1
|
Li M, Pai RA, Gomel R, Vyas M, Callif SC, Hatchett J, Bowlus CL, Lai JC. Patient-focused drug development in primary sclerosing cholangitis: Insights on patient priorities and involvement in clinical trials. Hepatol Commun 2024; 8:e0433. [PMID: 38727680 PMCID: PMC11093571 DOI: 10.1097/hc9.0000000000000433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 02/16/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND According to the new AASLD Practice Guidance, all patients with primary sclerosing cholangitis (PSC) should be considered for participation in clinical trials. However, PSC's rarity has posed challenges to characterizing patient interest in trial participation and identifying predictors of patient willingness to participate in drug trials. METHODS PSC Partners Seeking a Cure developed the "Our Voices" survey to inform the development of the Externally-Led Patient-Focused Drug Development Forum, an FDA initiative to capture patient experiences and perspectives on drug development. RESULTS Of 797 survey respondents from over 30 countries, 536 (67%) identified slowing disease progression as the most important outcome. Eighty-nine percent identified their hepatologist/gastroenterologist as someone they would approach for advice about trials. Although 61% reported being willing to participate in drug trials, only 26% had ever been asked to participate. Notable barriers to trial involvement included unknown long-term risks (71%), long travel times to the study center (32%), and a liver biopsy requirement (27%). On multivariable logistic regression, pruritus (OR 1.62, 95% CI: 1.09-2.40, p = 0.017) was positively associated with willingness to participate in disease-modifying therapy trials, while jaundice (OR 0.34, 95% CI: 0.19-0.61, p < 0.001) and inflammatory bowel disease (OR 0.64, 95% CI: 0.42-0.98, p = 0.038) were negatively associated. Pruritus (OR 2.25, 95% CI: 1.50-3.39, p < 0.001) was also independently associated with willingness to participate in symptom treatment trials. CONCLUSIONS Most patients with PSC report interest in participating in clinical trials, but few have been asked to participate. Referral of patients with PSC by their hepatologist/gastroenterologist to clinical trials and patient education on trial participation are vital to closing the gap between trial interest and participation. Pruritus may serve as a key indicator of patient interest in trial participation.
Collapse
Affiliation(s)
- Michael Li
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California, San Francisco, California, USA
| | - Ruth-Anne Pai
- PSC Partners Seeking a Cure, Greenwood Village, Colorado, USA
| | - Rachel Gomel
- PSC Partners Seeking a Cure, Greenwood Village, Colorado, USA
| | - Mary Vyas
- PSC Partners Seeking a Cure Canada, Toronto, ON, Canada
| | | | - Joanne Hatchett
- PSC Partners Seeking a Cure, Greenwood Village, Colorado, USA
| | - Christopher L. Bowlus
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California Davis Health, Sacramento, California, USA
| | - Jennifer C. Lai
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California, San Francisco, California, USA
| |
Collapse
|
2
|
Trivedi PJ, Arndtz K, Abbas N, Telford A, Young L, Banerjee R, Eddowes P, Jhaveri KS, Hirschfield GM. Quantitative MRCP and metrics of bile duct disease over time in patients with primary sclerosing cholangitis: A prospective study. Aliment Pharmacol Ther 2024; 59:1366-1375. [PMID: 38571284 DOI: 10.1111/apt.17944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 11/13/2024] [Accepted: 02/28/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Imaging markers of biliary disease in primary sclerosing cholangitis (PSC) have potential for use in clinical and trial disease monitoring. Herein, we evaluate how quantitative magnetic resonance cholangiopancreatography (MRCP) metrics change over time, as per the natural history of disease. METHODS Individuals with PSC were prospectively scanned using non-contrast MRCP. Quantitative metrics were calculated using MRCP+ post-processing software to assess duct diameters and dilated and strictured regions. Additionally, a hepatopancreatobiliary radiologist (blinded to clinical details, biochemistry and quantitative biliary metrics) reported each scan, including ductal disease assessment according to the modified Amsterdam Cholangiographic Score (MAS). RESULTS At baseline, 14 quantitative MRCP+ metrics were found to be significantly different in patients with PSC (N = 55) compared to those with primary biliary cholangitis (N = 55), autoimmune hepatitis (N = 57) and healthy controls (N = 18). In PSC specifically, baseline metrics quantifying the number of strictures and the number and length of bile ducts correlated with the MAS, transient elastography and serum ALP values (p < 0.01 for all correlations). Over a median 371-day follow-up (range: 364-462), 29 patients with PSC underwent repeat MRCP, of whom 15 exhibited quantitative changes in MRCP+ metrics. Compared to baseline, quantitative MRCP+ identified an increasing number of strictures over time (p < 0.05). Comparatively, no significant differences in biochemistry, elastography or the MAS were observed between timepoints. Quantitative MRCP+ metrics remained stable in non-PSC liver disease. CONCLUSION Quantitative MRCP+ identifies changes in ductal disease over time in PSC, despite stability in biochemistry, liver stiffness and radiologist-derived cholangiographic assessment (trial registration: ISRCTN39463479).
Collapse
Affiliation(s)
- Palak J Trivedi
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, Centre for Liver and Gastrointestinal Research and Gastrointestinal Research, National Institute of Health Research (NIHR) Birmingham Biomedical Research Centre (BRC), University of Birmingham, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- Liver Unit, University Hospitals Birmingham Queen Elizabeth, Birmingham, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Katherine Arndtz
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, Centre for Liver and Gastrointestinal Research and Gastrointestinal Research, National Institute of Health Research (NIHR) Birmingham Biomedical Research Centre (BRC), University of Birmingham, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- Liver Unit, University Hospitals Birmingham Queen Elizabeth, Birmingham, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Nadir Abbas
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, Centre for Liver and Gastrointestinal Research and Gastrointestinal Research, National Institute of Health Research (NIHR) Birmingham Biomedical Research Centre (BRC), University of Birmingham, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- Liver Unit, University Hospitals Birmingham Queen Elizabeth, Birmingham, UK
| | | | | | | | - Peter Eddowes
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, Centre for Liver and Gastrointestinal Research and Gastrointestinal Research, National Institute of Health Research (NIHR) Birmingham Biomedical Research Centre (BRC), University of Birmingham, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- NIHR Nottingham BRC, University of Nottingham, Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Kartik S Jhaveri
- Division of Radiology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Gideon M Hirschfield
- University Health Network and Department of Medicine, Toronto Centre for Liver Disease, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
3
|
Tenca A, Kolho KL, Consonni D, Jokelainen K, Färkkilä M. Dominant stricture in paediatric-onset primary sclerosing cholangitis is associated with impaired prognosis in a long-term follow-up. United European Gastroenterol J 2024. [PMID: 38733616 DOI: 10.1002/ueg2.12583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 04/08/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The impact of dominant stricture (DS) on the outcomes of paediatric-onset primary sclerosing cholangitis (PSC) is unknown. This study was aimed at investigating the impact of DS on the clinical course and prognosis of patients with paediatric-onset PSC. METHODS Patients with paediatric-onset PSC diagnosed between January 1993 and May 2017 were identified from hospital records or our PSC registry. Data including clinical, laboratory, cholangiography, and cytology at diagnosis and during follow-up (until July 2023) were reviewed. We graphed the Kaplan-Meier failure function and fitted crude and multivariable Cox model to calculate hazard ratios (HR) and 95% confidence intervals (CI) for selected variables. In these analyses, DS was treated as a time-varying variable. RESULTS We identified 68 patients (42 males) with paediatric-onset PSC (median age at diagnosis 15 years). The median follow-up was 13 years and the median age at the last follow-up was 27 years. In total, 35 (51%) had concomitant autoimmune hepatitis. DS was diagnosed in 33 patients (48%): in eight at the time of PSC diagnosis (12%) and in 25 (37%) by the end of follow-up. In patients with DS, two developed cirrhosis, seven were transplanted and one patient was operated for a biliary mass with low-grade dysplasia. In patients without a DS, two developed cirrhosis, and four were transplanted; one female was excluded from survival analysis because she already had cirrhosis at the time of PSC diagnosis. Cirrhosis or biliary dysplasia or needing liver transplantation for these indications were more frequent after the development of DS (10/33, adjusted HR 4.26, 95%CI: 1.26-14.4). No cholangiocarcinomas or deaths occurred during the follow-up. CONCLUSIONS DS was present at diagnosis or developed during follow-up in about half of the patients with paediatric-onset PSC and was associated with impaired outcome.
Collapse
Affiliation(s)
- Andrea Tenca
- Abdominal Center, Helsinki University and Helsinki University Hospital HUS, Helsinki, Finland
| | - Kaija-Leena Kolho
- Department of Paediatric Gastroenterology, Helsinki University and Children's Hospital, Helsinki University Hospital HUS, Helsinki, Finland
| | - Dario Consonni
- Epidemiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Kalle Jokelainen
- Abdominal Center, Helsinki University and Helsinki University Hospital HUS, Helsinki, Finland
| | - Martti Färkkilä
- Abdominal Center, Helsinki University and Helsinki University Hospital HUS, Helsinki, Finland
| |
Collapse
|
4
|
Wu J, Wang L, Yu F, Wang L, Leng Z. Robotic-assisted radical resection versus open surgery for cholangiocarcinoma: a systematic review and meta-analysis. J Robot Surg 2024; 18:201. [PMID: 38713337 DOI: 10.1007/s11701-024-01966-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 04/27/2024] [Indexed: 05/08/2024]
Abstract
To compare the clinical efficacy and safety of robot-assisted resection and open surgery for cholangiocarcinoma (CCA). We conducted a comprehensive search of PubMed, the Cochrane Library, and Embase databases for studies comparing treatment for CCA, covering the period from database inception to January 30, 2024. Two researchers will independently screen literature and extract data, followed by meta-analysis using Review Manager 5.3 software. A total of 5 articles with 513 patients were finally included. Among them, 231 in the robotic group, and 282 in the open group. The Meta-analysis revealed that the robotic group had a significant advantage in terms of intraoperative blood loss (MD = - 101.44, 95% CI - 135.73 to - 67.15, P < 0.05), lymph node harvest(MD = 1.03, 95% CI 0.30- 1.76, P < 0.05) and length of hospital stay(MD = - 1.92, 95% CI - 2.87 to- 0.97, P < 0.05). However, there were no statistically significant differences between the two groups in terms of transfusion rate (OR = 0.62, 95% CI 0.31-1.23, P > 0.05), R0 resection (OR = 1.49, 95% CI 0.89- 2.50, P > 0.05), 30-day mortality (OR = 1.68, 95% CI 0.43-6.65, P > 0.05) and complications (OR = 0.76, 95% CI 0.30- 1.95, P > 0.05). Robotic-assisted radical resection for CCA is feasible and safe, and its long-term efficacy and oncological outcomes need to be confirmed by further studies.
Collapse
Affiliation(s)
- Jianlin Wu
- Affiliated Hospital of North Sichuan Medical College, Nanchong City, 637000, Sichuan Province, China
| | - Lei Wang
- Affiliated Hospital of North Sichuan Medical College, Nanchong City, 637000, Sichuan Province, China
| | - Feng Yu
- Affiliated Hospital of North Sichuan Medical College, Nanchong City, 637000, Sichuan Province, China
| | - Lunbin Wang
- Affiliated Hospital of North Sichuan Medical College, Nanchong City, 637000, Sichuan Province, China
| | - Zhengwei Leng
- Affiliated Hospital of North Sichuan Medical College, Nanchong City, 637000, Sichuan Province, China.
| |
Collapse
|
5
|
Shah A, Holtmann G. Editorial: Is it time to include oral vancomycin in therapeutic guidelines for primary sclerosing cholangitis-associated inflammatory bowel disease? Aliment Pharmacol Ther 2024; 59:1290-1291. [PMID: 38652768 DOI: 10.1111/apt.17990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
LINKED CONTENTThis article is linked to Ricciuto et al paper. To view this article, visit https://doi.org/10.1111/apt.17936
Collapse
Affiliation(s)
- Ayesha Shah
- Faculty of Medicine, University of Queensland, Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Translational Research Institute, Brisbane, QLD, Australia
| | - Gerald Holtmann
- Faculty of Medicine, University of Queensland, Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Translational Research Institute, Brisbane, QLD, Australia
| |
Collapse
|
6
|
Tan N, Ngu N, Worland T, Lee T, Abrahams T, Freeman E, Hannah N, Gazelakis K, Madden RG, Lynch KD, Valaydon Z, Sood S, Dev A, Bell S, Thompson AJ, Ding JN, Nicoll AJ, Liu K, Pandya K, Gow P, Lubel J, Kemp W, Roberts SK, Majeed A. Surveillance MRI is associated with improved survival in patients with primary sclerosing cholangitis. Hepatol Commun 2024; 8:e0442. [PMID: 38696372 PMCID: PMC11068143 DOI: 10.1097/hc9.0000000000000442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 01/16/2024] [Indexed: 05/04/2024] Open
Abstract
BACKGROUND The benefits of regular surveillance imaging for cholangiocarcinoma in patients with primary sclerosing cholangitis (PSC) are unclear. Hence, we aimed to evaluate the impact of regular magnetic resonance cholangiopancreatography (MRCP) on outcomes of patients with PSC in Australia, where the practice of MRCP surveillance is variable. METHODS The relationship between MRCP surveillance and survival outcomes was assessed in a multicenter, retrospective cohort of patients with PSC from 9 tertiary liver centers in Australia. An inverse probability of treatment weighting approach was used to balance groups across potentially confounding covariates. RESULTS A total of 298 patients with PSC with 2117 person-years of follow-up were included. Two hundred and twenty patients (73.8%) had undergone MRCP surveillance. Regular surveillance was associated with a 71% reduced risk of death on multivariate weighted Cox analysis (HR: 0.29, 95% CI: 0.14-0.59, p < 0.001) and increased likelihood of having earlier endoscopic retrograde cholangiopancreatography from the date of PSC diagnosis in patients with a dominant stricture (p < 0.001). However, survival posthepatobiliary cancer diagnosis was not significantly different between both groups (p = 0.74). Patients who had surveillance of less than 1 scan a year (n = 41) had comparable survival (HR: 0.46, 95% CI 0.16-1.35, p = 0.16) compared to patients who had surveillance at least yearly (n = 172). CONCLUSIONS In this multicenter cohort study that employed inverse probability of treatment weighting to minimize selection bias, regular MRCP was associated with improved overall survival in patients with PSC; however, there was no difference in survival after hepatobiliary cancer diagnosis. Further prospective studies are needed to confirm the benefits of regular MRCP and optimal imaging interval in patients with PSC.
