Introduction

Transjugular intrahepatic portosystemic shunt (TIPS) is a well-established interventional treatment for complications of portal hypertension. Post-TIPS transient or persistent acute bilirubin elevation (ABE) is common, possibly due to impairment of portal perfusion. The outcomes of patients with ABE is not clear.

Aims & Methods

This study investigates the incidence, clinical outcomes, and prognostic factors associated with ABE in cirrhotic patients undergoing TIPS. Between January 2009 and November 2022, 1,287 patients (882 men, 405 women; mean age, 52 years) were included in this retrospective analysis. ABE was defined as a total serum bilirubin level exceeding 85.5 μmol/L (5 mg/dL) within one week after TIPS. Statistical analyses included the Kaplan-Meier method, log-rank test, multivariate Cox regression, and stepwise regression.

Results

Post-TIPS ABE occurred in 67 patients (5.2%). Patients with ABE had significantly higher baseline Child-Pugh scores (8.39 ± 1.62 vs. 7.41 ± 1.54, P < 0.001) and MELD scores (13.98 ± 4.13 vs. 10.72 ± 2.99, P < 0.001). Refractory ascites as the TIPS indication was more frequent in the ABE group (17.91% vs. 7.21%, P = 0.001). ABE was associated with a significantly higher incidence of hepatic encephalopathy (HE): 62.7% vs. 38.3% at 1 year and 80.6% vs. 62.8% at 5 years (P = 0.042). During follow-up, 441 patients died, with causes including liver failure (n = 129), gastrointestinal bleeding (n = 100), sepsis (n = 16), multi-organ dysfunction (MOD) (n = 41), hepatocellular carcinoma (HCC) (n = 43), and other or unknown causes (n = 112). Survival rates were significantly lower in the ABE group: 1-year (52.2% vs. 85.2%), 3-year (34.3% vs. 68.3%), and 5-year (25.4% vs. 46.6%) (P < 0.001). Multivariate analysis identified ABE (hazard ratio [HR]: 2.09; 95% confidence interval [CI]: 1.41–3.10; P < 0.001), age (HR: 1.05; 95% CI: 1.04–1.06; P < 0.001), albumin level (HR: 0.95; 95% CI: 0.94–0.97; P < 0.001), pre-TIPS grade 4 HE (HR: 1.93; 95% CI: 1.19–3.14; P = 0.008), presence of HCC (HR: 1.81; 95% CI: 1.24–2.65; P = 0.002), baseline MELD score (HR: 1.09; 95% CI: 1.04–1.14; P < 0.001), and change in MELD score (HR: 1.08; 95% CI: 1.06–1.11; P < 0.001) as independent predictors of post-TIPS mortality.

Conclusion

AEB is not rare in cirrhotic patients undergoing TIPS and is associated with an increased risk of HE and mortality. Risk factors for post-TIPS mortality include AB, older age, higher and fluctuating MELD scores, concurrent HCC, severe pre-TIPS HE, and lower albumin levels. Early identification, close monitoring, and prompt management of complications are essential to improving clinical outcomes and reducing the risk of liver failure after TIPS.

Introduction

Chronic liver disease remains one of the most common causes for hospital admission and is associated with high morbidity and mortality rates. Timely and adequate management within the first 24 hours is crucial for improving clinical outcomes in cases of decompensated cirrhosis. This study aimed to evaluate the impact of implementing a care bundle checklist during the first 24 hours of hospital admission on management and outcomes of decompensated cirrhosis.

Aims & Methods

We developed an adapted care bundle (based on the BSG/BASL care bundle, AASLD quality measures proposal, Baveno VII consensus, and EASL guidelines) and compared two patient groups from two Portuguese hospital centers: Group-A (retrospective, pre-care bundle implementation) and Group-B (prospective, post-care bundle implementation).

