Baveno VII - Renewing consensus in portal hypertension

Jehovah's Witnesses: Challenges in liver disease management and in liver transplantation

Patients of Jehovah's Witnesses faith who are in need of liver transplantation pose unique challenges. These patients should be seen at transplant centers with experience in caring for Jehovah's Witnesses to formulate careful preoperative, intraoperative, and postoperative strategies on an individualized basis with multidisciplinary input to mitigate the risk of bleeding complications and to prepare for potentially catastrophic scenarios. In-depth and individualized conversations about what constitutes acceptable bloodless transfusion strategies both for the patient and for the transplant center should begin as early as possible with an experienced coordinator or church liaison. A therapeutic physician-patient relationship is vital to formulating a safe care plan and to understanding the spectrum of beliefs among Jehovah's Witnesses. There remains a paucity of data on disparities in liver care and outcomes in patients of the Jehovah's Witnesses faith. Future research on liver diseases and liver transplantation in Jehovah's Witnesses should focus on creating registries of patient outcomes and centers with experience.

Endohepatology: Applications in Liver Transplant

The term "endohepatology" was coined over the last 15 years to describe the integration of interventional endoscopy and hepatology for the management of patients with chronic liver disease. In this article, we will review the diagnostic and therapeutic applications of endoscopic ultrasound and endoscopic retrograde cholangiopancreatography among liver transplantation candidates and recipients.

Intestinal failure-associated liver disease in adult patients with chronic intestinal failure receiving home parenteral nutrition: A descriptive cohort study

BACKGROUND

Intestinal failure-associated liver disease (IFALD) is a major complication of chronic intestinal failure. Few data exist about hepatic monitoring of IFALD using the liver stiffness measurement. The aim of this study was to provide a descriptive analysis of IFALD and its prevalence in a tertiary center and to determine the IFALD risk factors and high liver stiffness measurement values using FibroScan.

METHODS

Adult patients with chronic intestinal failure treated with home parenteral nutrition and followed in a tertiary center with no underlying liver disease and at least one liver stiffness measurement record were included between January 1, 2007, and June 6, 2023.

RESULTS

Eighty-nine patients were included from this cohort of 145 patients. The prevalence of IFALD was 34%. A total of 14% had a liver stiffness measurement >10 kPa, and 49% had a liver stiffness measurement <5 kPa. In multivariate analysis, IFALD was positively associated with the use of a customized admixture (odds ratio [OR] = 7.04; 95% CI, 1.44-43.64; P = 0.017) and negatively associated with the colon in continuity (OR = 0.25; 95% CI, 0.07-0.87; P = 0.029). No significant association was observed between liver stiffness measurement values and IFALD.

CONCLUSION

The prevalence of IFALD was low in our study. Absence of the colon and the use of a customized admixture were risk factors for IFALD. Liver stiffness measurement was abnormal in 51% of cases. A long-term follow-up of this cohort will help to assess the prognostic relevance of IFALD and liver stiffness measurement in these patients.

[Endo-Hepatology: New Endoscopic Solutions for Old Hepatological Problems]

With the rapid development of endoscopic ultrasound (EUS), diagnostic and therapeutic platforms have emerged that are applicable in hepatology. New tools such as EUS-guided portal pressure measurement (in combination with EUS-guided liver biopsy) or EUS-guided variceal obliteration using coils and glue present attractive procedures that can potentially overcome the limitations of current gold standards. In this review article, we provide an overview of these new 'endo-hepatology' techniques and highlight their current role in the treatment of liver diseases.

Integrative bioinformatics analysis and experimental validation of key biomarkers driving the progression of cirrhotic portal hypertension

Background

Portal hypertension is a driving factor of cirrhosis complications, but the specific molecular mechanism of portal hypertension in cirrhosis remains unclear. The aim of this study was to identify hub genes for predicting persistent progression of portal hypertension in patients with liver cirrhosis.

Methods

Related microarray datasets were obtained from the Gene Expression Omnibus database. Weighted gene co-expression network analysis and differential expression genes analysis were used to identify the correlation sets of genes. In addition, protein-protein interaction networks and machine learning algorithms were conducted to screen center of candidate genes. To validate the diagnostic effect of hub genes, receiver operating characteristic curves were utilized in another dataset that is publicly accessible. Furthermore, the CIBERSORT algorithm was employed to investigate the immune infiltration levels of 22 immune cells and their connection to hub gene markers. Immunohistochemistry and reverse transcription quantitative polymerase chain reaction (RT-qPCR) were conducted to validate novel hub genes in clinical specimens.

Results

We obtained 671 differentially expressed genes and 11 module genes related to cirrhotic portal hypertension. Two candidate genes namely oncoprotein-induced transcript 3 protein (OIT3) and lysyl oxidase like protein 1 (LOXL1) were identified as biomarkers. RT-qPCR and immunohistochemistry (IHC) verified the expression of LOXL1 and OIT3 at mRNA and protein levels in liver tissue.

Conclusions

OIT3 and LOXL1 were identified as potential novel targets for the diagnosis and treatment of cirrhotic portal hypertension (CPH).

Inappropriate use of proton pump inhibitors in patients with liver cirrhosis: a cross-sectional study

BACKGROUND

Proton pump inhibitors (PPIs) are widely prescribed for acid-related disorders; however, concerns have emerged regarding their misuse, particularly in patients with liver cirrhosis. This study aimed to assess the appropriateness of PPI prescriptions in patients with cirrhosis and to identify factors contributing to their overutilization in this patient population.

METHODS

In this cross-sectional study, 1000 patients with cirrhosis receiving PPIs were enrolled. Data on demographics, clinical parameters, and endoscopic findings were collected, and indications for PPI therapy were assessed according to established guidelines.

RESULTS

Among patients with cirrhosis, 60.5% were prescribed PPIs, with pantoprazole being the most prescribed (55.7%). Inappropriate PPI use was observed in 53.6% of the patients, mainly because of lacking an approved indication (78.54%) or exceeding the recommended treatment duration (21.46%). Causes contributing to misuse included prolonged PPI use postendoscopic band ligation (29.1%), extended treatment for functional dyspepsia (21.46%), failure to discontinue PPIs upon hospital discharge (17.54%), using PPIs for preventing portal hypertensive gastropathy (PHG) or variceal bleeding (16.42%), and stress ulcer prophylaxis in non-ICU patients (15.86%). Multivariate analysis identified independent predictors of inappropriate PPI use, including Child classification C, Mayo End-Stage Liver Disease score greater than 18, hepatocellular carcinoma, and previous variceal bleeding, whereas hematemesis was identified as an independent predictor of appropriate use.

CONCLUSION

This study underscores the prevalent inappropriate prescription of PPIs in patients with liver cirrhosis, particularly in those with advanced liver disease or a history of variceal bleeding. Enhancing prescribing practices and adhering to evidence-based guidelines are essential to mitigate the risks associated with PPI misuse in patients with cirrhosis.

Systemic treatment in patients with hepatocellular carcinoma and advanced liver dysfunction

Systemic therapy represents the standard of care treatment for patients with advanced hepatocellular carcinoma (HCC). Given the increased risk of death from cirrhosis-related complications in patients with advanced liver dysfunction, pivotal phase III trials traditionally limited inclusion to patients with Child-Pugh class A, where death is more likely to be attributed to HCC progression. Therefore, Western guidelines recommend the use of systemic therapies primarily in patients with preserved liver function. However, patients with HCC and Child-Pugh class B are commonly encountered in clinical practice, but due to limited prospective evidence, there is no clear guidance on their optimal management.In this recent advances article, we discuss how the clinical course of cirrhosis can affect eligibility to treatment in the modern era of systemic therapy for HCC, elaborate on strategies to improve liver function in HCC patients by targeting cirrhosis-related and tumour-related factors and summarise the current literature on systemic therapy in HCC patients with Child-Pugh class B. Based on this information, we finally propose a clinical algorithm on how to systematically approach patients with HCC and advanced liver dysfunction in clinical practice.

Endoscopic variceal ligation combined with carvedilol versus endoscopic variceal ligation combined with propranolol for the treatment of oesophageal variceal bleeding in cirrhosis: study protocol for a multicentre, randomised controlled trial

INTRODUCTION

Liver cirrhosis and its severe complication, oesophageal variceal bleeding (EVB), pose significant health risks. Standard treatment for EVB combines non-selective beta-blockers (NSBB) with endoscopic variceal ligation (EVL). Carvedilol, an NSBB with additional benefits, is preferred for compensated cirrhosis. However, no randomised controlled trial (RCT) has compared carvedilol with propranolol, a conventional NSBB, in combination with EVL for secondary prophylaxis. This study aims to compare the effectiveness and safety of these treatments in preventing variceal rebleeding or death in patients with cirrhosis and EVB.

METHODS AND ANALYSIS

This multicentre, RCT is scheduled to begin in December 2024, with recruitment and follow-up continuing until December 2026. Eligible participants are patients with liver cirrhosis and EVB. Participants are randomly assigned in a 1:1 ratio to receive EVL combined with either carvedilol or propranolol. The primary endpoint is the incidence of variceal rebleeding or all-cause death. Secondary endpoints include all-cause death, liver-related death, each of the complications of portal hypertension (overt ascites, overt hepatic encephalopathy, spontaneous bacterial peritonitis, hepatorenal syndrome, portal vein thrombosis), hepatocellular carcinoma, changes in liver function (assessed by Child-Pugh and Model for End-Stage Liver Disease scores), changes in liver stiffness, changes in spleen stiffness, and adverse events. Subgroup and sensitivity analyses will be conducted to evaluate the consistency and robustness of the treatment effects. A total sample size of 524 patients (262 per group) is required to detect a significant difference between the treatment arms.

