Enteral nutrition with or without N-acetylcysteine in the treatment of severe acute alcoholic hepatitis: a randomized multicenter controlled trial.

BACKGROUND & AIMS: Severe acute alcoholic hepatitis is associated with a high mortality rate. Oxidative stress is involved in the pathogenesis of acute alcoholic hepatitis. Previous findings had also suggested that enteral nutritional support might increase survival in patients with severe acute alcoholic hepatitis. Therefore, the aim of the present study was to evaluate the efficacy of N-acetylcysteine in combination with adequate nutritional support in patients with severe acute alcoholic hepatitis. METHODS: Patients with biopsy-proven acute alcoholic hepatitis and mDF ≥32 were randomized to receive N-acetylcysteine intravenously or a placebo perfusion along with adequate nutritional support for 14 days. The primary endpoint was 6-month survival; secondary endpoints were biological parameter evolution and infection rate. RESULTS: Fifty-two patients were randomized in the study (28 into the N-acetylcysteine arm, 24 into the control arm), and among them, five were excluded from the analysis for protocol violation. The two groups did not differ in baseline characteristics. Survival rates at 1 and 6 months in N-acetylcysteine and control groups were 70.2 vs. 83.8% (p=0.26) and 62.4 vs. 67.1% (p=0.60), respectively. Early biological changes, documented infection rate at 1 month, and incidence of hepatorenal syndrome did not differ between the two groups. CONCLUSIONS: In this study, high doses of intravenous N-acetylcysteine therapy for 14 days conferred neither survival benefits nor early biological improvement in severe acute alcoholic hepatitis patients with adequate nutritional support. However, these results must be viewed with caution, since the study suffered from a lack of power.

Gastrointestinal polypoid lesions: a poorly known endoscopic feature of portal hypertension.

AIM: To describe a poorly known endoscopic entity associated with portal hypertension, characterized by polypoid lesions either in the stomach or small intestine of patients with cirrhosis. METHODS: Between 2003 and 2012, patients with cirrhosis and portal hypertension underwent endoscopic workup of portal hypertension in our endoscopy unit. The clinical expression, endoscopic features of these lesions, and their pathological characteristics are described. RESULTS: A total of 1538 patients were included, among which 14 (0.9%) presented polypoid lesions; these patients had evidence of portal hypertension and had dilated capillaries in the lamina propria. Four patients presented with severe anaemia or melaena and required treatment. Propranolol was administered to three patients, and one patient needed a transjugular intrahepatic portosystemic shunt in order to control bleeding. For asymptomatic patients in whom polypoid lesions were resected, no recurrence of lesions was observed during follow-up gastroscopy (median 36 months, range 7-85 months). CONCLUSION: Portal hypertension-associated gastric or small intestine polypoid lesions may be associated with a significant risk of bleeding and are responsive to adequate treatment of portal hypertension.

Relationship between the degree of portal hypertension and the onset of spontaneous bacterial peritonitis in patients with cirrhosis.

BACKGROUND/AIM: Spontaneous bacterial peritonitis (SBP) is a severe complication of cirrhosis but its exact pathogenesis has not yet been elucidated and the role of portal hypertension in the development of SBP has been suggested. The aim of this study was to test the hypothesis that an association exists between the degree of portal hypertension and the occurrence of SBP. METHODS: 292 patients with cirrhosis who underwent a measurement of the hepatic venous pressure gradient (HVPG) were retrospectively studied. Following their ascites profile, patients were classified in three groups: patients with ascites who suffered from SBP, patients with sterile ascites, and patients who had no ascites. RESULTS: Among the 137 patients with ascites, 24 patients suffered from SBP (17.5%). The mean HVPG was significantly different: 20.7 +/- 6.2 mm Hg in the SBP group, 17.5 +/- 5.1 mm Hg in the sterile ascites group and 14.7 +/- 5.6 mm Hg in the group without ascites (p < 0.05). Patients with the most severe portal hypertension (HVPG > or =30 mm Hg) had the highest risk to suffer from SBP (50%). Using the multivariate analysis, only the serum albumin level (p = 0.004) and the HVPG (p = 0.02) were independently correlated with the occurrence of ascites infection. CONCLUSIONS: This study suggests that in patients with SBP the degree of portal hypertension is greater than in the non infected patients. Ascites infection is independently associated with a low serum albumin level and a high HVPG.

Zenker's diverticulum: a new endoscopic treatment with a soft diverticuloscope.

BACKGROUND: Recently developed treatments for Zenker's diverticulum include the use of a flexible endoscope, which is minimally invasive. A new endoscopic approach is described that uses a soft diverticuloscope to provide perfect exposure of the operative site and stabilizes the endoscope. METHODS: A total of 30 patients (15 men, 15 women; median age, 78 years) were treated with this diverticuloscope. All patients had significant symptoms including dysphagia (n = 24, 80%) and/or regurgitation (n = 17, 56%). Eighteen (60%) had a large diverticulum (>4 cm). RESULTS: All patients were successfully treated in a single session. In one patient, dysphagia persisted but was milder than before the treatment. A complication occurred in 4 patients (13%); in one (3%), it was severe. During follow-up (median, 12.5 months), dysphagia recurred in one patient 1 year after the initial procedure but was successfully re-treated with a CO(2) laser and rigid diverticuloscope. Four patients (13%) died during follow-up of causes unrelated to the treatment. CONCLUSIONS: Diverticulotomy with a flexible endoscope and soft diverticuloscope is an effective treatment for Zenker's diverticulum.

Self-expanding plastic stents for benign esophageal lesions.

BACKGROUND: A benign condition is a relative contraindication to the use of self-expanding metallic stents, because these devices usually are not retrievable. The self-expanding plastic stent is removable and induces less tissue hyperplasia. This study prospectively evaluated the use of a self-expanding plastic stent to treat benign esophageal conditions. METHODS: Over 4 years, 21 patients underwent self-expanding plastic stent placement for various benign esophageal disorders, including refractory peptic (n = 2), caustic (n = 3), post-radiotherapy (n = 3), and anastomotic (n = 4) stenoses; hyperplastic (n = 5) stenosis within a previously implanted metallic stent; and anastomotic leak (n = 4) after esophagectomy. The self-expanding plastic stent was removed from all patients. Patients were followed for at least 8 months after stent removal. RESULTS: Implantation was successful in all cases. Temporary self-expanding plastic stent placement was curative in 17/21 patients, especially those with caustic and hyperplastic strictures and anastomotic fistula, all of which were treated successfully without re-intervention. Median follow-up was 21 months (range 8-39 months) after stent removal. Moreover, by inducing tissue ischemia, self-expanding plastic stent allowed delayed removal of metallic stents. Only one severe complication (tracheal compression) was encountered, and this resolved after stent removal. CONCLUSIONS: A range of benign stenosing disorders of the esophagus can be treated safely with a self-expanding plastic stent. Because the long-term results were highly favorable, self-expanding plastic stent placement could be used as the initial treatment for various conditions. Self-expanding plastic stent insertion within an esophageal self-expanding metallic stent allowed removal of the latter, theoretically unretrievable, stent.