Adverse events with endoscopic ultrasound-guided gastroenterostomy for gastric outlet obstruction-A systematic review and meta-analysis.

BACKGROUND: The technical and clinical effectiveness of endoscopic ultrasonography (EUS)-guided gastroenterostomy (GE) has been reported by several meta-analyses, but few of them have addressed the adverse events (AE). The goal of the current meta-analysis was to analyze the AEs associated with various types of EUS-GE. METHODS: All relevant studies reporting the AEs with EUS-GE were searched from 2000 to 31st March 2023 in MEDLINE, Embase, and Scopus. The event rates were pooled using a random effects model. RESULTS: A total of 36 studies (n = 1846) were included in the meta-analysis. The present meta-analysis reports a pooled technical success rate of 96.9% (95.9-98.0; I2 = 29.3%) with a pooled clinical success rate of 90.6% (88.5-92.7; I2 = 60.9%). The pooled incidence of overall AEs with EUS-GE was 13.0% (10.3-15.7; I2 = 69.7%), with the commonest being maldeployment of the stent, seen in 4.6% (3.2-6.0; I2 = 50.6%). The pooled incidences of serious AE and procedure-related mortality were 1.2% (0.7-1.8; I2 = 1.9%) and 0.3% (0.0-0.7; I2 = 0.0%), respectively. Subgroup analysis of studies using only the free-hand technique showed a significantly lower overall AE and maldeployment but not serious AE and other individual AEs. The pooled incidences of delayed stent migration and stent occlusion were 0.5% (0.0-1.1; I2 = 0.0%) and 0.8% (0.2-1.3; I2 = 0.0%), respectively. CONCLUSION: Despite a technical and clinical success rate of >90%, AEs are seen in around one-seventh of the cases of EUS-GE, maldeployment being the commonest. However, the pooled incidence of serious AE and mortality remains low, which is reassuring.

Role of contrast-enhanced ultrasound for differentiation of benign vs. malignant portal vein thrombosis in hepatocellular carcinoma - A systematic review a meta-analysis.

Introduction/Purpose: Patients with cirrhosis and hepatocellular carcinoma (HCC) can develop both benign and malignant portal vein thrombosis (PVT). Characterising the nature of PVT is important for planning an optimal therapeutic strategy. In the absence of typical findings or contraindications to computed tomography (CT) or magnetic resonance imaging (MRI), contrast-enhanced ultrasound (CEUS) could help in this differentiation. The present meta-analysis aimed to evaluate the performance of CEUS for characterising PVT in patients with HCC. Methods: Electronic databases of PubMed, Embase and Scopus were searched from inception to 31 December 2022 for studies analysing the role of CEUS in the differentiation of benign and malignant PVT in HCC. Using the bivariate random effect model, pooled sensitivity and specificity were calculated, and the summary receiver operating characteristic (sROC) curve was plotted. Results: A total of 12 studies with data from 712 patients were included in the meta-analysis. The pooled sensitivity and specificity of CEUS for the diagnosis of tumour in vein were 97.0% (95% CI: 93.0-98.7) and 96.8% (95% CI: 92.1-98.7), respectively, without significant heterogeneity. A sROC curve was plotted, and the area under the receiver operating characteristic was 0.99 (95% CI: 0.98-1.00). Despite the presence of publication bias, sensitivity analysis did not show any change in sensitivity and specificity. Discussion: Our meta-analysis summarises the accuracy data from 12 studies, including >700 subjects. Contrast-enhanced ultrasound had excellent diagnostic accuracy with pooled sensitivity and specificity of 97.5% (95% CI: 93.5-99.1) and 98.2% (95% CI: 91.5-99.6), respectively, without any significant heterogeneity. Additionally, the pooled positive LR, negative LR and DOR were 54.6 (95% CI: 11.1-25.6), 0.02 (0.01-0.07) and 2186.8 (318.3-15022.2), respectively. A positive result increases the pretest probability of malignant PVT from 50% to 98%, whereas a negative result decreases it from 50% to 2%. Most of the studies included in our meta-analysis used identical techniques and 6-12-month follow-up scans to check for thrombus progression or regression. Our analysis showed no significant heterogeneity in the studies, and area under receiver operating characteristic curve (AUROC) with 95% CI was 1.00 (95% CI: 0.99-1.00). This critical meta-analysis thus propels CEUS to the forefront for differentiating benign from tumoural PVT and suggests routinely using CEUS in patients presenting with HCC and evidence of thrombus on greyscale ultrasound. Conclusion: Contrast-enhanced ultrasound is an effective diagnostic modality differentiation of benign and malignant PVT in patients with HCC and can be an alternative modality to CT or MRI. Further studies are required to study the role of CEUS as initial diagnostic modality for the characterisation of PVT in HCC.