ETHICS AND DISSEMINATION

The study protocol has been approved by the ethics committee of the First Hospital of China Medical University (No. 2024-656-2). The study will follow the Declaration of Helsinki and Good Clinical Practice guidelines. The findings of this trial will be disseminated through peer-reviewed publications, conference presentations and healthcare professionals to guide future clinical practice.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry (Registration number: ChiCTR2400089692).

Psoriasis, metabolic syndrome and methotrexate: Is this association suitable for a new subcategory in steatotic liver disease?

Psoriasis is a prevalent inflammatory disease that shares chronic inflammation pathways with the pathophysiology of metabolic syndrome (MetS), type-2 diabetes mellitus and atherosclerosis. A high prevalence of steatosis and advanced liver fibrosis has been described in psoriasis. The influence of MetS and its compounds, patatin-like phospholipase domain containing 3 and transmembrane 6 superfamily member 2 gene polymorphisms and the cumulative dose of methotrexate (MTX) in the progression of steatotic disease are still under debate. A suitable new classification for psoriasis-related liver disease, under the umbrella of steatotic liver disease (SLD), might be evaluated due to the potential impact of MTX on liver steatosis. Considering the interplay between the MetS, steatosis and MTX, a new definition for this complex disease might be discussed since it is not entirely addressed under the umbrella of SLD and metabolic-dysfunction associated SLD. Hence, shortly, a discussion could be raised on the feasible term "Met-Drug SLD", metabolic and drug-induced SLD, which comprises both metabolic dysfunction and drug-related SLD. This review aims to report the best evidence to accurately classify liver disease in psoriasis, considering the new definition of SLD, allowing appropriate management once it is carefully defined.

Incidence and efficacy of strategies for preventing hepatic encephalopathy following transjugular intrahepatic portosystemic shunt: A meta-analysis

BACKGROUND

Hepatic encephalopathy (HE) is a primary complication following transjugular intrahepatic portosystemic shunt (TIPS), but the utility of pharmacological prophylaxis for HE is unclear.

AIM

To assess the HE incidence post-TIPS across various groups and the prophylactic efficacies of various medications.

METHODS

A thorough literature search was performed in PubMed, Web of Science, EMBASE, and the Cochrane Library databases from their inception to November 24, 2024, to collect data regarding HE incidence. The main outcome was HE incidence post-TIPS. A meta-analysis using a random effects model was performed to obtain odds ratios (ORs) and 95% confidence intervals. Statistical analyses were conducted using Stata and RevMan software.

RESULTS

This meta-analysis included nine studies with 1140 patients; 647 received pharmacological agents including lactulose, rifaximin, albumin, and l-ornithin-l-aspartate, and 493 did not (controls). (1) In the single-group meta-analysis, the control group had higher short- and long-term HE rates than the drug intervention group. Among patients with and without prior HE, the non-intervention group's HE rates were also higher; (2) Pharmacological prevention post-TIPS significantly reduced HE incidence [OR = 0.59 (0.45, 0.77), P = 0.0001]. Compared with the no prophylaxis, rifaximin reduced the risk of HE after TIPS [OR = 0.52 (0.29, 0.95), P = 0.03], but lactulose did not; (3) In patients without prior HE, pharmacological prevention significantly reduced post-TIPS HE incidence [OR = 0.62 (0.41,0.95), P = 0.03]; and (4) Network meta-analysis showed no significant differences among five prevention strategies.

CONCLUSION

The HE incidence after TIPS was relatively high, and the use of drugs after TIPS may reduce the HE incidence. However, research, especially large-scale randomized controlled trials, is still lacking.

Role of etiological therapy in achieving recompensation of decompensated liver cirrhosis

The traditional view of the decompensated stage as a point of no return in the natural history of liver cirrhosis (LC) is currently being questioned. This is due to the appearance of data indicating the possibility of restoring the structure and function of the liver, reducing the portal pressure with a positive effect on complications associated with portal hypertension and decreasing the risk of developing hepatocellular carcinoma after elimination of the etiological factor. To create a unified understanding the recompensation of decompensated LC, at the Baveno VII consensus workshop were developed criteria confirming it. At the moment, the efficacy of etiological therapy in achieving established criteria for recompensation has been evaluated only in patients with alcohol-related, as well as hepatitis B virus-related and hepatitis C virus-related decompensated LC. The purpose of the review is to provide up-to-date information on the role of etiological therapy in achieving recompensation of decompensated LC according to Baveno VII criteria. So far, only the first steps have been taken in studying this problem. To further understand it, research is needed to identify pathophysiological mechanisms, modifying factors, predictors, and potential noninvasive biomarkers of recompensation of decompensated LC.

Nomogram for predicting survival after transjugular intrahepatic portosystemic shunt in portal hypertension patients with bleeding

BACKGROUND

Portal hypertension (PHT) is a life-threatening complication of cirrhosis, often resulting in gastrointestinal bleeding that requires transjugular intrahepatic portosystemic shunt (TIPS). While TIPS effectively reduces portal pressure, predicting long-term survival remains challenging due to the multifactorial nature of patient outcomes. Accurate survival prediction tools are lacking, and existing models often omit critical factors such as portal vein diameter. This study aimed to develop and validate a nomogram incorporating key clinical and biochemical variables to predict 1-year and 2-year survival following TIPS in PHT patients. We hypothesized that this model would provide improved risk stratification and guide clinical decisions.

AIM

To develop and validate a nomogram for predicting 1-year and 2-year survival in PHT patients post-TIPS.

METHODS

This retrospective cohort study included 848 TIPS-treated PHT patients with gastrointestinal bleeding from two tertiary hospitals (2013-2021). Mortality was the primary endpoint. Predictive variables were selected using least absolute shrinkage and selection operator regression, and a nomogram was developed with Cox regression to predict 1-year and 2-year survival. Model performance was evaluated through receiver operating characteristic curves, calibration plots, and decision curve analysis.

RESULTS

The mean age of the included (848) patients was 53.00 years ± 12.51, where 69.58% were men. Results showed that portal vein diameter, serum creatinine, potassium, and alpha-fetoprotein were the independent predictors of post-TIPS survival. Besides, the model showed strong discriminatory ability (C-index, 0.816 in the training set; 0.827 in the validation set) and good calibration. The area under the curve for 1-year and 2-year survival in the training set were 0.890 [95% confidence interval (CI): 0.802-0.948] and 0.838 (95%CI: 0.803-0.869), respectively. The area under the curve for 1-year and 2-year survival in the validation set were 0.934 (95%CI: 0.815-0.987) and 0.864 (95%CI: 0.811-0.907), respectively.

CONCLUSION

The developed nomogram could reliably predict 1-year and 2-year survival in patients undergoing TIPS for PHT-induced gastrointestinal bleeding.

Intestinal failure-associated steatosis and fibroblast growth factor 21 plasma levels among adult chronic intestinal failure patients

BACKGROUND & AIMS

Adult patients with chronic intestinal failure (CIF) may develop intestinal failure-associated steatosis. Asymptomatic steatosis can lead to steatohepatitis and its downstream complications. Monitoring steatosis in daily practice in adult CIF patients is hampered by limited, reliable, accessible, non-invasive methods to measure liver fat content (LFC). Fibroblast growth factor 21 (FGF21) is a hormone that is mainly produced by hepatocytes, and higher plasma levels are associated with the presence and the degree of liver steatosis in several clinical conditions. Furthermore, FGF21 analogues have been shown to reduce fatty liver. FGF21 has previously been suggested as a biomarker for liver steatosis. The aim of this study was to assess the diagnostic performance of FGF21 plasma levels to detect steatosis and steatosis severity in adult CIF patients.

METHODS

FGF21 plasma levels were quantified using enzyme-linked immunosorbent assay (ELISA) in 48 adult CIF patients who had been receiving home parenteral nutrition (HPN) or intravenous fluids for ≥3 months for ≥2 times per week. Liver fat content (LFC, %) was assessed with proton magnetic resonance spectroscopy (1H-MRS). Patient characteristics of patients with steatosis (LFC >5.5 %) and without steatosis (LFC ≤5.5 %) were compared using the Mann-Whitney U test or Fisher's exact test. The diagnostic value of FGF21 levels to diagnose the presence of steatosis (LFC >5.5 %) was performed by determining the area under the receiver operating characteristics curve (AUC), and the optimal cut-off value was determined. Furthermore, Spearman's rho correlation coefficient was calculated to evaluate the association between FGF21 levels and LFC.

RESULTS

FGF21 plasma levels were measured in 48 patients (median age of 56 years, 71 % female) with a median duration of HPN use of 57 months. Steatosis was diagnosed in 8/48 (17 %) patients, with a median LFC of 8.4 % (range 5.7-39.9 %). CIF patients with steatosis had higher median FGF21 plasma levels (658 pg/mL) than patients without steatosis (299 pg/mL). The area under the curve (AUC) of FGF21 to predict steatosis (LFC >5.5 %) was 0.80 [95 % CI 0.63, 0.96]. With the optimal FGF21 cut-off point at 453 pg/mL, the sensitivity as well as the specificity was 75 %. The calculated Spearman rho correlation found a significant positive correlation (ρ = 0.65, p < 0.001) between FGF21 plasma levels and LFC (%).

