Introduction

Clinically significant portal hypertension (CSPH) in patients with advanced chronic liver disease (ACLD) is associated with increasing risk of decompensation and death. Several scores have been developed as non-invasive tests to assess portal hypertension (PH) severity, such as the novel hepatic venous pressure gradient (HVPG) score. This score, consisting of platelet count, total serum bilirubin, and international normalized ratio (INR), showed good sensibility in the prediction of severe PH.

Aims & Methods

The aim of this study is to evaluate the ability of HVPG score in the detection of PH in a cohort of patients with ACLD.
A retrospective study was conducted at the University of Naples and all patients, referred to our Liver Unit from 2012 to 2022, with compensated ACLD who underwent esophagogastroduodenoscopy (EGD) for portal hypertension assessment were enrolled. Exclusion criteria were patients < 18 years old, liver transplantation, treatment with NSBB, portal vein thrombosis and incomplete data. Clinical, biochemical, and imaging data were collected from medical records. Patients were stratified according to the presence of endoscopic signs of PH.

Results

Among 294 compensated ACLD patients who performed EGD, 204 subjects were enrolled (62.7% males, mean age 62 years) according to inclusion and exclusion criteria. The main etiologies of liver disease were HCV (39.2%), MAFLD (13.7%) and HBV (11.7%). One-hundred-eight patients (52.9%) showed endoscopic signs of PH (91 patients with esophageal varices, 13 subjects with gastric varices and 64 patients with portal hypertensive gastropathy). Patients with endoscopic signs of PH have higher HVPG score (14.14±1.62 vs 12.71±5.2 mmHg, p <0.001), higher spleen diameter (150±30.55 Vs 130±20.84 mm, p <0.001), lower platelet count (95*10³/cc vs 136*10³/cc, p<0.001) and lower platelets/spleen diameter ratio (682±397 vs 1090±604, p <0.01) than patients without signs of PH. Instead, liver stiffness was not different between the two groups (26±13.1 vs 23.7±9.96 kPa, p =0.233).
Among patients with endoscopic signs of PH, 11 (10.1%) patients experienced variceal bleeding after a mean of 29 months (range 124-2746 days); they had higher baseline HVPG score (14.82±0.93 vs 14.07±1.66 mmHg; p=0.04), higher spleen diameter (172±26.10 vs 150±30.23 mm; p=0.028) and lower PLT/spleen ratio (436±172 vs 710±405; p < 0.001) than patients who didn’t experience bleeding.

Conclusion

HVPG score is a simple tool for non-invasive prediction of PH and could be used to stratify the risk of bleeding in patients with ACLD. However, this score needs to be validated in larger cohorts.

References

Reiniš, J., Petrenko, O., Simbrunner, B., Hofer, B. S., Schepis, F., Scoppettuolo, M., ... & Reiberger, T. (2023). Assessment of portal hypertension severity using machine learning models in patients with compensated cirrhosis. Journal of Hepatology, 78(2), 390-400. DOI: 10.1016/j.jhep.2022.09.012

Introduction

Suspected foreign body ingestion and food bolus impaction are common indications for urgent esophagogastroduodenoscopy. Nevertheless, most of the ingested foreign bodies (80 to 90%) pass spontaneously throughout the gastrointestinal tract. In 2022, the Decision-To-Scope (DTS) Score was developed, revealing an excellent accuracy in predicting foreign bodies in the esophagus.

Aims & Methods

Our aim was to prospectively evaluate the diagnostic accuracy of the DTS-Score.
We have prospectively included consecutive patients admitted for suspected foreign body in the upper gastrointestinal tract, for a 6-month period. Previously to endoscopic evaluation, the DTS-score - time since ingestion < 6 hours (+1pt); absence of any meal since the suspected ingestion (+2pts); dysphagia (+3pts); odynophagia (+1pt) and drooling (+4pts) - was applied in each patient. The maximal possible value was 11 points, with a DTS-Score ≥5 being considered to assign a high probability of endoscopic confirmation of the foreign body.

Results

Final sample included 47 patients, from which 26 (55.3%) were females, with a mean age of 60±16 years. From these, most (n=42; 91.5%) were evaluated for accidental ingestion of food-related foreign bodies (fish or chicken bones) or suspected food bolus impaction. A DTS-Score ≥5 was calculated in 11 (23.4%) of the patients, with an esophageal foreign body being confirmed in 12 (25.5%) of them. DTS-score presented an excellent accuracy in predicting the endoscopic confirmation of a foreign body in the esophagus (AUC=0.94; 95%CI 0.85-1.00; p<0.001). The originally defined cut-off (DTS-Score ≥5) presented a specificity of 97.1%, a sensitivity of 83.3%, a positive predictive value of 90.9% and a negative predictive value of 94.4%.