Collapse
Affiliation(s)
- Natassia Tan
- Department of Gastroenterology and Hepatology, The Alfred, Melbourne, Australia
- Central Clinical School, Monash University, Melbourne, Australia
| | - Natalie Ngu
- Central Clinical School, Monash University, Melbourne, Australia
- Department of Gastroenterology and Hepatology, Monash Health, Melbourne, Australia
| | - Thomas Worland
- Department of Gastroenterology and Hepatology, Austin Health, Melbourne, Australia
| | - Tanya Lee
- Department of Gastroenterology and Hepatology, St Vincent’s Health, Melbourne, Australia
| | - Tobie Abrahams
- Department of Gastroenterology and Hepatology, St Vincent’s Health, Melbourne, Australia
| | - Elliot Freeman
- Department of Gastroenterology and Hepatology, The Alfred, Melbourne, Australia
| | - Nicholas Hannah
- Department of Gastroenterology and Hepatology, Melbourne Health, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
| | - Kathryn Gazelakis
- Department of Gastroenterology and Hepatology, Western Health, Melbourne, Australia
| | - Richie G Madden
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, Australia
| | - Kate D Lynch
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, Australia
| | - Zina Valaydon
- Department of Gastroenterology and Hepatology, Western Health, Melbourne, Australia
| | - Siddharth Sood
- Department of Gastroenterology and Hepatology, Melbourne Health, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
| | - Anouk Dev
- Central Clinical School, Monash University, Melbourne, Australia
- Department of Gastroenterology and Hepatology, Monash Health, Melbourne, Australia
| | - Sally Bell
- Central Clinical School, Monash University, Melbourne, Australia
- Department of Gastroenterology and Hepatology, Monash Health, Melbourne, Australia
| | - Alexander J Thompson
- Department of Gastroenterology and Hepatology, St Vincent’s Health, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
| | - John Nik Ding
- Department of Gastroenterology and Hepatology, St Vincent’s Health, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
| | - Amanda J Nicoll
- Central Clinical School, Monash University, Melbourne, Australia
- Department of Gastroenterology and Hepatology, Eastern Health, Melbourne, Australia
| | - Ken Liu
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia
| | - Keval Pandya
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia
| | - Paul Gow
- Department of Gastroenterology and Hepatology, Austin Health, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
| | - John Lubel
- Department of Gastroenterology and Hepatology, The Alfred, Melbourne, Australia
- Central Clinical School, Monash University, Melbourne, Australia
| | - William Kemp
- Department of Gastroenterology and Hepatology, The Alfred, Melbourne, Australia
- Central Clinical School, Monash University, Melbourne, Australia
| | - Stuart K Roberts
- Department of Gastroenterology and Hepatology, The Alfred, Melbourne, Australia
- Central Clinical School, Monash University, Melbourne, Australia
| | - Ammar Majeed
- Department of Gastroenterology and Hepatology, The Alfred, Melbourne, Australia
- Central Clinical School, Monash University, Melbourne, Australia
| |
Collapse
|
7
|
Vishwanath A, Krishna S, Manudhane AP, Hart PA, Krishna SG. Early-Onset Gastrointestinal Malignancies: An Investigation into a Rising Concern. Cancers (Basel) 2024; 16:1553. [PMID: 38672634 PMCID: PMC11049592 DOI: 10.3390/cancers16081553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 04/11/2024] [Accepted: 04/17/2024] [Indexed: 04/28/2024] Open
Abstract
There is growing recognition of early-onset gastrointestinal (GI) malignancies in young adults < 50 years of age. While much of the literature has emphasized colorectal cancer, these also include esophageal, gastric, liver, pancreatic, and biliary tract malignancies. Various factors, including lifestyle, hereditary, and environmental elements, have been proposed to explain the rising incidence of GI malignancies in the younger population. This review aims to provide an overview of the recent literature, including global trends and information regarding genetic and environmental risk factors.
Collapse
Affiliation(s)
- Aayush Vishwanath
- Department of Neuroscience, The Ohio State University, Columbus, OH 43210, USA;
| | - Shreyas Krishna
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University, Columbus, OH 43210, USA; (S.K.); (A.P.M.)
| | - Albert P. Manudhane
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University, Columbus, OH 43210, USA; (S.K.); (A.P.M.)
| | - Phil A. Hart
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University, Columbus, OH 43210, USA; (S.K.); (A.P.M.)
| | - Somashekar G. Krishna
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University, Columbus, OH 43210, USA; (S.K.); (A.P.M.)
| |
Collapse
|
8
|
Del Chierico F, Cardile S, Baldelli V, Alterio T, Reddel S, Bramuzzo M, Knafelz D, Lega S, Bracci F, Torre G, Maggiore G, Putignani L. Characterization of the Gut Microbiota and Mycobiota in Italian Pediatric Patients With Primary Sclerosing Cholangitis and Ulcerative Colitis. Inflamm Bowel Dis 2024; 30:529-537. [PMID: 37696680 PMCID: PMC10988104 DOI: 10.1093/ibd/izad203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Primary sclerosing cholangitis (PSC) is a chronic, fibroinflammatory, cholestatic liver disease of unknown etiopathogenesis, often associated with inflammatory bowel diseases. Recent evidence ascribes, together with immunologic and environmental components, a significant role to the intestinal microbiota or its molecules in the PSC pathogenesis. METHODS By metagenomic sequencing of 16S rRNA and ITS2 loci, we describe the fecal microbiota and mycobiota of 26 pediatric patients affected by PSC and concomitant ulcerative colitis (PSC-UC), 27 patients without PSC but with UC (UC), and 26 healthy subjects (CTRLs). RESULTS Compared with CTRL, the bacterial and fungal gut dysbiosis was evident for both PSC-UC and UC groups; in particular, Streptococcus, Saccharomyces, Sporobolomyces, Tilletiopsis, and Debaryomyces appeared increased in PSC-UC, whereas Klebsiella, Haemophilus, Enterococcus Collinsella, Piptoporus, Candida, and Hyphodontia in UC. In both patient groups, Akkermansia, Bacteroides, Parabacteroides, Oscillospira, Meyerozyma and Malassezia were decreased. Co-occurrence analysis evidenced the lowest number of nodes and edges for fungi networks compared with bacteria. Finally, we identified a specific patient profile, based on liver function tests, bacterial and fungal signatures, that is able to distinguish PSC-UC from UC patients. CONCLUSIONS We describe the gut microbiota and mycobiota dysbiosis associated to PSC-UC disease. Our results evidenced a gut imbalance, with the reduction of gut commensal microorganisms with stated anti-inflammatory properties (ie, Akkermansia, Bacteroides, Parabacteroides, Oscillospira, Meyerozyma, and Malassezia) and the increase of pathobionts (ie, Streptococcus, Saccharomyces, and Debaryomyces) that could be involved in PSC progression. Altogether, these events may concur in the pathophysiology of PSC in the framework of UC.
Collapse
Affiliation(s)
- Federica Del Chierico
- Immunology, Rheumatology and Infectious Diseases Research Area, Unit of Human Microbiome, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Sabrina Cardile
- Hepatology, Gastroenterology, Nutrition and Liver transplantation Unit, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
| | - Valerio Baldelli
- Immunology, Rheumatology and Infectious Diseases Research Area, Unit of Human Microbiome, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Tommaso Alterio
- Hepatology, Gastroenterology, Nutrition and Liver transplantation Unit, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
| | - Sofia Reddel
- Immunology, Rheumatology and Infectious Diseases Research Area, Unit of Human Microbiome, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Matteo Bramuzzo
- Gastroenterology, Digestive Endoscopy and Nutrition Unit, Institute for Maternal and Child Health, IRCCS “Burlo Garofolo,”Trieste, Italy
| | - Daniela Knafelz
- Hepatology, Gastroenterology, Nutrition and Liver transplantation Unit, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
| | - Sara Lega
- Gastroenterology, Digestive Endoscopy and Nutrition Unit, Institute for Maternal and Child Health, IRCCS “Burlo Garofolo,”Trieste, Italy
| | - Fiammetta Bracci
- Hepatology, Gastroenterology, Nutrition and Liver transplantation Unit, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
| | - Giuliano Torre
- Hepatology, Gastroenterology, Nutrition and Liver transplantation Unit, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
| | - Giuseppe Maggiore
- Hepatology, Gastroenterology, Nutrition and Liver transplantation Unit, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
| | - Lorenza Putignani
- Unit of Microbiology and Diagnostic Immunology, Unit of Microbiomics and Immunology, Rheumatology and Infectious Diseases Research Area, Unit of Human Microbiome, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| |
Collapse
|
9
|
Boyd S, Mustamäki T, Sjöblom N, Nordin A, Tenca A, Jokelainen K, Rantapero T, Liuksiala T, Lahtinen L, Kuopio T, Kytölä S, Mäkisalo H, Färkkilä M, Arola J. NGS of brush cytology samples improves the detection of high-grade dysplasia and cholangiocarcinoma in patients with primary sclerosing cholangitis: A retrospective and prospective study. Hepatol Commun 2024; 8:e0415. [PMID: 38551383 PMCID: PMC10984659 DOI: 10.1097/hc9.0000000000000415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 02/06/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND Biliary dysplasia, a precursor of cholangiocarcinoma (CCA), is a common complication of primary sclerosing cholangitis. Patients with high-grade dysplasia (HGD) or early CCA who have received oncological treatment are candidates for liver transplantation. The preoperative diagnosis of CCA or HGD is challenging, and the sensitivity of biliary brush cytology (BC) is limited. METHODS By using next-generation sequencing (NGS), we retrospectively analyzed archived tissue samples (n=62) obtained from explanted liver tissue and CCA samples to identify oncogenic mutations that occur during primary sclerosing cholangitis carcinogenesis. BC samples were prospectively collected from patients with primary sclerosing cholangitis (n=97) referred for endoscopic retrograde cholangiography to measure the diagnostic utility of NGS combined with BC compared with traditional cytology alone. RESULTS Mutations in KRAS, GNAS, FLT3, RNF43, TP53, ATRX, and SMAD4 were detected in archived CCA or HGD samples. KRAS, GNAS, TP53, CDKN2A, FBXW7, BRAF, and ATM mutations were detected in prospectively collected brush samples from patients with histologically verified CCA or HGD. One patient with low-grade dysplasia in the explanted liver had KRAS and GNAS mutations in brush sample. No mutations were observed in brush samples or archived tissues in liver transplantation cases without biliary neoplasia. While KRAS mutations are common in biliary neoplasms, they were also observed in patients without biliary neoplasia during surveillance. CONCLUSIONS In summary, NGS of BC samples increased the sensitivity of detecting biliary neoplasia compared with traditional cytology. Performing NGS on BC samples may help diagnose HGD or early CCA, benefiting the timing of liver transplantation.
Collapse
Affiliation(s)
- Sonja Boyd
- Department of Pathology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Taru Mustamäki
- Department of Pathology, Hospital Nova of Central Finland University of Jyväskylä, Jyväskylä, Finland
| | - Nelli Sjöblom
- Department of Pathology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Arno Nordin
- Department of Liver and Transplantation Surgery, Helsinki University Hospital, University of Helsinki, Finland
| | - Andrea Tenca
- Department of Gastroenterology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Kalle Jokelainen
- Department of Gastroenterology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | | | | | - Laura Lahtinen
- Department of Pathology, Hospital Nova of Central Finland University of Jyväskylä, Jyväskylä, Finland
| | - Teijo Kuopio
- Department of Pathology, Hospital Nova of Central Finland University of Jyväskylä, Jyväskylä, Finland
| | - Soili Kytölä
- Department of Genetics, Helsinki University Hospital, University of Helsinki, Finland
| | - Heikki Mäkisalo
- Department of Liver and Transplantation Surgery, Helsinki University Hospital, University of Helsinki, Finland
| | - Martti Färkkilä
- Department of Gastroenterology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Johanna Arola
- Department of Pathology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| |
Collapse
|
10
|
Cornillet M, Villard C, Rorsman F, Molinaro A, Nilsson E, Kechagias S, von Seth E, Bergquist A. The Swedish initiative for the st udy of Primary sclerosing cholangitis (SUPRIM). EClinicalMedicine 2024; 70:102526. [PMID: 38500838 PMCID: PMC10945116 DOI: 10.1016/j.eclinm.2024.102526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 03/20/2024] Open
Abstract
Background Despite more than 50 years of research and parallel improvements in hepatology and oncology, there is still today neither a treatment to prevent disease progression in primary sclerosing cholangitis (PSC), nor reliable early diagnostic tools for the associated hepatobiliary cancers. Importantly, the limited understanding of the underlying biological mechanisms in PSC and its natural history not only affects the identification of new drug targets but implies a lack of surrogate markers that hampers the design of clinical trials and the evaluation of drug efficacy. The lack of easy access to large representative well-characterised prospective resources is an important contributing factor to the current situation. Methods We here present the SUPRIM cohort, a national multicentre prospective longitudinal study of unselected PSC patients capturing the representative diversity of PSC phenotypes. We describe the 10-year effort of inclusion and follow-up, an intermediate analysis report including original results, and the associated research resource. All included patients gave written informed consent (recruitment: November 2011-April 2016). Findings Out of 512 included patients, 452 patients completed the five-year follow-up without endpoint outcomes. Liver transplantation was performed in 54 patients (10%) and hepatobiliary malignancy was diagnosed in 15 patients (3%). We draw a comprehensive landscape of the multidimensional clinical and biological heterogeneity of PSC illustrating the diversity of PSC phenotypes. Performances of available predictive scores are compared and perspectives on the continuation of the SUPRIM cohort are provided. Interpretation We envision the SUPRIM cohort as an open-access collaborative resource to accelerate the generation of new knowledge and independent validations of promising ones with the aim to uncover reliable diagnostics, prognostic tools, surrogate markers, and new treatment targets by 2040. Funding This work was supported by the Swedish Cancer Society, Stockholm County Council, and the Cancer Research Funds of Radiumhemmet.
