A Low Geriatric Nutritional Risk Index Is Associated with Low Muscle Volume and a Poor Prognosis among Cirrhotic Patients.

Background and Objectives: The geriatric nutritional risk index (GNRI) is an easily calculable index that can be determined using three common clinical variables. The GNRI is suggested to be related to sarcopenia in cirrhotic patients. However, the relationship between the GNRI and the prognosis in patients with liver cirrhosis (LC) has not been reported. The aim of the present research is to study the association of the GNRI with the nutritional status, hepatic function reserve, and prognosis in patients with liver cirrhosis (LC). Materials and Methods: A total of 370 cirrhotic patients whose nutritional statuses were evaluated using anthropometric measurements and bioimpedance analysis were studied. The associations between the GNRI and nutritional status and the GNRI and hepatic function reserve were analyzed. We also investigated the GNRI and prognosis of patients with LC. Results: The median age of the enrolled patients was 66 years old, and 266 (71.9%) patients had viral hepatitis-related LC. The GNRI was shown to decrease with the progression of chronic liver disease, represented by an increased FIB-4 index and severe Child-Pugh and mALBI grades. In addition, a low GNRI (<92) was associated with severe cirrhosis-related metabolic disorders, including a low branched-chain amino acid-to-tyrosine ratio (BTR) and a low zinc value. The GNRI was positively correlated with two nutrition-related anthropometric variables (% arm circumference and % arm muscle circumference), and a low GNRI was related to a low skeletal muscle mass index (SMI) (<7.0 kg/m2 for men or <5.7 kg/m2 for women), as determined by using bioimpedance analysis. In addition, patients with a low GNRI (<92) had a poorer prognosis than those with a high GNRI (≥92) (log-rank test: p = 0.0161, and generalized Wilcoxon test, p = 0.01261). Conclusions: Our results suggest that a low GNRI is related to severe chronic liver disease, low muscle volume, and a poor prognosis of patients with cirrhosis.

Diagnosis of hepatic steatosis based on ultrasound attenuation imaging is not influenced by liver fibrosis.

AIM: Recently, a new technique using attenuation imaging (ATI) was developed to diagnose hepatic steatosis. The aim of this study was to investigate whether ATI for the evaluation of hepatic steatosis is influenced by liver fibrosis. METHODS: A total of 328 patients with chronic liver disease were enrolled to study the associations between histological hepatic steatosis or liver fibrosis and ATI findings. The interaction between liver fibrosis and ATI was also analyzed. RESULTS: Median ATI values according to steatosis grade and fibrosis stage increased in line with the progression of liver steatosis (p < 0.001) and fibrosis (p < 0.05). However, in each steatosis grade, ATI values according to fibrosis stage were not significantly increased. In multiple regression analyses for assessment of the effect of their interaction, the p values for fibrosis stage, steatosis grade, and fibrosis stage × steatosis grade were 0.096, <0.001, and 0.077, respectively. Variance inflation factor values for fibrosis stage, steatosis grade, and fibrosis stage × steatosis grade were 1.079, 1.094, and 1.074, respectively. CONCLUSION: Attenuation imaging values are not influenced by liver fibrosis.

Feasibility of Double-Deployment Small-Diameter Covered Metallic Stent for Malignant Distal Biliary Obstruction (with Video).

BACKGROUND/OBJECTIVES: Covered self-expandable metallic stents (CSEMS) are commonly used to treat malignant distal biliary obstructions. A 10-mm CSEMS carries the risk of obstructing the pancreatic and cystic duct orifices by adhering to the bile duct; therefore, postoperative pancreatitis and cholecystitis are reported to occur at a certain frequency. We have adopted a new drainage technique for malignant distal biliary obstruction called ''double-slim SEMS stenting" (DSS), where two small-diameter CSEMS are placed side-by-side. We aimed to compare the efficacy and safety of biliary drainage using DSS with those of conventional CSEMS. METHODS: In total, 50 patients who underwent endoscopic biliary drainage for malignant distal biliary obstructions between April 2019 and March 2022 at Hyogo Medical University Hospital were enrolled. Patients were divided into DSS and Conventional groups, and the technical success rate, clinical success rate, adverse events, success rate for reintervention, recurrent biliary obstruction (RBO) rate, and time to RBO (TRBO) were evaluated. RESULTS: There were no significant differences in patient characteristics between the DSS (n = 20) and Conventional groups (n = 30). The technical and clinical success rates were 100% in the DSS group. The incidence of adverse events was not significantly different between the two groups (DSS/Conventional: 10.0% [2/20]/20.0% [6/30]) (p = 0.34). No acute cholecystitis was observed in the DSS group. The incidence rates of RBO were 30% (6/20) and 43% (13/30) in the DSS and Conventional groups, respectively (p = 0.92). The median TRBO in the DSS group was 378 days, while the TRBO in the Conventional group was 195 days (p = 0.03), resulting in significantly longer TRBO in the DSS group. CONCLUSIONS: DSS emerges as a viable and safe approach for biliary drainage in malignant distal biliary obstruction, demonstrating a lower incidence of adverse events and longer TRBO compared to conventional CSEMS.