Conclusion

When prospectively applied, the DTS-score demonstrated an excellent acuity in stratifying the probability of endoscopic confirmation of a suspected foreign body in the esophagus. This tool may be included in future clinical algorithms for suspected foreign bodies ingestion.

Introduction

This paired biopsy study aimed to investigate the predictive value of various non-invasive scores for identifying the temporal evolution of hepatic fibrosis in patients with non-alcoholic fatty liver disease (NAFLD).

Aims & Methods

A total of 69 patients with NAFLD who had undergone two paired liver biopsies (mean interval: 21.3 ± 9.7 months) were examined. Fibrosis progression and regression were defined as an increase or decrease of at least one stage in fibrosis between the initial and second biopsy. Fibrosis-4 index (FIB-4), NAFLD Fibrosis Score (NFS), Agile 3+ score, Agile 4 score, and FibroScan-AST (FAST) score were calculated at the time of the initial biopsy.

Results

Upon comparing the results of paired biopsies, 45% of the participants (n = 31) showed no change in fibrosis, 26% (n = 18) experienced fibrosis progression, and 29% (n = 20) had evidence of fibrosis regression. In multivariable logistic regression analysis, the only independent predictive factor for progressive fibrosis was the FAST score. The odds ratio for progressive fibrosis was found to increase by 19% (95% confidence interval: 8–38%, p < 0.05) with every unit increase in FAST score at the time of the initial biopsy. No independent predictors for fibrosis regression were identified.

Conclusion

Patients with higher baseline FAST scores were more likely to experience fibrosis progression independent of potential confounders. Consequently, FAST could serve not only as a diagnostic tool for screening fibrosis in NAFLD, but also as a prognostic indicator.

Introduction

Piecemeal endoscopic mucosal resection (EMR) vs endoscopic submucosal dissection (ESD) has been a long standing debate in the endoscopic community worldwide with multiple studies done to evaluate the preferred method to manage large colorectal neoplasms. Piecemeal EMR with thermal ablation of the margin has been strongly advocated and reported by certain groups to be a simple, inexpensive and effective technique and this has been preferred widely due to its perceived ease of performance and shorter learning curve.¹ However, close, repeated surveillance colonoscopy is recommended even when the lesion is thought to have been completely resected² as residual tumors can cause interval cancers.³ Some groups, mainly from east Asian countries, have recommended en bloc resection by ESD due to significantly lower risk of local recurrence and precise pathological diagnosis.⁴ But its usage is limited due to concerns about risk of serious adverse events. With improvement in training and devices, colorectal ESD is now being performed by various centers globally. This study aims to report the outcomes of an international, multicenter study on colorectal ESD.

Aims & Methods

Patients who underwent colorectal ESD for lesions greater than 20mm between January 2022 to April 2024 from centers in USA, Japan, and India respectively were included in this study. Recurrent lesions after endoscopic therapy, neoplasms identified in patients with ulcerative colitis, and non-epithelial lesions were included. Primary outcomes were en bloc and R0 resection rate, delayed adverse events (bleeding/perforation), and local recurrence rate. Secondary outcomes were procedure time, lesion size, and pathology. Univariate and multivariate analysis were done to identify the risk factors for primary outcomes.

Results

309 patients (median size, 40(27.5-60)mm; location rectum 52.4%, left colon 26.2%, right colon 21.4%) were involved in this study. The en bloc resection rate was 96.1% and R0 resection rate was 90.3%. 3 patients experienced delayed bleeding which was managed endoscopically. 2 patients underwent surgery for delayed perforation. 6 patients had a local recurrence. 67(23%) patients had intramucosal carcinoma on pathology. Univariate analysis showed lesser procedure time (median(IQR) 145(80-236.25) vs 270(180-300) minutes, P= 0.005) and smaller lesion size (median(IQR) 40(26-56.25) vs 60(40-90) mm, P= 0.004) were significant factors for successful en bloc resection. However, lesser procedure time (median(IQR) 74(29.5-97.5) vs 150(82.5-240) minutes, P= 0.034) led to an increased delayed adverse event rate. Multivariate analysis using Cox regression showed en bloc resection (odds ratio 0.038; 95% confidence interval 0.003-0.421; P= 0.008) was an independent factor preventing local recurrence.