CONCLUSION

Adult CIF patients with steatosis had higher FGF21 plasma levels than CIF patients without steatosis. FGF21 is a good predictor for diagnosing steatosis and has a good correlation with LFC. FGF21 should be considered as a biomarker for steatosis in adult patients with CIF.

Predictive value of high-risk esophageal varices in cirrhosis based on dual-energy CT combined with clinical and serologic features

OBJECTIVE

To investigate the predictive value of dual-energy CT (DECT) in combination with clinical and serologic features for noninvasive assessment of high-risk esophageal variceal (EV) in cirrhosis patients.

DATA AND METHODS

120 patients who had undergone DECT and gastroscopy were retrospectively enrolled. They were categorized into low-risk variceal (LRV) and high-risk variceal (HRV) groups by gastroscopy (LRV: none, mild, HRV: moderate, severe). Clinical data, serologic and DECT parameters were recorded respectively. Multifactorial logistic regression analyses were conducted to develop clinical, serological, DECT, and combined models. AUC was utilized to assess the diagnostic performance. Non-parametric tests were employed to analyze differences in DECT parameters among different grading of EV.

RESULTS

In clinical model, ascites was the independent risk predictor, with 78.3% accuracy,50% sensitivity, 100% specificity, and an AUC of 0.693. The serological model revealed white blood cell count, hematocrit, alanine aminotransferase, and platelet count as predictors for HRV, demonstrating 83.3% accuracy, 90.9% sensitivity, 76.9% specificity, and an AUC of 0.784. The DECT model, identified liver normalized iodine volume (NIV-L) and spleen volume (V-S) as key predictors, with 84% accuracy, 72.7% sensitivity, 92.9% specificity, and an AUC of 0.84. The combined model, integrating NIV-L, V-S, and Ascites, demonstrated superior performance with 82.6% accuracy, 90% sensitivity, 76.9% specificity, and an AUC of 0.878, compared to the other models. Additionally, severe EV had higher V-S and NIV-S values than other grades (p < 0.05), with AUC of 0.874 and 0.864, respectively.

CONCLUSION

DECT-based NIV-L, V-S, and presence of ascites can predict high-risk esophageal varices.

CLINICAL RELEVANCE STATEMENT

Quantitative parameters of DECT can predict high-risk esophageal varices in cirrhotic patients, avoid gastroscopy, if possible, continue hierarchical management.

TRIAL REGISTRATION

retrospectively registered.

Liver Elastography Methods for Diagnosis of De Novo and Recurrent Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC), a common consequence of chronic liver disease, ranks among the most prevalent cancers globally and contributes significantly to cancer-related mortality. Liver fibrosis is intimately associated with hepatic function and the likelihood of future HCC occurrence. Despite the fact that liver biopsy continues to be the gold standard for diagnosing fibrosis, its utility is hindered by cost and invasiveness, along with patient unease, procedural rejection, and potential adverse effects. Liver elastography has become a leading noninvasive means of assessing tissue stiffness with considerable diagnostic precision. Malignant tumors generally exhibit higher cellularity in comparison to benign ones, resulting in increased stiffness. Elastography techniques capitalize on alterations in tissue elasticity stemming from specific pathological or physiological processes. Technological innovations, such as advanced ultrasound imaging and artificial intelligence (AI)-integrated systems, are paving the way for enhanced diagnostic accuracy and risk prediction. Recent research underscores the potential of elastography in managing HCC patients, presenting novel clinical applications, including prediction of HCC development, differentiation between malignant and benign liver lesions, evaluating treatment response, and forecasting recurrence post-treatment, though certain findings remain contentious. Therefore, this review aims to sum up the latest advancements in liver elastography for HCC patients, outlining its applications while addressing existing limitations and avenues for future progress.

Management of liver sinusoidal obstruction syndrome/veno-occlusive disease in adults: a 2025 perspective from an international expert group

Sinusoidal obstruction syndrome (SOS) formerly known as Veno-occlusive disease (VOD) is a potentially fatal complication that occurs mainly after haematopoietic cell transplantation, especially allogeneic transplantation. The liver is the principal organ affected, though other organs, such as the lungs, may also be involved to a lesser extent. The condition is characterised by obstruction of the hepatic venules, leading to sinusoidal congestion, hepatic ischaemia and, in severe cases, fulminant liver failure. Recent refined diagnostic criteria, published by the European Society for Blood and Marrow Transplantation in 2023, provide a more accurate method of detecting SOS/VOD, allowing earlier intervention and better stratification of patients according to the severity of their disease. This article focuses on liver SOS/VOD and discussing key risk factors, new diagnostic methods and therapeutic strategies, with an emphasis on the early use of defibrotide, which remains the reference treatment for severe SOS/VOD.

Management of hepatic encephalopathy following transjugular intrahepatic portosystemic shunts: Current strategies and future directions

Transjugular intrahepatic portosystemic shunts (TIPSs) are generally used for the management of complications of portal hypertension in patients with decompensated cirrhosis. However, hepatic encephalopathy (HE), which impairs neuropsychiatric function and motor control, remains the primary adverse effect of TIPS, limiting its utility. Prompt prevention and treatment of post-TIPS HE are critical, as they are strongly associated with readmission rates and poor quality of life. This review focuses on the main pathophysiological mechanisms underlying post-TIPS HE, explores advanced biomarkers and predictive tools, and discusses current management strategies and future directions to prevent or reverse HE following TIPS. These strategies include preoperative patient assessment, individualized shunt diameter optimization, spontaneous portosystemic shunt embolization during the TIPS procedure, postoperative preventive and therapeutic measures such as nutrition management, medical therapy, fecal microbiota transplantation, and stent reduction.

Readmission Events Following EGD for Upper Gastrointestinal Bleed: An Analysis Using the National Readmission Database

Background: Upper Gastrointestinal Bleed (UGIB) is a common and potentially life-threatening condition with an annual incidence of 80-150 per 100,000 individuals and a mortality rate of 2-10%. Esophagogastroduodenoscopy (EGD) is the gold standard for both diagnosis and treatment, but post-discharge outcomes, including readmissions, remain underexplored. Methods: This study utilized the 2021 National Readmission Database (NRD) to analyze 30-day readmission rates following EGD for UGIB. Adult patients (≥18 years) admitted for UGIB and undergoing EGD were included; those who died during the index hospitalization were excluded. Demographic, clinical, and socioeconomic factors associated with readmission were examined using multivariate logistic regression. Results: Among 34,257 patients admitted for UGIB and undergoing EGD, 11,088 (32.4%) were readmitted within 30 days, with 5423 (49%) due to recurrent UGIB. Readmitted patients had a higher mean age (68.46 vs. 67.63 years) and greater prevalence of cirrhosis (16.71% vs. 13.84%). Hospital resource utilization was significantly higher among readmissions, with increased total hospital charges (USD 82,544.82 vs. USD 61,521.17) and longer hospital stays (5.38 vs. 4.97 days). Mortality was lower among readmitted patients (1.46% vs. 3.53%). Multivariate analysis identified cirrhosis (OR 7.20, 95% CI: 6.45-8.02), untreated H. pylori infection (OR 3.43, 95% CI: 2.15-4.30), atrial fibrillation (OR 1.52, 95% CI: 1.36-1.69), and chronic antithrombotic therapy (OR 1.63, 95% CI: 1.41-1.89) as significant predictors of recurrent UGIB readmission. Lower socioeconomic status was also associated with increased readmission risk (OR 1.15, 95% CI: 1.05-1.25). Conclusions: Readmission following EGD for UGIB is common and driven primarily by recurrent bleeding. Cirrhosis, untreated H. pylori infection, atrial fibrillation, and chronic anticoagulation therapy are key risk factors. These findings highlight the need for targeted interventions, including improved post-discharge management and optimization of anticoagulation strategies, to reduce readmission rates and improve patient outcomes.

Diagnostic accuracy of liver stiffness measurement for the diagnosis of veno-occlusive disease/sinusoidal obstruction syndrome after hematopoietic stem cell transplantation (HSCT), the ELASTOVOD STUDY: an investigator-initiated, prospective, multicentre diagnostic clinical trial

Hepatic Veno-occlusive disease/sinusoidal obstruction syndrome (VOD/SOS) is a severe complication following hematopoietic stem cell transplantation (HSCT), traditionally diagnosed based on clinical criteria. This study aimed to evaluate the diagnostic performance of liver stiffness measurement (LSM) as a non-invasive tool for non invasive diagnosis of VOD/SOS. A multicentre clinical trial was conducted in Italy from April 2018 to December 2021, screening 1089 patients across 25 centers. VOD/SOS diagnosis followed established clinical guidelines, and patients underwent comprehensive clinical, laboratory, and imaging evaluations up to +100 days post-HSCT or until VOD/SOS diagnosis. LSM was measured pre-HSCT and on specific post-transplant days (ClinicalTrials.gov: NCT03426358). The study enrolled 774 adults and 167 children. The +100-day incidence of VOD/SOS HSCT was 5.53 and 5.26 in the overall and allo-HSCT population, higher in children (14.3%) than in adults (3.68%). The 100-day overall survival (OS) probability was 89.5% (overall) and 89.0% (allo-HSCT) while one-yr OS 79% and 78%, respectively, with outcomes varying by VOD/SOS occurrence and severity. LSM significantly differed between VOD/SOS patients and non-affected individuals at all post-HSCT time points, correlating with disease severity. A diagnostic algorithm was proposed, achieving ≥95% sensitivity and specificity, with a 6 kPa rule-out and 25 kPa rule-in cut-off, enhanced by the "three-time pre-HSCT rule." Survivors showed declining LSM over time, while non-survivors did not. Fully recovered patients had lower LSM than non-improvers. LSM also distinguished VOD/SOS from other liver complications within +100 days post-HSCT in both adults and children. In conclusion, LSM is a reliable, non-invasive diagnostic tool for VOD/SOS. LSM contribute to differential diagnosis and to treatment response as well. This study underscores the potential of LSM, combined with multidisciplinary expertise, to guide VOD/SOS diagnosis and management in HSCT patients, improving potentially the clinical outcomes.

