A comprehensive evaluation of emergency department utilization by patients with cirrhosis.

BACKGROUND: Emergency Department (ED) based care is required for cirrhosis management, yet the burden of cirrhosis-related ED healthcare utilization (HCU) is understudied. We aimed to describe ED utilization within a statewide health system and compare the outcomes of high ED use (HEDU) versus non-HEDU in individuals with cirrhosis. METHODS: We retrospectively reviewed charts of adults with cirrhosis who presented to any of 16 EDs within the Indiana University Health system in 2021. Patient characteristics, features of the initial ED visit, subsequent 90-day healthcare use, and 360-day outcomes were collected. Multivariable logistic regression models were used to identify predictors HEDU status which was defined as ≥2 ED visits within 90 days after the index ED visit. RESULTS: There were 2124 eligible patients (mean age 61.3 years, 53% male, and 91% White). Major etiologies of cirrhosis were alcohol (38%), MASH (27%), and viral hepatitis (21%). Cirrhosis was newly diagnosed in the ED visit for 18.4%. Most common reasons for ED visits were abdominal pain (21%), shortness of breath (19%), and ascites/volume overload (16%). Of the initial ED visits 20% (n=424) were potentially avoidable. The overall 90-day mortality was 16%. Within 90 days, there were 366 HEDU (20%). Notable variables independently associated with HEDU were MELD-Na (aOR=1.044, 95% CI 1.005-1.085), prior ED encounter (aOR=1.520, 95% CI 1.136-2.034), and avoidable initial ED visit (aOR=1.938, 95% CI 1.014-3.703). CONCLUSIONS: Abdominal pain, shortness of breath, and ascites/fluid overload are the common presenting reasons for ED visits for patients with cirrhosis. Patients with cirrhosis presenting to the ED experience a 90-day mortality rate of 16%, and among those who initially visited the ED, 20% were HEDU. We identified several variables independently associated with HEDU. Our observations pave the way for developing interventions to optimize the care of patients with cirrhosis presenting to the ED and to lower repeated ED visits.

EUS-guided treatment of bleeding peristomal varices (with video).

BACKGROUND AND AIMS: The use of EUS for peristomal varices (PV) is limited to case reports. METHODS: Patients who underwent EUS-guided treatment of PV with cyanoacrylate (CYA) and/or coils between April 2013 and December 2019 were identified. All patients had failed previous therapies or had comorbidities precluding other options. Endoscopic technique, adverse events (AEs), recurrent bleeding, and repeat interventions were assessed. RESULTS: Twenty patients (12 men; median age, 62 years [interquartile range {IQR}, 54.8-69.5]) underwent initial EUS-guided PV injection of CYA for secondary (n = 19) or primary (n = 1) prophylaxis. Within 30 days, AEs occurred in 11 patients (55%), of which 8 were mild. During a median 2.5 months (IQR, 2-8.5) of follow-up, confirmed (n = 6) or suspected (n = 2) PV bleeding recurred; 5 of 8 recurrences were retreated with CYA and/or coils without AEs. After retreatment, PV bleeding recurred in 2 patients a median of 6 months (IQR, 6-30) later. CONCLUSIONS: EUS appears to be a safe and promising technique for treatment of PV.

Safety of same-day discharge after peroral endoscopic myotomy.

There are limited data on the safety of same-day discharge (SDD) after peroral endoscopic myotomy (POEM). The aim of our study is to assess the frequency and relationship to POEM for emergency department (ED) visits and hospitalizations after SDD in these patients. We retrospectively identified consecutive patients between November 2019 and August 2021 who underwent POEM with SDD and at least 6 months follow-up. Criteria for SDD includes: (1) no serious procedure-related adverse event; (2) post-POEM esophagram without leak; (3) stable vital signs; (4) ability to take liquids orally; (5) pain controlled without IV analgesia; (6) adequate social support; (7) American Society of Anesthesiologists (ASA) class I-III. A causative relationship between POEM and ED visits and hospitalizations was assigned by consensus. Out of 185 POEMs performed, 78 (41.7%, 42M, mean 51±16 years) had SDD. Within 30 days of POEM, 8 ED visits occurred in 7/78 (9%) patients and 2 (25%) were considered related to POEM; hospitalization was required in 3 (38%). After 30 days, 11 ED visits occurred in 10/78 (12.8%) patients and 1 (9%) was considered related to POEM; hospitalization was required in 5 (45%). In this study of consecutive SDD patients after POEM, 3/19 (16%) ED visits and 2/8 (25%) hospitalizations within 6 months were considered related to the procedure. Therefore, eligible patients who follow and fulfill a strict protocol after POEM may be safely discharged the same day.

Comparison of endoscopic ultrasound-guided primary and secondary prophylaxis for gastric variceal bleeding.

