Referral for liver transplant following acute variceal bleeding: a multicenter cohort study.

OBJECTIVES: Referral for liver transplant (LT) following acute variceal bleeding (AVB) varies widely. We aimed to characterize and assess its impact on clinical outcomes. METHODS: Observational retrospective cohort including cirrhosis patients with AVB from 3 hospitals in Lisbon, Portugal, from 2018 to 2019. Primary exposure was referral for LT and primary endpoint was all-cause mortality within 2 years of index hospital admission. RESULTS: Among 143 patients, median (IQR) age was 59 (52-72) years and 90 (62.9%) were males. Median (IQR) MELDNa scores on hospital admission and discharge were 15 (11-21) and 13 (10-16), respectively. Overall, 30 (21.0%) patients were assessed for LT, 13 (9.1%) prior to and 17 (11.9%) within 2 years of hospital admission. Overall, 58 (40.6%) patients had at least one potential contra-indication for transplant. LT was performed in 3 (2.1%) patients (among 5 listed). Overall, 34 (23.8%) and 62 (43.4%) patients died at 6 weeks and 2 years post hospital admission, respectively. Following adjustment for confounders, referral for LT was associated with lower 2-year mortality (aHR (95% CI) = 0.20 (0.05-0.85)). CONCLUSION: In a multicenter cohort of cirrhosis patients with AVB, less than a quarter underwent formal LT evaluation. Improved referral for LT following AVB may benefit cirrhosis patients' longer-term mortality.

Endoscopic cyanoacrylate injection for massive bleeding from a ruptured pseudocyst.

Arterial bleeding is a dreadful late complication of acute pancreatitis that usually mandates emergent endovascular embolization or surgery. We present the case of a massive arterial bleeding resulting from fistulization of a pseudocyst to the stomach, which was successfully managed by endoscopic injection of cyanoacrylate.

Sequential Use of High-Volume Plasma Exchange and Continuous Renal Replacement Therapy in Hepatitis B Virus-Related Acute Liver Failure: A Case Report.

Background: Acute liver failure (ALF) may represent an indication for liver transplantation (LT). However, in patients who do not meet the criteria or who have contraindications for LT, support measures remain indicated since they may improve survival. Continuous renal replacement therapy (CRRT) can be considered in the presence of hyperammonemia, 3 times above the upper normal limit, and hepatic encephalopathy (HE), even in the absence of the classic indications. High-volume plasma exchange (HVPE) is an artificial liver support system with proven benefits in ALF, allowing ammonia and inflammatory mediator clearance. Both techniques, HVPE and CRRT, are associated with an increase in transplant-free survival. Case Summary: We share a case of a 51-year-old male, without relevant personal history, diagnosed with severe acute hepatitis B which progressed to ALF, with grade IV HE (West-Haven criteria) and hyperammonemia (423 µg/dL). Due to the simultaneously diagnosed malignant neoplasm, he was not a candidate for LT. After refractory to medical therapy, HVPE was started, followed by CRRT. There was a significant improvement in liver tests, allowing surgical treatment of malignancy. After recovery, the patient returned to his everyday life. Conclusion: The authors present a successful case in which an early and invasive approach to ALF was revealed to be a game changer. The lack of response to the measures instituted, as well as the contraindication for LT, motivated the institution of HVPE and CRRT. Both techniques proved to be an asset, allowing complete clinical recovery, reaffirming their role in ALF.

