Introduction

The incidence of caustic ingestion has remained stable in recent years due to its difficult prevention and limited changes in its management.

Aims & Methods

Aims:
1. To explore changes in the epidemiological and clinical characteristics of caustic ingestion over the last decades
2. To identify epidemiological risk factors of adverse outcomes.
Methods: We present data from an observational study that prospectively collected caustic ingestions in our centre since 1995 and included all adult patients whose acute episode was evaluated in the emergency department. Epidemiological data and variables related to the type of ingestion, prognostic risk factors and the adverse outcomes, defined as the need for admission to the intensive care unit, emergency surgery, patient death and oesophageal or gastric stricture development, were analysed; the results were compared for the periods 1995-2009 and 2010-2024.

Results

A total of 582 episodes of caustic ingestion were included, 305 during the first period and 277 during the second.
Epidemiological characteristics and type of ingestion were overall similar in both periods, as were the clinical, analytical, endoscopic and radiologic indicators of severity.
Adverse outcomes were also similar in the two time periods, both in the short term (comparable frequency of intensive care unit admission, need for surgery and death) and in the long term (stricture development).
The main risk groups for severe ingestions were patients older than 45 years (OR 4.3; 95%CI: 2.3-7.9) and psychiatric comorbidity (OR 5.2; 95%CI: 3.0-9.1), especially depressive syndrome (OR 7.2; 95%CI: 4.2-12.4).
Recurrent ingestions were more frequent in men (OR 1.9; 95%CI: 1.0-3.5) and psychiatric illness (OR 7.6; 95%CI: 3.5-16.5), mainly personality disorder (OR 11.0; 95%CI: 5.5-21.9).

	1995-2009	2010-2024	p value
Women	164 (53,8)	133 (48,0)	0,192
Age	44 (30)	50 (30)	0,193
Voluntary intake	154 (50,5)	121 (44,0)	0,139
pH of caustic Strong acid Weak acid Weak alkali Strong alkali	50 (16,9) 17 (5,8) 215 (72,9) 13 (4,4)	40 (14,7) 25 (9,2) 200 (73,3) 8 (2,9)	0,318
Psychiatric illness Depression Bipolar disorder Personality disorder Psychotic disorder Alcohol/toxic substances consumption	155 (50,8) 112 (36,7) 5 (1,6) 28 (9,2) 16 (5,2) 23 (7,5)	119 (43,0) 75 (27,1) 11 (4,0) 20 (7,2) 13 (4,7) 26 (9,4)	0,007 0,016 0,143 0,479 0,908 0,515
Intensive care unit admission	40 (13,1)	29 (10,5)	0,391
Emergency surgery	8 (2,6)	10 (3,6)	0,655
Death	15 (4,9)	19 (6,9)	0,412
Stricture formation	11 (5,1)	8 (3,7)	0,624

Conclusion

No relevant changes were identified in the epidemiological and clinical characteristics of caustic ingestions over the last decades, nor in their evolution. The most vulnerable groups to prioritise prevention measures would be patients with psychiatric cormobility.

Introduction

Biliary complications are estimated to occur in 5-32% of patients undergoing liver transplantation (LT) and are an important source of morbimortality, with mortality and retransplantation rates up to 20% and 13%, respectively. Their early recognition and multidisciplinary management are critical in improving outcomes.

Aims & Methods

Our aim was to evaluate post LT biliary complications, their endoscopic management, and clinical outcomes.
We conducted a retrospective study of a prospectively maintained database of LT adult patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) at a transplantation center between July 2020 - December 2022. Demographic, clinical, surgical, and endoscopic data were collected and analyzed in Stata®V17 (p<0,05). The outcomes assessed were ERCP’s technical success, procedure-related complications, complete resolution of the biliary complication, need for surgical reintervention, and mortality.

Results

We performed 166 ERCPs in 64 patients (2,6±1,3 ERCPs/patient), 86% males, mean-aged 56±11 years. The median interval between LT and first ERCP was 10 [2;46] months. The most frequent indications for ERCP were radiological documentation of biliary stenosis (BS) (33%) and cholangitis (27%). All patients had prophylactic antibiotic treatment and rectal indomethacin.
The most common biliary complication was anastomotic BS (75%), followed by bile leakage (14%), non-anastomotic BS (5%) and choledocholithiasis without BS (5%). 56% of anastomotic BS presented in the first year, whereas all the non-anastomotic BS were diagnosed after the first year. The bile leaks were detected from the fourth week following LT, 67% were high-output leaks and 67% associated with a BS.
Biliary cannulation ± sphincterotomy was achieved in 100% of the procedures, with a 97% technical success rate (4 BS were not traversed by the guidewire and 1 high output leakage was considered not amenable to endoscopic treatment). We performed dilation in 28% of the procedures, plastic stent placement in 62% (mean number of 2±1 stents with a total caliber of 15±6Fr per procedure) and fully covered self-expandable metal stent in 5% of the cases.
There were 4.8% procedure-related complications (4 intraprocedural bleedings treated endoscopically, 2 post-ERCP cholangitis, 1 mild pancreatitis and 1 delayed bleeding requiring blood transfusion), with no associated deaths.
Median follow-up was 10 [4;21] months. From the initial 64 patients, 16 patients are still under treatment, 4 were retransplanted for unrelated reasons, 3 died of other causes and 1 abandoned follow-up.
Our clinical success rate was 77.5% (31/40), achieving complete endoscopic resolution of the biliary complication within 3,2±1,3 ERCPs during a median of 196 days of treatment. Success rates per diagnosis were 100% in isolated choledocholithiasis, 79% in anastomotic BS, 67% in bile leaks and 50% in non-anastomotic BS.
Among the 9 patients with treatment failure (22.5%), 5 had presented with cholangitis, 3 of whom with multiple liver abscesses. Seven underwent surgical reintervention and 4 died of complications related to the post-LT biliary condition (mortality rate: 4/40, 10%). We did not find statistically significant associations of age, number of index surgeries, T tube placement, and indication for ERCP with clinical failure in multivariable logistic regression analysis.

