Nivene Saad

Retrospective audit to determine the diagnostic accuracy of Primovist-enhanced MRI in the detection of hepatocellular carcinoma in cirrhosis with explant histopathology correlation

This study aims to determine the diagnostic accuracy of Primovist‐enhanced MRI in the detection of hepatocellular carcinoma (HCC) in cirrhosis, using liver explant histopathology correlation.

Underappreciation of non-alcoholic fatty liver disease by primary care clinicians: limited awareness of surrogate markers of fibrosis

Non‐alcoholic fatty liver disease (NAFLD) is a common cause of incidental liver test abnormalities. General practitioners (GP) have a key role in identifying people with NAFLD at risk of significant liver disease. Recent specialist guidelines emphasise the use of fibrosis algorithms or serum biomarkers rather than routine liver tests, to assess advanced fibrosis.

Endoscopic ultrasound-guided, through-the-needle forceps biopsy in the assessment of an incidental large pancreatic cystic lesion with prior inconclusive fine-needle aspiration

A 68-year-old man underwent endoscopic ultrasound (EUS) and fine-needle aspiration of a large cystic lesion of the pancreatic neck seen incidentally on computed tomography (CT). CT demonstrated a nonenhancing, exophytic, multilocular cystic mass, measuring 82×72mm (▶Fig. 1, ▶Video1). A mural calcific focus was noted posteroinferiorly and a more solid component posteriorly. The CT density averaged 19 HU for the cystic component and 40 HU for the solid component. EUS showed a mixed solid/cystic-appearing lesion without mural nodules. The cystic component contained multiple mobile ball-like structures (▶Fig. 2) and the solid component appeared to be hypoechoic and heterogeneous. No infiltration into the surrounding tissue or pancreatic duct communication was identified and the pancreas was otherwise unremarkable. In addition, no lymphadenopathy was present. EUS-guided transgastric cyst aspiration was performed using a 19-gauge needle, and 8ml of an opaque, turbid fluid was sent for cytological examination. Amylase and carcinoembryonic antigen (CEA) levels did not contribute to the diagnosis and the results of cytology investigation were inconclusive, revealing only cholesterol crystals, lipoid droplets, and scant leukocytes. A repeat EUS was undertaken to biopsy the cyst wall with dedicated throughthe-needle Moray micro forceps (US Endoscopy, Mentor, Ohio, USA) (▶Fig. 3). The forceps were passed through a 19-gauge needle and allowed precise and targeted sampling of the cyst wall (▶Fig. 2). In a second pass, the solidappearing component was targeted and 5ml of a thick, brown fluid were aspirated. Histological assessment revealed fragments of keratinizing squamous epitheE-Videos

Diffusion-weighted Imaging Is a Sensitive and Specific Magnetic Resonance Sequence in the Diagnosis of Ankylosing Spondylitis

Objective. We tested the discriminatory capacity of diffusion-weighted magnetic resonance imaging (DWI) and its potential as an objective measure of treatment response to tumor necrosis factor inhibition in ankylosing spondylitis (AS). Methods. Three cohorts were studied prospectively: (1) 18 AS patients with Bath Ankylosing Spondylitis Disease Activity Index > 4, and erythrocyte sedimentation rate > 25 and/or C-reactive protein > 10 meeting the modified New York criteria for AS; (2) 20 cases of nonradiographic axial spondyloarthritis (nr-axSpA) as defined by the Assessment of Spondyloarthritis international Society (ASAS) criteria; and (3) 20 non-AS patients with chronic low back pain, aged between 18 and 45 years, who did not meet the imaging arm of the ASAS criteria for axSpA. Group 1 patients were studied prior to and following adalimumab treatment. Patients were assessed by DWI and conventional magnetic resonance imaging (MRI), and standard nonimaging measures. Results. At baseline, in contrast to standard nonimaging measures, DWI apparent diffusion coefficient (ADC) values showed good discriminatory performance [area under the curve (AUC) > 80% for Group 1 or 2 compared with Group 3]. DWI ADC values were significantly lower posttreatment (0.45 ± 0.433 before, 0.154 ± 0.23 after, p = 0.0017), but had modest discriminating capacity comparing pre– and posttreatment measures (AUC = 68%). This performance was similar to the manual Spondyloarthritis Research Consortium of Canada (SPARCC) scoring system. Conclusion. DWI is informative for diagnosis of AS and nr-axSpA, and has moderate utility in assessment of disease activity or treatment response, with performance similar to that of the SPARCC MRI score.