Novel predictors of response to therapy with terlipressin and albumin in hepatorenal syndrome-acute kidney injury.

Background: A combination of terlipressin and albumin is the first-line pharmacologic treatment for hepatorenal syndrome-acute kidney injury (HRS-AKI). We assessed the response rates to terlipressin-albumin therapy in patients with HRS-AKI and determined early predictors of treatment response and survival. Methods: A total of 84 patients with HRS-AKI (International Club of Ascites definition 2015) treated with terlipressin-albumin were included. Predictors of HRS reversal were identified by logistic regression analysis. Survival analysis was performed using the Kaplan-Meier method, and Cox regression models were used to determine independent predictors of mortality. Results: Complete response to therapy was observed in 54.8%, partial response in 14.3%, and no response in 31% of patients. The factors associated with complete treatment response were the presence of systemic inflammatory response syndrome (SIRS), baseline serum creatinine, a rise in mean arterial pressure by day 3, and a reduction in the renal resistive index (ΔRRI) by day 3 of treatment. Independent predictors of HRS reversal were the presence of SIRS at baseline (P=0.022; odds ratio [OR] 15.74, 95% confidence interval [CI] 1.47-167.82) and ΔRRI ≥5% by day 3 of treatment (P=0.048; OR 6.67, 95%CI 1.021-43.62). Mean transplant-free survival at 6 months was significantly better in treatment responders (148 vs. 90 days, P<0.001). Independent predictors of 6-month mortality were response to treatment (P=0.004) and model for end-stage liver disease-sodium >23 (P=0.018). Conclusions: SIRS and ΔRRI are simple parameters to predict treatment response in HRS-AKI. Non-responders have higher mortality and should be identified early to expedite liver transplantation.

Prothrombotic states in portal vein thrombosis and Budd-Chiari syndrome in India: A systematic review and meta-analysis.

BACKGROUND: Both Budd-Chiari syndrome (BCS) and portal vein thrombosis (PVT) have been linked to various prothrombotic (PT) conditions. The PT profile in Asians is different from the west and there are no nationwide epidemiological surveys from India. Hence, the present meta-analysis was aimed at analyzing the prevalence of acquired and hereditary thrombophilia among Indian patients with non-cirrhotic PVT and BCS. METHODS: A comprehensive literature search of Embase, Medline and Scopus was conducted from January 2000 to February 2022 for studies evaluating the prevalence of various PT conditions in Indian patients with PVT and BCS. Pooled prevalence rates across studies were expressed with summative statistics. RESULTS: Thirty-five studies with 1005 PVT patients and 1391 BCS patients were included in the meta-analysis. At least one PT condition was seen in 46.2% (28.7-63.7) of the PVT patients and 44.9% (37.3-60.7) of the BCS patients. Multiple PT conditions were seen in 13.0% (4.2-21.8) of the PVT patients and 7.9% (3.5-12.4) of the BCS patients. Among PVT patients, hyperhomocysteinemia was the commonest prothrombotic condition (21.6%) followed by protein C (PC) deficiency (10.7%), Janus kinase 2 (JAK-2) mutation (8.5%) and antiphospholipid antibodies (APLA) (7.5%). Among patients with BCS, PC deficiency was the commonest prothrombotic condition (10.6%) followed by methylenetetrahydrofolate reductase (MTHFR) mutation (9.8%), APLA (9.7%) and JAK-2 mutation (9.1%). CONCLUSION: The PT profile in Indian patients with abdominal vein thrombosis is different from that of the western data with a lower prevalence of PT conditions in patients with BCS.

The Role of Gastroenterologists in Preoperative Assessment and Management of Prospective Renal Transplantation Candidates.

Renal transplant is the most common organ transplant worldwide, accounting for 65% of the total number of transplants. End-stage renal disease (ESRD) often has multiple significant comorbidities. Among the gastrointestinal (GI) disorders, peptic ulcer disease (PUD), cholelithiasis, and colon and liver diseases increase the risk of posttransplant morbidity. Potential renal transplantation (RT) candidates need a multidisciplinary assessment of coexisting illnesses, which may affect the perioperative risk and survival after transplantation. Successful outcome of RT depends on careful selection of the recipients by a thorough medical evaluation and screening. This review summarizes the role of gastroenterologists and hepatologists in preoperative assessment and management of renal transplant recipients. How to cite this article: Giri S, Dash KA, Varghese J, et al. The Role of Gastroenterologists in Preoperative Assessment and Management of Prospective Renal Transplantation Candidates. Euroasian J Hepato-Gastroenterol 2023;13(1):18-25.

