Kieron B. Lim

An analysis of the efficacy and safety of a strategy of early precut for biliary access during difficult endoscopic retrograde cholangiopancreatography in a general hospital.

OBJECTIVE:  The use of early precut during endoscopic retrograde cholangiopancreatography (ERCP) is controversial because of its association with a higher risk of complications. This study examined the efficacy and safety of a strategy of early precut for biliary access during difficult ERCP in a general hospital.

Management of hepatitis C virus infection in the Asia-Pacific region: an update

The Asia-Pacific region has disparate hepatitis C virus (HCV) epidemiology, with prevalence ranging from 0·1% to 4·7%, and a unique genotype distribution. Genotype 1b dominates in east Asia, whereas in south Asia and southeast Asia genotype 3 dominates, and in Indochina (Vietnam, Cambodia, and Laos), genotype 6 is most common. Often, availability of all-oral direct-acting antivirals (DAAs) is delayed because of differing regulatory requirements. Ideally, for genotype 1 infections, sofosbuvir plus ledipasvir, sofosbuvir plus daclatasvir, or ombitasvir, paritaprevir, and ritonavir plus dasabuvir are suitable. Asunaprevir plus daclatasvir is appropriate for compensated genotype 1b HCV if baseline NS5A mutations are absent. For genotype 3 infections, sofosbuvir plus daclatasvir for 24 weeks or sofosbuvir, daclatasvir, and ribavirin for 12 weeks are the optimal oral therapies, particularly for patients with cirrhosis and those who are treatment experienced, whereas sofosbuvir, pegylated interferon, and ribavirin for 12 weeks is an alternative regimen. For genotype 6, sofosbuvir plus pegylated interferon and ribavirin, sofosbuvir plus ledipasvir, or sofosbuvir plus ribavirin for 12 weeks are all suitable. Pegylated interferon plus ribavirin has been replaced by sofosbuvir plus pegylated interferon and ribavirin, and all-oral therapies where available, but cost and affordability remain a major issue because of the absence of universal health coverage. Few patients have been treated because of multiple barriers to accessing care. HCV in the Asia-Pacific region is challenging because of the disparate epidemiology, poor access to all-oral therapy because of availability, cost, or regulatory licensing. Until these problems are addressed, the burden of disease is likely to remain high.

Melioidosis complicated by pericarditis

Melioidosis is a bacterial infection caused by the Gram-negative bacillus Burkholderia pseudomallei. We report an unusual case of melioidosis that presented as a pyrexia of unknown origin complicated by pericardial effusion. Our patient received a 6-week course of intravenous antibiotics, followed by 8 months of oral antibiotics, and made a complete recovery. This report illustrates the diagnostic and therapeutic challenge that clinicians may encounter when faced with this potentially fatal infection.

Acute-on-chronic liver failure in a multi-ethnic Asian city: A comparison of patients identified by Asia-Pacific Association for the Study of the Liver and European Association for the Study of the Liver definitions

AIM To explore the applicability of the Asia-Pacific Association for the Study of the Liver (APASL) and European Association for the Study of the Liver (EASL) guidelines for acute-on-chronic liver failure (ACLF) in profiling patients and determining the outcome. METHODS Patients admitted to a tertiary hospital in Singapore with acute decompensation of liver disease from January 2004 to July 2014 are screened for ACLF according to the APASL and EASL criteria. The patients’ data (including basic demographics, information about existing chronic liver disease, information about the acute decompensation, relevant laboratory values during admission, treatment, and outcome) are retrospectively analyzed to determine the background, precipitating factors and outcome. RESULTS A total of 458 liver patients is analyzed, and 78 patients with ACLF are identified. Sixty-three patients (80.8%) meet the APASL criteria, 64 patients (82.1%) meet the EASL criteria, and 49 patients (62.8%) fulfilled both criteria. The most common causes of acute liver injury are bacterial infections (59.0%), hepatitis B flare (29.5%), and variceal bleeding (24.4%). The common aetiologies of the underlying chronic disease included hepatitis B (43.6%), alcoholic (20.5%) and cryptogenic (11.5%) liver disease. The overall mortality rate is 61.5%. Increased age, the number of organ failures (as per CLIF-SOFA score), peak creatinine, INR, and amylase levels are associated with increased mortality or the need for liver transplantation. 14.3% of patients undergo liver transplantation with a 100% 1-year survival rate. CONCLUSION Both APASL and EASL criteria have identified ACLF patients with high three-month mortality, but those who fulfill APASL criteria alone have a better survival.

Sa1012 Virological Response Does Not Lower Liver Disease Progression Among Chronic Hepatitis B Cirrhotic Patients Treated With Long-Term Nucleos(T)Ide-Analogue

Background: A large number of chronic hepatitis B patients with cirrhosis are on long-term nucleos(t)ide-analogue therapy. The impact of anti-viral treatment on liver disease progression among these cirrhotics remains to be characterized. Method: CHB cirrhotics treated with long-term LAM-ADV combination therapy or ETV monotherapy in our center were enrolled and followed for outcomes. Liver disease progression was defined as liver decompensation, development of hepatocellular carcinoma and death. Cumulative probability of virological and clinical outcomes was evaluated by Kaplan–Meier analysis, logrank test and Cox-regression analysis. Results: A total of 264 cirrhotics (compensated disease 87.5%) fulfilled enrollment criteria, of which 143 and 121 were treated with LAM-ADV and ETV respectively. In LAM-ADV group, 57 (39.9%) were HBeAg-positive, mean HBV-DNA was 5.8 (5.5–6.1) log IU/mL, mean LAM-ADV duration was 41.4 (14.5–68.3) months and mean follow-up was 72.8 (31.5–114.1) months. In ETV group, 48 (39.7%) were HBeAg-positive, mean HBV-DNA was 4.4 (4.1–4.7) log IU/mL, mean ETV duration was 33.3 (15.2–51.4) months and mean follow-up was 45.7 (16.8–74.6) months. Among LAM-ADV group, cumulative probability of (a) virological response were 59.9%, 92.2%, 95.6% and (b) liver disease progression was 4.5%, 17.6%, 32.9%, at year 1, 3 and 5 respectively. Among ETV group, cumulative probability of (a) virological response was 74.5%, 94.8%, 100% and (b) liver disease progression was 7.8%, 12.5%, 17.7% at year 1, 3 and 5 respectively. The probability of liver disease progression was not influenced by virological response (p = 0.174). When stratified by treatment group, virological response again did not impact on the cumulative probability of liver disease progression (LAM-ADV group: p =0.173 and ETV group: p =0.433). Among virological responders, there was also no difference between LAM-ADV combination and ETV monotherapy group (p =0.199). Cox-regression showed baseline decompensated disease status was a significant predictor of disease progression (HR 4.96; 95%CI 2.61–9.44; p < 0.01) whereas virological response had no impact (p = 0.196). Conclusion: Among cirrhotics treated with long-term LAM-ADV combination therapy or ETV monotherapy, despite the excellent anti-viral efficacy, there was still significant probability of liver disease progression. LAM-ADV combination or ETV-monotherapy induced virological response did not lower the probability of liver disease progression in these patients.