Decompensated cirrhosis: an update of the BSG/BASL admission care bundle

Acute decompensated cirrhosis (DC) and acute-on-chronic liver failure are common reasons for hospital admission that have a high in-hospital mortality rate (10%–20%). Patients require a detailed assessment for precipitating factors and management of complications such as infections, ascites, acute kidney injury and hepatic encephalopathy. Multiple reports have demonstrated unwarranted variability in the care of patients with DC. In 2014, the British Society of Gastroenterology (BSG)/British Association for the Study of the Liver (BASL) DC care bundle (DCCB) was introduced to provide a structured approach for the management of patients with DC in the first 24 hours. Usage of the DCCB has been shown to improve care of patients with DC. However, despite evidence indicating the beneficial impact of the DCCB, overall usage across the UK was only 11.4% in a national audit. Our aim was to update the DCCB to incorporate recent advances in care and improve its usability and develop a strategy to improve its usage nationally. The updated bundle was developed by a multidisciplinary group of specialists from BSG, BASL and the Society for Acute Medicine with the quality of evidence supporting the bundle recommendations assessed using the Grading of Recommendation Assessment Development and Evaluation tool. Proposed minimum standards for audit were also developed. Finally, a strategy to promote usage of the bundle including education/training at a national and local level, improving accessibility for the bundle, and promotion of frameworks for use at an institutional level to improve and monitor utilisation of DCCB.

Effectiveness of a Model of Care Based on Fibrosis-4 and Liver Stiffness Measurement for the Screening of Patients With Type 2 Diabetes Mellitus at Risk of Advanced Liver Disease: Results From an Italian Prospective Multicenter Study

INTRODUCTION

Patients with type 2 diabetes mellitus (T2DM) are at increased risk of metabolic dysfunction-associated steatotic liver disease, advanced liver fibrosis, and metabolic dysfunction-associated steatohepatitis (MASH). We evaluated the prevalence and severity of metabolic dysfunction-associated steatotic liver disease among patients with T2DM at their first referral to diabetes clinics and assessed the effectiveness of the 2-tier screening approach by Fibrosis-4 (FIB-4) and vibration-controlled transient elastography (VCTE).

METHODS

Consecutive patients with T2DM from 6 different diabetes clinics were prospectively enrolled. Liver stiffness measurement (LSM) was assessed by VCTE, whereas liver steatosis by controlled attenuation parameter (Fibroscan, Echosens, France). "At-risk MASH" was assessed by FibroScan-aspartate aminotransferase score.

RESULTS

Eight hundred patients (median age: 59, 53-65 years; males: 485, 60.6%) met the inclusion criteria. Prevalence of liver steatosis (controlled attenuation parameter ≥ 248 db/m) was 73.6%. The proportion of patients at medium/high risk of advanced liver fibrosis (LSM ≥ 8.0 kPa) was 16.9%. Patients with "at-risk MASH" (FibroScan-aspartate aminotransferase > 0.67) were 12.0%. A 2-tier screening for advanced liver fibrosis by FIB-4 and VCTE would have led to 70 patients (8.8%) referred to liver clinics with a false-negative rate of 9.6% (n = 77; patients with FIB-4 < 1.3 and LSM ≥ 8.0 kPa). At multivariate analysis, overweight/obesity (odds ratio = 3.13, 95% confidence interval 1.23-7.97) and elevated alanine aminotransferase (odds ratio = 1.91, 95% confidence interval 1.17-3.10) were independently associated with LSM ≥ 8.0 kPa in patients with FIB-4 < 1.3.

DISCUSSION

In diabetes clinics, the 2-tier screening using FIB-4 and VCTE is effective for the identification of patients with T2DM to be referred to hepatologists. VCTE referral may be considered for patients with overweight/obesity and elevated alanine aminotransferase classified as at low risk of advanced liver fibrosis by FIB-4.

Spleen Stiffness Predicts the Risk of Liver-related Complications in Patients With Compensated Advanced Chronic Liver Disease

BACKGROUND & AIMS

The development of portal hypertension (PH) is a key prognostic factor in patients with compensated advanced chronic liver disease (cACLD). The gold standard for assessing PH is the hepatic venous pressure gradient measurement. However, noninvasive tools have gained significant importance in recent years, mainly liver stiffness measurement (LSM) by vibration-controlled transient elastography (VCTE). Spleen stiffness measurement (SSM) by VCTE using a dedicated 100-Hz module has emerged as a promising non-invasive diagnostic tool, although data on its prognostic value remain limited. This study aimed to evaluate the accuracy of SSM, as measured by transient elastography, in predicting the risk of liver decompensation.

METHODS

A prospective study was conducted including patients with cACLD followed at a tertiary center from January 2020 to April 2024. All patients underwent liver and spleen VCTE (utilizing the 100-Hz module) performed by the same blinded operator. Patients were subsequently monitored at the same institution for the development of PH complications.

RESULTS

The study included 242 patients with cACLD, with a mean age of 63.0 ± 10.5 years and who were 78.5% male. The most common etiology was alcoholic liver disease (62.0%). The median LSM value was 21.9 kPa (interquartile range [IQR], 15.0-34.0 kPa), and the median SSM value was 38.9 kPa (IQR, 28.0-58.0 kPa). The median follow-up period was 501.5 days (IQR, 343.0-725.3 days). During this time, 28 patients (11.6%) developed liver decompensations, with 20 requiring hospital admission. SSM demonstrated good predictive capacity for the risk of liver decompensation (area under the curve, 0.823; 95% confidence interval, 0.742-0.904). Alongside LSM, SSM was an effective predictor of liver decompensation, with a cutoff of 50.0 kPa indicating a significantly increased risk of hepatic decompensation.

CONCLUSION

Noninvasive assessment using SSM may serve as an excellent tool for predicting the risk of liver-related complications and risk-stratifying patients with cACLD, thereby improving their management.

Validation and expansion of Baveno VII recompensation criteria in patients with cirrhosis and curable liver disease

BACKGROUND AND AIMS

Baveno-VII consensus recently defined recompensation in patients with decompensated cirrhosis achieving etiological cure. However, incidence, predictors and clinical significance of recompensation are poorly known. This study aimed to evaluate the incidence and prognostic impact of recompensation in patients with decompensated cirrhosis.

METHODS

Outpatients with cirrhosis and curable etiologies (alcohol, HCV, HBV) were consecutively included and followed up. Recompensation was defined according to Baveno VII criteria. Additionally, expanded recompensation criteria were evaluated for patients on low dose diuretics and/or lactulose/rifaximin for ≥12 months. In 160 patients, inflammatory cytokines (IL-6,IL-1β, IL-10) were measured in serum samples. An external cohort was used to validate study findings.

RESULTS

298 out of 525 decompensated cirrhotic outpatients achieved an effective etiological treatment and 21 (7%) achieved recompensation (Baveno-VII criteria), while 112 patients achieved expanded recompensation criteria (37.6%). MELD score (sHR=0.89; p<0.001), BMI (sHR=0.93; p=0.020), hemoglobin (sHR=1.14; p=0.010) and further decompensation (sHR=0.50; p=0.001) were independent predictors of recompensation. In multivariable analysis, mortality risk was not significantly different between patients achieving recompensation and compensated patients (HR=0.97; p=0.947), while decompensated patients had the highest mortality risk (HR=4.96; p<0.001). Mortality risk was not significantly different between patients meeting expanded recompensation criteria and Baveno-VII criteria (HR=0.97; p=0.938). Serum IL-6, IL-1beta and IL-10 were significantly higher in decompensated patients than in compensated and recompensated patients.

CONCLUSION

Baveno-VII criteria identify cirrhotic patients with a good prognosis, but fewer than 10% of decompensated patients achieve recompensation. Expanding these criteria to include patients receiving minimal decompensation treatment identifies those with similarly low mortality risk.

IMPACT AND IMPLICATIONS

In recent years, growing evidence has shown that achieving an etiological cure can significantly improve the prognosis of decompensated patients, leading to the development of the concept of recompensation. Baveno VII recently proposed a definition for recompensation; however, data on the clinical impact of this condition remain limited. In this study we evaluated Baveno VII criteria and developed and validated expanded Baveno VII criteria for recompensation. Our findings demonstrates that recompensation is associated with improved survival, reduced hyperdynamic circulation and decreased systemic inflammation in outpatients with decompensated cirrhosis. These results are valuable for hepatologists and researchers aiming to refine patient management strategies and risk stratification in cirrhosis care.

Multiparametric MRI Including T1ρ Mapping for Hepatic Fibrosis Assessment in Preclinical Models of Steatotic Liver Disease

OBJECTIVES

The diagnostic value of hepatic native T1, extracellular volume fraction (ECV), and T2 mapping for noninvasive assessment of liver fibrosis is limited in the complex spectrum of steatotic liver disease due to confounding factors, including hepatic fat and inflammation. Therefore, this study aimed to histologically validate T1ρ mapping and compare it with conventional mapping parameters for assessing hepatic fibrosis across different animal models of steatotic liver disease.