OBJECTIVES: Endoscopic ultrasound (EUS)-guided injection of cyanoacrylate (CYA) for primary prophylaxis (PP) of gastric varices (GV) is controversial. This study evaluates the safety and efficacy of this intervention. METHODS: Patients treated for PP of GV bleeding by EUS injection of CYA with or without coils were identified. Endoscopic techniques, outcomes, and adverse events (AEs) were reviewed and compared with a group treated for secondary prophylaxis (SP). Patients were followed until: (i) loss to follow-up; (ii) GV bleeding; (iii) interventional radiology or surgery decompression; (iv) liver transplant; or (v) death or comfort care. RESULTS: One hundred and nineteen patients (61 men; mean 59 ± 12 years) underwent EUS for PP (n = 24) or SP (n = 95). The PP group was treated with CYA alone (n = 18) or with coils (n = 4). Eight (33%) mild (n = 6) or moderate (n = 2) AEs and no index GV bleeding occurred during a mean of 6.1 ± 5.9 months follow-up. Repeat EUS in 22 (92%) PP patients showed 7 (32%) residual GVs, which were retreated with CYA alone (n = 6) or with coils (n = 1). Two (29%) mild (n = 1) or moderate (n = 1) AEs occurred after repeat EUS and 1/22 (5%) index GV bleed occurred during a mean 23 ± 25 months follow-up. Compared to the SP group, the PP group had lower Model for End-stage Liver Disease (MELD) score (P = 0.03), fewer GV stigmata (P < 0.001), required less CYA (P = 0.019) during index EUS, and had a longer time between index and surveillance EUS (P = 0.014). The incidence of AEs and GV bleeding between the two groups were similar. CONCLUSION: Posttreatment GV bleeding and AEs are similar following EUS-guided primary and secondary GV prophylaxis.

High index of suspicion: diagnosing a carotid-cavernous fistula.

A woman in her 70s presented with acute bilateral retro-orbital headache, diplopia, chemosis and eye swelling. Ophthalmology and neurology were consulted after detailed physical examination and diagnostic workup including laboratory analysis, imaging and lumbar puncture. The patient was diagnosed with non-specific orbital inflammation and was started on methylprednisolone and dorzolamide-timolol for intraocular hypertension. The patient's condition improved slightly, but a week later, she developed subconjunctival haemorrhage in the right eye, which prompted investigation for a low-flow carotid-cavernous fistula. Digital subtraction angiography showed bilateral indirect carotid-cavernous fistula (Barrow type D). The patient underwent bilateral carotid-cavernous fistula embolisation. Her swelling improved considerably on day 1 after the procedure and her diplopia improved over the following weeks.

COVID-Associated Cast-Forming Cholangiopathy: A Commentary on Disease Mechanism, Treatment, and Prognosis.

The complete impact of COVID-19 infection continues to develop since the onset of the COVID-19 pandemic. COVID-19 cholangiopathy has been recently described in a subset of patients who recovered from severe COVID-19 infection. The most common phenotype of patients suffering from COVID-19 cholangiopathy had severe infection requiring a stay in the intensive care unit, mechanical ventilation and vasopressor medications. Patients with COVID-cholangiopathy present with severe and prolonged cholestatic liver injury. In cases where biliary cast formation is identified, we defined the entity as "COVID-19 cast-forming cholangiopathy". This subset of COVID-19 cholangiopathy is not well understood and there are no standardized diagnosis or management to this date. The reported clinical outcomes are variable, from resolution of symptoms and liver test abnormalities to liver transplant and death. In this commentary, we discuss the proposed pathophysiology, diagnosis, management, and prognosis of this disease.

Lumen-Apposing Metal Stent With and Without Concurrent Double-Pigtail Plastic Stent for Pancreatic Fluid Collections: A Comparative Systematic Review and Meta-Analysis.

Background: Lumen-apposing metal stents (LAMSs) are often used to drain pancreatic fluid collections (PFCs). However, adverse events, such as stent obstruction, infection, or bleeding, have been reported. Concurrent double-pigtail plastic stent (DPPS) deployment has been suggested to prevent these adverse events. This meta-analysis aimed to compare the clinical outcomes of LAMS with DPPS vs. LAMS alone in the drainage of PFCs. Methods: An extensive search was conducted in the literature to include all the eligible studies that compared LAMS with DPPS vs. LAMS alone for drainage of PFCs. Pooled risk ratios (RRs) with the 95% confidence intervals (CIs) were obtained within a random-effect model. The outcomes were technical and clinical success, and overall adverse events, including stent migration and occlusion, bleeding, infection, and perforation. Results: Five studies involving 281 patients with PFCs (137 received LAMS plus DPPS vs. 144 received LAMS alone) were included. LAMS plus DPPS group was associated with comparable technical success (RR: 1.01, 95% CI: 0.97 - 1.04, P = 0.70) and clinical success (RR: 1.01, 95% CI: 0.88 - 1.17). Lower trends of overall adverse events (RR: 0.64, 95% CI: 0.32 - 1.29), stent occlusion (RR: 0.63, 95% CI: 0.27 - 1.49), infection (RR: 0.50, 95% CI: 0.15 - 1.64), and perforation (RR: 0.42, 95% CI: 0.06 - 2.78) were observed in LAMS with DPPS group compared to LAMS alone but without a statistical significance. Stent migration (RR: 1.29, 95% CI: 0.50 - 3.34) and bleeding (RR: 0.65, 95% CI: 0.25 - 1.72) were similar between the two groups. Conclusions: Deployment of DPPS across LAMS for drainage of PFCs has no significant impact on efficacy or safety outcomes. Randomized, controlled trials are necessary to confirm our study results, especially in walled-off pancreatic necrosis.

Will advanced cholangiocarcinoma become a targetable malignancy?

Cholangiocarcinoma and biliary tract cancers are rare but aggressive tumors that are characterized by an heterogenous molecular and genetic footprint. Genetic aberrations such as FGFR2 fusion and ErBb2 amplification are common in those cancers. Recent studies aimed at exploring the efficacy and benefit of targeted therapy in the treatment of advanced cholangiocarcinoma. Many promising drugs exist and warrant additional investigations. This review will summarize available results and highlight therapeutic strategies incorporated in clinical trials.