Introduction

Acute variceal bleeding (AVB) is a common and life-threatening complication of cirrhosis and portal hypertension. Despite advances in therapeutic strategies, the 6-week mortality rate remains high, ranging from 10% to 20%. Current clinical guidelines recommend standard treatment for cirrhotic patients with AVB, including vasoactive agents, prophylactic antibiotics, and endoscopic intervention. However, real-world clinical practices are often influenced by physician awareness, institutional resources, and patient preferences. In late 2019, West China Hospital of Sichuan University established a multidisciplinary rapid-response pathway for the emergency management of high-risk upper gastrointestinal bleeding (UGIB). This initiative aimed to improve the treatment protocol, integrate endoscopic and interventional resources, and finally improve the outcomes.

Aims & Methods

The present study evaluates the impact of this rapid-response pathway on clinical outcomes in cirrhotic patients with AVB. This retrospective study included consecutive patients admitted for acute UGIB to West China Hospital between January 2016 and November 2022. Inclusion criteria were: (1) cirrhosis; and (2) presentation with hematemesis and/or melena within five days before admission. Exclusion criteria included: (1) non-variceal bleeding or an unconfirmed bleeding source on endoscopy; and (2) less than six weeks of follow-up. Patients were categorized into two groups based on the timing of rapid-response pathway implementation: Group A (2016–2019, pre-implementation) and Group B (2020–2022, post-implementation). Primary outcomes were 6-week mortality and 5-day treatment failure. Propensity score matching (PSM) was applied to adjust for baseline confounders: a 1:1 PSM was used to compare Group A and B.

Results

A total of 1,529 cirrhotic patients with AVB were included. Following 1:1 PSM, Groups A and B comprised 654 patients each. The most common etiology of cirrhosis is chronic hepatitis B virus infection. No significant intergroup differences were observed in Child-Pugh score, MELD score, MELD-Na score, prevalence of PVT, HCC, infection, ascites, or hepatic encephalopathy (all P > 0.05). Group B had a higher rate of prophylactic antibiotics, early endoscopic or interventional treatment use, and less balloon tamponade and intubation. Group B demonstrated significantly lower 6-week mortality compared to Group A [52 (8.0%) vs. 88 (13.5%), P = 0.001]. Multivariate Cox regression identified Child-Pugh score (HR = 1.203), MELD-Na score (HR = 1.040), PVT (HR = 1.733), HCC (HR = 2.398), and 5-day treatment failure (HR = 4.385) as independent risk factors for 6-week mortality. Similarly, Group B exhibited a significantly reduced 5-day treatment failure rate [64 (9.8%) vs. 137 (20.9%), P < 0.001]. While no significant differences in overall 6-week mortality or 5-day treatment failure were observed between the PVT and non-PVT groups, patients with coPVT had significantly higher 6-week mortality compared to non-PVT patients (HR = 4.81).

Conclusion

The implementation of a multidisciplinary rapid-response pathway significantly improved early intervention, endoscopy utilization, and TIPS procedures in cirrhotic patients with AVB. These changes were associated with marked reductions in both 6-week mortality and 5-day treatment failure. Key independent predictors of 6-week mortality included Child-Pugh score, MELD-Na score, HCC, PVT, and 5-day treatment failure.

Introduction

Patients with acute-on-chronic liver failure (ACLF) have traditionally been considered with a tendecy for bleeding however, they frequently display a paradoxical prothrombotic state. ACLF is characterized systemic inflammation and an increased risk of both bleeding and thrombosis. Bleeding arises from decreased pro-coagulation factors and platelet sequestration due to portal hypertension, while thrombosis is exacerbated by endothelial dysfunction and elevated heparinoids, thrombomodulin, or von Willebrand factor.

Aims & Methods

The aim of this study was to evaluate platelet aggregation pattern in patients with ACLF compared to acute decompensated (AD) liver cirrhosis.
The study took place in between the 1^st of July 2024- 31^st of January 2025 and we prospectively included cirrhotic patients, divided in two groups: ACLF group and AD group. The exclusion criteria were people with compensated liver cirrhosis, antiaggregant or anticoagulant treatment and patients with hepatocellular carcinoma or other malignancies. We investigated platelet aggregability in whole blood, by using multiplate aggregometry. For analysis, platelet aggregometry was performed induced by: adenosine diphosphate (ADP), arachidonic acid (ASPI), prostaglandin E2 (PGE2) and thrombin receptor-activated peptide (TRAP-6) as agonist were determined. TRAP‑6 is a peptide that stimulates protease-activated receptor 1 (PAR1) on platelet membrane.