MATERIALS AND METHODS

In male Sprague-Dawley rats, different models of steatotic liver disease were induced using a high-fat diet (HFD) and carbon-tetrachloride (CCl4) inhalation: (1) 12-week HFD group resulting in steatosis/steatohepatitis without fibrosis; (2) 6-week HFD + CCl4 group resulting in steatohepatitis with fibrosis; (3) 12-week HFD + CCl4 resulting in steatohepatitis-associated cirrhosis. Hepatic T1, ECV, T2, and T1ρ were assessed by quantitative MRI. Portal pressure was invasively measured. Hepatic fibrosis was assessed using Sirius red, alpha-smooth muscle actin (α-SMA) staining, and measurement of hydroxyproline content. Hepatic fat content was estimated in Oil red staining and triglyceride content.

RESULTS

Fifty-seven animals were analyzed (12-week HFD, n = 15; 6-week HFD + CCl4, n = 14; 12-week HFD + CCl4; n = 16; controls, n = 12). T1ρ values were higher in the fibrosis groups, for example, 12-week HFD + CCl4 versus HFD group (71 msec ±5 vs 60 msec ±3, P < 0.001). T1ρ values correlated with fibrosis markers (Sirius red r = 0.41; α-SMA: r = 0.67; hydroxyproline: r = 0.76; each P < 0.001) and portal pressure (r = 0.55, P < 0.001). T1ρ had the highest diagnostic performance for the detection of histologically defined fibrosis and invasively measured portal hypertension (eg, for fibrosis, T1ρ: AUC 0.96, P < 0.001; T1: AUC 0.74, P = 0.017; ECV: AUC 0.79, P = 0.043; T2: AUC 0.51, P < 0.001). T1ρ was an independent marker for the detection of histologically defined fibrosis (odds ratio: 3.81, P = 0.02).

CONCLUSIONS

In preclinical models of steatotic liver disease, T1ρ mapping could most reliably detect hepatic fibrosis and portal hypertension across different mapping parameters.

Correlation and consistency analysis between various indirect portal pressure gradients and actual portal pressure gradient

OBJECTIVE

To evaluate the correlation and consistency between hepatic venous pressure gradient(F-HVPG) calculated as the wedged hepatic venous pressure (WHVP) minus free hepatic venous pressure (FHVP), I-HVPG calculated as WHVP minus inferior vena cava pressure (IVCP) in the hepatic segment, and portal pressure gradient (PPG).

METHODS

Data were collected from 112 patients with portal hypertension undergoing transjugular intrahepatic portosystemic shunt (TIPS) along with HVPG measurement. FHVP, IVCP, WHVP, and portal venous pressure (PVP) were collected intraoperatively. Pearson's correlation and Bland-Altman method were used to assess correlation and consistency.

RESULTS

A total of 112 patients were retrospectively collected. The correlation coefficient (r) values (p < 0.001) between FHVP and IVCP, WHVP and PVP, F-HVPG and I-HVPG, F-HVPG and PPG, I-HVPG and PPG were 0.835, 0.717, 0.946, 0.667 and 0.698, respectively; the determination coefficient (R2) values were 0.697, 0.514, 0.895, 0.445 and 0.487, respectively. Bland-Altman plots showed that F-HVPG and I-HVPG had the narrowest 95% limits of agreement. Among patients with FHVP-IVCP > 2 mmHg, the (r) values (p < 0.05) between F-HVPG and I-HVPG, F-HVPG and PPG, I-HVPG and PPG were 0.907, 0.648 and 0.807, respectively; the (R2) values were 0.822, 0.420 and 0.651, respectively. Bland-Altman plots showed that I-HVPG had the narrower 95% limits of agreement with PPG.

CONCLUSION

F-HVPG and I-HVPG demonstrated high correlation and consistency. I-HVPG consistently correlates more closely with PPG than F-HVPG, both in the overall cohort and in patients with FHVP-IVCP > 2 mmHg. These results suggest that I-HVPG may serve as a more reliable alternative. Due to the significant underestimation of the PPG, HVPG measurement should not be used to exclude patients from a TIPS intervention.

Advances in Endo-Hepatology: The Role of Endoscopic Ultrasound in the Management of Portal Hypertension

Portal hypertension (PH) is a complication of advanced liver diseases, including cirrhosis and hepatocellular carcinoma, often leading to unfavorable outcomes. Endo-hepatology, particularly endoscopic ultrasound (EUS) has revolutionized the assessment of PH. Notably, EUS-guided portal pressure gradient (EUS-PPG) enables measurement of portal and hepatic venous pressures, offering diagnostic precision for both cirrhotic and non-cirrhotic forms of PH, including porto-sinusoidal vascular disorder (PSVD). EUS-based assessment of PH in advanced liver disease can refine diagnostic workup and prognostication, supporting therapeutic decisions. Additionally, EUS-guided liver biopsy (EUS-LB) achieves high-quality histological samples with fewer complications compared to percutaneous techniques, enabling thorough evaluation of chronic liver diseases and vascular abnormalities. EUS-shear wave elastography (EUS-SWE) further refines stiffness measurements where standard imaging fails. Moreover, EUS plays a major role in controlling variceal hemorrhage, a severe PH complication. EUS-guided coil and cyanoacrylate injection for gastric varices demonstrate a great efficacy, often surpassing conventional endoscopy. Similarly, EUS-based identification and treatment of perforator vessels feeding esophageal varices reduce rebleeding risks, particularly in challenging patients. The combination of these state-of-the-art interventions supports a "one-stop strategy", integrating variceal screening, biopsy, and portal pressure measurement within a single procedure. Despite these advancements, refinements in sedation protocols, patient selection, and cost-effectiveness data are necessary. While noninvasive tools remain central in guidelines, EUS-based methods continue to expand their role, especially in complex cases. This review summarizes the applications and impact of EUS in evaluating PH, emphasizing its importance in contemporary hepatology and its potential as a pivotal diagnostic modality in cirrhosis complicated by PH.

Management of Ascites: AJR Expert Panel Narrative Review

Ascites can develop in the setting of a variety of pathologies. The approach to treatment depends on accurate determination of the underlying cause, for which fluid analysis plays a central role. In particular, the serum-ascites-albumin gradient serves as a primary diagnostic test for differentiating among causes, with certain additional fluid tests performed based on clinical suspicion. Treatment options range from nonspecific fluid removal, including large-volume paracentesis and tunneled peritoneal catheters, to targeted therapies (e.g., diuretics, transjugular intrahepatic portosystemic shunt, and lymphangiography). Societal guidelines exist for the approach to cirrhotic ascites, but the management of other less common causes remains less well defined. The goal of this AJR Expert Panel Narrative Review is to provide guidance for the diagnosis and management of ascites, based on available evidence and the authors' clinical experience.

Ectopic varices - An unusual cause of digestive haemorrhage

A 54-year-old man with decompensated cirrhosis (Child-Pugh B8, MELD-Na 23) and a prior ileostomy was admitted with hemorrhage from the stoma. Initial hemostasis was achieved with mechanical suturing, but recurrent bleeding led to worsening anemia and hepatorenal syndrome. Contrast-enhanced CT identified peristomal varices without thrombosis. Endovascular cyanoacrylate embolization was performed successfully, with no further bleeding. This case highlights peristomal varices as a rare but serious complication in cirrhosis, requiring multidisciplinary management.

Hepatic Encephalopathy and MELD-Na Predict Treatment Benefit in Autoimmune Hepatitis-related Decompensated Cirrhosis

BACKGROUND & AIMS

Management of patients with autoimmune hepatitis (AIH)-related decompensated cirrhosis is challenging because of the risk of treatment-related complications and lack of clinical recommendations. We investigated the predictive factors for treatment benefit in AIH-related decompensated cirrhosis at diagnosis and developed an algorithm to guide treatment decisions in clinical practice.

METHODS

This retrospective, international, multicenter study included 232 patients with histologically confirmed AIH-related decompensated cirrhosis at diagnosis. The sub-hazard ratio (SHR) of mortality was determined by competing risk analysis, considering liver transplantation (LT) as competing event. A decision tree analysis was used to develop a treatment algorithm.

RESULTS

At diagnosis, 89% of patients had ascites, and 41% had overt hepatic encephalopathy (OHE). Treated patients (n = 214; 92%) had higher aminotransferases, bilirubin, and modified hepatic activity index. The SHR of mortality was lower in treated patients (0.438; 95% confidence interval [CI], 0.196-0.981; P = .045). Patients without OHE grade 3/4 and Model for End-Stage Liver Disease-Sodium (MELD-Na) ≤28 at diagnosis were more likely to benefit from treatment. In these patients, a decline in MELD-Na ≥11 after 4 weeks of treatment had a 100% negative predictive value for death/LT. Forty-nine percent of treated patients recompensated during follow-up. Twenty percent of patients had to discontinue treatment, 65% during the first 4 weeks, and only 4% due to infectious complications. OHE ≥grade 2 and MELD-Na at diagnosis predicted the need for treatment discontinuation.

CONCLUSIONS

Immunosuppression is beneficial in patients with AIH-related decompensated cirrhosis and active disease. OHE and MELD-Na at diagnosis, along with a decline in MELD-Na at 4 weeks of treatment, are the most important determinants of outcome and can guide treatment decisions.