Conclusion

The endoscopic management of biliary complications after LT had a high success rate in our patients, with few associated complications and an important contribution to decreasing the need for surgical reinterventions.

References

• Bañares R, et al. Long-term management after liver transplantation: Primary care physician versus transplant hospital. Transplant Proc. 2014;46(9):3095–6.
• Fasullo M, et al. Post-transplant biliary complications: advances in pathophysiology, diagnosis, and treatment. BMJ Open Gastroenterol. 2022;9(1):e000778.
• Magro B, et al. Biliary complications after liver transplantation: current perspectives and future strategies. Hepatobiliary Surg Nutr. 2021;10(1):76–92.
• Aparício DP da S, et al. Endoscopic approach for management of biliary strictures in liver transplant recipients: A systematic review and meta-analysis. United Eur Gastroenterol J. 2017;5(6):827–45.
• Jarlot-Gas C, Muscari F, Mokrane FZ, Del Bello A, Culetto A, Buscail E, Péré G, Fares N, Péron JM, Cuellar E, Barange K, Kamar N, Suc B, Maulat C. Management of anastomotic biliary stricture after liver transplantation and impact on survival. HPB (Oxford). 2021 Aug;23(8):1259-1268.
• López Álvarez M, Otero A, Vázquez Millán MA, Suárez López F, Alonso Aguirre P. Endoscopic treatment of biliary complications after liver transplantation. Rev Esp Enferm Dig. 2020 Aug;112(8):605-608.

Introduction

The incidence and severity of metabolic dysfunction-associated steatotic liver disease (MASLD) are notably higher in individuals diagnosed with type 2 diabetes mellitus (T2DM). However, studies evaluating the progression of MASLD in patients with T2DM and normal serum aminotransferase (ALT) levels are limited.

Aims & Methods

This 5-year prospective cohort study aimed to evaluate the progression of MASLD in T2DM patients with normal ALT. People with type 2 diabetes who had MASLD (defined by controlled attenuation parameter (CAP) >250 dB/min) and ALT levels that stayed normal (defined by ALT ≤40 IU/L for at least two occasions spanning at least six months) at Rajavithi Hospital, Bangkok, from November 2016 to 2017 were included. We excluded patients with viral hepatitis and alcohol consumption exceeding moderate levels. Transient elastography (TE) and CAP measurements were performed at baseline and ≥5 years of follow-up. The cutoffs to define significant and advanced fibrosis were TE >8 kPa and TE >12 kPa, respectively. All patients were instructed to reduce their weight and abstain from herbal remedies; medications for comorbidities were prescribed without limitations, subject to the physician's assessment. (most patients were under endocrinologist care.)

Results

The study included 84 patients, 57% of whom were female and had a mean age of 58.5 years. Of these, 62% were obese, with a mean BMI of 28.6 kg/m2. At baseline, the median TE was 6.92±3.35 kPa; 57 (68%) had no significant fibrosis, 22 (26%) had significant fibrosis, and 5 (6%) had advanced fibrosis, and after a 5-year follow-up, the median TE was 6.54±3.57 kPa; 69 (82%) had no significant fibrosis, 15 (18%) had significant fibrosis, and 2 (2%) had advanced fibrosis. During the follow-up, fibrosis decreased in 45 (54%), remained stable in 6 (7%), and increased in 33 (39%) patients, while a small proportion of patients experienced changes in the stages of fibrosis: 1.2% progressed from significant to advanced fibrosis; 17.4% regressed from advanced to significant fibrosis or transitioned from significant to no fibrosis; 12.8% remained stable with significant and advanced fibrosis; and the majority (66.3%) remained without significant fibrosis. A significant factor associated with fibrosis progression was alcohol consumption (p=0.013), while the use of angiotensin receptor blockers (p=0.042) was associated with fibrosis regression. Significant factors associated with steatosis progression included high baseline BMI (p=0.013), an increase in BMI ≥ 5% (p=0.04), high fasting plasma glucose, and LDL cholesterol levels, while a decrease in BMI ≥ 5% (p=0.002) the use of calcium channel blockers (p=0.038) and coffee consumption >3 cups per day (p=0.031) were associated with steatosis regression. ALT elevation during the follow-up occurred in a small proportion of patients, and it was not significantly associated with fibrosis or steatosis progression.

Conclusion

The majority of MASLD patients with T2DM and normal ALT maintained a relatively stable liver disease during 5 years of follow-up. Obesity, weight gain, alcohol consumption, and inadequate metabolic control were all associated with the progression of MASLD, whereas weight loss, coffee consumption, angiotensin receptor blockers, and calcium channel blockers were all associated with the improvement of MASLD.

Disclosure

I have nothing to disclose