Laura Turco

Measurement of Spleen Stiffness to Evaluate Portal Hypertension and the Presence of Esophageal Varices in Patients With HCV-Related Cirrhosis

BACKGROUND & AIMS The hepatic vein pressure gradient (HVPG) is the standard used to determine the degree of portal hypertension (PH) and an important prognostic factor for patients with cirrhosis; HVPG values correlate with the presence of esophageal varices (EV). However, HVPG can only be accurately determined at specialized centers; noninvasive methods are needed to predict HVPG values and the presence of EV. We compared the diagnostic performance of spleen stiffness (SS) measurement by transient elastography with that of liver stiffness (LS) and of other recently proposed noninvasive tests. METHODS We measured SS and LS in 100 consecutive patients with hepatitis C virus-induced cirrhosis. Patients were also assessed by FibroScan, HVPG, esophagogastroduodenoscopy, and liver biopsy. We also analyzed LS-spleen diameter to platelet ratio score and platelet count to spleen diameter. RESULTS SS and LS were more accurate than other noninvasive parameters in identifying patients with EV and different degrees of PH. A linear model that included SS and LS accurately predicted HVPG values (R(2) = 0.85). The results were internally validated using bootstrap analysis. CONCLUSIONS Measurement of SS can be used for noninvasive assessment and monitoring of PH and to detect EV in patients with hepatitis C virus-induced cirrhosis.

Adverse effects of proton pump inhibitors.

Proton pump inhibitors (PPI) are very effective drugs used largely in acid related disorders. During the last years concern have been raised regarding their overutilisation in benign condition, such as gastroesophageal reflux disease. The debate focussed also on the risk of adverse events related to long term use of PPI. Apart of the case of Helicobacter Pylori (H. Pylori) positive patients, in whose long term acid suppression lead to the development of corpus predominant atrophic gastritis, precursor of cancer; the other assumed adverse events, have never been demonstrated in prospective studies. The attention should move towards the appropriate prescription of PPI, rather than the fear adverse effects of PPI. In fact, in clinical practise, PPI are often prescribed in patients without a specific acid related disease and continued long term based on their safety profile. This review focus on the main adverse events related to long term PPI use.

Indocyanine green retention test as a noninvasive marker of portal hypertension and esophageal varices in compensated liver cirrhosis

Noninvasive markers would be useful for the assessment of portal hypertension (PH) and esophageal varices (EV) in patients with cirrhosis. The aim of our study was to evaluate the performance of the indocyanine green (ICG) retention test as a noninvasive marker of PH and EV, measured against the gold standards (hepatic venous pressure gradient [HVPG] measurement and upper endoscopy). We prospectively enrolled patients with compensated cirrhosis referral to our unit. All patients underwent laboratory tests, abdominal ultrasound, upper gastrointestinal endoscopy, HVPG measurement, and the ICG 15‐minute retention (ICG‐r15) test. We evaluated the sensitivity and specificity of the ICG retention test and other noninvasive tools for the diagnosis of PH and EV. Ninety‐six consecutive Child‐Pugh A patients (67 male and 29 female; 60.3 ± 11.8 years of age) were enrolled. Seventy‐four patients had clinically significant portal hypertension (CSPH), of whom 59 had severe portal hypertension (SPH). ICG‐r15 and Lok index were independently related to the presence of both CSPH and SPH, whereas ICG‐r15 and INR were related to EV. ICG‐r15 values (<6.7% and <6.9%, respectively) were able to rule out the presence of CSPH and SPH (LR− 0.15 and 0.14); ICG‐r15 <10% provided a 97.8% sensitivity (LR− 0.042) for the exclusion of EV and a 100% sensitivity (LR− 0.0) for large EV. Conclusion: The ICG‐r15 test is an effective tool for assessment of PH in patients with compensated cirrhosis. Although this would not replace endoscopy, the ICG‐r15 appears able to identify patients with advanced liver disease in which endoscopy is mandatory as well as rule out the presence of EV in patients with compensated cirrhosis. (Hepatology 2014;59:643–650)

Pneumatosis cystoides intestinalis

Pneumatosis cystoides intestinalis (PCI) is a rare condition that may be associated with a variety of diseases. The presenting clinical picture may be very heterogeneous and represent a challenge for the clinician. In the present paper we describe both a common and an uncommon clinical presentation of PCI and review the pertaining literature. Our cases confirm that, apart from asymptomatic cases, the clinical presentation of PCI may be widely different and suggest that a new onset of stipsis might be the presenting symptom. Diagnosis might be suggested by a simple X-ray of the digestive tract showing a change in the characteristics of the intestinal wall in two-thirds of these patients. However, one third of the patients do not have a suggestive X-ray and require a computed tomography (CT) scan/nuclear magnetic resonance that may reveal a thickened bowel wall containing gas to confirm the diagnosis and distinguish PCI from intraluminal air or submucosal fat. CT also allows the detection of additional findings that may suggest an underlying, potentially worrisome cause of PCI such as bowel wall thickening, altered contrast mucosal enhancement, dilated bowel, soft tissue stranding, ascites and the presence of portal air. Our results also point out that clinicians and endoscopists should be aware of the possible presentations of PCI in order to correctly manage the patients affected with this disease and avoid unnecessary surgeries. The increasing number of colonoscopies performed for colon cancer screening makes PCI more frequently casually encountered and/or provoked, therefore the possible endoscopic appearances of this disease should be well known by endoscopists.

