Carla Marinho

Cirrhotic cardiomyopathy: Isn’t stress evaluation always required for the diagnosis?

AIM To describe the proportion of patients with cirrhotic cardiomyopathy (CCM) evaluated by stress echocardiography and investigating its association with the severity of liver disease. METHODS A cross-sectional study was conducted. Cirrhotic patients without risk factors for cardiovascular disease were included. Data regarding etiology and severity of liver disease (Child-Pugh score and model for end-stage liver disease), presence of ascites and gastroesophageal varices, pro-brain natriuretic peptide (pro-BNP) and corrected QT (QTc) interval were collected. Dobutamine stress echocardiography (conventional and tissue Doppler imaging) was performed. CCM was considered present when diastolic and/or systolic dysfunction was diagnosed at rest or after pharmacological stress. Therapy interfering with cardiovascular system was suspended 24 h before the examination. RESULTS Twenty-six patients were analyzed, 17 (65.4%) Child-Pugh A, mean model for end-stage liver disease (MELD) score of 8.7. The global proportion of patients with CCM was 61.5%. At rest, only 2 (7.7%) patients had diastolic dysfunction and none of the patients had systolic dysfunction. Dobutamine stress echocardiography revealed the presence of diastolic dysfunction in more 6 (23.1%) patients and of systolic dysfunction in 10 (38.5%) patients. QTc interval prolongation was observed in 68.8% of the patients and increased pro-BNP levels in 31.2% of them. There was no association between the presence of CCM and liver impairment assessed by Child-Pugh score or MELD (P = 0.775, P = 0.532, respectively). Patients with QTc interval prolongation had a significant higher rate of gastroesophageal varices comparing with those without QTc interval prolongation (95.0% vs 50.0%, P = 0.028). CONCLUSION CCM is a frequent complication of cirrhosis that is independent of liver impairment. Stress evaluation should always be performed, otherwise it will remain an underdiagnosed condition.

AIMS65 score: a new prognostic tool to predict mortality in variceal bleeding

Sir,Since upper gastrointestinal bleeding (UGIB) remains a common condition worldwide, efforts are being continuously made to optimize its management and to improve patients’ outcomes. Latest guide...

Optimizing the Risk Assessment in Upper Gastrointestinal Bleeding: Comparison of 5 Scores Predicting 7 Outcomes

Introduction: Although different scores have been suggested to predict outcomes in the setting of upper gastrointestinal bleeding (UGIB), few comparative studies between simplified versions of older scores and recent scores have been published. We aimed to evaluate the accuracy of pre- (PreRS) and postendoscopic Rockall scores (PostRS), the Glasgow-Blatchford score (GBS) and its simplified version (sGBS), as well as the AIMS65 score in predicting different clinical outcomes. Methods: In this retrospective study, PreRS, PostRS, GBS, sGBS, and AIMS65 score were calculated, and then, areas under the receiver operating characteristic curve were used to evaluate the performance of each score to predict blood transfusion, endoscopic therapy, surgery, admission to intensive/intermediate care unit, length of hospital stay, as well as 30-day rebleeding or mortality. Results: PreRS, PostRS, GBS, and sGBS were calculated for all the 433 included patients, but AIMS65 calculation was only possible for 315 patients. Only the PreRS and PostRS were able to fairly predict 30-day mortality. The GBS and sGBS were good in predicting blood transfusion and reasonable in predicting surgery. None of the studied scores were good in predicting the need for endoscopic therapy, admission to intensive/intermediate care unit, length of hospital stay, and 30-day rebleeding. Conclusions: Owing to the identified limitations, none of the 5 studied scores could be singly used to predict all the clinically relevant outcomes in the setting of UGIB. The sGBS was as precise as the GBS in predicting blood transfusion and surgery. The PreRS and PostRS were the only scores that could predict 30-day mortality. An algorithm using the PreRS and the sGBS as an initial approach to patients with UGIB is presented and suggested.

Acute Diverticulitis and Subsequent Colonoscopy: Instigating an Old Discussion

Pertinently, we performed a recent retrospective single-center study to assess the impact of colonoscopy after acute diverticulitis [5]. From the 632 patients with known colonic diverticulosis evaluated in our study, 246 had at least one hospital admission because of CT-diagnosed acute diverticulitis: 129 were men (52.4%), and the mean age was 61 ± 15. While a great majority of patients had uncomplicated disease, 35 patients (14.2%) had associated complications: 20 had colonic perforation, 12 had intra-abdominal abscess, and 3 had colonic fistulae. No cases of bowel obstruction due to acute diverticulitis were found. Colonoscopy was performed in 187 patients (76.0%): 25 patients had a colonoscopy before the acute event (mean of 12 months before, range 1–41 months), whereas 162 patients were scoped after the hospitalization (mean of 8 months after, range 1–44 months). There was no temporal relationship between previous colonoscopy and acute diverticulitis. Regarding endoscopic findings, diverticulosis was confirmed in 154 patients (82.4%), inflammatory changes of the colonic mucosa were present in 16 (6.4%), while bowel rigidity was described in 6 (3.2%). Polyps were present in 61 (32.6%) patients (50 adenomas with low-grade dysplasia, 9 hyperDear Editors, Diverticulosis of the colon is the most common anatomical colonic alteration, being found in more than 40% of all colonoscopies and in more than 70% of patients older than 80 years of age [1]. While colonic diverticulosis will remain asymptomatic in a majority of people, about 20% will have clinical manifestations, with acute diverticulitis being the most frequent complication of diverticulosis [2]. The issue of performing a colonoscopy after an episode of acute diverticulitis remains controversial and, according to the recently published American Gastroenterology Association guidelines on the Management of Acute Diverticulitis, the quantification of the yield, risks and timing of colonoscopy after an episode of acute diverticulitis should be a research priority [3]. It was with great interest that we read the paper from Andrade et al. [4] entitled “Routine colonoscopy after uncomplicated acute diverticulitis – challenging a putative indication,” in which the authors conclude that as the prevalence of advanced colonic neoplasia found on colonoscopy in patients with uncomplicated diverticulitis is quite similar to the average-risk population, an episode of CT-diagnosed uncomplicated diverticulitis does not seem to be a recommendation for colonoscopy. Received: March 5, 2017 Accepted: March 8, 2017 Published online: June 28, 2017