Diagnostic performance and safety of endoscopic ultrasound-guided tissue acquisition of gallbladder lesions: A systematic review with meta-analysis.

BACKGROUND: Endoscopic ultrasound (EUS)-guided tissue acquisition (TA) is widely used for various target samples, but its efficacy in gallbladder (GB) lesions is unknown. The aim of the present meta-analysis was to assess the pooled adequacy, accuracy and safety of EUS-TA of GB lesions. METHODS: A literature search from January 2000 to August 2022 was done for studies analyzing the outcome of EUS-guided TA in patients with GB lesions. Pooled event rates were expressed with summative statistics. RESULTS: The pooled rate of sample adequacy for all GB lesions and malignant GB lesions was 97.0% (95% CI: 94.5-99.4) and 96.6% (95% CI: 93.8-99.3), respectively. The pooled sensitivity and specificity for the diagnosis of malignant lesions were 90% (95% CI: 85-94; I2 = 0.0%) and 100% (95% CI: 86-100; I2 = 0.0%), respectively, with an area under the curve of 0.915. EUS-guided TA had a pooled diagnostic accuracy rate of 94.6% (95% CI: 90.5-96.6) for all GB lesions and 94.1% (95% CI: 91.0-97.2) for malignant GB lesions. There were six reported mild adverse events (acute cholecystitis = 1, self-limited bleeding = 2, self-limited episode of pain = 3) with a pooled incidence of 1.8% (95% CI: 0.0-3.8) and none of the patients had serious adverse events. CONCLUSION: EUS-guided tissue acquisition from GB lesions is a safe technique with high sample adequacy and diagnostic accuracy. EUS-TA can be an alternative when traditional sampling techniques fail or are not feasible.

Outcome of pharmacological thromboprophylaxis in hospitalized patients with cirrhosis - a systematic review and meta-analysis.

BACKGROUND: Portal hypertension in cirrhosis brings about a complex interplay in the risks of bleeding and thrombosis. It is unclear whether hospitalized patients with cirrhosis need pharmacological prophylaxis for venous thromboembolism (VTE), as it may increase the risk of bleeding. We aimed to compare the outcome of hospitalized patients with cirrhosis with and without pharmacological thromboprophylaxis. METHODS: A comprehensive search of three databases was conducted from inception to August 2022 for studies comparing the outcome of hospitalized patients with cirrhosis with and without pharmacological prophylaxis for VTE. Odds ratios (OR) with 95% confidence intervals (CIs) were calculated for the outcomes of VTE or bleeding. RESULTS: Overall, 12 studies were included in the final analysis. The pooled incidence of VTE in patients with and without thromboprophylaxis was 1.9% (95% CI: 0.8-2.9) and 1.9% (95% CI: 0.9-2.9), respectively. The odds of VTE were comparable between the groups with OR 1.11 (95% CI: 0.76-1.62). The pooled incidence of bleeding events in patients with and without thromboprophylaxis was 6.7% (95% CI: 3.6-9.8) and 10.4% (95% CI: 6.6-14.1), respectively. There was no significant difference in the odds of overall bleeding (OR 0.68; 95% CI: 0.30-1.52) or major bleeding (OR 1.18; 95% CI: 0.55-2.56) between the groups. There was no significant difference in the relative effects on sensitivity analysis. CONCLUSION: The present analysis could not demonstrate the benefit of pharmacological thromboprophylaxis in reducing in-hospital VTE in patients with cirrhosis. Future studies are required to assess the role of risk prediction models in hospitalized patients with cirrhosis.

CRAB score for prediction of colectomy within 2 years following admission for acute severe ulcerative colitis.