Results

In this study we included 52 patients – 25 patients with ACLF and 27 patients with AD. There were no differences regarding demographic parameters and liver disease etiology between the two study groups. Compared to AD group, patients with ACLF showed an enhanced maximal platelet aggregation with TRAP-6 (AUC 85±12 U vs 45±10 U, p<0.0001). In contrast, we did not detect any differences in platelet aggregation between the two groups after ADP, ASPI or PGE2 activations. We observe that PAR-1 stimulation induces the highest aggregation curve and area under the curve in patients with ACLF and AD, but ACLF patients show the strongest response, highlighting that the degree of liver decompensation influences aggregation results. Severe decompensation correlates with a stronger TRAP response, suggesting that there are more PAR-1 receptors on platelets of this patients.

Conclusion

Our results indirectly indicate that platelet reactivity is higher in patients with ACLF likely due to enhanced PAR-1 receptor activity. Severe decompensation correlates with a stronger TRAP response, suggesting that there are more PAR-1 receptors on platelets of this patients.

References

1. EASL Clinical Practice Guidelines on acute on liver failure; J. Hepatol. 2023
2. Napolitano et al. European Journal of Internal Medicine 2017
3. Tripodi et al. Hepatology 2006
4. Lisman et al. Hepatology 2006
5. Nassar et al. BIOMEDICINES 2023
6. Rogalski et al. Scandinavian Journal of Gastroenterology 2019
7. Zanetto et al. Liver International 2022
8. Vecerzan et al. Cureus 2024
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Introduction

Currently, there are several prognostic scores developed to predict mortality in liver cirrhosis. Child-Pugh-Turcotte (CPT) and MELD-Na scores are the most used and validated in current practice. Recently, BAVENO consensus issued new recommendations for a better assessment of the rate of decompensation of liver cirrhosis as well as long- and short-term mortality rates. In this study, we aimed to evaluate the accuracy of both CPT and MELD-Na scores to predict BAVENO stages.

Aims & Methods

We conducted a retrospective study in which consecutive patients with liver cirrhosis admitted to the St. Spiridon Emergency Hospital Iasi between January 2023 and April 2024, were included. All cases were assigned to different prognostic stages according to BAVENO and MELD-Na and CPT scores were compared between the groups.

Results

Of the 155 patients included, 54.8% were males, with an average age of 57.81±12.36 years. According to BAVENO staging, 68% of patients were classified as a BAVENO stage 6, 10% as stage 5, 5% as stage 4, 10% as stage 3, 6% as stage 2, and 1% as stage 1. We found a positive correlation between MELD-Na Score and Child Pugh Score (r=0,774) with significant p-value (P<0.0001). Furthermore, our results demonstrate superior sensitivity and specificity for the MELD-Na score (98.7% and 97.9%, AUC-0.997) compared to the Child-Pugh score, which showed a sensitivity of 71.2% (AUC-0.792) to predict a stage 6 diagnosis and worst prognosis overall. At a cut-off of 34, MELD-Na score was the most accurate to discriminate between BAVENO stage 5 and 6, a cut off of 22 between BAVENO 4 and 5 and a cut off of 13 was the most accurate to discriminate between BAVENO stage 3 and stage 4.

Conclusion

Mortality rates and poor prognosis increase exponentially with liver cirrhosis decompensation, thus their assessment through predictive scores remains a highly desirable target for clinicians, MELD-Na score retaining its superiority in predicting the evolution through the BAVENO stages.

Introduction

Patients with ulcerative colitis (UC) and concurrent cytomegalovirus (CMV) colitis are at higher risk of poorer outcomes, including developing steroid refractoriness or toxic megacolon. Given its relevance, the European Crohn's and Colitis Organization recommends, in case of flare-ups, to search for CMV by endoscopic biopsy, preferably with tissue polymerase chain reaction (PCR) or alternatively with immunohistochemistry (IHC).