Conclusion

This international, multicenter study with data from three countries shows favorable outcomes for colorectal ESD for large lesions. The high en bloc and R0 resection rate, and low adverse event rate show increased global adaptation to this procedure. Reduced local recurrence is an added benefit. Data from a more centers globally will be valuable to establish ESD as the standard for large colorectal neoplasms.

References

1. Sidhu M, Shahidi N, Gupta S et al. Outcomes of thermal ablation of the mucosal defect margin after endoscopic mucosal resection: a prospective, international, multicenter trial of 1000 large nonpedunculated colorectal polyps. Gastroenterology. 2021 Jul 1;161(1):163-70.
2. Gupta S, Lieberman D, Anderson JC et al. Recommendations for Follow-Up After Colonoscopy and Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer. Gastrointest Endosc 2020;91:463-485.e5.
3. Rutter MD, Beintaris I, Valori R et al. World Endoscopy Organization Consensus Statements on Post-Colonoscopy and Post-Imaging Colorectal Cancer. Gastroenterology 2018;155:909-925.e3.
4. Ohata K, Kobayashi N, Sakai E et al. Long-term outcomes after endoscopic submucosal dissection for large colorectal epithelial neoplasms: a prospective, multicenter, cohort trial from Japan. Gastroenterology. 2022 Nov 1;163(5):1423-34.

Introduction

In cirrhosis, several prognostic scores have been developed to predict overall and complication-free survival. The MELD (Model for End-Stage Liver Disease), MELD-Na and MELD3.0 scores have been proposed as a criteria for allocating organs.

Aims & Methods

The aim of our study was to assess the performance of these 3 scores for the prediction of overall and complication-free survival in decompensated Tunisian cirrhotic patients.
Methods: We conducted an observational, retrospective study involving all patients with decompensated cirrhosis managed in Gastroenterology department of Taher Maamouri hospital during the period from January 2010 to December 2021. Mortality was assessed using the Kaplan Meier model. The performance of the scores was assessed using the AUROC (Area under the Receiver Operating Characteristic curve).

Results

One hundred and fifty-two patients were included with an average age of 61 years. Viral liver cirrhosis was the most common (65.13%). The mean value of the MELD-Na and MELD3.0 scores was 17.74 and 19.4, respectively. The mean follow-up time was 17.1 months. The rate of complications and short-term mortality was 33.6% and 18.4% respectively.
The AUROC of the MELD3.0 score in predicting of the occurrence of further decompensation was the highest (0.775) compared to those of the MELD and MELD-Na score (0.743 and 0.756 respectively). The cut-off value of the MELD3.0 score in predicting further decompensation was 20 (sensitivity 60.7%, specificity 73.3%).
In the prediction of 3-month mortality, the AUROCs of the MELD, MELD-Na and MELD3.0 scores were 0.786; 0.841 and 0.850 respectively. The cut-off value of the MELD3.0 score was 24 (sensitivity 68%, specificity 88%). A statistically significant correlation was noted between the MELD3.0 score ≥24 and 3-month mortality (p=0.04).

Conclusion

The MELD3.0 score had the best predictive value for the occurrence of further decompensation and short-term mortality in decompensated cirrhotic patients. Those with a MELD 3.0 score ≥24 should be prioritized on waiting lists.

Introduction

Minimal hepatic encephalopathy (MHE) represents the earliest and mildest form of hepatic encephalopathy. MHE does not represent clinically significant neurological and psychiatric abnormalities, and cognitive dysfunction is detected only with neuropsychological testing. Early diagnosis of HE is a prerequisite for maintaining the quality of life of patients and preventing overt HE.

Aims & Methods

Purpose of the study.To compare the dynamics of clinical and laboratory data and evaluate the incidence of complications during 3 months of follow-up with or without rifaximin-α therapy in patients with MHE associated with liver cirrhosis (LC).
Materials and research methods. Patients were selected according to the inclusion criteria: age from 18 to 75 years, the presence of cirrhosis (regardless of severity on the Child-Pugh scale), the presence of MHE, and signed voluntary informed consent. In total, the study included 40 patients with MHE against the background of cirrhosis of various etiology and severity according to the Child-Pugh scale (A-C). Depending on the MHE treatment regimen, patients were randomly divided into groups: group 1 (n=14; 35%) - permanent therapy with rifaximin-α at a dose of 1200 mg/day, group 2 (n=12; 30%) - course rifaximin-α therapy at a dose of 1200 mg/day in courses (7 days of each month), group 3 (n=14; 35%) - without rifaximin-α therapy. Patients underwent an analysis of clinical (assessment of the severity of hepatic encephalopathy according to the results of psychometric tests: a number connection test, an animal name test-ANT, a short scale for assessing mental status-MMSE) and laboratory data (clinical and biochemical analysis, blood, coagulogram, capillary blood ammonia level), and also assessment of the quality of life (questionnaire-SF36) at the beginning of the study and after 3 months of observation.