Collapse
Affiliation(s)
- Martin Cornillet
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Christina Villard
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
- Department of Transplantation Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Rorsman
- Department of Gastroenterology and Hepatology, Akademiska University Hospital, Uppsala, Sweden
| | - Antonio Molinaro
- Department of Hepatology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Emma Nilsson
- Gastroenterology Clinic, Skåne University Hospital, Sweden
| | - Stergios Kechagias
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Erik von Seth
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Annika Bergquist
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
11
|
Trauner M, Halilbasic E, Tatscher E, Fickert P. [Primary sclerosing cholangitis-Diagnosis and treatment 2024]. Inn Med (Heidelb) 2024; 65:347-356. [PMID: 38498179 PMCID: PMC10959807 DOI: 10.1007/s00108-024-01697-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/05/2024] [Indexed: 03/20/2024]
Abstract
The etiology of primary sclerosing cholangitis (PSC) remains unclear, which explains in part the lack of a causal treatment. The differential diagnostic distinction from the even rarer immunoglobulin 4 (IgG4)-associated cholangitis (IAC) is becoming increasingly more successful. Advances in the understanding of different clinical courses, improvements in noninvasive diagnostics through modern magnetic resonance imaging (MRI) and the introduction of liver elastography have led to the development of improved prognostic models. The evidence for recommendations on medicinal (e.g., ursodeoxycholic acid) or endoscopic treatment (e.g., balloon dilatation and/or stent insertion) for PSC is still low. In contrast, the long-term results of liver transplantation in PSC patients are constantly improving. Due to the lack of highly sensitive and specific screening methods the early recognition of cholangiocellular carcinoma (CCC) as the most important complication is rarely successful. The continuous improvement of endoscopic retrograde cholangiopancreatography (ERCP) and direct cholangioscopy in combination with molecular biological and fluorescence in situ hybridization (FISH) analyses of bile duct tissue samples are promising for refined diagnostics. Due to the significantly increased risk of colorectal cancer, an annual colonoscopy is recommended in the presence of inflammatory bowel disease. Improvement of the early diagnostics of PSC and successful testing of new treatment strategies raise hope for a continuous improvement in the medical support of these complex patients.
Collapse
Affiliation(s)
- Michael Trauner
- Klinische Abteilung für Gastroenterologie und Hepatologie, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich.
| | - Emina Halilbasic
- Klinische Abteilung für Gastroenterologie und Hepatologie, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - Elisabeth Tatscher
- Klinische Abteilung für Gastroenterologie und Hepatologie, Universitätsklinik für Innere Medizin, Medizinische Universität Graz, Auenbruggerplatz 15, 8036, Graz, Österreich
| | - Peter Fickert
- Klinische Abteilung für Gastroenterologie und Hepatologie, Universitätsklinik für Innere Medizin, Medizinische Universität Graz, Auenbruggerplatz 15, 8036, Graz, Österreich.
| |
Collapse
|
12
|
Sohal A, Kowdley KV. Novel preclinical developments of the primary sclerosing cholangitis treatment landscape. Expert Opin Investig Drugs 2024; 33:335-345. [PMID: 38480008 DOI: 10.1080/13543784.2024.2330738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 03/11/2024] [Indexed: 03/19/2024]
Abstract
INTRODUCTION Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease associated with inflammation, fibrosis, and destruction of intra- and extrahepatic bile ducts. Despite substantial recent advances in our understanding of PSC, the only proven treatment of PSC is liver transplantation. There is an urgent unmet need to find medical therapies for this disorder. AREAS COVERED Multiple drugs are currently under evaluation as therapeutic options for this disease. This article summarizes the literature on the various novel therapeutic options that have been investigated and are currently under development for the treatment of PSC. EXPERT OPINION In the next decade, more than one drug will likely be approved for the treatment of the disease, and we will be looking at combination therapies for the optimal management of the disease.
Collapse
Affiliation(s)
- Aalam Sohal
- Department of Hepatology, Liver Institute Northwest, Seattle, USA
| | - Kris V Kowdley
- Department of Hepatology, Liver Institute Northwest, Seattle, USA
- Elson S. Floyd College of Medicine, Washington State University, Spokane, USA
| |
Collapse
|
13
|
Miller LJ, Holmes IM, Chen-Yost HI, Smola B, Lew M, Betz BL, Brown NA, Pang J. Performance of fluorescence in situ hybridization in biliary brushings with equivocal cytology: an institutional experience. J Am Soc Cytopathol 2024:S2213-2945(24)00022-X. [PMID: 38589274 DOI: 10.1016/j.jasc.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 03/12/2024] [Accepted: 03/12/2024] [Indexed: 04/10/2024]
Abstract
INTRODUCTION Biliary brushing (BB) cytology has a sensitivity of 15%-65% and specificity approaching 100% for detecting malignancy. Fluorescence in-situ hybridization (FISH) using the UroVysion probe set has been advocated to enhance the detection of malignancies with reported sensitivity of 43%-84%. We sought to evaluate the performance of FISH in BB with equivocal cytology at our institution. MATERIALS AND METHODS Patients with atypical and suspicious BB with concurrent diagnostic FISH performed at our institution from 2014 to 2021 were identified through a query of our pathology database. FISH (using UroVysion probe set containing centromere enumeration probes to chromosomes 3, 7, and 17) was positive if at least 5 cells demonstrated polysomy. Electronic medical records were reviewed for pathology results and outcomes. Patients were classified malignant if they had positive pathology or documented clinical impression of malignancy and benign if they had negative pathology and/or documented benign clinical course for at least 12 months. RESULTS We identified 254 equivocal BB (238 atypical/16 suspicious) with concurrent FISH results from 191 patients (105 benign, 86 malignant). 12% (22/191) of patients were FISH positive. Twenty-four percent (21/86) of patients with malignancy had positive FISH but were nonspecific for pancreaticobiliary/ampullary adenocarcinomas. Almost all positive FISH were associated with malignancy (21/22; 95%). There was 1 positive FISH in a patient with primary sclerosing cholangitis who had a benign outcome. CONCLUSIONS The small number of positive FISH results in BB with equivocal cytology raises the question of the optimal criteria for malignancy. Using only polysomy could result in lower sensitivity.
Collapse
Affiliation(s)
- Lauren J Miller
- Department of Pathology, Michigan Medicine, Ann Arbor, Michigan
| | | | | | - Brian Smola
- Department of Pathology, Michigan Medicine, Ann Arbor, Michigan
| | - Madelyn Lew
- Department of Pathology, Michigan Medicine, Ann Arbor, Michigan
| | - Bryan L Betz
- Department of Pathology, Michigan Medicine, Ann Arbor, Michigan
| | - Noah A Brown
- Department of Pathology, Michigan Medicine, Ann Arbor, Michigan
| | - Judy Pang
- Department of Pathology, Michigan Medicine, Ann Arbor, Michigan.
| |
Collapse
|
14
|
Mehta S, Rosenstengle CA. Policy Corner: Cholangitis exception update. Liver Transpl 2024; 30:321-322. [PMID: 38009937 DOI: 10.1097/lvt.0000000000000301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 10/25/2023] [Indexed: 11/29/2023]
Affiliation(s)
- Shivang Mehta
- Transplant, Baylor All Saints Medical Center, Fort Worth, Texas, USA
| | - Craig A Rosenstengle
- Division of Gastroenterology and Hepatology, Baylor Medical Center, Dallas, Texas, USA
| |
Collapse
|
15
|
Pratt CG, Whitrock JN, Shah SA, Fong ZV. How to Determine Unresectability in Hilar Cholangiocarcinoma. Surg Clin North Am 2024; 104:197-214. [PMID: 37953036 DOI: 10.1016/j.suc.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Hilar cholangiocarcinoma is considered a biologically aggressive disease for which surgical resection remains the only curative treatment. Preoperative evaluation for resectability is challenging given tumor proximity to the porta hepatis, but minimal benefit and increased morbidity precludes recommendation for margin positive resection. This article reviews the determination of unresectability in hilar cholangiocarcinoma through discussion of the preoperative assessment, the intraoperative assessment, and key steps of surgical resection, as well as treatment options for unresectable tumors. Overall, evaluating patients preoperatively for resectability requires a multidisciplinary, holistic, and individualized approach to accurately determine resectability and optimize clinical outcomes for patients with hilar cholangiocarcinoma.
Collapse
Affiliation(s)
- Catherine G Pratt
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS) Research Group, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0558, Cincinnati, OH 45267-0558, USA. https://twitter.com/CPrattMD
| | - Jenna N Whitrock
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS) Research Group, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0558, Cincinnati, OH 45267-0558, USA. https://twitter.com/JennaWhitrockMD
| | - Shimul A Shah
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS) Research Group, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0558, Cincinnati, OH 45267-0558, USA; Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, MSB 2006C, ML 0519, Cincinnati, OH 45267-0558, USA. https://twitter.com/shimulshah73
| | - Zhi Ven Fong
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Mayo Clinic Arizona, Mayo Clinic College of Medicine, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA.
| |
Collapse
|
16
|
Grigoriadis A, Ippolito D, Itani M, Tan CH, Venkatesh SK. The Global Reading Room: Imaging Surveillance for Primary Sclerosing Cholangitis. AJR Am J Roentgenol 2024; 222:e2329661. [PMID: 37255043 DOI: 10.2214/ajr.23.29661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Aristeidis Grigoriadis
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
- Department of Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Davide Ippolito
- Department of Radiology, University of Milano-Bicocca School of Medicine and Surgery, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Malak Itani
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, MO
| | - Cher Heng Tan
- Department of Diagnostic Radiology, Tan Tock Seng Hospital, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | | |
Collapse
|
17
|
Horwich BH, Dieterich DT. Phenotypes of Primary Sclerosing Cholangitis and Differential Diagnosis. Clin Liver Dis 2024; 28:143-155. [PMID: 37945155 DOI: 10.1016/j.cld.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Primary sclerosing cholangitis is a heterogenous immune-mediated disorder characterized by chronic inflammation and stricturing of the bile ducts. Though the driving pathophysiologic mechanisms remain elusive, there are several observed clinical phenotypes of the disease. The distribution of bile duct involvement, presence of concomitant inflammatory bowel disease, significant infiltration of IgG4-positive plasma cells, and overlapping features with other autoimmune disease has significant implications for prognosis and treatment. As there remains no pathognomonic finding for primary sclerosing cholangitis, a broad differential diagnosis and extensive evaluation of other underlying causes is critical to appropriate management.
Collapse
Affiliation(s)
- Brian H Horwich
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, PO Box 1076, New York, NY 10029, USA
| | - Douglas T Dieterich
- Division of Liver Diseases, Institute for Liver Medicine, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, Annenberg 5-04, New York, NY 10029, USA.
| |
Collapse
|
18
|
Sonnenday CJ. Liver Transplantation for Hilar Cholangiocarcinoma. Surg Clin North Am 2024; 104:183-196. [PMID: 37953035 DOI: 10.1016/j.suc.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Hilar cholangiocarcinoma (hCCA) is an infiltrative disease that often presents with locally advanced and/or metastatic disease, with a minority of patients eligible for surgical resection. Select patients with unresectable hCCA, or patients with hCCA in the setting of primary sclerosing cholangitis, with tumors less than 3 cm and no evidence of extrahepatic disease, can be effectively treated with neoadjuvant chemoradiation followed by liver transplantation. Staging laparotomy documenting lack of occult metastatic disease, including a portal lymphadenectomy documenting no nodal metastases, is essential to achieve optimal outcomes. Overall 5 year survival among treated patients is approximately 60%.
Collapse
Affiliation(s)
- Christopher J Sonnenday
- Department of Surgery, University of Michigan Health, F6686 UH-South, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5296, USA.
| |
Collapse
|
19
|
Eletta OA, Panayotova GG, Lunsford KE. Liver Transplant for Intrahepatic Cholangiocarcinoma. Surg Clin North Am 2024; 104:215-225. [PMID: 37953037 DOI: 10.1016/j.suc.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Intrahepatic cholangiocarcinoma (iCCA) tends to be asymptomatic until late stages, leading most of the patients to present at advanced stages of the disease. A combination of medical and surgical therapy is crucial for patient management. Historically, poor outcomes resulted in liver transplantation being formally contraindicated for patients with iCCA; however, recent advances in patient selection and neoadjuvant therapy have resulted in a paradigm shift in liver transplant oncology. As a result, the feasibility of liver transplantation for iCCA is being reevaluated by several centers as a therapeutic alternative for select patients with locally advanced unresectable disease.
Collapse
Affiliation(s)
- Olanrewaju A Eletta
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, MEB 596, New Brunswick, NJ 08901, USA
| | - Guergana G Panayotova
- Division of Transplant and HPB Surgery, Department of Surgery Rutgers, New Jersey Medical School, 185 South Orange Avenue, Newark, NJ 07103, USA
| | - Keri E Lunsford
- Division of Transplant and HPB Surgery, Department of Surgery Rutgers, New Jersey Medical School, 185 South Orange Avenue, Newark, NJ 07103, USA.
| |
Collapse
|
20
|
Zapata M, Pagan-Torres H, Mayo MJ. Systemic Complications of Primary Biliary Cholangitis. Clin Liver Dis 2024; 28:115-128. [PMID: 37945153 DOI: 10.1016/j.cld.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Chronic cholestasis is the hallmark clinical feature of primary biliary cholangitis. In addition to progressive liver damage, chronic cholestasis can lead to serious complications, many of which occur outside the liver. Bile acids are ligands for nuclear hormone receptors, and alterations in their concentration disrupt normal functioning of numerous different cell types. This article discusses the clinical presentation, pathophysiology, and management of pruritus (itching), fatigue, osteoporosis, hyperlipidemia, fat-soluble vitamin deficiencies, malignancies, cardiac dysfunction, bacterial cholangitis, cholemic (bile cast) nephropathy, and Sicca syndrome.
Collapse
Affiliation(s)
- Mariana Zapata
- University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, Texas 75390-8887, USA
| | - Hendrick Pagan-Torres
- University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, Texas 75390-8887, USA
| | - Marlyn J Mayo
- University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, Texas 75390-8887, USA.
| |
Collapse
|
21
|
Henson JB, King LY. Post-Transplant Management and Complications of Autoimmune Hepatitis, Primary Biliary Cholangitis, and Primary Sclerosing Cholangitis including Disease Recurrence. Clin Liver Dis 2024; 28:193-207. [PMID: 37945160 PMCID: PMC11033708 DOI: 10.1016/j.cld.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Autoimmune liver diseases have unique post-transplant considerations. These recipients are at increased risk of rejection, and recurrent disease may also develop, which can progress to graft loss and increase mortality. Monitoring for and managing these complications is therefore important, though data on associated risk factors and immunosuppression strategies has in most cases been mixed. There are also other disease-specific complications that require management and may impact these decisions, including inflammatory bowel disease in PSC. Further work to better understand the optimal management strategies for these patients post-transplant is needed.