Association of PNPLA3 SNP With the Development of HBV-related Hepatocellular Carcinoma.

BACKGROUND/AIM: Concomitant nonalcoholic fatty liver disease (NAFLD)/hepatic steatosis (HS) is suggested to increase the risk of hepatocellular carcinoma (HCC) in hepatitis virus B (HBV)-infected patients. Patatin-like phospholipase domain-containing 3 (PNPLA3) rs738409 gene single-nucleotide polymorphism (SNP) is well-known to be associated with the development of NAFLD/HS; however, it is still unclear whether this SNP is related to the development of HCC in HBV-infected patients. PATIENTS AND METHODS: We investigated a total of 202 HBV-infected patients who received percutaneous liver biopsy, and simultaneously assessed biopsy-proven HS, insulin resistance, and the PNPLA3 SNP status. We further investigated the relationships of these factors with the development of HCC in HBV-infected patients. RESULTS: Most of the enrolled cases (196/202: 97.0%) were non-cirrhotic patients. One hundred seventy-three patients (85.6%) received antiviral therapy. A Kaplan-Meier analysis showed that the incidence of HCC development in patients with HS was higher than that in patients without HS (p<0.01). An increased homeostasis model assessment as an index of insulin resistance (HOMA-IR) value (≥1.6) was associated not only with the presence of HS (p<0.0001) but also with the development of HCC (p<0.01). The PNPLA3 rs738409 SNP was also associated with the presence of HS (p<0.01) and the development of HCC (p<0.05) in HBV-infected patients. CONCLUSION: In addition to HS and IR, PNPLA3 rs738409 SNP was suggested to be associated with the development of HCC in Japanese patients with HBV infection.

Metastasis of Hepatocellular Carcinoma in the Pouch of Douglas Successfully Treated by Radiation Therapy: A Case Report.

Metastasis of hepatocellular carcinoma (HCC) in the pouch of Douglas is relatively rare. A 65-year-old man with liver cirrhosis was admitted for detailed examination of a pelvic tumor. He had a previous history of ruptured HCC, and received emergent hemostasis with transcatheter arterial embolization followed by curative ablation. His blood tests showed an increase in des-gamma-carboxy prothrombin (DCP). Contrast-enhanced computed tomography (CE-CT) revealed a heterogeneously enhanced large pelvic tumor, but no additional tumorous lesions were detected in other organs, including the lungs, liver and abdominal lymph nodes. The colonoscopy showed compression by an extra-luminal/submucosal tumor, and computed tomography-guided percutaneous needle biopsy revealed that the pelvic tumor was metastasis of HCC. Because of the poor liver function, the solitary pelvic tumor was treated with three-dimensional conformal radiation therapy (3D-CRT). The tumor size and the DCP value were markedly decreased after radiation therapy. Nine months later, occasional mild bloody stool due to radiation proctitis was observed; however, no serious side effects occurred. Our case suggests that radiation therapy may be a therapeutic option for a solitary metastatic lesion of HCC in the pouch of Douglas.

Clinical Characteristics of ICI-Related Pancreatitis and Cholangitis Including Radiographic and Endoscopic Findings.

The indications for immune checkpoint inhibitors (ICIs) have expanded to include carcinomas of various organs. However, as ICI therapy expands, the management of immune-related adverse events (irAEs) has become a problem. ICI-related pancreatitis and cholangitis are relatively rare irAEs. Although some patients with ICI-related pancreatitis and cholangitis are asymptomatic and do not require treatment, there have been reports of patients who did not respond to immunosuppressive therapy and died. Thus, the pathogenesis of ICI-related pancreatitis and cholangitis should be clarified immediately. Currently, the role of endoscopy in the diagnosis and treatment of inflammatory pancreatic and biliary duct diseases is becoming increasingly important. In this review, we summarize clinical characteristics as well as radiographic and endoscopic findings of ICI-related pancreatitis and cholangitis.