Results

According to the results of the study, in group 1, against the background of constant therapy with rifaximin-α, 85.7% (n=12) showed a decrease in the level of ammonia in capillary blood, 28.5% (n=4) showed regression of MHE according to the results of psychometric tests, 71.4% (n=10) improved their quality of life. At the same time, 21.4% (n=3) had progression of MHE to overt HE, 21.4% (n=3) had an increase in the level of ammonia in capillary blood, 14,2% (n=2) had infectious complications (sinusitis, otitis media, ARI). In group 2, with the course use of rifaximin-α, 100% (n=12) showed a decrease in the level of ammonia in capillary blood, 16,6% (n=2) showed regression of MHE in the form of an improvement in psychometric tests, and 58,3% (n=7) showed an improvement in the quality of life. It should be noted that 8,3% (n=1) were diagnosed with the addition of a new coronavirus infection, as well as 8,3% (n=1) had bleeding from the esophageal varices. In group 3, 42.8% (n=6) showed a deterioration in the course of MHE, in the form of its progression to overt HE, 50% (n=7) showed an increase in ammonia levels, 64.2% (n=9) deteriorating quality of life indicators. In addition, 14,2% (n=2) were diagnosed with bleeding from the esophageal varices with a fatal outcome.

Conclusion

The study found that rifaximin-α reduces the progression of MHE to overt HE, the progression of portal hypertension, and also improves the quality of life in patients of this category. When comparing the effectiveness of continuous and course therapy with rifaximin-α, the results did not show significant differences, so further studies are needed in patients with cirrhosis and MHE to improve diagnostic and treatment approaches in patients of this category.

References

1. GBD 2017 Cirrhosis Collaborators. The global, regional, and national burden of cirrhosis by cause in
195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study
2017. Lancet Gastroenterol Hepatol. 2020;5(3):245–266.
2. Butterworth R.F. Hepatic Encephalopathy in Cirrhosis: Pathology and Pathophysiology. Drugs.
2019;79(Suppl 1):17–21. DOI: 10.1007/s40265-018-1017-0.
3. Agrawal S., Umapathy S., Dhiman R.K. Minimal hepatic encephalopathy impairs quality of life. J Clin
Exp Hepatol. 2015;5(Suppl 1):S42–S48. DOI: 10.1016/j.jceh.2014.11.006.

Introduction

Complete excision of upper gastrointestinal sub-epithelial lesions (SELs) eliminates diagnostic uncertainty, obviates the need for surveillance and may be necessary for definitive diagnosis and management. Current guidelines lack precision and cohesion, and surgery is associated with significant morbidity. Herein, we describe and report on the outcomes of our SEL algorithm for endoscopic (SAFE) resection.

Aims & Methods

SELs were enrolled prospectively over 115 months until March 2023. All underwent axial (CT) imaging and endoscopic-ultrasonography (EUS) to exclude a large exophytic component or invasion into local structures, and assess for muscularis propria involvement.

Results

106 SELs were resected (mean age 60.6±13.4, 51.9% male; 41 oesophageal, 65 gastric). Oesophageal SELs underwent ESD (n=22) or STER if MP involvement was suspected (n=19). Gastric SELs underwent STER (n=6 at cardia), ESD (n=47) or exposing-EFTR (n=12). Technical success was 97.6% and 92.3% respectively. Five (7.7%) were completed laparoscopically due to deep and broad full-thickness involvement. Five (7.7%) required laparoscopic gastrotomy and surgical retrieval after successful resection and closure due to a large lesion size (mean 47 mm). There was no delayed bleeding, perforation or recurrence at a median of 13 months.

Conclusion

Upper GI SELs are effectively and safely treated by endoscopic resection. The SAFE approach provides a framework that facilitates structured decision-making. Oesophageal SELs suspected to involve the MP should undergo STER. Gastric SELs can be best managed by ESD with a view to proceed to exposing-EFTR. A laparoscopic UGI surgeon should be available in case surgical retrieval of the specimen or laparoscopic completion is required.

Disclosure

Michael J. Bourke: Research Support: Olympus, Cook Medical, Boston Scientific.