Endoscopic ultrasound-guided therapies versus retrograde transvenous obliteration for gastric varices: Multicenter propensity matched analysis

Background and study aims

Retrograde transvenous obliteration (RTO) is an established technique for managing fundal varices. Endoscopic ultrasound (EUS)-guided glue injection with or without coil is an alternate approach. The present study compared outcomes of EUS-guided therapies with RTO for managing fundal varices.

Patients and methods

We retrospectively analyzed data from patients with fundal varices undergoing EUS-guided intervention or RTO at 10 tertiary centers in India and compared after propensity score matching. The primary outcome was variceal bleeding within 1 year. Secondary outcomes included procedure-related adverse events (AEs), variceal obliteration, reintervention, and mortality.

Results

A total of 167 patients (EUS 108, RTO 59) were included, with 59 in each group after propensity score matching. Incidence of variceal bleeding (15.3% vs. 13.6%, P = 0.793) within 1 year was comparable between the groups. Procedure-related AEs were higher in the RTO group (22% vs. 5.1%, P = 0.007), primarily new onset or worsening of ascites. Variceal obliteration at 4 weeks was similar between groups (83.1% vs. 91.5%, P = 0.167). Although reintervention within 1 year of the index procedure (30.5% vs. 22.0%, P = 0.296) was comparable, the EUS group required more frequent reintervention for GVs (28.8% vs. 5.1%, P = 0.001), and the RTO group required more frequent reintervention for EVs (16.9% vs. 1.7%, P = 0.008).

Conclusions

EUS-guided therapy offers a safe and effective alternative to RTO for managing fundal varices. Although reintervention rate for GVs were higher than for EUS, incidence of AEs and reintervention for EVs was higher with RTO.

Advances in imaging-Elastography

Chronic liver disease affects over a billion people worldwide. Liver fibrosis is the key driver of liver-related complications and mortality. Elastography has been a transformative tool in hepatology, allowing for the diagnosis and staging of liver fibrosis noninvasively, and is evolving beyond these purposes into a prognostication tool. By measuring tissue stiffness, elastography techniques such as shear-wave and magnetic resonance elastography offer critical insights into liver fibrosis, portal hypertension, and the progression of disease. Magnetic resonance elastography stands out for its reliability across fibrosis stages and robustness in obese patients affected by metabolic liver disease. Spleen stiffness measurement complements liver assessments, enhancing the identification of portal hypertension and refining patient risk stratification. This review covers current clinical applications but also anticipates future innovations such as artificial intelligence-based algorithms that could expand elastography's clinical impact, thereby improving patient outcomes.

Hemodynamic profile of terlipressin and octreotide in patients with cirrhosis and portal hypertension: a randomized, single-blind clinical trial

Background & Aims

Continuous infusion of terlipressin may result in a more sustained reduction in portal pressure with fewer adverse effects than administered as a bolus. This study aimed to compare the hepatic and cardiopulmonary hemodynamic effects and safety profiles of bolus vs. terlipressin continuous infusion.

Methods

This is a single-center, single-blinded, double-dummy, parallel-group, clinical trial in which 38 patients with cirrhosis and portal hypertension were randomized to receive the following: 1 mg bolus of terlipressin + continuous infusion of placebo (TERLBOL, n = 12), a bolus of placebo + continuous infusion of terlipressin (2 or 4 mg/day if <10% reduction in hepatic venous pressure gradient [HVPG] at 30 min of infusion) (TERLINF, n = 14), or a bolus of octreotide (50 μg) + continuous infusion of octreotide (50 μg/h) (OCTR, n = 12) as an additional control group. HVPG, cardiopulmonary pressures, and cardiac output were measured at baseline and after 30, 60, and 120 min.

Results

Sixty-eight percent of patients were male, with a median age of 59 years. There were no significant differences in baseline characteristics. In the TERLBOL group, there was a nonsignificant reduction in HVPG (at 120 min, -4.9%; p = 0.14). However, cardiopulmonary and mean arterial pressures significantly increased, whereas cardiac output and heart rate significantly decreased. In the TERLINF group, there were nonsignificant changes in cardiopulmonary hemodynamics or HVPG (NS) despite doubling the infusion dose after 30 min in 13/14 patients. In the OCTR group, there was a nonsignificant reduction in HVPG (at 120 min, -4.9%; p = 0.08), and pulmonary capillary pressure significantly decreased. All treatments were well tolerated, and no adverse events were observed.

Conclusions

There were nonsignificant reductions in HVPG with the three therapeutic strategies. Further investigations are warranted to determine the optimal dosing strategy for continuous infusion of terlipressin in patients with cirrhosis and portal hypertension.

Impact and implications

The results of our study do not show a significant reduction in portal pressure, at least in the first 2 h after the selected dose. Although the study was not performed in the setting of acute variceal bleeding and terlipressin was used as a standard therapy, these results do not support the treatment strategy of terlipressin infusion alone at the doses studied for the management of acute variceal bleeding, where a quick reduction in portal pressure is thought to play a major role controlling variceal bleeding. It is important to highlight that the continuously infused terlipressin regimen is better tolerated and appears to have a better cardiopulmonary safety profile. Other treatment strategies of continuous terlipressin infusion, such as initial bolus administration or higher infusion doses, should be evaluated to support its use in managing variceal bleeding.

Clinical trial identifier

EudraCT No. 2019-004328-39.

Diagnostic insights into splenic pathologies: the role of multiparametric ultrasound

Ultrasound (US) evaluation of the spleen is mandatory in the assessment of patients with chronic liver disease, and splenomegaly can be a sign of systemic diseases. However, due to the lack of distinctive ultrasound findings in specific splenic pathologies, clinical diagnosis can be very challenging. Splenomegaly, defined by increased splenic dimensions, can indicate underlying systemic conditions and is a common manifestation of portal hypertension (PH). Ultrasound and Doppler techniques help assessing splenic involvement in PH. Splenic stiffness measurement, using elastography, offers additional diagnostic accuracy, especially when liver stiffness measurements are inconclusive. CEUS enhances the diagnostic capability for focal splenic lesions, differentiating between benign and malignant lesions by their distinct enhancement patterns, and plays also a critical role in the context of splenic traumatic pathology. Overall, CEUS significantly improves the characterization of splenic pathology, reducing the need for invasive procedures and ensuring appropriate patient management. This review article describes the normal US findings of the spleen and examines the role of multiparametric US in the evaluation of the most common splenic pathologies encountered in the daily clinical practice.

Association between MASLD and increased risk of serious bacterial infections requiring hospital admission: A meta-analysis

BACKGROUND

Previous studies have reported an association between metabolic dysfunction-associated steatotic liver disease (MASLD) and the risk of serious bacterial infections. However, the magnitude of the risk and whether this risk varies with the severity of MASLD remains uncertain. We performed a meta-analysis of observational studies to quantify the association between MASLD and serious bacterial infections requiring hospital admission.

METHODS

We systematically searched PubMed, Scopus, Web of Science and Embase from database inception to 1 April 2024, using predefined keywords to identify studies examining the risk of serious bacterial infections among individuals with and without MASLD. MASLD was diagnosed using liver biopsy, imaging or International Classification of Diseases codes. Meta-analysis was performed using random-effects modelling.

RESULTS

We identified six cross-sectional and two prospective cohort studies with aggregate data on ~26.6 million individuals. MASLD was significantly associated with higher odds of serious bacterial infections (pooled random-effects odds ratio 1.93, 95% confidence interval [CI] 1.44-2.58; I2 = 93%). Meta-analysis of prospective cohort studies showed that MAFLD was associated with an increased risk of developing serious bacterial infections (pooled random-effects hazard ratio 1.80, 95% CI 1.62-2.0; I2 = 89%). This risk further increased across the severity of MASLD, especially the severity of fibrosis (pooled random-effects hazard ratio 2.42, 95% CI 1.89-2.29; I2 = 92%). These results remained significant after adjusting for age, sex, obesity, diabetes and other potential confounders. Sensitivity analyses did not modify these findings. The funnel plot did not reveal any significant publication bias.

CONCLUSIONS

This meta-analysis shows a significant association between MASLD and an increased risk of serious bacterial infections requiring hospital admission.

Non-invasive assessment of esophageal and fundic varices in patients with primary biliary cholangitis

OBJECTIVES

The Baveno VII consensus recommends endoscopic screening for varicose veins in cases of liver stiffness measurement (LSM) ≥ 20 kPa or platelet count ≤ 150 × 109/L. Whether this approach was appropriate for patients with primary biliary cholangitis (PBC) remains uncertain. This study expanded the observed risk factors by adding analysis of ultrasound images as a non-invasive tool to predict the risk of esophageal or fundic varices.

METHODS

We enrolled 111 patients with PBC whose complete ultrasound images, measurement data, and LSM data were available. The value of the periportal hypoechoic band (PHB), splenic area, and LSM in determining the risk of varicose veins and variceal rupture was analyzed. A prospective cohort of 67 patients provided external validation.

RESULTS

The area under the receiver operating characteristic curve (AUC) for predicting varicose veins using LSM > 12.1 kPa or splenic areas > 41.2 cm2 was 0.806 (95% confidence interval (CI): 0.720-0.875) and 0.852 (95% CI: 0.772-0.912), respectively. This finding could assist in avoiding endoscopic screening by 76.6% and 83.8%, respectively, with diagnostic accuracy surpassing that suggested by Baveno VII guidelines. The AUCs for predicting variceal rupture using splenic areas > 56.8 cm2 was 0.717 (95% CI: 0.623-0.798). The diagnostic accuracy of PHB for variceal rupture was higher than LSM and splenic areas (75.7% vs. 50.5% vs. 68.5%).