Collapse
Affiliation(s)
- Jacqueline B Henson
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, DUMC Box 3913, Durham, NC 27710, USA
| | - Lindsay Y King
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, DUMC Box 3923, Durham, NC 27710, USA.
| |
Collapse
|
22
|
Thomson M, Scott A, Trost S, Lake J, Lim N. Low screening rates and high prevalence of osteoporosis in cirrhosis: A real-world retrospective analysis. Aliment Pharmacol Ther 2024; 59:535-546. [PMID: 38059360 DOI: 10.1111/apt.17823] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 09/23/2023] [Accepted: 11/21/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND Patients with cirrhosis are at increased risk for osteoporosis, and those who suffer a fracture are at high risk for mortality. Despite this, osteoporosis is often overlooked and undertreated. This study aimed to evaluate osteoporosis screening, management, and adverse osteoporosis medication events in patients with cirrhosis. METHODS We performed a retrospective chart review of adult outpatients with compensated and decompensated cirrhosis seen in single health system over a 6-year period. Patient demographics, liver and bone health comorbidities, DEXA scan results, and medications were abstracted. RESULTS In total, 5398 patients met criteria. The cohort was predominately white (79.1%) and older (age 59). 44.4% were female. 64.6% had decompensated cirrhosis. Median MELD-Na score was 12.8. 23.5% had a DEXA scan ordered, approximately 50% completed this test. Patients who were older, female, white, with more severe liver disease, and other osteoporosis risk factors were more likely to have a DEXA scan ordered. 48.5% of patients had osteopenia and 30.2% had osteoporosis on DEXA scan. Only 22.6% of patients with osteoporosis received treatment, most commonly oral bisphosphonates. Oral bisphosphonate prescription was not associated with variceal bleeding (8.4% without vs. 4.8% with, p = 0.487). CONCLUSION A minority of patients with cirrhosis were screened for osteoporosis. The majority screened had osteopenia or osteoporosis on DEXA scan. Less than a quarter of patients with osteoporosis were started on treatment. Real-world experience of oral bisphosphonate use did not reveal higher rates of gastrointestinal bleeding. There is room for improvement in all aspects of bone health care in cirrhosis.
Collapse
Affiliation(s)
- Mary Thomson
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Adam Scott
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Suzanne Trost
- Division of Diabetes, Endocrinology and Metabolism, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jack Lake
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Nicholas Lim
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| |
Collapse
|
23
|
Wheless WH, Russo MW. Treatment of Primary Sclerosing Cholangitis Including Transplantation. Clin Liver Dis 2024; 28:171-182. [PMID: 37945158 DOI: 10.1016/j.cld.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Primary sclerosing cholangitis is a progressive cholestatic liver disease that causes stricturing of the intra and extrahepatic bile ducts that can lead to cirrhosis and end stage liver disease. Effective medical therapy has been elusive, but a course of ursodeoxycholic acid may be prescribed at doses of 17-23 mg/kg/day for up to a year to determine if a reduction in serum alkaline phosphatase is observed. A number of drugs are under investigation, including FXR agonists with choleretic and antimicrobial properties. Liver transplantation for PSC has one of the highest survival rates, but recurrent PSC is seen in up to 25% of recipients.
Collapse
Affiliation(s)
- William H Wheless
- Division of Hepatology, Atrium Health Wake Forest, Charlotte, NC, USA
| | - Mark W Russo
- Division of Hepatology, Atrium Health Wake Forest, Charlotte, NC, USA.
| |
Collapse
|
24
|
Saca D, Flamm SL. Cholangiocarcinoma Surveillance Recommendations in Patients with Primary Sclerosing Cholangitis. Clin Liver Dis 2024; 28:183-192. [PMID: 37945159 DOI: 10.1016/j.cld.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Cholangiocarcinoma (CCA) is a deadly complication observed in the setting of primary sclerosing cholangitis (PSC). When symptoms develop and CCA is diagnosed, it is usually at an advanced stage. Median survival is less than 12 months. Early identification of CCA leads to improved outcomes. Although diagnostic tests have excellent specificity, they are plagued by low sensitivity. No surveillance strategies have been widely agreed upon, but most societies recommend measurement of serum carbohydrate antigen 19-9 and MRCP every 6 to 12 months in patients with PSC. Advances in understanding of the genetic factors that lead to CCA are awaited.
Collapse
Affiliation(s)
- Daniel Saca
- Rush University Medical School, 1725 West Harrison Street Suite 110, Chicago, IL 60612, USA
| | - Steven L Flamm
- Rush University Medical School, 1725 West Harrison Street Suite 110, Chicago, IL 60612, USA.
| |
Collapse
|
25
|
Tow CY, Chung E, Kaul B, Bhalla A, Fortune BE. Diagnostic Tests in Primary Sclerosing Cholangitis: Serology, Elastography, Imaging, and Histology. Clin Liver Dis 2024; 28:157-169. [PMID: 37945157 DOI: 10.1016/j.cld.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease characterized by progressive inflammation and fibrosis of the biliary tree leading to biliary strictures, cholangitis, and cirrhosis. Early in presentation, patients may have normal liver tests, though over time develop a cholestatic pattern of liver injury. Diagnosis is made radiographically with magnetic resonance or endoscopic cholangiography. While several autoantibodies are associated with PSC, none have proven to have adequate diagnostic utility. Liver biopsy is rarely recommended unless to evaluate for small-duct PSC or overlap syndrome. Elastography, in various forms, is an effective, non-invasive modality to evaluate liver fibrosis in PSC.
Collapse
Affiliation(s)
- Clara Y Tow
- Division of Hepatology, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA; Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461, USA
| | - Erica Chung
- Division of Gastroenterology, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA
| | - Bindu Kaul
- Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461, USA; Department of Radiology, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA
| | - Amarpreet Bhalla
- Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461, USA; Department of Pathology, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA
| | - Brett E Fortune
- Division of Hepatology, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA; Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461, USA.
| |
Collapse
|
26
|
Yazdanfar M, Zepeda J, Dean R, Wu J, Levy C, Goldberg D, Lammert C, Prenner S, Reddy KR, Pratt D, Forman L, Assis DN, Lytvyak E, Montano-Loza AJ, Gordon SC, Carey EJ, Ahn J, Schlansky B, Korzenik J, Karagozian R, Hameed B, Chandna S, Yu L, Bowlus CL. African American race does not confer an increased risk of clinical events in patients with primary sclerosing cholangitis. Hepatol Commun 2024; 8:e0366. [PMID: 38285883 PMCID: PMC10830082 DOI: 10.1097/hc9.0000000000000366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 11/01/2023] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND The natural history of primary sclerosing cholangitis (PSC) among African Americans (AA) is not well understood. METHODS Transplant-free survival and hepatic decompensation-free survival were assessed using a retrospective research registry from 16 centers throughout North America. Patients with PSC alive without liver transplantation after 2008 were included. Diagnostic delay was defined from the first abnormal liver test to the first abnormal cholangiogram/liver biopsy. Socioeconomic status was imputed by the Zip code. RESULTS Among 850 patients, 661 (77.8%) were non-Hispanic Whites (NHWs), and 85 (10.0%) were AA. There were no significant differences by race in age at diagnosis, sex, or PSC type. Inflammatory bowel disease was more common in NHWs (75.8% vs. 51.8% p=0.0001). The baseline (median, IQR) Amsterdam-Oxford Model score was lower in NHWs (14.3, 13.4-15.2 vs. 15.1, 14.1-15.7, p=0.002), but Mayo risk score (0.03, -0.8 to 1.1 vs. 0.02, -0.7 to 1.0, p=0.83), Model for End-stage Liver Disease (5.9, 2.8-10.7 vs. 6.4, 2.6-10.4, p=0.95), and cirrhosis (27.4% vs. 27.1%, p=0.95) did not differ. Race was not associated with hepatic decompensation, and after adjusting for clinical variables, neither race nor socioeconomic status was associated with transplant-free survival. Variables independently associated with death/liver transplant (HR, 95% CI) included age at diagnosis (1.04, 1.02-1.06, p<0.0001), total bilirubin (1.06, 1.04-1.08, p<0.0001), and albumin (0.44, 0.33-0.61, p<0.0001). AA race did not affect the performance of prognostic models. CONCLUSIONS AA patients with PSC have a lower rate of inflammatory bowel disease but similar progression to hepatic decompensation and liver transplant/death compared to NHWs.
Collapse
Affiliation(s)
- Maryam Yazdanfar
- Division of Gastroenterology and Hepatology, University of California Davis, Sacramento, California, USA
| | - Joseph Zepeda
- Division of Gastroenterology and Hepatology, University of California Davis, Sacramento, California, USA
| | - Richard Dean
- Division of Gastroenterology and Hepatology, University of California Davis, Sacramento, California, USA
| | - Jialin Wu
- Division of Gastroenterology and Hepatology, Schiff Center for Liver Disease, University of Miami, Miami, Florida, USA
| | - Cynthia Levy
- Division of Gastroenterology and Hepatology, Schiff Center for Liver Disease, University of Miami, Miami, Florida, USA
| | - David Goldberg
- Division of Gastroenterology and Hepatology, Schiff Center for Liver Disease, University of Miami, Miami, Florida, USA
| | | | - Stacey Prenner
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - K. Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Lisa Forman
- University of Colorado, Denver, Colorado, USA
| | | | - Ellina Lytvyak
- Division of Preventive Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Aldo J. Montano-Loza
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Stuart C. Gordon
- Henry Ford Health and Wayne State University School of Medicine, Detroit, Michigan, USA
| | | | - Joseph Ahn
- Oregon Health Sciences University, Portland, Oregon, USA
| | | | | | | | - Bilal Hameed
- UC San Francisco, San Francisco, California, USA
| | | | - Lei Yu
- University of Washington, Seattle, Washington, USA
| | - Christopher L. Bowlus
- Division of Gastroenterology and Hepatology, University of California Davis, Sacramento, California, USA
| |
Collapse
|
27
|
Morelli MC, Gambato M, Martini S, Carrai P, Toniutto P, Giannelli V, Donato F, Lenci I, Pasulo L, Mazzarelli C, Ferrarese A, Rendina M, Grieco A, Lanza AG, Baroni GS, De Maria N, Marenco S, Mameli L, Ponziani FR, Vitale G, Burra P, Viganò R, Fornasiere E, Catanzaro E, Marrone G, Milana M, Calleri A, Scorzoni C, Frassanito G, Lionetti R, Dibenedetto C. Trends in liver transplantation for primary sclerosing cholangitis. Dig Liver Dis 2024:S1590-8658(24)00194-4. [PMID: 38233315 DOI: 10.1016/j.dld.2024.01.175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 01/04/2024] [Accepted: 01/08/2024] [Indexed: 01/19/2024]
Abstract
BACKGROUND Primary sclerosing cholangitis is a cholestatic disease with a low prevalence in Italy. Indications for liver transplantation and the time of listing are not stated. AIM We performed a national survey to investigate the listing criteria, comorbidities, and outcomes. METHODS In April 2022, we surveyed liver transplantation in primary sclerosing cholangitis nationwide for the last 15 years. RESULTS From 2007 to 2021, 445 patients were included on waiting lists, and 411 had undergone liver transplants. The median age at transplantation was 46 years (males 63.9%); 262 patients (59%) presented an inflammatory bowel disease. Transplants increased over the years, from 1.8 % in 2007 to 3.0 % in 2021. Cholangitis (51%) and hepatic decompensation (45%) were the main indications for listing. The disease recurred in 81 patients (20%). Patient survival after the first transplant was 94 %, 86% and 84% at one, five, and ten years. Twenty-four died in the first year (50% surgical complications, 25% infections); 33 between one to five years (36% recurrence, 21% cholangiocarcinoma recurrence) and nine after five years (56% de novo cancer, 44% recurrence). CONCLUSIONS Primary sclerosing cholangitis has been an increasing indication for transplantation in Italy. Cholangitis and decompensation were the main indications for listing. Recurrence and cancer were the leading causes of death.