Multimorbidity and polypharmacy in diabetic patients with Nafld: Implications for disease severity and management

Abstract An observational study describing the number and type of chronic conditions and medications taken by diabetic patients with NAFLD and identifying characteristics that may impact liver disease severity or clinical management. Adults with type 2 diabetes have a high prevalence of nonalcoholic fatty liver disease (NAFLD) and increased risk of developing advanced liver disease. Appropriate management should consider the characteristics of the diabetic NAFLD population, as comorbid conditions and medications may increase the complexity of treatment strategies. Diabetic patients with NAFLD at risk of clinically significant liver disease (as assessed by the FIB-4 or NAFLD fibrosis scores) were recruited consecutively from the Endocrine clinic or primary care. Medical conditions, medication history, anthropometric measurements, and laboratory tests were obtained during assessment. NAFLD severity was classified by transient elastography and liver ultrasound into “no advanced disease” (LSM < 8.2 kPa) or “clinically significant liver disease” (LSM ≥ 8.2 kPa). The most common coexistent chronic conditions were metabolic syndrome (94%), self-reported “depression” (44%), ischaemic heart disease (32%), and obstructive sleep apnoea (32%). Polypharmacy or hyperpolypharmacy was present in 59% and 31% of patients respectively. Elevated LSM (≥ 8.2 kPa) suggesting significant liver disease was present in 37% of this at-risk cohort. Increasing obesity and abdominal girth were both independently associated with likelihood of having significant liver disease. There is a high burden of multimorbidity and polypharmacy in diabetic NAFLD patients, highlighting the importance of multidisciplinary management to address their complex health care needs and ensure optimal medical treatment.

Splenic Injury Following Endoscopic Retrograde Cholangiopancreatography: A Case Report and Literature Review

Splenic injury following endoscopy is a rare but potentially fatal complication. While this has been found to occur more frequently after colonoscopy, splenic injury following endoscopic retrograde cholangiopancreatography (ERCP) remains highly uncommon since its first reported case in 1989. Indeed, there have been only 19 such cases reported in the English, German, and Spanish literature collectively over the past 27 years. We report on a 59-year-old woman who developed a peri-splenic haematoma diagnosed on abdominal computed tomography the day following ERCP and stenting for Mirizzi syndrome. The patient was treated conservatively and made a full recovery. We reviewed all cases of post-ERCP splenic injuries reported to date and discuss the published opinions on the likely mechanism of injury, predisposing factors, presenting features, investigation, and treatment options. Ultimately, patient outcome relies on clinical suspicion of this rare complication following ERCP.

Alcohol Consumption in Diabetic Patients with Nonalcoholic Fatty Liver Disease

Aim To examine the association between lifetime alcohol consumption and significant liver disease in type 2 diabetic patients with NAFLD. Methods A cross-sectional study assessing 151 patients with NAFLD at risk of clinically significant liver disease. NAFLD fibrosis severity was classified by transient elastography; liver stiffness measurements ≥8.2 kPa defined significant fibrosis. Lifetime drinking history classified patients into nondrinkers, light drinkers (always ≤20 g/day), and moderate drinkers (any period with intake >20 g/day). Result Compared with lifetime nondrinkers, light and moderate drinkers were more likely to be male (p = 0.008) and to be Caucasian (p = 0.007) and to have a history of cigarette smoking (p = 0.000), obstructive sleep apnea (p = 0.003), and self-reported depression (p = 0.003). Moderate drinkers required ≥3 hypoglycemic agents to maintain diabetic control (p = 0.041) and fibrate medication to lower blood triglyceride levels (p = 0.044). Compared to lifetime nondrinkers, light drinkers had 1.79 (95% CI: 0.67–4.82; p = 0.247) and moderate drinkers had 0.91 (95% CI: 0.27–3.10; p = 0.881) times the odds of having liver stiffness measurements ≥8.2 kPa (adjusted for age, gender, and body mass index). Conclusions In diabetic patients with NAFLD, light or moderate lifetime alcohol consumption was not significantly associated with liver fibrosis. The impact of lifetime alcohol intake on fibrosis progression and diabetic comorbidities, in particular obstructive sleep apnea and hypertriglyceridemia, requires further investigation.

Consensus statements on the imaging of axial spondyloarthritis in Australia and New Zealand

Free to read Spondyloarthritis (SpA) describes a group of related inflammatory conditions, including ankylosing spondylitis (AS), psoriatic arthritis, reactive arthritis, SpA associated with inflammatory bowel disease and undifferentiated SpA.[1] Classification criteria have been developed and validated by the Assessment of SpondyloArthritis international Society (ASAS) to distinguish axial-predominant SpA from peripherally predominant SpA (Fig. 1).[1, 2] These criteria contribute to diagnosis, but are not ideal diagnostic criteria as they possess only moderate sensitivity.[3] Diagnosis of axial SpA should be established by a rheumatologist, after careful consideration of these criteria and individual patient factors.