CONCLUSION

We recommend LSM > 12.1 kPa as a cutoff value to predict the risk of varicosity presence in patients with PBC. Additionally, the splenic area demonstrated high accuracy and relevance for predicting varicose veins and variceal rupture, respectively. The method is simple and reproducible, allowing endoscopy to be safely avoided.

CLINICAL RELEVANCE STATEMENT

The measurement of the splenic area and identification of the periportal hypoechoic band (PHB) on ultrasound demonstrated high accuracy and relevance for predicting the risk of esophageal or fundic varices presence and variceal rupture, respectively.

KEY POINTS

Predicting varices in patients with primary biliary cholangitis (PBC) can reduce the morbidity and mortality of gastrointestinal hemorrhage. Transient elastography (TE) and ultrasound play an important role in predicting patients with PBC with varices. TE and ultrasound can predict varicose veins and variceal rupture. Liver stiffness measurement and splenic area measurements can allow endoscopy to be safely avoided.

Revisiting the place of surgical portal decompression for adults with noncirrhotic portal hypertension due to chronic extrahepatic portal vein obstruction: a scoping review

BACKGROUND

Liver cirrhosis accounts for more than 90 % of portal hypertension cases, and the other cases are due to noncirrhotic portal hypertension (NCPH). Variceal bleeding is the most life-threatening complication of portal hypertension and its primary treatment is medical according to the Baveno VII guidelines. This review discusses the evidence on surgical portal decompression for adult patients with NCPH secondary to chronic extrahepatic portal vein obstruction (EHPVO).

METHODS

This is a scoping review of the evidence for the feasibility and effectiveness of surgical portal decompression in adults with NCPH secondary to EHPVO.

RESULTS

This scoping review yielded 17 studies, including a total of 110 patients. Patient age(s) ranged from 19 to 68 years, with the majority undergoing nonphysiological (i.e., portosystemic shunts) shunts (N = 84, 76.4 %), mostly for variceal bleeding refractory to medical and endoscopic treatments. Physiological shunts (i.e., Rex shunts) had a potential advantage over nonphysiological shunts in postoperative rebleeding (5 % vs. 10 %) and hepatic encephalopathy rates (0 % vs. 13 %). Conversely, nonphysiological shunts had a potential advantage over physiological shunts in postoperative shunt thrombosis (8 % vs. 22 %).

DISCUSSION

This scoping review reported that surgical portal decompression is feasible in adults with NCPH due to EHPVO with favorable outcomes and long-term patency.

Advancements of direct oral anticoagulants in cirrhotic individuals with portal vein thrombosis

Individuals with cirrhosis maintain a delicate balance between pro- and anticoagulation, which can lead to a state of hypercoagulability. This hypercoagulable condition not only exacerbates liver fibrosis but also increases the risk of venous thrombosis, particularly portal vein thrombosis (PVT). PVT has detrimental effects on liver function, complicates the success of liver transplantation, and negatively impacts the survival rate of patients with cirrhosis. Currently, multiple studies have confirmed that individuals with cirrhosis responded well to treatment with novel direct oral anticoagulants (DOACs), showing both safety and efficacy. Furthermore, the use of DOACs as a preventive measure in patients with cirrhosis following surgery has been shown to lower the occurrence of portal vein thrombosis and postpone the progression of liver fibrosis.

Efficacy and Safety of Tenofovir Amibufenamide and Tenofovir Alafenamide for First-Time HBV-Related Decompensated Cirrhosis

Clinical studies of tenofovir amibufenamide (TMF) and tenofovir alafenamide (TAF) treatment in patients with HBV-related decompensated cirrhosis (HBV-DC) are limited. This study evaluated the efficacy and safety of TMF versus TAF in naive-treated patients with first-time HBV-DC. Based on the antiviral drug used, patients were categorised into the TMF group and the TAF group. Virological and serological responses, hepatic and renal functions and blood lipid changes in both groups were evaluated during 48 weeks of treatment. A total of 98 patients were enrolled, 45 in the TMF group and 53 in the TAF group. At 48 weeks of treatment, the proportions of patients who achieved complete virological response (CVR) were 85.7% and 90.7%, respectively (p = 0.791). Improvement of at least 2 points in Child-Turcotte-Pugh scores was observed in 64.3% versus 79.1% (p = 0.169) of the patients. There were no significant changes in serum creatinine, estimated glomerular filtration rate or total cholesterol from baseline to week 48 between the two groups. Cystatin C remained stable in the TMF group but increased over time in the TAF group (p < 0.001). Low-density lipoprotein cholesterol remained stable in the TMF group but increased significantly in the TAF group at week 48 (p = 0.015). These results suggest that both TMF and TAF can rapidly suppress HBV replication, improve hepatic function and have no negative effects on renal function among patients with HBV-DC. Regarding lipid metabolism, both showed a better safety, while regular monitoring of blood lipid levels is recommended.

Identification of Clinically Significant Portal Hypertension in cACLD Individuals With Spleen Stiffness Measurement

BACKGROUND AND AIMS

The Baveno VII consensus recommends spleen stiffness measurement (SSM) for the detection of clinically significant portal hypertension (CSPH) in patients with compensated advanced chronic liver disease (cACLD). We aimed to evaluate the performance of SSM-based algorithms.

METHODS

Consecutive cACLD individuals who underwent hepatic venous pressure gradient measurement, liver stiffness measurement (LSM), and SSM measured with the dedicated 100-Hz probe by vibration-controlled transient elastography were prospectively enrolled.

RESULTS

From July 2021 to August 2024, a total of 395 patients were screened, and 185 cACLD cases were enrolled, of which 101 patients had CSPH. An SSM > 50 kPa demonstrated a positive predictive value (PPV) of 98.0% and a specificity of 98.8% for ruling in CSPH, correctly identifying 47.5% (48/101) of CSPH cases. Sensitivity analysis revealed that in 60 patients with aetiology removal or suppression, SSM > 50 kPa achieved both a PPV and specificity of 100%. Among the 125 patients with ongoing aetiologies, the PPV and specificity were 96.4% and 98.3%, respectively. Across HBV (with or without viral suppression) and non-HBV subgroups, the PPV and specificity consistently exceeded 90%. In decision curve analysis, SSM > 50 kPa provided the highest net benefit compared with other elastography-based algorithms when threshold probabilities exceeded 0.8.

CONCLUSIONS

We prospectively validated that SSM > 50 kPa, measured using the spleen-dedicated probe, is sufficient for identifying CSPH in individuals with cACLD.

TRIAL REGISTRATION

NCT04820166.

A targeted endoscopic band ligation technique for management of acute esophageal variceal bleeding

BACKGROUND/AIMS

Endoscopic band ligation (EBL) standard therapy is traditionally performed with banding from the distal esophagus upwards. However, esophageal varices (EV) with stigma of recent bleeding are not consistently banded at the first attempt. We aimed to compare conventional banding in acute variceal bleeding (AVB) vs targeted banding of EV in patients with stigma of recent bleeding (white nipple sign).

METHODS

This case-control study included patients treated in our hospital from December 2016 to September 2019 with endoscopic signs of recent variceal bleeding. The targeted technique involves deploying the first band at the recent bleeding stigmata and then completing the procedure with standard variceal banding technique. The conventional group included patients treated with standard EBL.

RESULTS

We analyzed 92 patients, 54 (58.7%) in conventional technique and 38 (41.3%) in the targeted group. Active bleeding during endoscopy occurred in 11 (20.0%) of conventional and two (6.5%) of the targeted group (p=0.021). Although procedure time was longer in the conventional group (24.3min SD 11.58) compared to the targeted group (21.52min SD 8.73) this difference was not significant. One detached band episode was documented in targeted group and none in the conventional group (p=0.418). TIPS were not used during this study due to health system policy. There were no significant differences in mortality, rebleeding or transfusion requirements between groups.

CONCLUSIONS

The targeted technique for EV with stigma of recent bleeding had a low band detachment incidence and fewer bleeding events during endoscopy, however, the limitations of the study should be considered.

Preventing the progression of cirrhosis to decompensation and death

Two main stages are differentiated in patients with advanced chronic liver disease (ACLD), one compensated (cACLD) with an excellent prognosis, and the other decompensated (dACLD), defined by the appearance of complications (ascites, variceal bleeding and hepatic encephalopathy) and associated with high mortality. Preventing the progression to dACLD might dramatically improve prognosis and reduce the burden of care associated with ACLD. Portal hypertension is a major driver of the transition from cACLD to dACLD, and a portal pressure of ≥10 mmHg defines clinically significant portal hypertension (CSPH) as the threshold from which decompensating events may occur. In recent years, innovative studies have provided evidence supporting new strategies to prevent decompensation in cACLD. These studies have yielded major advances, including the development of noninvasive tests (NITs) to identify patients with CSPH with reasonable confidence, the demonstration that aetiological therapies can prevent disease progression and even achieve regression of cirrhosis, and the finding that non-selective β-blockers can effectively prevent decompensation in patients with cACLD and CSPH, mainly by reducing the risk of ascites, the most frequent decompensating event. Here, we review the evidence supporting new strategies to manage cACLD to prevent decompensation and the caveats for their implementation, from patient selection using NITs to ancillary therapies.