Collapse
Affiliation(s)
- Maria Cristina Morelli
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Internal Medicine Unit for the treatment of Severe Organ Failure, Bologna, Italy
| | - Martina Gambato
- Multivisceral Transplant Unit, Padua University Hospital, Padova, Italy
| | - Silvia Martini
- Gastrohepatology Unit, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - Paola Carrai
- Hepatobiliary Surgery and Liver Transplantation Unit, University of Pisa Medical School and Hospital, Pisa, Italy
| | - Pierluigi Toniutto
- Hepatology and Liver Transplant Unit, Department of Medical Area, Udine University Hospital, Udine, Italy
| | - Valerio Giannelli
- San Camillo Hospital, Department of Transplantation and General Surgery, Rome, Italy
| | - Francesca Donato
- Gastroenterology and Hepatology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ilaria Lenci
- Hepatology and Transplant Unit, Fondazione Policlinico Tor Vergata, Roma, Italy
| | - Luisa Pasulo
- Gastroenterology and Transplant Hepatology Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Chiara Mazzarelli
- Gastroenterology and Hepatology Department, Liver Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Alberto Ferrarese
- Unit of Gastroenterology, Borgo Trento University Hospital of Verona, Verona, Italy
| | - Maria Rendina
- Gastroenterology Unit, Department of Emergency and Organ Transplantation, University of Bari, Italy
| | - Antonio Grieco
- Liver Transplant Medicine Unit, Gastroenterological Area, Department of Gastroenterological, Endocrine and Metabolic Sciences, Fondazione Policlinico Universitario Gemelli, Catholic University of the Sacred Heart, Rome, Italy
| | | | | | - Nicola De Maria
- Gastroenterology Unit, Department of Medical Specialties, University of Modena and Reggio Emilia and Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Simona Marenco
- Department of Internal Medicine, Gastroenterology Unit, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, Genova 16132, Italy
| | - Laura Mameli
- Liver and Pancreas Transplant Center, Azienda Ospedaliera Brotzu Cagliari, Italy
| | - Francesca Romana Ponziani
- Hepatology Unit, CEMAD Centro Malattie dell'Apparato Digerente, Medicina Interna e Gastroenterologia, Fondazione Policlinico Universitario Gemelli IRCCS, Rome, Italy
| | - Giovanni Vitale
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Internal Medicine Unit for the treatment of Severe Organ Failure, Bologna, Italy.
| | - Patrizia Burra
- Multivisceral Transplant Unit, Padua University Hospital, Padova, Italy
| | - Raffaella Viganò
- Gastroenterology and Hepatology Department, Liver Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Ezio Fornasiere
- Hepatology and Liver Transplant Unit, Department of Medical Area, Udine University Hospital, Udine, Italy
| | - Elisa Catanzaro
- Multivisceral Transplant Unit, Padua University Hospital, Padova, Italy
| | - Giuseppe Marrone
- Liver Transplant Medicine Unit, Fondazione Policlinico Universitario Gemelli, Catholic University of the Sacred Heart, Rome, Italy
| | - Martina Milana
- Hepatology and Transplant Unit, Fondazione Policlinico Tor Vergata, Roma, Italy
| | - Alberto Calleri
- Gastrohepatology Unit, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - Chiara Scorzoni
- Liver Injury and Transplant Unit, Polytechnic University of Marche, 60121 Ancona, Italy
| | - Gabriella Frassanito
- Gastroenterology Unit, Department of Medical Specialties, University of Modena and Reggio Emilia and Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Raffaella Lionetti
- Infectious diseases and Hepatology Unit, National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Clara Dibenedetto
- Gastroenterology and Hepatology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore, Policlinico, Milan, Italy
| |
Collapse
|
28
|
Cazzagon N, Sarcognato S, Catanzaro E, Bonaiuto E, Peviani M, Pezzato F, Motta R. Primary Sclerosing Cholangitis: Diagnostic Criteria. Tomography 2024; 10:47-65. [PMID: 38250951 PMCID: PMC10820917 DOI: 10.3390/tomography10010005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 12/24/2023] [Accepted: 01/02/2024] [Indexed: 01/23/2024] Open
Abstract
Primary sclerosing cholangitis is a chronic cholestatic liver disease characterized by inflammation and fibrosis of intra- and/or extrahepatic bile ducts leading to the formation of multifocal strictures alternated to bile duct dilatations. The diagnosis of the most common subtype of the disease, the large duct PSC, is based on the presence of elevation of cholestatic indices, the association of typical cholangiographic findings assessed by magnetic resonance cholangiography and the exclusion of causes of secondary sclerosing cholangitis. Liver biopsy is not routinely applied for the diagnosis of large duct PSC but is mandatory in the case of suspicion of small duct PSC or overlap with autoimmune hepatitis.
Collapse
Affiliation(s)
- Nora Cazzagon
- Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy (F.P.)
- Gastroenterology Unit, Azienda Ospedale—Università Padova, 35128 Padova, Italy
| | - Samantha Sarcognato
- Department of Pathology, Azienda ULSS2 Marca Trevigiana, 31100 Treviso, Italy
| | - Elisa Catanzaro
- Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy (F.P.)
- Gastroenterology Unit, Azienda Ospedale—Università Padova, 35128 Padova, Italy
| | - Emanuela Bonaiuto
- Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy (F.P.)
| | - Matteo Peviani
- Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy (F.P.)
- Gastroenterology Unit, Azienda Ospedale—Università Padova, 35128 Padova, Italy
| | - Francesco Pezzato
- Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy (F.P.)
- Gastroenterology Unit, Azienda Ospedale—Università Padova, 35128 Padova, Italy
| | - Raffaella Motta
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health—DCTV, University of Padova, 35128 Padova, Italy;
- Radiology Unit, Azienda Ospedale—Università Padova, 35128 Padova, Italy
| |
Collapse
|
29
|
Lim DYZ, Tan YB, Koh JTE, Tung JYM, Sng GGR, Tan DMY, Tan CK. ChatGPT on guidelines: Providing contextual knowledge to GPT allows it to provide advice on appropriate colonoscopy intervals. J Gastroenterol Hepatol 2024; 39:81-106. [PMID: 37855067 DOI: 10.1111/jgh.16375] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 09/06/2023] [Accepted: 09/22/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND AND AIM Colonoscopy is commonly used in screening and surveillance for colorectal cancer. Multiple different guidelines provide recommendations on the interval between colonoscopies. This can be challenging for non-specialist healthcare providers to navigate. Large language models like ChatGPT are a potential tool for parsing patient histories and providing advice. However, the standard GPT model is not designed for medical use and can hallucinate. One way to overcome these challenges is to provide contextual information with medical guidelines to help the model respond accurately to queries. Our study compares the standard GPT4 against a contextualized model provided with relevant screening guidelines. We evaluated whether the models could provide correct advice for screening and surveillance intervals for colonoscopy. METHODS Relevant guidelines pertaining to colorectal cancer screening and surveillance were formulated into a knowledge base for GPT. We tested 62 example case scenarios (three times each) on standard GPT4 and on a contextualized model with the knowledge base. RESULTS The contextualized GPT4 model outperformed the standard GPT4 in all domains. No high-risk features were missed, and only two cases had hallucination of additional high-risk features. A correct interval to colonoscopy was provided in the majority of cases. Guidelines were appropriately cited in almost all cases. CONCLUSIONS A contextualized GPT4 model could identify high-risk features and quote appropriate guidelines without significant hallucination. It gave a correct interval to the next colonoscopy in the majority of cases. This provides proof of concept that ChatGPT with appropriate refinement can serve as an accurate physician assistant.
Collapse
Affiliation(s)
- Daniel Yan Zheng Lim
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
- Medicine Academic Clininical Programme, Duke-NUS Medical School, Singapore, Singapore
| | - Yu Bin Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Jonathan Tian En Koh
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | | | | | - Damien Meng Yew Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
- Medicine Academic Clininical Programme, Duke-NUS Medical School, Singapore, Singapore
| | - Chee-Kiat Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
- Medicine Academic Clininical Programme, Duke-NUS Medical School, Singapore, Singapore
| |
Collapse
|
30
|
Bednarsch J, Lang SA, Heise D, Strnad P, Neumann UP, Ulmer TF. Laparoscopic Living donor liver transplantation in irresectable intrahepatic cholangiocarcinoma in primary sclerosing cholangitis associated liver cirrhosis. Z Gastroenterol 2024; 62:50-55. [PMID: 38195108 DOI: 10.1055/a-2221-6126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
Intrahepatic cholangiocarcinoma (iCCA) is the second most common primary liver tumor and usually associated with a poor oncological prognosis. The current gold standard is the surgical resection of the tumor with subsequent adjuvant therapy. However, in case of irresectability e.g. in case of liver cirrhosis, a palliative treatment regime is conducted.This report demonstrates the case of an irresectable iCCA in liver cirrhosis due to primary sclerosing cholangitis (PSC) treated by living-donor liver transplantation (LDLT) facilitated by minimal invasive donor hepatectomy. No postoperative complications were observed in the donor and the donor was released on the 6th postoperative day. Further, after a follow-up of 1.5 years, no disease recurrence was detected in the recipient.According to the recent international literature, liver transplantation can be evaluated in case of small solitary iCCA (< 3 cm) in cirrhosis. Less evidence is provided for transplantation in advanced tumors which are surgically not resectable due to advanced liver disease or infiltration of major vessels, however some reports display adequate long-term survival after strict patient selection. The selection criteria comprise the absence of distant metastases and locoregional lymph node metastases as well as partial remission or stable disease after neoadjuvant chemotherapy. Due to no established graft allocation for iCCA in Germany, LDLT is currently the best option to realize transplantation in these patients. Developments in the last decade indicate that LDLT should preferentially be performed in minimal invasive manner (laparoscopic or robotic) as this approach is associated with less overall complications and a shorter hospitalization. The presented case illustrates the possibilities of modern surgery and the introduction of transplant oncology in the modern therapy of patients combining systemic therapy, surgical resection and transplantation to achieve optimal long-term results in patients which were initially indicated for palliative treatment.
Collapse
Affiliation(s)
- Jan Bednarsch
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- Department of Surgery and Transplantation, University Hospital Essen, Essen, Germany
| | - Sven A Lang
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- Department of Surgery and Transplantation, University Hospital Essen, Essen, Germany
| | - Daniel Heise
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- Department of Surgery and Transplantation, University Hospital Essen, Essen, Germany
| | - Pavel Strnad
- Department of Internal Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - Ulf P Neumann
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- Department of Surgery and Transplantation, University Hospital Essen, Essen, Germany
| | - Tom F Ulmer
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- Department of Surgery and Transplantation, University Hospital Essen, Essen, Germany
| |
Collapse
|
31
|
Ahmed W, Joshi D, Huggett MT, Everett SM, James M, Menon S, Oppong KW, On W, Paranandi B, Trivedi P, Webster G, Hegade VS. Update on the optimisation of endoscopic retrograde cholangiography (ERC) in patients with primary sclerosing cholangitis. Frontline Gastroenterol 2024; 15:74-83. [PMID: 38487565 PMCID: PMC10935540 DOI: 10.1136/flgastro-2023-102491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 08/28/2023] [Indexed: 03/17/2024] Open
Affiliation(s)
- Wafaa Ahmed
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Deepak Joshi
- Gastroenterology, King's College Hospital Liver Unit, London, UK
| | - Matthew T Huggett
- Gastroenterology, St James's University Hospital, The Leeds Teaching Hospitals NHS Foundation Trust, Leeds, UK
| | - Simon M Everett
- Gastroenterology, St James's University Hospital NHS Trust, Leeds, UK
| | - Martin James
- Gastroenterology, Nottingham University, Nottingham, UK
| | - Shyam Menon
- Department of Hepatology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Wei On
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Bharat Paranandi
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Palak Trivedi
- National Institute for Health Research, Centre for Liver Research, University Hospitals Birmingham, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - George Webster
- Department of Gastroenterology, University College London Hospital NHS Foundation Trust, London, UK
| | - Vinod S Hegade
- Leeds Liver Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| |
Collapse
|
32
|
Sohal A, Kowdley KV. Complete Biochemical Remission With Oral Vancomycin in a Patient With Primary Sclerosing Cholangitis and High Serum Immunoglobulin G4 Levels. ACG Case Rep J 2024; 11:e01256. [PMID: 38236497 PMCID: PMC10793982 DOI: 10.14309/crj.0000000000001256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 12/13/2023] [Indexed: 01/19/2024] Open
Abstract
Primary sclerosing cholangitis (PSC) is a progressive cholestatic liver disease characterized by intrahepatic and extrahepatic bile duct strictures leading to cirrhosis. A subtype with elevated serum immunoglobulin (Ig) G4 levels has been recently identified. Elevated IgG4 titers can be present in 9%-15% of patients with PSC. Currently, liver transplantation is the only effective treatment of PSC, although multiple medical therapies are under evaluation. We report a case of a young adult with PSC and elevated IgG4 levels who had marked serum aminotransferase elevation; the patient had an incomplete response to steroids but achieved complete biochemical remission after initiation of oral vancomycin.
Collapse
Affiliation(s)
| | - Kris V. Kowdley
- Liver Institute Northwest, Seattle, WA
- Elson Floyd College of Medicine, Spokane, WA
| |
Collapse
|
33
|
Pang C, Li J, Dou J, Li Z, Li L, Li K, Chen Q, An C, Zhou Z, He G, Lou K, Liang F, Xi H, Wang X, Zuo M, Cheng Z, Han Z, Liu F, Yu X, Yu J, Jiang X, Yang M, Liang P. Microwave ablation versus liver resection for primary intrahepatic cholangiocarcinoma within Milan criteria: a long-term multicenter cohort study. EClinicalMedicine 2024; 67:102336. [PMID: 38261915 PMCID: PMC10796969 DOI: 10.1016/j.eclinm.2023.102336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 11/09/2023] [Accepted: 11/09/2023] [Indexed: 01/25/2024] Open
Abstract
Background Ablation has been recommended by worldwide guidelines as first-line treatment for hepatocellular carcinoma (HCC), while evidence regarding its efficacy for primary intrahepatic cholangiocarcinoma (iCCA) is lacking. We aimed to study the efficacy of ablation in treating iCCA by comparing its prognosis with surgery. Methods In this real-world multicenter cohort study from January 2009 to June 2022, 10,441 iCCA patients from ten tertiary hospitals were identified. Patients who underwent curative-intent microwave ablation (MWA) or liver resection (LR) for tumors within Milan criteria were included. One-to-many propensity score matching (PSM) at variable ratios (1:n ≤4) was used to balance baseline characteristics. Mediation analysis was applied to identify potential mediators of the survival difference. Findings 944 patients were finally enrolled in this study, with 221 undergoing MWA and 723 undergoing LR. After PSM, 203 patients in the MWA group were matched with 588 patients in the LR group. The median follow-up time was 4.7 years. Compared with LR, MWA demonstrated similar overall survival (5-year 44.8% versus 40.4%; HR 0.96, 95% CI 0.71-1.29, P = .761). There was an improvement in the 5-year disease-free survival rate for MWA from 17.1% during the period of 2009-2016 to 37.3% during 2017-2022, becoming comparable to the 40.8% of LR (P = .129). The proportion of ablative margins ≥5 mm increased from 25% to 61% over the two periods, while this proportion of surgical margins was 62% and 77%, respectively. 34.5% of DFS disparity can be explained by the mediation effect of margins (P < .0001). Similar DFS was observed when both ablative and surgical margins exceeded 5 mm (HR 0.83, 95% CI 0.52-1.32, P = .41). Interpretation MWA may be considered as a viable alternative to LR for iCCA within Milan criteria when an adequate margin can be obtained. Funding National Natural Science Foundation of China.