The Pharmacological Management of Intrahepatic Cholestasis of Pregnancy

Intrahepatic cholestasis of pregnancy is the most common liver disease occurring in the second half of pregnancy, characterized by pruritus and elevated serum bile acids often coupled to abnormal liver tests. Maternal prognosis is favourable with a complete symptom resolution after delivery, while preterm deliveries, fetal respiratory distress and stillbirths may occur. The goal of the pharmacological treatment of the disease is to improve maternal symptoms and biochemical alterations and, most importantly, to reduce fetal adverse events.The present manuscript will review the current knowledge on the pharmacological treatment of intrahepatic cholestasis of pregnancy.

Prevention and Management of Bleeding Risk Related to Invasive Procedures in Cirrhosis.

Cirrhosis represents the end stage of chronic liver disease and its transition from a compensated to a decompensated status is mainly driven by portal hypertension and systemic inflammation. Although relevant modifications in the evaluation of the coagulative balance in cirrhosis across its natural history have occurred and alterations in routine indices of hemostasis have lost their role as indicators of the hemorrhagic risk of patients with liver cirrhosis, these are still perceived as prone to bleed when admitted to invasive procedures. This view, which is still present in guidelines addressing the management of bleeding risk, makes preprocedural transfusion of plasma and platelets still an ongoing clinical practice. In this review, we describe the limitations of both bleeding risk assessment in cirrhotic patients admitted to radiologic and endoscopic invasive procedures and evaluate whether preventive strategies indicated by current guidelines can affect the procedure-related hemorrhagic events.

OC.10.7: SPLEEN STIFFNESS MEASUREMENT: A NEW NON INVASIVE PREDICTOR OF PORTAL HYPERTENSION AND ESOPHAGEAL VARICES IN VIRAL CHRONIC LIVER DISEASE

to international guidelines. Moreover the effectiveness of AASLD guidelines application has never been prospectively addressed. This is a prospective survey on a large cohort of newly diagnosed HCC observed in the last 2 years. Material and methods: From September 2008 to September 2010, 710 consecutive patients with HCC referring to 30 non-tertiary referral Hospitals were included. Inclusion criteria were newly detected HCC and cirrhosis. Patients were classified according to Child-Pugh and Meld score and BCLC stage. No prefixed protocols on diagnosis and treatment of HCC were operative. Statistical analysis is based on the first 536 cases. Results: Mean age was 70±4.7 yrs (71% M). Comorbidities were present in 322 patients (76%). Prevalent etiology was HCV (56%). Cirrhosis was Child A in 266 (63%), B in 125 (29%) and mean MELD score was 9.5±5.3. The mean size of nodules was 3.8±2.3 cm, monofocal in 57% and paucifocal in 23% cases. Age > 70 yrs and moderate/severe comorbidities were equally distributed among different BCLC stages. Regular follow-up was recorded in 289 cases (54%). Early HCC was more frequently observed in patients on regular follow-up (71% vs 39%). The most frequently employed imaging technique for diagnosis of HCC was TC (93%) followed by CEUS (62%); MRI was utilized in 17% of cases. Adherence to the non-invasive diagnostic criteria was 59% in nodules = 2 cm and 97% in larger nodules. The overall adherence to BCLC treatment algorithm was 52%. Ratio between ideal and real treatment offered was: OLT 42/9, resection 78/36, ablation 160/152, TACE 129/159, Sorafenib 67/21, palliative 60/134. In 25 cases combination therapy was performed. In particular 119 (40%) patients in BCLC stage A did not receive curative therapies. Conclusions: This translational study showed that adherence to either diagnostic and therapeutic AASLD 2005 algorithms was low particularly in early HCC stages. These discrepancies are mainly due to: 1) the difficulty in applying the algorithms in routine clinical practice and 2) the high prevalence of patients > 70 yrs with relevant comorbidities. The effectiveness of AASLD guidelines application remains to be verified.

P.1.17: INDOCYANINE GREEN AS A PREDICTOR OF CLINICALLY SIGNIFICANT PORTAL HYPERTENSION IN A PROSPECTIVE COHORT STUDY OF PATIENTS WITH CHRONIC LIVER DISEASE

169 DIFFERENT PATTERN OF DECOMPENSATION IN ALCOHOLIC VERSUS NON-ALCOHOLIC LIVER CIRRHOSIS M. Kuehne, J. Wiegand, P. Pradat, J. Moessner, F. Zoulim, C. Trepo, H.L. Tillmann. Gastroenterology and Rheumatology, University of Leipzig, Leipzig, Germany; Department of Hepatogastroenterology, Hotel Dieu Hospital University, Lyon, France; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA E-mail: johannes.wiegand@medizin.uni-leipzig.de