Controlled attenuation parameter in NAFLD identifies risk of suboptimal glycaemic and metabolic control

AIMS To examine the relationship between steatosis quantified by controlled attenuation parameter (CAP) values and glycaemic/metabolic control. METHODS 230 patients, recruited from an Endocrine clinic or primary care underwent routine Hepatology assessment, with liver stiffness measurements and simultaneous CAP. Multivariable logistic regression was performed to identify potential predictors of Metabolic Syndrome (MetS), HbA1c ≥ 7%, use of insulin, hypertriglyceridaemia and CAP ≥ 300 dB/m. RESULTS Patients were 56.7 ± 12.3 years of age with a high prevalence of MetS (83.5%), T2DM (81.3%), and BMI ≥ 40 kg/m2 (18%). Median CAP score was 344 dB/m, ranging from 128 to 400 dB/m. BMI (aOR 1.140 95% CI 1.068-1.216), requirement for insulin (aOR 2.599 95% CI 1.212-5.575), and serum ALT (aOR 1.018 95% CI 1.004-1.033) were independently associated with CAP ≥ 300 dB/m. Patients with CAP interquartile range < 40 (68%) had a higher median serum ALT level (p = 0.029), greater prevalence of BMI ≥ 40 kg/m2 (p = 0.020) and higher median CAP score (p < 0.001). Patients with higher CAP scores were more likely to have MetS (aOR 1.011 95% CI 1.003-1.019), HBA1c ≥ 7 (aOR 1.010 95% CI 1.003-1.016), requirement for insulin (aOR 1.007 95% CI 1.002-1.013) and hypertriglyceridemia (aOR 1.007 95% CI 1.002-1.013). CONCLUSIONS Our data demonstrate that an elevated CAP reflects suboptimal metabolic control. In diabetic patients with NAFLD, CAP may be a useful point-of-care test to identify patients at risk of poorly controlled metabolic comorbidities or advanced diabetes.

A Pragmatic Approach Identifies a High Rate of Nonalcoholic Fatty Liver Disease With Advanced Fibrosis in Diabetes Clinics and At-Risk Populations in Primary Care

Noninvasive serum biomarkers (nonalcoholic fatty liver disease fibrosis score [NFS], fibrosis 4 score [FIB‐4], or enhanced liver fibrosis [ELF] test) are recommended as first‐line tools to determine the risk of advanced fibrosis in nonalcoholic fatty liver disease. We aimed to assess the utility of a pragmatic approach to screening for clinically significant fibrosis in primary care and diabetes clinics. We recruited 252 patients from an endocrine clinic or primary care facility. Anthropometric measurements, ELF test, ultrasound, and liver stiffness measurements (LSMs) were performed. Clinically significant fibrosis was defined as LSM ≥8.2 kPa or ELF ≥9.8. A subgroup of patients underwent liver biopsy (n = 48) or had imaging diagnostic of cirrhosis (n = 14). Patients were 57.3 ± 12.3 years old with a high prevalence of metabolic syndrome (84.5%), type 2 diabetes (82.5%), and body mass index (BMI) ≥40 kg/m2 (21.8%). LSM met quality criteria in 230 (91.3%) patients. NFS and FIB‐4 combined had a high negative predictive value (90.0%) for excluding LSM ≥8.2 kPa. However, 84.1% of patients had indeterminate or high NFS or FIB‐4 scores requiring further assessment. LSM ≥8.2 kPa and ELF ≥9.8 were present in 31.3% and 28.6% of patients, respectively. Following adjustment for age, BMI, sex, and presence of advanced fibrosis, older age was independently associated with ELF ≥9.8 (adjusted odds ratio, 1.14; 95% confidence interval, 1.06‐1.24), whereas increasing BMI was independently associated with LSM ≥8.2 kPa (adjusted odds ratio, 1.15; 95% confidence interval, 1.01‐1.30). Concordant LSM <8.2 kPa and ELF <9.8 and concordant LSM ≥8.2 kPa and ELF ≥9.8 had a high negative predictive value (91.7%) and positive predictive value (95.8%) for excluding and identifying clinically significant fibrosis, respectively. Conclusion: Simple scoring tools alone lack accuracy. LSM accuracy is influenced by severe obesity, whereas age impacts the ELF test. Further studies are required to confirm whether combining LSM and ELF may enhance accuracy and confidence in identifying clinically significant fibrosis. (Hepatology Communications 2018; 00:000‐000)