Background: The Oxford and Swedish indexes were developed to predict in-hospital colectomy in acute severe ulcerative colitis (ASUC), but not long-term prediction, and all these indexes were based on Western data. Our study aimed to analyze the predictors of colectomy within 3 years of ASUC in an Indian cohort and derive a simple predictive score. Methods: A prospective observational study was conducted in a tertiary health care center in South India over a period of 5 years. All patients admitted with ASUC were followed up for a period of 24 months after the index admission, to look for progression to colectomy. Results: A total of 81 (47 male) patients were included in the derivation cohort. Fifteen (18.5%) patients required colectomy during a follow-up period of 24 months. On regression analysis, C-reactive protein (CRP) and serum albumin were independent predictors of 24-month colectomy. The CRAB (CRP + AlBumin) score was obtained by multiplying coefficient of beta to albumin and CRP (CRAB score = CRP x 0.2 - Albumin x 0.26). The CRAB score demonstrated an AUROC of 0.923 and a score of >0.4 with a sensitivity of 82% and specificity of 92% for the prediction of 2-year colectomy following ASUC. The score was validated in a validation cohort of 31 patients, and at >0.4, the score had a sensitivity of 83% and a specificity of 96% in predicting colectomy. Conclusion: CRAB score is a simple prognostic score that can predict 2-year colectomy in ASUC patients with high sensitivity and specificity.

Influence of biliary stents on the diagnostic outcome of endoscopic ultrasound-guided tissue acquisition from solid pancreatic lesions: a systematic review and meta-analysis.

BACKGROUND/AIMS: This meta-analysis analyzed the effect of an indwelling biliary stent on endoscopic ultrasound (EUS)-guided tissue acquisition from pancreatic lesions. METHODS: A literature search was performed to identify studies published between 2000 and July 2022 comparing the diagnostic outcomes of EUS-TA in patients with or without biliary stents. For non-strict criteria, samples reported as malignant or suspicious for malignancy were included, whereas for strict criteria, only samples reported as malignant were included in the analysis. RESULTS: Nine studies were included in this analysis. The odds of an accurate diagnosis were significantly lower in patients with indwelling stents using both non-strict (odds ratio [OR], 0.68; 95% confidence interval [CI], 0.52-0.90) and strict criteria (OR, 0.58; 95% CI, 0.46-0.74). The pooled sensitivity with and without stents were similar (87% vs. 91%) using non-strict criteria. However, patients with stents had a lower pooled sensitivity (79% vs. 88%) when using strict criteria. The sample inadequacy rate was comparable between groups (OR, 1.12; 95% CI, 0.76-1.65). The diagnostic accuracy and sample inadequacy were comparable between plastic and metal biliary stents. CONCLUSION: The presence of a biliary stent may negatively affect the diagnostic outcome of EUS-TA for pancreatic lesions.

Comparative outcome of transjugular intrahepatic portosystemic shunt with or without variceal obliteration: a systematic review and meta-analysis.

BACKGROUND: Transjugular intrahepatic portosystemic shunt (TIPS) has been used for the secondary prevention of variceal bleeding. TIPS can be combined with variceal embolization (TIPS-VO), but its benefit remains controversial. The present systematic review and meta-analysis were conducted to compare the incidence of rebleeding, adverse events, and mortality among patients with TIPS alone and with TIPS-VO. METHODS: A literature search from January 2000 to June 2022 was done for studies comparing the outcome of patients undergoing TIPS alone or TIPS-VO. A subgroup analysis was conducted for patients undergoing TIPS with covered stents. RESULTS: A total of 11 studies with data from 1044 patients were included. The incidence of rebleeding was significantly higher in the TIPS alone group in both overall population OR 2.01 (1.42-2.83) and the subgroup (OR 1.92, 95% CI 1.21-3.04). There was no difference between the two groups concerning the risk of hepatic encephalopathy (OR 1.15, 95% CI 0.83-1.59), procedural adverse events (OR 0.86, 95% CI 0.54-1.39), shunt dysfunction (OR 1.20, 95% CI 0.82-1.75), overall mortality (OR 1.03, 95% CI 0.73-1.46), and mortality due to variceal rebleeding (OR 1.58, 95% CI 0.44-5.64). There was no significant heterogeneity or publication bias among the included studies. The certainty of evidence remains low for all the outcome expect for variceal rebleeding. CONCLUSION: The present meta-analysis provides a moderate-quality evidence for the benefit of TIPS-VO in reducing the incidence of rebleeding. However, the decision for combining variceal embolization with TIPS should be made on a case-to-case basis.

Risk of Bleeding with Endoscopic Ultrasound-Guided Tissue Acquisition in Patients on Antithrombotic Therapy: A Systematic Review and Meta-Analysis.