Collapse
Affiliation(s)
- Chuan Pang
- Department of Interventional Ultrasound, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of General Surgery, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Jianming Li
- Department of Interventional Ultrasound, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Jianping Dou
- Department of Interventional Ultrasound, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Zhishuai Li
- Biliary Tract Surgery Department I, Eastern Hepatobiliary Surgery Hospital, Secondary Military Medical University, Shanghai, China
| | - Lu Li
- Department of Interventional Ultrasound, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Kai Li
- Department of Ultrasound, Guangdong Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Qi Chen
- Department of Health Statistics, Naval Medical University, Shanghai, China
| | - Chao An
- Department of Minimal Invasive Intervention, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Zhongsong Zhou
- Department of Infectious Diseases, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Guangbin He
- Department of Ultrasound, Xijing Hospital, The Fourth Military Medical University, Xian, China
| | - Kexin Lou
- Department of Medical Ultrasound, Xuzhou Central Hospital, Xuzhou, China
| | - Feng Liang
- Department of General Surgery, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Hongqing Xi
- Department of General Surgery, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xiaohui Wang
- Department of Hepatobiliary Surgery, Hunan Provincial People's Hospital (The First Affiliated Hospital of Hunan Normal University), Changsha, China
| | - Mengxuan Zuo
- Department of Minimal Invasive Intervention, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Zhigang Cheng
- Department of Interventional Ultrasound, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Zhiyu Han
- Department of Interventional Ultrasound, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Fangyi Liu
- Department of Interventional Ultrasound, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xiaoling Yu
- Department of Interventional Ultrasound, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Jie Yu
- Department of Interventional Ultrasound, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xiaoqing Jiang
- Biliary Tract Surgery Department I, Eastern Hepatobiliary Surgery Hospital, Secondary Military Medical University, Shanghai, China
| | - Minghui Yang
- Senior Department of Traditional Chinese Medicine, The Sixth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Ping Liang
- Department of Interventional Ultrasound, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| |
Collapse
|
34
|
van Munster KN, Bergquist A, Ponsioen CY. Inflammatory bowel disease and primary sclerosing cholangitis: One disease or two? J Hepatol 2024; 80:155-168. [PMID: 37940453 DOI: 10.1016/j.jhep.2023.09.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 09/01/2023] [Accepted: 09/29/2023] [Indexed: 11/10/2023]
Abstract
Primary sclerosing cholangitis (PSC) was declared one of the biggest unmet needs in hepatology during International Liver Congress 2016 in Berlin. Since then, not much has changed unfortunately, largely due to the still elusive pathophysiology of the disease. One of the most striking features of PSC is its association with inflammatory bowel disease (IBD), with the majority of patients with PSC being diagnosed with extensive colitis. This review describes the epidemiology of IBD in PSC, its specific phenotype, complications and potential pathophysiological mechanisms connecting the two diseases. Whether PSC is merely an extra-intestinal manifestation of IBD or if PSC and IBD are two distinct diseases that happen to share a common susceptibility that leads to a dual phenotype is debated. Implications for the management of the two diseases together are also discussed. Overall, this review summarises the available data in PSC-IBD and discusses whether PSC and IBD are one or two disease(s).
Collapse
Affiliation(s)
- Kim N van Munster
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Annika Bergquist
- Department of Medicine Huddinge, Division of Hepatology, Karolinska Institutet, Department of Upper GI Disease, Karolinska University Hospital, Stockholm, Sweden
| | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, the Netherlands.
| |
Collapse
|
35
|
Grave EC, Loehfelm T, Corwin MT, Zepeda J, Bath HK, Dhaliwal S, Yazdanfar M, Bowlus CL. Interobserver agreement and prognostic value of image-based scoring systems in patients with primary sclerosing cholangitis. Abdom Radiol (NY) 2024; 49:60-68. [PMID: 37831167 DOI: 10.1007/s00261-023-04051-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 09/07/2023] [Accepted: 09/08/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Primary sclerosing cholangitis (PSC) is a cholestatic liver disease that progresses to cirrhosis and liver failure. The Anali and Amsterdam scores are based upon imaging features on MRI and ERCP, respectively. AIMS We aimed to compare the interobserver variability and performances of these scores. METHODS Patients with PSC with at least 1 MRCP were included. Images were independently scored by 2 experts. Agreement and prognostic performance with a primary end point of hepatic decompensation was assessed. RESULTS Fifty-nine patients were included (67.8% male, 86.4% IBD). Interobserver agreement for the Anali and Amsterdam scores were moderate (k = 0.49; 95% CI 0.35-0.64 and k = 0.43; 95% CI 0.30-0.56, respectively). Among the Anali components, dysmorphy (caudate/right lobe ratio > 0.9) had fair agreement (k = 0.37; 95% CI 0.14-0.60) and portal hypertension (k = 0.64, 95% CI 0.32-0.89) and intrahepatic dilation (k = 0.70; 95% CI 0.53-0.87) had substantial agreement. The Amsterdam extrahepatic and intrahepatic scores had fair agreement (k = 0.38; 95% CI 0.23-0.52) and moderate agreement (k = 0.50; 95% CI 0.34-0.67), respectively. Anali score (HR 5.90, 95% CI 1.64-21.21), total bilirubin (HR = 3.23; 95% Cl 1.06-9.91), and age (HR = 1.05; 95% CI 1.00-1.11) were independent predictors of hepatic decompensation. Mayo risk score and Anali score had good discriminative ability with c-statistics of 0.78 (CI 0.59-0.96) and 0.76 (CI 0.56-0.91). Anali score remained an independent predictor after adjusting for Mayo risk score. CONCLUSION Anali score adds additional predictive value for hepatic decompensation in patients with PSC.
Collapse
Affiliation(s)
- Erick Cruz Grave
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento, USA
| | - Thomas Loehfelm
- Department of Radiology, University of California Davis School of Medicine, Sacramento, USA
| | - Michael T Corwin
- Department of Radiology, University of California Davis School of Medicine, Sacramento, USA
| | - Joseph Zepeda
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento, USA
| | - Harjot K Bath
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento, USA
| | - Sandeep Dhaliwal
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento, USA
| | - Maryam Yazdanfar
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento, USA
| | - Christopher L Bowlus
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento, USA.
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, 4150 V Street, Suite 3500, Sacramento, CA, 95817, USA.
| |
Collapse
|
36
|
Shah A, Jones MP, Callaghan G, Fairlie T, Ma X, Culver EL, Stuart K, De Cruz P, O’Beirne J, Tabibian JH, Dignass A, Canbay A, Gores GJ, Holtmann GJ. Efficacy and safety of biologics in primary sclerosing cholangitis with inflammatory bowel disease: A systematic review and meta-analysis. Hepatol Commun 2024; 8:e0347. [PMID: 38206197 PMCID: PMC10786591 DOI: 10.1097/hc9.0000000000000347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 10/16/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Primary sclerosing cholangitis (PSC) is an immune-mediated, chronic cholestatic liver disease. Currently, liver transplantation is the only established life-saving treatment. Several studies have evaluated the effect of different biologic therapies on PSC with inconclusive findings. We conducted a systematic review and meta-analysis to assess the effects of biologics in PSC and associated inflammatory bowel disease (IBD). METHODS MEDLINE, Scopus, and Embase were searched up to July 31, 2023, for studies reporting the effects of biologics in patients with PSC-IBD. Effects of biologic therapy on alkaline phosphatase, total bilirubin, ulcerative colitis response score, and adverse events were calculated and expressed as standardized difference of means (SMD), proportions, and 95% CI using a random-effects model. RESULTS Six studies, including 411 PSC-IBD patients who received biologics, were included. Biologic treatment was associated with no change in alkaline phosphatase (SMD: 0.1, 95% CI: -0.07 -0.17, p=0.43), but a small and statistically significant increase in total bilirubin (SMD: 0.2, 95% CI: 0.05-0.35, p<0.01). 31.2% (95% CI: 23.8-39.7) of patients with IBD achieved endoscopic response, and there was a significant improvement in ulcerative colitis response score (SMD: -0.6,95% CI: -0.88 to 0.36, p<0.01). Furthermore, 17.6% (95% CI: 13.0-23.5) of patients experienced adverse events severe enough to discontinue therapy, and 29.9% (95% CI: 25.2-34.8) had a loss of response to biologics. CONCLUSIONS Treatment of patients with PSC-IBD with biologics (vedolizumab, infliximab, and adalimumab) was not associated with improvement of biochemical markers of cholestasis. Biologics are effective in treating the colitis associated with PSC. Vedolizumab was associated with worsening liver enzymes in contrast to other biologics, a finding that warrants further study.
Collapse
Affiliation(s)
- Ayesha Shah
- The University of Queensland, Faculty of Medicine, Australia
- Department of Gastroenterology & Hepatology, Princess Alexandra Hospital
- Translational Research Institute, Queensland, Australia
- AGIRA (Australian Gastrointestinal Research Alliance) and the NHMRC Centre of Research Excellence in Digestive Health
| | - Michael P. Jones
- AGIRA (Australian Gastrointestinal Research Alliance) and the NHMRC Centre of Research Excellence in Digestive Health
- Department of Psychology, Macquarie University, Sydney, New South Wales, Australia
| | - Gavin Callaghan
- The University of Queensland, Faculty of Medicine, Australia
- Department of Gastroenterology & Hepatology, Princess Alexandra Hospital
| | - Thomas Fairlie
- The University of Queensland, Faculty of Medicine, Australia
- Department of Gastroenterology & Hepatology, Princess Alexandra Hospital
- Translational Research Institute, Queensland, Australia
- AGIRA (Australian Gastrointestinal Research Alliance) and the NHMRC Centre of Research Excellence in Digestive Health
| | - Xiaomin Ma
- The University of Queensland, Faculty of Medicine, Australia
- Department of Gastroenterology & Hepatology, Princess Alexandra Hospital
| | - Emma L. Culver
- Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - Katherine Stuart
- The University of Queensland, Faculty of Medicine, Australia
- Department of Gastroenterology & Hepatology, Princess Alexandra Hospital
| | - Peter De Cruz
- Department of Gastroenterology, Austin Health, Melbourne, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Australia
| | - James O’Beirne
- University of the Sunshine Coast, Sunshine Coast, Queensland, Australia
- Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - James H. Tabibian
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Axel Dignass
- Department of Medicine I, Agaplesion Markus Hospital, Frankfurt, Germany
| | - Ali Canbay
- Department of Medicine, University Hospital of the Ruhr-University Bochum, Germany
| | - Gregory J. Gores
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Gerald J. Holtmann
- The University of Queensland, Faculty of Medicine, Australia
- Department of Gastroenterology & Hepatology, Princess Alexandra Hospital
- Translational Research Institute, Queensland, Australia
- AGIRA (Australian Gastrointestinal Research Alliance) and the NHMRC Centre of Research Excellence in Digestive Health
| |
Collapse
|
37
|
Edeline J, Bridgewater J, Campillo-Gimenez B, Neveu E, Phelip JM, Neuzillet C, Boudjema K, Rolland Y, Valle JW, Garin E, Malka D, Lamarca A. Chemotherapy with or without selective internal radiation therapy for intrahepatic cholangiocarcinoma: Data from clinical trials. Hepatology 2024; 79:96-106. [PMID: 37505216 DOI: 10.1097/hep.0000000000000544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/17/2023] [Indexed: 07/29/2023]
Abstract
BACKGOUND AND AIMS In advanced, liver-only intrahepatic cholangiocarcinoma (iCCA), selective internal radiation therapy (SIRT) has been suggested as promising in nonrandomized studies. We aimed to compare data from patients with advanced, liver-only iCCA treated in the first line in clinical trials with either chemotherapy alone or the combination with SIRT. APPROACH AND RESULTS We collected individual patients' data from the ABC-01, ABC-02, ABC-03, BINGO, AMEBICA, and MISPHEC prospective trials. Data from patients with liver-only iCCA treated in chemotherapy-only arms of the first 5 trials were compared with data from patients treated with SIRT and chemotherapy in MISPHEC. Emulated target trial paradigm and Inverse Probability of Treatment Weighting (IPTW methods) using the propensity score were used to minimize biases. We compared 41 patients treated with the combination with 73 patients treated with chemotherapy alone, the main analysis being in 43 patients treated with cisplatin-gemcitabine or gemcitabine-oxaliplatin. After weighting, overall survival was significantly higher in patients treated with SIRT: median 21.7 months (95% CI: 14.1; not reached) versus 15.9 months(95% CI: 9.8; 18.9), HR = 0.59 (95% CI: 0.34; 0.99), p = 0.049. Progression-free survival was significantly improved: median 14.3 months (95% CI: 7.8; not reached) versus 8.4 months (95% CI: 5.9; 12.1), HR = 0.52 (95% CI: 0.31; 0.89), p < 0.001. Results were confirmed in most sensitivity analyses. CONCLUSIONS This analysis derived from prospective clinical trials suggests that SIRT combined with chemotherapy might improve outcomes over chemotherapy alone in patients with advanced, liver-only iCCA. Randomized controlled evidence is needed to confirm these findings.
Collapse
Affiliation(s)
- Julien Edeline
- Department of Medical Oncology, Centre Eugène Marquis, Rennes, France and INSERM, Univ Rennes, COSS [(Chemistry Oncogenesis Stress Signaling)] - UMR_S 1242, F-35000 Rennes, France
| | | | | | - Estelle Neveu
- Department of Research on Data, Centre Eugène Marquis, Rennes, France
| | - Jean-Marc Phelip
- Department of Gastroenterology, CHU St Etienne, St Etienne, France
| | | | - Karim Boudjema
- Department of Hepatobiliary Surgery, CHU Pontchaillou, Rennes, France
| | - Yan Rolland
- Department of Interventional Radiology, Centre Eugène Marquis, Rennes, France
| | - Juan W Valle
- Department of Medical Oncology, Division of Cancer Sciences, University of Manchester, The Christie NHS Foundation Trust, Manchester, UK
| | - Etienne Garin
- Department of Nuclear Medicine, Centre Eugène Marquis, Rennes, France
| | - David Malka
- Department of Medical Oncology, Institut Mutualiste Montsouris, Paris, and INSERM U1279, Université Paris-Saclay, Gustave Roussy, Villejuif, France
| | - Angela Lamarca
- Department of Medical Oncology, Division of Cancer Sciences, University of Manchester, The Christie NHS Foundation Trust, Manchester, UK
| |
Collapse
|
38
|
Schramm C, Sapuk A, Hoyer D, Radünz S, Schmidt H. Tumour stage and overall survival in patients with intrahepatic cholangiocarcinoma and primary sclerosing cholangitis - a retrospective cohort study. Z Gastroenterol 2024; 62:37-42. [PMID: 38195106 DOI: 10.1055/a-2207-5519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
BACKGROUND Patients with primary sclerosing cholangitis (PSC) carry increased risks for malignancy, among which cholangiocarcinoma (CCA) is the most frequent. We aimed to characterise a cohort of patients with PSC and intrahepatic CCA (iCCA) and to compare this cohort with CCA in different localisations. METHODS We performed a retrospective analysis of our medical database from 01.01.2007 to 30.06.2023 and differentiated CCA according to its localisation within the biliary tract into iCCA, perihilar CCA (pCCA), distal CCA (dCCA), and gallbladder carcinoma (GBC). RESULTS We identified 8 (28%) patients with iCCA, 14 (48%) patients with pCCA, 6 (21%) patients with GBC, and 1 (3%) patient with dCCA without significant differences in gender distribution and mean age. Mean time between diagnosis of PSC and CCA was 158±84 months for iCCA, 93±94 months for pCCA, and 77±69 months for GBC (p=0.230). At the time of CCA diagnosis, advanced-stage disease was present in 6 (75%) patients with iCCA, 13 (93%) patients with pCCA, and 2 (40%) patients with GBC (p=0.050). Only 5 (63%) patients with iCCA received curatively intended surgery, of whom 4 (80%) patients developed recurrence after a mean time of 38±31 months. Mean survival time in patients with iCCA (35±33 months) lay between patients with pCCA (14±8 months) and patients with GBC (57±58 months), but the difference was not statistically significant (p=0.131). CONCLUSION Patients with PSC and iCCA showed an advanced tumour stage at diagnosis and limited long-time survival, which was classified between pCCA with worse prognosis and GBC with better prognosis.
