. Lammert F, Acalovschi M, Ercolani G, et al. EASL Clinical Practice Guidelines on the prevention, diagnosis and treatment of gallstones. J Hepatol. 2016;65(1):146-181. doi:10.1016/J.JHEP.2016.03.005
2. Yamamoto R, Tazuma S, Kanno K, et al. Ursodeoxycholic acid after bile duct stone removal and risk factors for recurrence: a randomized trial. J Hepatobiliary Pancreat Sci. 2016;23(2):132-136. doi:10.1002/jhbp.316
3. Swobodnik W, Janowitz P, Kratzer W, et al. [Preventing the recurrence of common bile duct calculi following endoscopic papillotomy with ursodeoxycholic acid]. Z Gastroenterol. 1990;28(11):621-625.

Disclosure

The authors report no conflict of interests

Introduction

Hepatic venous pressure gradient (HVPG) measurement is invasive. Non-invasive methods for evaluating the severity of portal hypertension in patients with transjugular intrahepatic portosystemic shunt (TIPS) are warranted.

Aims & Methods

This study aims to evaluate the efficacy of spleen stiffness in predicting HVPG and TIPS dysfunction. We performed a systematic review in PubMed, Embase and Cochrane databases, searching for studies comparing spleen stiffness measurements pre-TIPS and post-TIPS. The primary outcome was spleen stiffness. The secondary outcome was spleen stiffness in the context of TIPS dysfunction. The MD was used for continuous outcomes with their respective 95% confidence interval (CI). Heterogeneity was assessed using the Cochran Q test and I² statistics.

Results

The meta-analyses included 13 studies and 521 patients. There was a significant difference in spleen stiffness reduction after TIPS compared to baseline, measured by SSW m/s (MD -0.49; 95% CI -0.55 to -0.43; p<0.01; I²=0%) and by SSM kPa (MD -11.19; 95% CI -13.32 to -9.07; p<0.01; I²=0%). TIPS dysfunction was associated with increased spleen stiffness values (MD 0.35; 95% CI 0.24 to 0.45; p<0.01; I²=0%) compared to normal tips function similarly to those found in pre-TIPS patients.

Conclusion

Our study showed that spleen stiffness is a non-invasive measure to evaluate HPVG reduction after TIPS placement. Spleen stiffness may also be useful in monitoring TIPS dysfunction.

Introduction

Standard treatment of autoimmune hepatitis (AIH) typically includes a combination of azathioprine and corticosteroids. However, approximately 20% of patients do not respond well to this conventional therapy. In this scenario, mycophenolate mofetil (MMF) may be used as an alternative treatment for patients with intolerance or non-response to first-line options.

Aims & Methods

This study aims to evaluate the performance of MMF in intolerant or non-responders patients with AIH previously treated with conventional therapy. We performed a systematic review in PubMed, Embase, and Cochrane databases. We analyzed overall remission, remission at AZA intolerance, and remission at AZA non-response. We also compared the outcome of overall remission in patients with AZA intolerance vs. AZA non-response. Statistical analyses were performed using R language 4.3.1.

Results

21 studies and 646 patients were included. The pooled overall remission rate was 62.21 (95% CI 54.31, 70.10). We found an overall remission rate of 66.74 (95% CI 57.48, 76.00) in patients intolerant to AZA, and 27.80 (95% CI 11.56, 44.04) in AZA non-responders. The comparison of overall remission in both groups favored the intolerance group (OR 4.98; 95% CI 1.69, 14.72; p = 0.004).

Conclusion

MMF is effective in inducing remission in patients with AIH who failed the first-line treatment. The overall effect is more prominent in patients who failed conventional therapy due to intolerance. Non-response to AZA may be correlated to suboptimal response to MMF as well.

Introduction

Acute esophageal variceal bleeding (EVB) typically requires initial treatment involving pharmacotherapy and endoscopy, particularly endoscopic variceal ligation (EVL). In cases of rebleeding, transjugular intrahepatic portosystemic shunt (TIPS) is recommended, but in regions with limited TIPS access, repeated endoscopic therapy is common. This study evaluates the outcomes of EVL in managing rebleeding and mortality in resource-constrained settings.