Aims & Methods

The aims of our study were to compare the diagnostic yield of tissue and plasma CMVDNA PCR to IHC and to explore the different level of tissue viral load in both steroid-refractory and steroid-sensitive UC patients. This prospective study included consecutive patients undergoing colonoscopy or proctosigmoidoscopy for UC, independent of disease activity, in a single tertiary center betwen July 2024 and January 2025. Patients underwent the same day endoscopy with multiple biopsies (3 from sigmoid colon and 4 from rectum) and plasma sampling for CMVDNA analysis using real-time quantitative PCR assay; histological presence of CMV was evaluated using IHC and hematoxylin-eosin staining. Concordance among CMV detection techniques was calculated using K cohen concordance index. Continuous variables were compared using Mann-Whithney test. ROC analysis allowed to identify an ideal cut-off of viral load value of CMV infection.

Results

Twenty-one consecutive patients were enrolled. Twelve (57,1%) patients were male and 9 (42,9%) female, (range 19-79 years). Nine (42,8%) patients had a diagnosis of pancolitis, three (14,3%) of left-sided UC, seven (33,4%) of procto-sigmoiditis and two (9,5%) of proctitis. Six (28,6%) patients were subclassified as steroid-refractory, the remaining fifteen (71,4%) as steroid-responsive.
IHC positivity was observed in tissue samples from 3 (14,3%) patients, while CMVDNA was detected in tissue samples from 5 (23,8%) patients and in 3 (14,3%) plasma samples. Comparing IHC to plasma CMVDNA, the k index was only fair consistent (0.277 CI -0.327 to 0.758), while IHC versus tissue DNA showed a higher consistency, with a k index of 0.500 (CI 0.048 to 0.952).
Interestingly, the mean value of tissue CMVDNA in the steroid-refractory group was higher, although not significant, than the steroid-responsive group (respectively 140.00 copies/mg ±260.00 vs 98.00 copies/mg ±360.00, p value= 0.14). In order to identify a possible tissue CMVDNA level able to distinguish between the two groups, a receiver operating characteristic (ROC) curve analysis was performed: a cut-off value of 102.56 was associated with a sensitivity of 92.86% and a specificity of 33.3%, resulting in a likelihood ratio of 1.39. The area under the ROC curve (AUC) was 0.6667 ± 0.1415, indicating a modest discriminative ability.

Conclusion

This study showed a good concordance between immunohistochemistry and tissue PCR for the detection of CMV in UC patients. Steroid-refractory UC patients showed a higher tissue viral load compared to steroid-responsive patients.

Disclosure

No conflict of interest to declare

Introduction

Patients with inflammatory bowel disease (IBD) experiencing severe flares are at increased risk of opportunistic infections, particularly cytomegalovirus (CMV), due to immunosuppressive therapy.

Aims & Methods

This study aimed to assess the prevalence and risk factors associated with CMV infection during severe acute colitis.
We conducted a retrospective analytical study on hospitalized patients with severe acute colitis. CMV infection was confirmed by positive anti-CMV IgM serology, positive colonic biopsy PCR for CMV DNA, or histological evidence of CMV cytopathic effect. Patients were divided into two groups: Group 1 (CMV-positive) and Group 2 (CMV-negative). Clinical, biological, and therapeutic data were compared (SPSS, p<0.05).

Results

Among 41 patients (mean age 39.8 years, 14 men), 17 (41.5%) had confirmed CMV infection. CMV was diagnosed by PCR (n=13), serology (n=3), or histology (n=1). Most received antiviral therapy (Ganciclovir or Valganciclovir). One patient required emergency colectomy; three experienced relapse, with two receiving Foscarnet and one undergoing colectomy for bleeding. No significant association was found between CMV infection and age, sex, disease duration, corticosteroid or immunosuppressant use, anemia, hypoalbuminemia, or CRP >45 mg/L. However, CMV infection was significantly associated with steroid resistance (p=0.003).

Conclusion

CMV infection is frequent during severe IBD flares and is strongly associated with corticosteroid resistance. Early recognition of this risk factor is essential for timely diagnosis and management to avoid complications.