BACKGROUND: The present guidelines stratify endoscopic ultrasound-guided tissue acquisition (EUS-TA) as a high-bleeding risk procedure in patients on antithrombotics. However, the data regarding the same are conflicting. Therefore, this meta-analysis aimed to analyze the bleeding event rates associated with EUS-TA in patients receiving antithrombotic therapy. METHODS: A literature search from January 2000 to August 2022 was done for studies on EUS-guided TA in patients receiving antithrombotics. The primary outcome was incidence of overall and major bleeding. Pooled event rates across studies were expressed with summative statistics. RESULTS: A total of 12 studies were included in the meta-analysis. The pooled risk of overall bleeding and major bleeding in patients on antithrombotics was 2.0% (0.6-3.4) and 0.8% (0.0-1.6), respectively. In patients taking thienopyridine or anticoagulants, the pooled risk of overall bleeding and major bleeding was 2.4% (0.9-3.9) and 1.7% (0.4-3.1), respectively. Patients on antithrombotics had a higher odd of overall bleeding (OR 2.12, 1.20-3.83) and major bleeding (OR 3.58, 1.11-11.52) compared to controls. The odds of overall bleeding (OR 0.95, 95%CI 0.38-2.42) and major bleeding (OR 1.57, 95%CI 0.45-5.54) were comparable between patients on antithrombotics who continued and those who discontinued it preprocedural. CONCLUSION: Despite an increase risk of bleeding with EUS-TA in patients on antithrombotics, the pooled incidence remains low. Compared to the previous guidelines stating thienopyridine use as high risk for bleeding, the present analysis showed a bleeding rate of less than 1%. Discontinuing antithrombotics prior to EUS-TA does not reduce the bleeding risk significantly, requiring strict monitoring.

Diagnostic outcome and safety of plugged liver biopsy in high-risk patients: a systematic review and meta-analysis.

BACKGROUND: Percutaneous liver biopsy is the gold standard test for the assessment of liver disease. In patients with coagulopathy, ascites, post-transplantation, and hypervascular tumors, biopsy is associated with increased risk of adverse events (AEs). Transjugular liver biopsy (TJLB) is recommended in these conditions but is expensive and unavailable at many centers. Plugged liver biopsy (PLB) provides an alternate diagnostic modality in these high-risk cases. PURPOSE: To analyze the pooled diagnostic outcome and safety of PLB in high-risk cases. MATERIAL AND METHODS: A literature search of various databases from January 1990 to July 2022 was conducted for studies evaluating the outcome of PLB in high-risk cases. The primary outcomes were pooled sample adequacy and AEs. Pooled event rates across studies were expressed with summative statistics. RESULTS: A total of 17 studies (2329 patients) were included in the meta-analysis. The pooled proportion of sample adequacy was 98.9% (95% confidence interval [CI]=98.2-99.6). Severe AEs, major bleeding, and minor AEs were seen in 0.7% (95% CI=0.1-1.3), 0.4% (95% CI=0.1-0.8), and 11.5% (95% CI=2.4-20.6) of the patients. There was only one reported mortality, giving a pooled incidence of 0.0002% (95% CI=0.0-0.0038). Compared to TJLB (5 studies, n = 336), there was no difference in either sample adequacy (odds ratio [OR]=2.34, 95% CI=0.83-6.58) or risk of serious AEs (OR=0.47, 95% CI=0.173-1.31). CONCLUSION: PLB can be safely performed on patients with coagulopathy and/or ascites with high sample adequacy rates and low incidence of AEs and mortality.

Standard and Extended Thromboprophylaxis in Patients with Inflammatory Bowel Disease: A Literature Review.

Patients with inflammatory bowel disease (IBD), both Crohn's disease and ulcerative colitis, frequently experience venous thromboembolism (VTE), a potentially fatal consequence. The pathophysiological mechanisms contributing to VTE include inflammation, modifications in coagulation factors, endothelial dysfunction, and platelet activation. Numerous pro-inflammatory cytokines and markers, such as tumor necrosis factor-alpha and interleukin-6, have a significant impact on the thrombotic cascade. Patients with IBD are more likely to suffer VTE for a variety of causes. Exacerbations of preexisting conditions, admission to the hospital, surgical intervention, immobilization, corticosteroid usage, central venous catheterization, and hereditary susceptibility all fit into this category. The mainstay of therapy for VTE in IBD patients includes anticoagulation that is individualized for each patient depending on the thrombosis site, severity, bleeding risk, and interaction with other drugs. In some high-risk IBD patients, such as those having major surgery or hospitalized with severe flare, preventive anticoagulation may play a role. However, the acceptance rate for this recommendation is low. Additionally, there is a subset of patients who would require extended thromboprophylaxis. The majority of the studies that looked into this question consisted of patients in the surgical setting. Emerging data suggest that risk factors other than surgery can also dictate the duration of anticoagulation. While extending anticoagulation in all patients may help reduce VTE-related mortality, identifying these risk factors is important. Hence, the decision to initiate prophylaxis should be individualized, considering the overall thrombotic and bleeding risks. This review explores the relationship between IBD and VTE, including risk factors, epidemiology, and prevention. A multifactorial approach involving aggressive management of underlying inflammation, identification of modifiable risk factors, and judicious use of anticoagulant therapy is essential for reducing the burden of VTE in this vulnerable population. How to cite this article: Harindranath S, Varghese J, Afzalpurkar S, et al. Standard and Extended Thromboprophylaxis in Patients with Inflammatory Bowel Disease: A Literature Review. Euroasian J Hepato-Gastroenterol 2023;13(2):133-141.