Percutaneous endoscopic gastrostomy: confirming the clinical benefits far beyond anthropometry

Objectives The real benefit of gastrostomy is still a matter of debate. We aimed to prospectively evaluate the global impact of percutaneous endoscopic gastrostomy (PEG) in patients followed at a specialized multidisciplinary clinic, namely, the impact on the need for healthcare resources, anthropometric measures, pressure ulcers prevention and healing, and nutritional and hydration status. Patients and methods From the 201 patients who underwent PEG between May 2011 and September 2014, 60 were included in a prospective study. Anthropometric, clinical, and laboratorial variables were collected and compared before and after PEG. Follow-up duration, mortality, and number of emergency department visits or hospital admissions were also assessed. Results Thirty-three (55.0%) patients were women and the median age was 79 years. The main indications for PEG were dementia (43.3%) and poststroke dysphagia (30.0%). Four months following PEG, significant decreases in the tricipital skinfold (P=0.002) and brachial perimeter (P=0.003) were found. A decrease in the mean number of hospitalizations (1.4 vs. 0.3; P<0.001) and visits to emergency department (2.2 vs. 1.1; P=0.003) was noted in the next 6 months after PEG compared with the previous semester. In 53.8% of patients with pressure ulcers, complete healing was observed after PEG. PEG was associated with increases in hemoglobin (P=0.024), lymphocytes (P=0.041), cholesterol (P=0.008), transferrin (P<0.001), albumin (P<0.001), and total proteins (P<0.001), and a decrease in serum sodium (P=0.001). Conclusion Anthropometric values may not translate the early benefits of a gastrostomy. PEG decreases the need for hospital health care, facilitates healing of pressure ulcers, and induces biochemical changes that may reflect better nutrition and hydration.

Treating Gastric Antral Vascular Ectasia – When Argon Therapy Is Not Enough

Gastric antral vascular ectasia (GAVE) is a capillary-type vascular malformation of the gastric antrum and an infrequent cause of chronic gastrointestinal blood loss and iron deficiency anemia. The authors describe a case report of GAVE in a female cirrhotic patient presenting with severe symptomatic iron deficiency anemia. After failure of argon plasma coagulation (APC), the patient was treated with endoscopic band ligation (EBL) with resolution of anemia, without new episodes of rebleeding and no need for further hospitalizations or transfusion requirements. Even though APC is the current treatment of choice for GAVE recurrence-free survival at one year is achieved in less than 50% of the patients and failed therapy has been described in up to 14% of the patients. EBL has been reported to be a relatively easy technique for GAVE therapy and has been shown to be safe and effective with lower complication rates in comparison with APC. This technique may in the future be used as the initial endoscopic treatment to eradicate GAVE.

Sa1305 Assessment of Liver Fibrosis in Patients With Chronic Hepatitis B -Diagnostic Accuracy of Four Noninvasive Tests

Background: Liver biopsy remains the gold standard to assess liver fibrosis in chronic hepatitis B (CHB). However, the use of noninvasive methods has emerged in recent years, namely tests based on serum fibrosis markers. The aim of our study was to evaluate the accuracy to predict liver fibrosis in CHB patients using four noninvasive tests: APRI [aspartate aminotransferase/platelet ratio index], AAR [aspartate aminotransferase/alanine aminotransferase ratio], FibroQ (fibro-quotient) and FIB-4. Methods: Forty CHB patients who underwent liver biopsy were included in the study. The patients were divided into two groups according to their METAVIR fibrosis scores (F0-1, no/minimal fibrosis; F2-4, significant fibrosis). Diagnostic accuracy for each test was measured using the area under the receiver operating curve (AUC), followed by calculation of sensitivity, specificity, positive predictive value (PPV) and negative predictive values (NPV). Results: The FIB-4 score had the best diagnostic accuracy for significant fibrosis (AUC 0,81, 95% CI 0,661-0,963), followed by APRI (AUC 0,80, 95% CI 0,645-0,954), and FibroQ (AUC 0,72, 95% CI 0,504-0,929). AAR did not have a good accuracy for liver fibrosis (AUC 0,48, 95% CI 0,263-0,698). The optimal cutoff value for FIB-4 was 1 (sensitivity 67%, specificity 77%, PPV 46%, NPV 89%), 0,5 for APRI (sensitivity 78%, specificity 68%, PPV 41%, NPV 91%) and 1,7 for FibroQ (sensitivity 67%, specificity 74%, PPV 43%, NPV 88%). Conclusion: FIB-4, APRI and FibroQ are accessible and useful tools to assess liver fibrosis in patients with CHB.