Possible Alterations in Appetite-related Molecules After the Elimination of Hepatitis C Virus.

BACKGROUND/AIM: Recent advances in antiviral treatment have achieved a sustained viral response (SVR) in over 95% of hepatitis C virus (HCV) infections. HCV elimination is suggested to improve several lifestyle-related factors; however, few studies have focused on dietary habit-/appetite-related factors. PATIENTS AND METHODS: HCV-infected patients who received Daclatasvir/Asnaprevir (DCV/ASV) therapy were enrolled, and the changes in appetite-related molecules after antiviral therapy were assessed with a multiple cytokine-measuring system. RESULTS: Among 119 HCV-infected patients who received DCV/ASV treatment, 104 (87.3%) achieved an SVR. In the SVR group, DCV/ASV treatment improved several liver-related variables at 24 weeks after the completion of therapy. In patients with an SVR, the values of glucagon-like peptide 1 (GLP-1) and leptin were significantly increased at 24 weeks after completing direct-acting antiviral therapy. However, no significant change was observed in non-SVR patients, regardless of the receipt of direct-acting antiviral treatment. CONCLUSION: Gastrointestinal hormones related to the dietary habit and/or appetite may be influenced by HCV elimination.

Modification of the ALBI-PLT Score for the Prediction of High-risk Varices.

BACKGROUND/AIM: A new scoring system [albumin-bilirubin-platelet (ALBI-PLT) score] was reported for identifying cirrhotic patients without high-risk varices (HRV), and patients with ALBI grade 1 (≤-2.60) and a platelet count over 150×109/l were shown to have a low risk of having HRV. The present study modified the cut-off values of the variables in the ALBI-PLT score. PATIENTS AND METHODS: Among a total of 338 patients with chronic liver diseases, possible cut-off values of the ALBI score and the platelet count were determined by analyzing the first-half group (training cohort: N=169) with the receiver operating characteristic (ROC) method. The utility of the determined values was evaluated in the second-half group (validation cohort: N=169) and total cohort (N=338). In addition, the utility of the modified cut-off values was evaluated in patients with compensated cirrhosis (cirrhotic cohort: N=87). RESULTS: Possible cut-off values of the ALBI score and platelet count were found to be -2.36 and 114×109/l, respectively. In the training cohort, these cut-off values provided a higher ratio of avoiding esophagogastroduodenoscopy than the original ALBI-PLT score (53.3% vs. 25.4%, p<0.01). Consistent results were observed in the validation cohort (28.4% vs. 15.4%, p<0.01), total cohort (40.8% vs. 20.4%, p<0.01), and cirrhotic cohort (32.2% vs. 11.5%, p<0.01). However, the missing ratio of patients with the HRV was not significantly increased in any cohort studied. CONCLUSION: Modification of the ALBI-PLT score may be useful for predicting patients without HRV.

Multiple Inflammatory Pseudotumors of the Liver Demonstrating Spontaneous Regression: A Case Report.

Inflammatory pseudotumor (IPT) of the liver is a rare benign disease. IPTs generally develop as solitary nodules, and cases with multiple lesions are uncommon. We herein report a case of multiple IPTs of the liver that spontaneously regressed. A 70-year-old woman with a 10-year history of primary biliary cholangitis and rheumatoid arthritis visited our hospital to receive a periodic medical examination. Abdominal ultrasonography revealed multiple hypoechoic lesions, with a maximum size of 33 mm, in the liver. Contrast-enhanced computed tomography revealed low-attenuation areas in the liver with mild peripheral enhancement at the arterial and portal phases. We first suspected metastatic liver tumors, but fluorodeoxyglucose positron emission tomography, magnetic resonance imaging and contrast-enhanced ultrasonography suggested the tumors to be inconsistent with malignant nodules. A percutaneous biopsy showed shedding of liver cells and abundant fibrosis with infiltration of inflammatory cells. Given these findings, we diagnosed the multiple tumors as IPTs. After careful observation for two months, the tumors almost vanished spontaneously. Physicians should avoid a hasty diagnosis of multiple tumors based solely on a few clinical findings, and a careful assessment with various imaging modalities should be conducted.