Assessment of Visceral Fat Volume and Its Correlation with the Severity of Hepatic Fibrosis in Patients with NAFLD.

INTRODUCTION: Nonalcoholic fatty liver disease (NAFLD) is one of the leading causes of chronic liver disease. The spectrum of NAFLD includes simple steatosis, nonalcoholic steatohepatitis (NASH), advanced fibrosis, and cirrhosis. Our study aimed to calculate visceral fat volume at the L3-L4 vertebral level and its association with hepatic fibrosis assessed by transient elastography. METHODS: All patients above 18 years undergoing computed tomography (CT) abdomen in the Department of Radiodiagnosis of Medical College Thiruvananthapuram during the study period with NAFLD were included. Transient elastography was done. Patients were categorized to advanced fibrosis (>10 kPa) and without advanced fibrosis (<10 kPa). The area under the receiver operating characteristic (AUROC) curve was plotted. RESULTS: Sixty-four patients comprised 36 males and 28 females. Thirty-one (46%) were having advanced fibrosis (transient elastography>10 kPa) and 34 (54%) patients were without advanced fibrosis. About 0.733 was the AUROC for visceral fat in predicting advanced fibrosis. The cutoff was 167.5cm3 (sensitivity was 77.4% and specificity was 51.5% in predicting advanced fibrosis). CONCLUSION: About 0.733 was the AUROC for visceral fat in predicting advanced fibrosis. The cutoff was 167.5cm3 (sensitivity was 77.4% and specificity was 51.5% in predicting advanced fibrosis).

Barrett's Esophagus: A Comparison Study between Two Cohorts of Gastroesophageal Reflux Disease.

INTRODUCTION: Barrett's esophagus (BE) is a complication of gastroesophageal reflux disease (GERD). It is seen among 15% of GERD patients as per a population-based study by Ronkainen et  al. Barrett's has malignant potential and annual progression to carcinoma depends on the presence or absence of dysplasia. There are various risk factors for the development of BE. We compared two symptomatic cohorts of GERD patients from the same geographical area who were evaluated for the presence of Barrett's and various factors that can contribute to Barrett's Materials and methods: Cross-sectional study. Two GERD cohorts, one from Kottayam and the other from Trivandrum were taken. The presence of Barrett's and the factors contributing to the development of Barrett's were analyzed between the two groups. Since biopsy data of all patients were not available, endoscopically suspected esophageal metaplasia (ESEM) was taken as Barrett's Results: 415 patients were enrolled for the study (203 from Trivandrum and 212 from Kottayam). 192 females (99 from Trivandrum and 93 from Kottayam), and 223 males (104 from Trivandrum and 119 from Kottayam). Barrett's esophagus and especially long-segment Barrett's were significantly more common in Kottayam than Trivandrum (68 vs 22 and 36 vs 9) (p-value <0.001). Among the factors that were traditionally thought to contribute to the development of Barrett's esophagus, age (>50 years) was not statistically significant among the two cohorts (mean age of Trivandrum was 48 years and Kottayam was 49 years). Duration of GERD symptoms was significantly more in the Trivandrum cohort compared to Kottayam (p-value <0.001). Hiatus hernia and body mass index (BMI) were more common in Kottayam. There were no statistically significant differences in erosive esophagitis and antral gastritis (%age?) between the two cohorts. CONCLUSION: Both Trivandrum and Kottayam belong to the same geographical area and are separated by a distance of only 150 km. The Kottayam cohort is more prone to develop distal esophageal carcinoma as the BE is more in Kottayam. This data also suggests the need for GERD registries so that high-risk population can be targeted and early intervention can lead to a decrease in the incidence of distal esophageal carcinomas.

Validation of Spleen Shear Wave Elastography for the Screening of High-risk Varices in Patients with Compensated Advanced Chronic Liver Disease.