Background: A insuficiência hepática aguda (IHA) pode constituir uma indicação para transplante hepático (TH). Contudo, nos doentes que não cumprem os critérios ou que apresentam contraindicação para TH, as medidas de suporte continuam indicadas dado que podem ter benefício na sobrevivência. A terapêutica de substituição da função renal (TSFR) pode ser considerada na presença de hiperamonémia, superior a três vezes do limite superior do normal, e encefalopatia hepática (EH), mesmo na ausência das indicações clássicas. A plasmaferese de alto volume (PFAV) é um sistema de suporte artificial ao fígado (SSAF) com benefícios comprovados na IHA, permitindo a clearance de amónia bem como de mediadores inflamatórios. Ambas as técnicas, PFAV e TSFR, estão associadas ao aumento da sobrevivência livre de transplante. Resumo do caso: Apresentamos o caso de um homem de 51 anos, sem antecedentes pessoais de relevo, com o diagnóstico de hepatite B aguda grave que progrediu para IHA, com EH grau IV (critérios de West-Haven) e hiperamonémia (423 µg/dL). Devido ao diagnóstico simultâneo de neoplasia maligna, o doente não foi candidato a TH. Após refratariedade ao tratamento médico instituído, iniciou-se PFAV, seguida de TSFR. Verificou-se melhoria significativa das provas hepáticas, permitindo o tratamento cirúrgico da neoplasia. Após recuperação, o doente regressou ao seu quotidiano. Conclusão: Os autores apresentam um caso de sucesso em que uma abordagem precoce e invasiva revelou-se game-changer. A refratariedade às medidas instituídas, bem como a contraindicação ao TH, motivaram a instituição de HVPE e CRRT. Ambas as técnicas revelaram-se uma mais-valia permitindo a recuperação clínica total, reafirmando o seu papel na IHA.

A rare cause of severe esophagitis in an immunocompetent patient - double complication with an endoscopic resolution.

A 75-year-old male, without relevant medical history and negative HIV1/2 serology, presented at the emergency department with mixed shock (septic - from pleuroparenchymal origin - and hypovolemic due to upper gastrointestinal bleeding [UGIB]). Thoracoabdominal CT scan showed an esophagopleural fistula (EPF), with a large right pleural effusion (lately known to be compatible with exudate - Light's criteria) and right pneumothorax, without active bleeding. The upper gastrointestinal endoscopy (UGIE) showed a severe esophagitis and, in distal oesophagus, an ulcer with an orifice in the center. Biopsies of the edges of the ulcer were performed. Anatomopathological (AP) studies were negative for viral agents but tissue molecular studies (polymerase chain reaction [PCR]) identified cytomegalovirus (CMV) DNA. Despite no immunosuppression condition was identified, CMV severe esophagitis complicated by EPF with right-side empyema and UGIB was diagnosed. An oesophageal fully covered metal stent (FCMS), with anti-migration system, was left in place during 5-weeks and ganciclovir therapy (5mg/kg/day) was maintained for 21-days. Clinical-analytical, radiological and endoscopic improvement was noticed. No recurrence in the following year of follow-up.

COVID-19-associated secondary sclerosing cholangitis - A case series of 4 patients.

We report a case series of four patients diagnosed with COVID-19-associated secondary sclerosing cholangitis (SSC), a recently described rare late complication of severe COVID-19. Following prolonged stays in the intensive care unit, these patients developed marked sustained cholestasis and jaundice despite clinical improvement. Cholangiography showed beaded appearance of intra-hepatic bile ducts and bile casts were removed in one patient. None of the patients reached normalization of liver enzymes and at least one progressed to liver cirrhosis (follow-up time of 11 to 16 months). COVID-19-associated SSC has a dismal prognosis with rapid progression to advanced chronic liver disease.

Proposal for a method to estimate nutrient shock effects in bacteria.

BACKGROUND: Plating methods are still the golden standard in microbiology; however, some studies have shown that these techniques can underestimate the microbial concentrations and diversity. A nutrient shock is one of the mechanisms proposed to explain this phenomenon. In this study, a tentative method to assess nutrient shock effects was tested. FINDINGS: To estimate the extent of nutrient shock effects, two strains isolated from tap water (Sphingomonas capsulata and Methylobacterium sp.) and two culture collection strains (E. coli CECT 434 and Pseudomonas fluorescens ATCC 13525) were exposed both to low and high nutrient conditions for different times and then placed in low nutrient medium (R2A) and rich nutrient medium (TSA).The average improvement (A.I.) of recovery between R2A and TSA for the different times was calculated to more simply assess the difference obtained in culturability between each medium. As expected, A.I. was higher when cells were plated after the exposition to water than when they were recovered from high-nutrient medium showing the existence of a nutrient shock for the diverse bacteria used. S. capsulata was the species most affected by this phenomenon. CONCLUSIONS: This work provides a method to consistently determine the extent of nutrient shock effects on different microorganisms and hence quantify the ability of each species to deal with sudden increases in substrate concentration.