Collapse
Affiliation(s)
- Christoph Schramm
- Department of Gastroenterology, Hepatology and Transplantational Medicine, University Hospital Essen, and Faculty of Medicine, University of Duisburg-Essen, Essen, Germany, Essen, Germany
| | - Ayaz Sapuk
- Department of Gastroenterology, Hepatology and Transplantational Medicine, University Hospital Essen, and Faculty of Medicine, University of Duisburg-Essen, Essen, Germany, Essen, Germany
| | - Dieter Hoyer
- Department of General, Visceral and Transplant Surgery, University Hospital Essen, and Faculty of Medicine, University of Duisburg-Essen, Essen, Germany, Essen, Germany
| | - Sonia Radünz
- Department of General, Visceral and Transplant Surgery, University Hospital Essen, and Faculty of Medicine, University of Duisburg-Essen, Essen, Germany, Essen, Germany
| | - Hartmut Schmidt
- Department of Gastroenterology, Hepatology and Transplantational Medicine, University Hospital Essen, and Faculty of Medicine, University of Duisburg-Essen, Essen, Germany, Essen, Germany
| |
Collapse
|
39
|
Özdirik B, Schnabl B. Microbial Players in Primary Sclerosing Cholangitis: Current Evidence and Concepts. Cell Mol Gastroenterol Hepatol 2023; 17:423-438. [PMID: 38109970 PMCID: PMC10837305 DOI: 10.1016/j.jcmgh.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 12/12/2023] [Accepted: 12/12/2023] [Indexed: 12/20/2023]
Abstract
Primary sclerosing cholangitis (PSC) is a rare cholestatic liver disease with progressive biliary inflammation, destruction of the biliary tract, and fibrosis, resulting in liver cirrhosis and end-stage liver disease. To date, liver transplantation is the only definitive treatment option for PSC. The precise etiology of PSC remains elusive, but it is widely accepted to involve a complex interplay between genetic predisposition, immunologic dysfunction, and environmental influence. In recent years, the gut-liver axis has emerged as a crucial pathway contributing to the pathogenesis of PSC, with particular focus on the role of gut microbiota. However, the role of the fungal microbiome or mycobiome has been overlooked for years, resulting in a lack of comprehensive studies on its involvement in PSC. In this review, we clarify the present clinical and mechanistic data and concepts concerning the gut bacterial and fungal microbiota in the context of PSC. This review sheds light on the role of specific microbes and elucidates the dynamics of bacterial and fungal populations. Moreover, we discuss the latest insights into microbe-altering therapeutic approaches involving the gut-liver axis and bile acid metabolism.
Collapse
Affiliation(s)
- Burcin Özdirik
- Department of Medicine, University of California San Diego, La Jolla, California
| | - Bernd Schnabl
- Department of Medicine, University of California San Diego, La Jolla, California; Department of Medicine, VA San Diego Healthcare System, San Diego, California.
| |
Collapse
|
40
|
Shao T, Hsu R, Rafizadeh DL, Wang L, Bowlus CL, Kumar N, Mishra J, Timilsina S, Ridgway WM, Gershwin ME, Ansari AA, Shuai Z, Leung PSC. The gut ecosystem and immune tolerance. J Autoimmun 2023; 141:103114. [PMID: 37748979 DOI: 10.1016/j.jaut.2023.103114] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 09/12/2023] [Accepted: 09/12/2023] [Indexed: 09/27/2023]
Abstract
The gastrointestinal tract is home to the largest microbial population in the human body. The gut microbiota plays significant roles in the development of the gut immune system and has a substantial impact on the maintenance of immune tolerance beginning in early life. These microbes interact with the immune system in a dynamic and interdependent manner. They generate immune signals by presenting a vast repertoire of antigenic determinants and microbial metabolites that influence the development, maturation and maintenance of immunological function and homeostasis. At the same time, both the innate and adaptive immune systems are involved in modulating a stable microbial ecosystem between the commensal and pathogenic microorganisms. Hence, the gut microbial population and the host immune system work together to maintain immune homeostasis synergistically. In susceptible hosts, disruption of such a harmonious state can greatly affect human health and lead to various auto-inflammatory and autoimmune disorders. In this review, we discuss our current understanding of the interactions between the gut microbiota and immunity with an emphasis on: a) important players of gut innate and adaptive immunity; b) the contribution of gut microbial metabolites; and c) the effect of disruption of innate and adaptive immunity as well as alteration of gut microbiome on the molecular mechanisms driving autoimmunity in various autoimmune diseases.
Collapse
Affiliation(s)
- Tihong Shao
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, China; Division of Rheumatology/Allergy and Clinical Immunology, Department of Internal Medicine, University of California, Davis, CA, 95616, USA
| | - Ronald Hsu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of California, Davis, CA, 95616, USA
| | - Desiree L Rafizadeh
- Division of Rheumatology/Allergy and Clinical Immunology, Department of Internal Medicine, University of California, Davis, CA, 95616, USA
| | - Li Wang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Beijing, China
| | - Christopher L Bowlus
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of California, Davis, CA, 95616, USA
| | - Narendra Kumar
- Department of Pharmaceutical Science, ILR-College of Pharmacy, Texas A&M University, 1010 W. Ave B. MSC 131, Kingsville, TX, 78363, USA
| | - Jayshree Mishra
- Department of Pharmaceutical Science, ILR-College of Pharmacy, Texas A&M University, 1010 W. Ave B. MSC 131, Kingsville, TX, 78363, USA
| | - Suraj Timilsina
- Division of Rheumatology/Allergy and Clinical Immunology, Department of Internal Medicine, University of California, Davis, CA, 95616, USA
| | - William M Ridgway
- Division of Rheumatology/Allergy and Clinical Immunology, Department of Internal Medicine, University of California, Davis, CA, 95616, USA
| | - M Eric Gershwin
- Division of Rheumatology/Allergy and Clinical Immunology, Department of Internal Medicine, University of California, Davis, CA, 95616, USA
| | - Aftab A Ansari
- Division of Rheumatology/Allergy and Clinical Immunology, Department of Internal Medicine, University of California, Davis, CA, 95616, USA
| | - Zongwen Shuai
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, China.
| | - Patrick S C Leung
- Division of Rheumatology/Allergy and Clinical Immunology, Department of Internal Medicine, University of California, Davis, CA, 95616, USA.
| |
Collapse
|
41
|
Helgadottir H, Folseraas T, Kemmerich G, Aabakken L, Jørgensen KK, Vesterhus M. Primær skleroserende kolangitt. Tidsskr Nor Laegeforen 2023; 143:23-0156. [PMID: 37987062 DOI: 10.4045/tidsskr.23.0156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2023] Open
Abstract
Primary sclerosing cholangitis is a severe liver disease and a leading cause of liver transplantation in Scandinavia. This clinical review article examines recently revised recommendations on diagnosis, follow-up and treatment of patients with this disease. Treatment of symptoms, assessment of fibrosis and monitoring for the development of cancer in the liver and bowel are central.
Collapse
Affiliation(s)
- Holmfridur Helgadottir
- Norsk senter for PSC, Avdeling for transplantasjonsmedisin, Klinikk for kirurgi, inflammasjonsmedisin og transplantasjon, Oslo universitetssykehus, Rikshospitalet, og, Medisinsk avdeling, Haraldsplass Diakonale Sykehus
| | - Trine Folseraas
- Norsk senter for PSC, Avdeling for transplantasjonsmedisin, Klinikk for kirurgi, inflammasjonsmedisin og transplantasjon, Oslo universitetssykehus, Rikshospitalet
| | - Gunter Kemmerich
- Avdeling for radiologi, Klinikk for radiologi og nukleærmedisin, Oslo universitetssykehus, Rikshospitalet
| | - Lars Aabakken
- Norsk senter for PSC, Avdeling for transplantasjonsmedisin, Klinikk for kirurgi, inflammasjonsmedisin og transplantasjon, Oslo universitetssykehus, Rikshospitalet, og, Institutt for klinisk medisin, Det medisinske fakultet, Universitetet i Oslo
| | - Kristin Kaasen Jørgensen
- Norsk senter for PSC, Avdeling for transplantasjonsmedisin, Klinikk for kirurgi, inflammasjonsmedisin og transplantasjon, Oslo universitetssykehus, Rikshospitalet, og, Gastromedisinsk avdeling, Akershus universitetssykehus, Lørenskog
| | - Mette Vesterhus
- Norsk senter for PSC, Avdeling for transplantasjonsmedisin, Klinikk for kirurgi, inflammasjonsmedisin og transplantasjon, Oslo universitetssykehus, Rikshospitalet, og, Medisinsk avdeling, Haraldsplass Diakonale Sykehus, og, Klinisk institutt 2, Universitetet i Bergen
| |
Collapse
|
42
|
Ge J, Sun S, Owens J, Galvez V, Gologorskaya O, Lai JC, Pletcher MJ, Lai K. Development of a Liver Disease-Specific Large Language Model Chat Interface using Retrieval Augmented Generation. medRxiv 2023:2023.11.10.23298364. [PMID: 37986764 PMCID: PMC10659484 DOI: 10.1101/2023.11.10.23298364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
Background Large language models (LLMs) have significant capabilities in clinical information processing tasks. Commercially available LLMs, however, are not optimized for clinical uses and are prone to generating incorrect or hallucinatory information. Retrieval-augmented generation (RAG) is an enterprise architecture that allows embedding of customized data into LLMs. This approach "specializes" the LLMs and is thought to reduce hallucinations. Methods We developed "LiVersa," a liver disease-specific LLM, by using our institution's protected health information (PHI)-complaint text embedding and LLM platform, "Versa." We conducted RAG on 30 publicly available American Association for the Study of Liver Diseases (AASLD) guidelines and guidance documents to be incorporated into LiVersa. We evaluated LiVersa's performance by comparing its responses versus those of trainees from a previously published knowledge assessment study regarding hepatitis B (HBV) treatment and hepatocellular carcinoma (HCC) surveillance. Results LiVersa answered all 10 questions correctly when forced to provide a "yes" or "no" answer. Full detailed responses with justifications and rationales, however, were not completely correct for three of the questions. Discussions In this study, we demonstrated the ability to build disease-specific and PHI-compliant LLMs using RAG. While our LLM, LiVersa, demonstrated more specificity in answering questions related to clinical hepatology - there were some knowledge deficiencies due to limitations set by the number and types of documents used for RAG. The LiVersa prototype, however, is a proof of concept for utilizing RAG to customize LLMs for clinical uses and a potential strategy to realize personalized medicine in the future.
Collapse
Affiliation(s)
- Jin Ge
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California – San Francisco, San Francisco, CA
| | - Steve Sun
- UCSF Health Information Technology, University of California – San Francisco, San Francisco, CA
| | - Joseph Owens
- UCSF Health Information Technology, University of California – San Francisco, San Francisco, CA
| | - Victor Galvez
- UCSF Health Information Technology, University of California – San Francisco, San Francisco, CA
| | - Oksana Gologorskaya
- UCSF Health Information Technology, University of California – San Francisco, San Francisco, CA
- Bakar Computational Health Sciences Institute, University of California – San Francisco, San Francisco, CA
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California – San Francisco, San Francisco, CA
| | - Mark J. Pletcher
- Department of Epidemiology and Biostatistics, University of California – San Francisco, San Francisco, CA
| | - Ki Lai
- UCSF Health Information Technology, University of California – San Francisco, San Francisco, CA
| |
Collapse
|
43
|
Lattanzi B, Covotta F, Cardinale V. The potential role of endoscopic ultrasound in primary sclerosing cholangitis. J Hepatol 2023; 79:e199-e200. [PMID: 37302577 DOI: 10.1016/j.jhep.2023.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 05/15/2023] [Accepted: 05/23/2023] [Indexed: 06/13/2023]
Affiliation(s)
- Barbara Lattanzi
- Gastroenterology and Emergency Endoscopy Unit, Department of Emergency, Sandro Pertini Hospital of Rome, Roma, Italy
| | - Francesco Covotta
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Vincenzo Cardinale
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy.
| |
Collapse
|
44
|
Tan N, Lubel J, Kemp W, Roberts S, Majeed A. Current Therapeutics in Primary Sclerosing Cholangitis. J Clin Transl Hepatol 2023; 11:1267-1281. [PMID: 37577219 PMCID: PMC10412694 DOI: 10.14218/jcth.2022.00068s] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 01/01/2023] [Accepted: 01/20/2023] [Indexed: 07/03/2023] Open
Abstract
Primary sclerosing cholangitis (PSC) is an orphan, cholestatic liver disease that is characterized by inflammatory biliary strictures with variable progression to end-stage liver disease. Its pathophysiology is poorly understood. Chronic biliary inflammation is likely driven by immune dysregulation, gut dysbiosis, and environmental exposures resulting in gut-liver crosstalk and bile acid metabolism disturbances. There is no proven medical therapy that alters disease progression in PSC, with the commonly prescribed ursodeoxycholic acid being shown to improve liver biochemistry at low-moderate doses (15-23 mg/kg/day) but not alter transplant-free survival or liver-related outcomes. Liver transplantation is the only option for patients who develop end-stage liver disease or refractory complications of PSC. Immunosuppressive and antifibrotic agents have not proven to be effective, but there is promise for manipulation of the gut microbiome with fecal microbiota transplantation and antibiotics. Bile acid manipulation via alternate synthetic bile acids such as norursodeoxycholic acid, or interaction at a transcriptional level via nuclear receptor agonists and fibrates have shown potential in phase II trials in PSC with several leading to larger phase III trials. In view of the enhanced malignancy risk, statins, and aspirin show potential for reducing the risk of colorectal cancer and cholangiocarcinoma in PSC patients. For patients who develop clinically relevant strictures with cholestatic symptoms and worsening liver function, balloon dilatation is safer compared with biliary stent insertion with equivalent clinical efficacy.