Results

A total of 224 patients (Group-A: 148; Group-B: 76) were included. More than one decompensation was observed in 118 patients (52.7%), and 69 patients (30.8%) were experiencing their index hospitalization for liver decompensation. Regarding etiology, alcoholic liver disease was the most common (n=200; 89.3%). The groups were similar in terms of gender, age, length of hospital stay, and Child-Pugh and MELD-Na scores at admission. The most common decompensations were gastrointestinal bleeding (n=91; 40.6%), ascites (n=75; 33.5%), and hepatic encephalopathy (n=72; 32.1%). Group B was more likely to present with multiple decompensations at admission and exhibited significantly higher rates of acute kidney injury, hepatocellular carcinoma, acute-on-chronic liver failure, and portal vein thrombosis (p<0.05). Following care bundle implementation, we found significant improvements in patient care. At admission, patients were significantly more likely to undergo urine and blood cultures, chest X-ray, and abdominal ultrasound (p<0.05), receive diagnostic paracentesis (p<0.05), and have an accurate alcohol history documented (p=0.04). During admission, Group-B was significantly more likely to be prescribed lactulose for encephalopathy prophylaxis, vasopressor therapy for gastrointestinal bleeding, and venous thromboembolism prophylaxis, as well as undergo nutritional assessment (p<0.05). While in-hospital mortality rates were similar (4.7% vs. 5.3%; p=1), 6-week mortality rates (8.8% vs. 3.9%; p=0.01) and 3-month readmission rates (31.1% vs. 15.8%; p=0.02) were significantly lower in the post-intervention cohort.

Conclusion

The implementation of a standardized care bundle was associated with higher rates of appropriate investigation and treatment within the first 24 hours of hospital admission and improved patient outcomes, reducing 6-week mortality and 3-month readmission rates.

Introduction

Aspiration Pneumonia is a well described complication of upper digestive endoscopy. However, limited data are available on incidence, risk factors and clinical consequences of post- Endoscopic retrograde cholangiopancreatography (ERCP) aspiration pneumonia (pEP).

Aims & Methods

All consecutive ERCPs performed under anesthesiologist-administered sedation at the Endoscopy Unit of the University of Verona between April 1st 2022 and August 31st 2024 were retrospectively evaluated. Demographical, clinical and endoscopic data were collected.

Results

One-thousand-one-hundred-forty consecutive ERCPs were included. Main indication was malignant biliary stricture and patient’s mean age was 68±13.9 years. Overall incidence of pEP was 2.7%. American Society of Anesthesiologists (ASA) score, presence of active cholangitis before ERCP and performance of endoscopic ultrasound (EUS) and ERCP in the same sedation session were significantly associated to higher risk of pEP at both univariable and multivariable analysis. pEP was an independent risk factor for post-ERCP 30-days-mortality and for prolonged hospital stay.

Conclusion

pEP is a relatively frequent adverse event after ERCP. In patent with high ASA score, active cholangitis and scheduled EUS and ERCP in the same sedation session, preventive medical and/or anesthesiological strategies might be considered. Additional prospective studies are needed to confirm these data.

References

Incidence rates of post-ERCP complications: a systematic survey of prospective studies. Complications of ERCP: a prospective study.
ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.
Unrecognised aspiration pneumonitis during enteroscopy: two case report.
Efficecay and safety of therapeutic endoscopic retrograde cholangiopancreatography in patients with native papillae with a performance status score of 3 or 4: a single-center retrospective study.
A prospective assessment of sedation-related adverse events and patient and endoscopist satisfaction in ERCP with anesthesiologist-administred sedation.
Increased ERCP-related adverse event from premature urgent ERCP following symptom onset in acute biliary pancreatitis with cholangitis.
Acute sedation-associated complications in GI endoscopy (ProSed 2 Study): results from the prospective multicentre electronic registry of sedation-associated complications.
Deep sedation without intubation for ERCP is appropriate in healthier, non-obese patients.
Comparative efficacy and safety of anesthetic and sedative regimens for endoscopic retrograde cholangiopancreatography: a network meta-analysis.
International consensus recommendations for difficult biliary access.
Intraprocedural quality in endosocpic retrograde cholangiopancreatography: e meta-analysis.
Criteria for difficult biliary cannulation: start to count.
Safety and efficacy of therapeutic endoscopic retrograde cholangiopancreatography for patients over 90 years of age.
Risk factors for post-endoscopic retrograde cholangiopancreatography complications in very elderly patients aged 90 years or older-no additional risk.