OBJECTIVES: Total number of avoided endoscopies using Baveno VI criteria is relatively low. Spleen elastography is an attractive tool and when compared with liver stiffness, it better represents the dynamic changes occurring in portal hypertension. The aim of the study was to evaluate spleen shear wave elastography (SWE) in compensated advanced chronic liver disease (cACLD) patients for ruling out the presence of esophageal high-risk varices (HRV). METHODS: A total of 401 patients with cACLD were included in this cross-sectional study. The total sample was split into training set (200 patients) and validation set (201 patients). Spleen stiffness was measured with two-dimensional shear wave elastography (2D SWE). Esophageal HRV were defined as large varices (diameter >5 mm) or small varices with red color signs. In the training set, the receiver operating characteristic (ROC) curve was drawn and the area under the curve (AUC) of spleen SWE was assessed. A cutoff value was chosen (highest sensitivity and negative predictive value). In the validation set, the spleen SWE cutoff score and Baveno VI criteria were validated. RESULTS: The prevalence of HRV was 12% in the training set and 13% in the validation set. Spleen SWE had an AUC of 0.89 in ruling out the presence of high-risk esophageal varices (cutoff value of 48.7 kPa, sensitivity of 100%, and specificity of 53%). Validating spleen SWE ≤48.7 kPa in a different cohort of 201 cACLD patients, 55% of screening endoscopies could be avoided without missing any HRV, whereas using Baveno VI criteria only 30% of screening endoscopies could be spared. CONCLUSION: Spleen SWE ≤48.7 kPa was able to identify cACLD patients who could safely avoid screening endoscopy with good accuracy. Spleen SWE could avoid an additional 25% of screening endoscopies compared to the Baveno VI criteria and no HRV were missed.

Association of Sarcopenia with Health Related Quality of Life in Cirrhotics.

BACKGROUND & OBJECTIVES: Sarcopenia is one of the most common complication associated with mortality in cirrhotic patients. However, the lack of an objective and reliable method to quantify muscle mass has limited the general incorporation of sarcopenia into cirrhosis prognostic scores. In this article, we highlight crosssectional imaging-based estimation of skeletal muscle mass for diagnosing sarcopenia in cirrhotic patients and its effect on health related quality of life. METHODS: After getting ethical clearance and informed consent, all patients with cirrhosis were taken and assessed for sarcopenia using thigh muscle based index The average feather index was used in conjunction with BMI in determining the probability of sarcopenia. The CLDQ was used to assess the health related quality of life. The chi-square and Pearsons coefficient were used for analyzing correlation between sarcopenia and other variables. RESULTS & DISCUSSION: In our study, out of the 288 patients, sarcopenia was present in 132 patients (45.83%). Sarcopenia was present in 18.2% in CHILD A,42.4 % in CHID B and 90.5 % in CHILD C cirrhotics. Sarcopenia was highest in autoimmune hepatitis related cirrhosis (80%), followed by NASH (61.9%),followed by ethanol (42.4%), followed by HCV (28.5%) and HBV (16.6%). Sarcopenia had a moderate negative correlation with health related Quality of life as assessed by CLD Q particularly in relation with systemic symptoms and activity. CONCLUSION: The factors like high MELD, CHILD C cirrhosis, NASH as etiology, were associated with higher prevalence of sarcopenia.NASH related cirrhotics have high prevalance of sarcopenia even in CHILD A patients. The patients with sarcopenia were having a low overall quality of life as per CLDQ,especially in specific aspects related to systemic symptoms and activity.

Low Bifidobacterium Abundance in the Lower Gut Microbiota Is Associated With Helicobacter pylori-Related Gastric Ulcer and Gastric Cancer.