Collapse
Affiliation(s)
- Natassia Tan
- Department of Gastroenterology and Hepatology, Alfred Health; Central Clinical School, Monash University, Melbourne, Australia
| | - John Lubel
- Department of Gastroenterology and Hepatology, Alfred Health; Central Clinical School, Monash University, Melbourne, Australia
| | - William Kemp
- Department of Gastroenterology and Hepatology, Alfred Health; Central Clinical School, Monash University, Melbourne, Australia
| | - Stuart Roberts
- Department of Gastroenterology and Hepatology, Alfred Health; Central Clinical School, Monash University, Melbourne, Australia
| | - Ammar Majeed
- Department of Gastroenterology and Hepatology, Alfred Health; Central Clinical School, Monash University, Melbourne, Australia
| |
Collapse
|
45
|
Garcia Moreno AS, Guicciardi ME, Wixom AQ, Jessen E, Yang J, Ilyas SI, Bianchi JK, Pinto E Vairo F, Lazaridis KN, Gores GJ. IL-17 Signaling in Primary Sclerosing Cholangitis Patient-Derived Organoids. Res Sq 2023:rs.3.rs-3406046. [PMID: 37886596 PMCID: PMC10602181 DOI: 10.21203/rs.3.rs-3406046/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
The pathogenesis of primary sclerosing cholangitis (PSC) is unclear, although studies implicate IL-17A as an inflammatory mediator in this disease. However, a direct assessment of IL-17 signaling in PSC cholangiocytes is lacking. In this study we aimed to investigate the response of PSC extrahepatic cholangiocyte organoids (ECO) to IL-17A stimulation. Cholangiocytes obtained from PSC and non-PSC patients by endoscopic retrograde cholangiography (ERC) were cultured as ECO. The ECO were treated with vehicle or IL-17A and assessed by transcriptomics, secretome analysis, and genome sequencing (GS). Unsupervised clustering of all integrated scRNA-seq data identified 8 cholangiocyte clusters which did not differ between PSC and non-PSC ECO. However, PSC ECO cells demonstrated a robust response to IL-17 treatment, noted by an increased number of differentially expressed genes (DEG) by transcriptomics, and more abundant chemokine and cytokine expression and secretion. After rigorous filtering, GS identified candidate somatic variants shared among PSC ECO from unrelated individuals. However, no candidate rare variants in genes regulating the IL-17 pathway were identified, but rare variants regulating the MAPK signaling pathway were present in all PSC ECO. In conclusion, PSC and non-PSC patient derived ECO respond differently to IL-17 stimulation implicating this pathway in the pathogenesis of PSC.
Collapse
|
46
|
Catanzaro E, Gringeri E, Burra P, Gambato M. Primary Sclerosing Cholangitis-Associated Cholangiocarcinoma: From Pathogenesis to Diagnostic and Surveillance Strategies. Cancers (Basel) 2023; 15:4947. [PMID: 37894314 PMCID: PMC10604939 DOI: 10.3390/cancers15204947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 10/09/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023] Open
Abstract
Cholangiocarcinoma (CCA) is the most common malignancy in patients with primary sclerosing cholangitis (PSC), accounting for 2-8% of cases and being the leading cause of death in these patients. The majority of PSC-associated CCAs (PSC-CCA) develop within the first few years after PSC diagnosis. Older age and male sex, as well as concomitant inflammatory bowel disease (IBD) or high-grade biliary stenosis, are some of the most relevant risk factors. A complex combination of molecular mechanisms involving inflammatory pathways, direct cytopathic damage, and epigenetic and genetic alterations are involved in cholangiocytes carcinogenesis. The insidious clinical presentation makes early detection difficult, and the integration of biochemical, radiological, and histological features does not always lead to a definitive diagnosis of PSC-CCA. Surveillance is mandatory, but current guideline strategies failed to improve early detection and consequently a higher patient survival rate. MicroRNAs (miRNAs), gene methylation, proteomic and metabolomic profile, and extracellular vesicle components are some of the novel biomarkers recently applied in PSC-CCA detection with promising results. The integration of these new molecular approaches in PSC diagnosis and monitoring could contribute to new diagnostic and surveillance strategies.
Collapse
Affiliation(s)
- Elisa Catanzaro
- Gastroenterology, Department of Surgery, Oncology, and Gastroenterology, Padova University Hospital, 35128 Padova, Italy
- Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padova University Hospital, 35128 Padova, Italy
| | - Enrico Gringeri
- Hepatobiliary Surgery and Liver Transplantation Center, Department of Surgery, Oncology, and Gastroenterology, Padova University Hospital, 35128 Padova, Italy
| | - Patrizia Burra
- Gastroenterology, Department of Surgery, Oncology, and Gastroenterology, Padova University Hospital, 35128 Padova, Italy
- Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padova University Hospital, 35128 Padova, Italy
| | - Martina Gambato
- Gastroenterology, Department of Surgery, Oncology, and Gastroenterology, Padova University Hospital, 35128 Padova, Italy
- Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padova University Hospital, 35128 Padova, Italy
| |
Collapse
|
47
|
Kim YS, Hurley EH, Park Y, Ko S. Treatment of primary sclerosing cholangitis combined with inflammatory bowel disease. Intest Res 2023; 21:420-432. [PMID: 37519211 PMCID: PMC10626010 DOI: 10.5217/ir.2023.00039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 04/28/2023] [Accepted: 04/29/2023] [Indexed: 08/01/2023] Open
Abstract
Primary sclerosing cholangitis (PSC) is a progressive cholestatic, inflammatory, and fibrotic disease that is strongly associated with inflammatory bowel disease (IBD). PSC-IBD represents a unique disease entity and patients with this disease have an increased risk of malignancy development, such as colorectal cancer and cholangiocarcinoma. The pathogenesis of PSC-IBD involves genetic and environmental factors such as gut dysbiosis and bile acids alteration. However, despite the advancement of disease characteristics, no effective medical therapy has proven to have a significant impact on the prognosis of PSC. The treatment options for patients with PSC-IBD do not differ from those for patients with PSC alone. Potential candidate drugs have been developed based on the pathogenesis of PSC-IBD, such as those that target modulation of bile acids, inflammation, fibrosis, and gut dysbiosis. In this review, we summarize the current medical treatments for PSC-IBD and the status of new emerging therapeutic agents.
Collapse
Affiliation(s)
- You Sun Kim
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Edward H. Hurley
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Pittsburgh Liver Research Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Yoojeong Park
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Pittsburgh Liver Research Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Sungjin Ko
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Pittsburgh Liver Research Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| |
Collapse
|
48
|
Lee DU, Adonizio EA, Hastie DJ, Ponder R, Lee KJ, Jung D, Fan GH, Malik R. The Trends in Health Care Utilization and Costs Associated With Primary Liver Cancer: An Analysis of United States Hospitals Between 2016 and 2019. J Clin Gastroenterol 2023:00004836-990000000-00219. [PMID: 37983843 DOI: 10.1097/mcg.0000000000001927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 08/20/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Primary liver cancer (PLC) has placed an increasing economic and resource burden on the health care system of the United States. We attempted to quantify its epidemiology and associated costs using a national inpatient database. METHODS Hospital discharge and insurance claims data from the National Inpatient Sample were used to conduct this analysis. Patients diagnosed with PLC (hepatocellular carcinoma or cholangiocarcinoma) were included in the study population, which was then stratified using patient demographics, comorbidities, degree of cancer spread, liver disease complications, and other descriptors. Trends were analyzed via regression curves for each of these strata from the years 2016 to 2019, with special attention to patterns in hospitalization incidence, inpatient mortality rate, total costs, and average per-capita costs. The resulting curves were evaluated using goodness-of-fit statistics and P-values. RESULTS Aggregate hospitalization incidence, inpatient mortality rates, and total costs were found to significantly increase throughout the study period (P=0.002, 0.002, and 0.02, respectively). Relative to their demographic counterparts, males, White Americans, and those older than 65 years of age contributed the largest proportions of total costs. These population segments also experienced significant increases in total expenditure (P=0.04, 0.03, and 0.02, respectively). Admissions deemed to have multiple comorbidities were associated with progressively higher total costs throughout the study period (P=0.01). Of the categorized underlying liver diseases, only admissions diagnosed with alcoholic liver disease or nonalcoholic fatty liver disease saw significantly increasing total costs (P=0.006 and 0.01), although hepatitis C was found to be the largest contributor to total expenses. CONCLUSIONS From 2016 to 2019, total costs, admission incidence, and inpatient mortality rates associated with PLC hospitalization increased. Strata-specific findings may be reflective of demographic shifts in the PLC patient populations, as well as changes in underlying chronic liver disease etiologies.
Collapse
Affiliation(s)
- David U Lee
- Division of Gastroenterology and Hepatology, University of Maryland, Baltimore, MD
| | - Elyse A Adonizio
- Department of Medicine, Tufts University School of Medicine, Boston, MA
| | - David J Hastie
- Department of Medicine, Tufts University School of Medicine, Boston, MA
| | - Reid Ponder
- Department of Medicine, Tufts University School of Medicine, Boston, MA
| | - Ki Jung Lee
- Department of Medicine, Tufts University School of Medicine, Boston, MA
| | - Daniel Jung
- Department of Medicine, University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Gregory H Fan
- Department of Medicine, Tufts University School of Medicine, Boston, MA
| | - Raza Malik
- Division of Gastroenterology, Liver Center, Albany Medical Center, Albany, NY
| |
Collapse
|
49
|
Elfert K, Abosheaishaa H, Aboursheid T, Beran A, Ahmed M, Musallam R, Al-Taee A. Primary sclerosing cholangitis hospitalizations in the United States: characteristics and predictors of clinical outcomes. Proc AMIA Symp 2023; 36:700-704. [PMID: 37829220 PMCID: PMC10566382 DOI: 10.1080/08998280.2023.2254196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 08/29/2023] [Indexed: 10/14/2023] Open
Abstract
Background Primary sclerosing cholangitis (PSC) is a chronic progressive disease that primarily affects the medium and large biliary ducts. Methods This study investigated the baseline characteristics and predictors of clinical outcomes among hospitalized patients with PSC in the US. Using the National Inpatient Sample database from 2018 to 2020, we included adults with a principal diagnosis of PSC. Results Our study included 2585 adult hospitalizations. The prevalence of cirrhosis, ulcerative colitis (UC), Crohn's disease (CD), and cholangiocarcinoma among hospitalized PSC patients was 44.5%, 32.3%, 13.15%, and 5.2%, respectively. Over a third of patients (38.1%) underwent endoscopic retrograde cholangiopancreatography (ERCP). UC, CD, cholangiocarcinoma, and autoimmune hepatitis had no impact on mortality, length of stay, or ERCP utilization. Interestingly, individuals of Asian/Pacific Islander ethnicity had higher odds of undergoing ERCP compared to White ethnicity (odds ratio 4.67, 95% confidence interval 1.25-17.4). Conversely, patients with cirrhosis and liver transplant recipients were less likely to undergo ERCP. Conclusion This is the first nationwide study to assess the clinical characteristics and outcomes of hospitalized patients with PSC. It highlights various factors associated with increased utilization of ERCP, longer length of stay, and increased inpatient mortality. Further research is warranted to explore these associations.
Collapse
Affiliation(s)
- Khaled Elfert
- Department of Internal Medicine, SBH Health System, New York, New York, USA
| | - Hazem Abosheaishaa
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, Queens, New York, USA
| | - Tarek Aboursheid
- Department of Internal Medicine, Ascension Saint Francis Hospital, Evanston, Illinois, USA
| | - Azizullah Beran
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Mohamed Ahmed
- Department of Internal Medicine, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Rami Musallam
- Department of Internal Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Ahmad Al-Taee
- Department of Gastroenterology, Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Urbana, Illinois, USA
| |
Collapse
|
50
|
Wentworth BJ, Khot R, Caldwell SH. The Many Faces of Primary Sclerosing Cholangitis: Controversy Abounds. Dig Dis Sci 2023; 68:3514-3526. [PMID: 37358638 DOI: 10.1007/s10620-023-08003-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 03/10/2023] [Indexed: 06/27/2023]
Abstract
Primary sclerosing cholangitis (PSC) is notoriously challenging to manage given its heterogeneity with regard to diagnosis, management, and progression. The lack of disease-modifying therapy and variable rate of onset of cirrhosis, portal hypertension-related decompensating events, jaundice, pruritus, biliary complications, and need for liver transplantation is deeply unsettling to clinicians and patients alike. Recent updated practice guidance by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver endeavored to highlight some of these challenges. However, these references only briefly address clinical dilemmas that providers face on a daily basis. This review aims to further discuss these controversial topics, including providing insight into the utility of ursodeoxycolic acid, the significance of alkaline phosphatase normalization, when to consider PSC variants and mimickers, and the implications of continuous hepatobiliary malignancy screening. In particular, there has been a growing body of literature raising concern about repeat exposure to gadolinium-containing contrast. Patients with PSC are potentially at risk for large lifetime exposure to gadolinium related to frequent magnetic resonance imaging scans and whether this carries any negative long-term adverse effects remains unknown.
Collapse
Affiliation(s)
- Brian J Wentworth
- Division of Gastroenterology and Hepatology, School of Medicine, University of Virginia, PO Box 800708, Charlottesville, VA, 22908, USA.
| | - Rachita Khot
- Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, VA, USA
| | - Stephen H Caldwell
- Division of Gastroenterology and Hepatology, School of Medicine, University of Virginia, PO Box 800708, Charlottesville, VA, 22908, USA
| |
Collapse
|