Aims & Methods

Patients experiencing acute EVB and undergoing EVL were followed for up to five years or until death. Treatment involved vasoactive drugs and EVL until variceal eradication was achieved. Primary endpoints included bleeding control effectiveness and the need for a second EVL session to manage rebleeding. Rebleeding and mortality rates at 6 weeks and 5 years were analyzed. Logistic regression analysis identified risk factors associated with rebleeding and mortality.

Results

Among 118 patients with acute EVB undergoing EVL, no treatment failures occurred within five days. Eighty-three percent were successfully controlled with one EVL session, while 17% required at least two sessions for recurrent bleeding. In the rebleeding group, no patients rebled within five days after the first EVL, but 75% rebled within 6 weeks. Second EVL was performed for these patients, with a failure rate of 25%. Recurrent EVBs were ultimately controlled by other endoscopic therapy. There was no significant difference in 6-week mortality between rebleeding (15%) and non-rebleeding (18%) groups (p=0.72). Factors associated with 6-week mortality included age, hepatocellular carcinoma, post-bleeding beta-blocker use, creatinine, bilirubin, albumin, Child-Pugh class, and MELD score (Table). Beta-blocker use was associated with preventing recurrent EVB within six months (OR 0.053, 95% CI: 0.004-0.687, p = 0.025). Over five years, the rebleeding group showed a higher mortality trend (90%) compared to the non-rebleeding group (68.8%), though not statistically significant (p=0.06).

Conclusion

In resource-limited settings, multiple attempts of EVL demonstrate success in controlling rebleeding. Long-term trends indicate higher mortality in rebleeding cases, although not statistically significant.

Disclosure

The authors declare that they have no conflict of interest.

Introduction

Recent findings suggest a higher risk of progressive liver disease and hepatocellular cancer in first-degree relatives of individuals with metabolic dysfunction-associated steatotic liver disease (MASLD). The familial risk of extrahepatic cancer is, however, unclear.

Aims & Methods

We conducted a nationwide multigenerational cohort study involving all family members of Swedish adults with biopsy-proven MASLD (1969−2017) and of matched general population comparators. We included 36,684 first-degree relatives (FDRs: parents, siblings, offspring) and 8,788 spouses of MASLD individuals as well as 190,501 FDRs and 44,694 spouses of matched comparators without previous diagnosis of any cancer. Cox proportional hazards models were used to calculate multivariable adjusted hazard ratios (aHR) and 95% CIs.

Results

Over a median of 24.6 years the incidence rate for any extrahepatic cancer was slightly higher in MASLD FDRs than in comparator FDRs (72.3 vs. 71.9/10,000 person years (PY); aHR 1.04, 95%CI, 1.01−1.08). They were also at slightly higher risk of cancer-related mortality (24.0 vs. 23.6/10,000PY; aHR 1.08, 95% CI, 1.01−1.16). Compared to FDRs of comparators, largest differences were observed in rates of esophagus/stomach cancer (1.8 vs. 1.5/10,000PY; aHR 1.26, 95% CI, 1.01−1.58) and lung cancer (4.9 vs. 4.3/10,000PY; aHR 1.18, 95% CI 1.03−1.35). Across generations of FDRs, the risk of cancer was uniformly increased with no differences by relationship (i.e., parents, siblings, and offspring; p>0.05). MASLD spouses were also at a slightly increased risk of extrahepatic cancer (119.1 vs. 113.4/10,000PY; aHR 1.07, 95%CI, 1.00−1.14) and cancer-related mortality (43.9 vs. 38.8/10,000PY; aHR 1.21, 95%CI, 1.07−1.38). Compared to spouses of comparators, largest differences were observed in rates of colorectal cancer (17.0 vs. 13.4/10,000PY; aHR 1.34, 95% CI, 1.15−1.56).

Conclusion

First-degree relatives and spouses of individuals with biopsy-proven MASLD were at slightly higher risks of incident extrahepatic cancers, suggesting that shared lifestyle factors may contribute to the associations. Absolute cancer risks for family members were low and thus do not motivate implementation of screening programs.

Disclosure

Dr F. Ebrahimi has served as an advisory board member for Boehringer Ingelheim. Dr Ludvigsson has coordinated an unrelated study on behalf of the Swedish IBD quality register (SWIBREG). That study received funding from Janssen Corporation. Dr Ludvigsson has also received financial support from MSD to develop a paper reviewing national healthcare registers in China. Ludvigsson has also a research collaboration on celiac disease with Takeda. The other authors have nothing to disclose.