Helicobacter pylori infection in stomach leads to gastric cancer, gastric ulcer, and duodenal ulcer. More than 1 million people die each year due to these diseases, but why most H. pylori-infected individuals remain asymptomatic while a certain proportion develops such severe gastric diseases remained an enigma. Several studies indicated that gastric and intestinal microbiota may play a critical role in the development of the H. pylori-associated diseases. However, no specific microbe in the gastric or intestinal microbiota has been clearly linked to H. pylori infection and related gastric diseases. Here, we studied H. pylori infection, its virulence genes, the intestinal microbiota, and the clinical status of Trivandrum residents (N = 375) in southwestern India by standard H. pylori culture, PCR genotype, Sanger sequencing, and microbiome analyses using Illumina Miseq and Nanopore GridION. Our analyses revealed that gastric colonization by virulent H. pylori strains (vacAs1i1m1cagA+) is necessary but not sufficient for developing these diseases. Conversely, distinct microbial pools exist in the lower gut of the H. pylori-infected vs. H. pylori-non-infected individuals. Bifidobacterium (belonging to the phylum Actinobacteria) and Bacteroides (belonging to the phylum Bacteroidetes) were present in lower relative abundance for the H. pylori+ group than the H. pylori- group (p < 0.05). On the contrary, for the H. pylori+ group, genus Dialister (bacteria belonging to the phylum Firmicutes) and genus Prevotella (bacteria belonging to the phylum Bacteroidetes) were present in higher abundance compared to the H. pylori- group (p < 0.05). Notably, those who carried H. pylori in the stomach and had developed aggressive gastric diseases also had extremely low relative abundance (p < 0.05) of several Bifidobacterium species (e.g., B. adolescentis, B. longum) in the lower gut suggesting a protective role of Bifidobacterium. Our results show the link between lower gastrointestinal microbes and upper gastrointestinal diseases. Moreover, the results are important for developing effective probiotic and early prognosis of severe gastric diseases.

Validation of Baveno VI Criteria for Screening of Esophageal Varices in a Cohort of South Asian Patients with Compensated Chronic Liver Disease.

OBJECTIVES: A patient with liver stiffness by Vibration controlled Transient elastography(TE) <20 kPa and a platelet count >150,000/mm3 does not require screening endoscopy according to Baveno VI consensus. The Baveno consensus statement on esophageal varices screening has not been validated in the South Asian population. TE may not be widely available in resource limited areas. We tried to see whether easily available parameters could be used to predict high risk varices(HRV). METHOD: A cross-sectional study evaluating patients with liver stiffness >10 kPa who had endoscopy within 6 months of TE evaluation. RESULTS: 375 patients who underwent TE and upper GI endoscopy over one year were included. Commonest etiology was HBV(42 %) followed by Hepatitis C(39%), NAFLD(9.1%) and alcohol(9%). 262 of the 266 patients satisfying Baveno VI consensus criteria for avoiding screening endoscopy did not have HRV. Sensitivity, specificity, positive predictive value(PPV) and negative predictive value(NPV) was 96 %, 90 %, 74% and 99 % respectively and (AUC = 0.91). By using MELD 6 or MELD < 8 and platelet >150000/mm3 criteria, 67% endoscopies could have been circumvented. Using Baveno VI criteria, 70% endoscopies could have been circumvented. CONCLUSION: This study validates the Baveno VI consensus statement on esophageal variceal screening in cirrhosis, in a South Asian population. It also describes a new strategy using MELD 6 or MELD < 8 and platelet > 150000/mm3 in areas with limited resources where TE is not widely available.

Quality of life, caregiver burden and mental health disorders in primary caregivers of patients with Cirrhosis.

BACKGROUND AND AIMS: Caregivers are needed for cirrhotic patients as there is progressive decline in cognition and self-care. We intend to study the quality of life (QOL), psychosocial burden and prevalence of mental health disorders among caregivers. METHODS: Cross-sectional study where caregivers, defined as person who takes responsibility of providing care to patient, of cirrhotic patients were included. Short form 36 health survey (SF-36) to assess QOL, Zarit Burdern Index12 (ZBI) for caregiver burden (CB). Patient Health Questionnaire (PHQ) identified depression and Generalized Anxiety Disorder (GAD-7) questionnaires, anxiety. RESULTS: Of 132 caregivers, mean age of caregiver was 41.2 ± 10.3 years, with female preponderance. Mean MELD was 21.4 ± 7, majority belonged to CHILD C. Comparing the SF36 score of caregivers to normal population showed lower level of QOL for caregivers. Mean ZBI score - 14 ± 5.8. Mean GAD score - 8.1 ± 5.1, 54 (41%) had anxiety. Mean PHQ score - 7.8 ± 5.2, 45 (34%) had depression. REGRESSION ANALYSIS: Alcoholic cirrhosis, history of hepatic encephalopathy (HE), Anxiety, Depression and recidivism predicted CB. Treatment costs (ODDS-1.15), alcoholic cirrhosis (ODDS -8.9), history of HE (ODDS-7.5) and caregiver duration (ODDS-0.25) predicted anxiety. Treatment costs (ODDS-1.5), caregiver age (ODDS-0.87), spouse as caregiver (ODDS-10.9) and higher education (ODDS-0.79) predicted depression. CONCLUSIONS: Caregivers of cirrhotic patients have high prevalence of CB with low QOL and high incidence of anxiety and depression, compared with the general population. Alcoholism in patients precipitates while higher education helps cope up with these disorders.