Disclosure

I have no conflict of interest

Introduction

The 2016 National Institute for Health and Care Excellence (NICE) guideline on the diagnosis and management of cirrhosis recommends that very heavy daily drinkers should be screened for cirrhosis using one of the newer non-invasive diagnostic technologies.¹ NICE suggests FibroScan® and in 2020 published a Medtech innovation briefing around its use in primary care setting^.2 Enhanced Liver Fibrosis (ELF) blood test are available allowing for more universal rapid screening for fibrosis^.3 A Commissioning for Quality and Innovation (CQUIN) Framework aims to support this by recommending early detection of fibrosis in patients who are dependent drinkers.⁴

Results & Findings

A newly established ACT at a District General Hospital in England took on the task to screen alcohol dependent patients for liver fibrosis. Using an opportunistic approach, we identified those patients who were drinking alcohol harmfully, at least 50 units a week for men and 35 units a week for women, then screened them for their risk of liver fibrosis with blood tests to calculate fibrosis 4 (Fib4) score or ELF test. 
In line with Commissioning Quality and Innovation Group CQUIN 9: (Cirrhosis and fibrosis tests for alcohol dependent patients)4 patients who were admitted to hospital and reviewed by ACT were assessed for harmful drinking patterns, and if present would have an ELF blood test requested to screen for fibrosis. Anyone with established liver cirrhosis or not dependently consuming alcohol were excluded.
Any patient with a Fib4 >3.25 was positive. Those with a mid-range Fib4 1.29-3.25 (under 65 years of age), 1.99-3.25 (over 65 years of age) would then get an ELF test. An ELF test >9.5 was positive^.5
If positive we offered an appointment in clinic which included a review by a hepatology clinical nurse specialist and a FibroScan®.  

Summary & Discussion

The electronic records of patients who were screened for advanced fibrosis were reviewed. 
Over a 20-month period 562 patients were screened for liver fibrosis.
Of the 562, 21 patients died prior to establishing if they had fibrosis or cirrhosis.
223 patients (39%) were identified to have an elevated ELF test.  
Of those patients 60 (27%) were identified have advanced liver fibrosis or cirrhosis based on FibroScan® reading ≥ F3 or clinician opinion. 
The mean age for this group was 57, with a 60% male to 40% female ratio. 
Of these 60, 40 had an endoscopy, with 9 found to have oesophageal varices. 
Of these 60 patients 14 (23%) died.

Conclusion

A high proportion of patients with harmful drinking patterns were subsequently identified to have advanced fibrosis. We have found that an alcohol nurse led service for screening patients allows for early identification of advanced fibrosis or cirrhosis, where this might otherwise not have been identified.

References

1 NICE. (6 July 2016). Cirrhosis in over 16s assessment and management. [Online]. nice.org.uk. Last Updated: 8 September 2023. Available at: www.nice.org.uk/guidance/ng50 [Accessed 16 April 2025]. 
2 NICE. (June 2020). FibroScan for assessing liver fibrosis and cirrhosis in primary care Medtech innovation briefing. [Online]. NICE. Last Updated: June 2023. Available at: nice.org.uk [Accessed 20 April 2025].  
3 Office for Health Improvement & Disparities. (2022). Liver disease: applying All Our Health. [Online]. GOV.UK. Last Updated: May 2022. Available at: www.gov.uk [Accessed 20 April 2025]. 
4 NHS England. (2022). Commissioning for Quality and Innovation. [Online]. NHS England. Available at: https://www.nice.org.uk [Accessed 11 April 2025].
5 Newsome PN, Cramb R, Davison SM, et al. (2017). Guidelines on the management of abnormal liver blood tests. Gut British Medical Journal. 10.1136(2017-314924), pp.1-14. [Online]. Available at: bsg.org.uk [Accessed 20 April 2025].