Hepatopulmonary syndrome in patients with porto-sinusoidal vascular disorder: Characteristics and outcome

Background & Aims

Porto-sinusoidal vascular disorder (PSVD) is a rare cause of portal hypertension. Data on hepatopulmonary syndrome (HPS) in PSVD are limited. This study aimed to determine the associated factors, plasma mediators, and evolution of HPS in patients with PSVD.

Methods

Multicenter observational study of patients with PSVD with signs of portal hypertension in whom contrast-enhanced transthoracic echocardiography (CE-TTE) was performed.

Results

Among 196 patients with PSVD who underwent CE-TTE in 17 centers, 14 (7% [95% confidence interval 3-11%]) had a confirmed diagnosis of HPS. Patients with HPS more frequently had a genetic disorder associated with PSVD (50% vs. 6%, p <0.001), especially telomere biology disorders (p <0.001). Liver function was less preserved in patients with HPS, because they had lower prothrombin index (63% vs. 86%, p = 0.04), higher serum total bilirubin (37 μmol/L vs. 14 μmol/L, p <0.001), and lower serum albumin (32 g/L vs. 38 g/L, p <0.001). HPS tended to be associated with more portal venule obliterations (p = 0.085) and with nodular liver architecture (p = 0.069). Plasma concentrations of Angiopoietin-2, ICAM3, and Tie2 were higher in patients with HPS (p = 0.02, p = 0.04, p = 0.01, respectively). Out of the 14 patients with HPS, five underwent liver transplantation after a median follow-up of 34 months. Overall cumulative incidence of liver-related events and of death was similar between patients with and without HPS, when considering liver transplantation for HPS as a competing risk.

Conclusions

HPS in patients with PSVD was associated with genetic disorders, less preserved liver function, and higher plasma concentrations of angiogenic mediators. When applying HPS model for end-stage liver disease exception policy for liver transplantation, overall survival of patients with PSVD and HPS was similar to that of patients with PSVD without HPS.

Impact and implications

Hepatopulmonary syndrome (HPS) is a rare complication of porto-sinusoidal vascular disorder (PSVD). This multicentric study found that patients with PSVD and HPS had less preserved liver function, and harbored genetic disorders more frequently (especially telomere biology disorders) than patients without HPS. HPS did not negatively impact transplantation-free survival when applying HPS MELD exception policy for liver transplantation through a competitive risk analysis. Our findings suggest that patients with PSVD with respiratory symptoms and/or telomere biology disorders may benefit from systematic screening for HPS.

Predicting response to non-selective beta-blockers with liver-spleen stiffness and heart rate in patients with liver cirrhosis and high-risk varices

INTRODUCTION

Non-selective beta-blockers (NSBB) are used for primary prophylaxis in patients with liver cirrhosis and high-risk varices (HRVs). Assessing therapeutic response is challenging due to the invasive nature of hepatic venous pressure gradient (HVPG) measurement. This study aims to define a noninvasive machine-learning based approach to determine response to NSBB in patients with liver cirrhosis and HRVs.

METHODS

We conducted a prospective study on a cohort of cirrhotic patients with documented HRVs receiving NSBB treatment. Patients were followed-up with clinical and elastography appointments at 3, 6, and 12 months after NSBB treatment initiation. NSBB response was defined as stationary or downstaging variceal grading at the 12-month esophagogastroduodenoscopy (EGD). In contrast, non-response was defined as upstaging variceal grading at the 12-month EGD or at least one variceal hemorrhage episode during the 12-month follow-up. We chose cut-off values for univariate and multivariate model with 100% specificity.

RESULTS

According to least absolute shrinkage and selection operator (LASSO) regression, spleen stiffness (SS) and liver stiffness (LS) percentual decrease, along with changes in heart rate (HR) at 3 months were the most significant predictors of NSBB response. A decrease > 11.5% in SS, > 16.8% in LS, and > 25.3% in HR was associated with better prediction of clinical response to NSBB. SS percentual decrease showed the highest accuracy (86.4%) with high sensitivity (78.8%) when compared to LS and HR. The multivariate model incorporating SS, LS, and HR showed the highest discrimination and calibration metrics (AUROC = 0.96), with the optimal cut-off of 0.90 (sensitivity 94.2%, specificity 100%, PPV 95.7%, NPV 100%, accuracy 97.5%).

A systematic review of noninvasive laboratory indices and elastography to predict hepatic decompensation

BACKGROUND

Hepatic decompensation carries profound implications for patient quality of life and risk of mortality. We lack comparative data on how noninvasive tools perform in risk stratification for those with compensated cirrhosis. We performed a systematic review to assess the performance of laboratory and transient elastography-based models for predicting hepatic decompensation in patients with compensated cirrhosis.

METHODS

The following databases were searched by an informationist to identify relevant studies, including adult patients with compensated cirrhosis from inception to August 2023: Medline, Embase, Scopus, Web of Science, and ClinicalTrials.gov. Title and abstract screening followed by full-text review were performed by 2 independent reviewers, and data abstraction was completed using standardized forms. Studies of patients with decompensation at baseline (defined by ascites, variceal bleeding, and HE) or any primary hepatic malignancy were excluded. The primary outcome was hepatic decompensation, as defined above. Pooled HRs were calculated using the common-effect inverse-variance model.

RESULTS

Forty-four full-text studies met the inclusion criteria. Across 52,589 patients, the cumulative incidence of any decompensation was 17.9% over a follow-up time of 111,401 patient years. Pooled risk estimates for all-cause decompensation demonstrated that MELD (HR: 1.08; 95% CI: 1.06-1.10), albumin-bilirubin (HR: 2.13, 95% CI: 1.92-2.36), fibrosis-4 (HR: 1.04, 95% CI: 1.03-1.06), albumin-bilirubin-fibrosis-4 (HR: 1.25, 95% CI: 1.18-1.33), and liver stiffness by transient elastography (HR: 1.04; 95% CI: 1.04-1.05) predict decompensation.

CONCLUSIONS

Available blood and imaging-based biomarkers can risk-stratify patients for hepatic decompensation. Changes in albumin-bilirubin appear to have the highest discrimination in predicting decompensation events.

Recompensation of Liver Cirrhosis by TIPS Reduces Epithelial Cell Death Markers, Translating Into Improved Clinical Outcome

BACKGROUND AND AIMS

Portal hypertension is the main pathophysiological driver of decompensation in patients with liver cirrhosis. Epithelial cell death markers, m30 and m65, correlate with hepatic injury and predict outcomes across various stages of liver disease. We aim (i) to evaluate whether portal hypertension itself contributes to liver outcome-relevant epithelial injury, and (ii) to analyse the capacity of m30/m65 to predict outcome in patients receiving a transjugular intrahepatic portosystemic shunt (TIPS) for refractory ascites.

METHODS

Sixty-six patients undergoing TIPS placement for refractory ascites and 20 patients with compensated cirrhosis as controls were prospectively enrolled in this monocentric cohort study. Epithelial cell death markers were analysed pre-TIPS, as well as 1-3 and 6-9 months post-TIPS. The capacity of baseline levels of m30/m65 in predicting six-month transplant-free survival rates was analysed by multivariable Cox proportional hazards regression.

RESULTS

Levels of m30 and m65 were higher in patients with decompensated cirrhosis (pre-TIPS) compared with compensated cirrhosis (controls). Following correction of portal hypertension by TIPS and recompensation, both markers decreased over time, reaching levels comparable to patients with compensated cirrhosis. On multivariable analysis, pre-TIPS baseline levels of m30 and m65 were not predictive for six-month survival.

CONCLUSION

Correction of portal hypertension via TIPS reduces levels of epithelial cell death markers, indicating that portal hypertension is a driver of outcome-relevant, hepatic cell death in patients with decompensated cirrhosis. Baseline m30/m65 values do not affect six-month survival rates, which suggests that TIPS placement overcomes the unfavourable spontaneous prognosis otherwise indicated by elevated baseline m30/65 levels.

Exploring the Relationship Between NOD2 Risk Variants and First Decompensation Events in Cirrhotic Patients With Varices

BACKGROUND AND AIMS

NOD2 mutations are associated with impaired gut mucosal barrier function. According to the systemic inflammation hypothesis, bacterial translocation is central in the development of decompensation. The aim was to evaluate whether the presence of NOD2 variants is associated with the development of first decompensation.

METHOD

Secondary analysis of prospectively collected consecutive patients with compensated cirrhosis, who were screened between 2014 and 2018. Patients with and without NOD2 variants were compared and stratified analysis according to the presence of varices was performed.

RESULTS

360 patients [239 (66%) men, median age 61 (53-69) years, 70 (19%) with NOD2 variants, 90 (25%) with varices] were followed for a median of 9 (4-16) months. Similar baseline characteristics were observed across NOD2 status groups, except for beta-blocker use (45% vs. 32% amongst variant carriers vs. non-carriers, p = 0.05). During follow-up, 34 patients (12%) developed their first decompensation, with no differences according to NOD2 status [HR 1.75 (95% CI 0.84-3.67)]. On multivariate analysis, only MELD remained an independent predictor of decompensation. Amongst patients with varices (n = 90), 18 (24.4%) carried a NOD2 variants, with a higher incidence of first decompensation [HR 3.00 (95% CI 1.08-8.32)], primarily due to ascites [HR 3.32 (95% CI 1.07-10.32)]. In this subgroup, MELD [HR 1.18 (95% CI 1.06-1.32)] and NOD2 variants [HR 2.91 (95% CI 0.95-8.89)] were determined to be independent predictors of decompensation.

CONCLUSIONS

The presence of NOD2 risk variants leads to a greater incidence of first decompensation only in compensated patients with varices.