Mesenteric panniculitis associated with non-alcoholic fatty liver disease: A case series.

Mesenter ic p anniculitis (MP) is a b enign infla mmatory condi tion of the abdomin al mesentery, whi ch presents with a wid e variety of symptoms. I t is diagnosed non - invasively through com puted to mography (CT ) scan, whereas biopsy is still co nside red th e gold standa rd. Steroids are the first line of treatment. Here, we report four cases who presented with abdominal pain. These patients were overweight and the CT scan findings were suggestive of mese nte ric panniculitis. Three cases had concomitant non- alcoholic steatohep atitis w ith el evated alanine transaminase levels, dyslipidaemia, and insulin resistance. FibroSca n showed moderate to severe steatosis. PNPLA3 rs738409 genotype was homozygous positive (GG) in one patient, whereas two patients were heterozygous positive (CG ). This a ssociat io n has not been well-described so far and w arrants f ur ther inve s tigation. There may be some common predisposing factors.

Des-gamma-carboxy prothrombin and alpha-fetoprotein levels as biomarkers for hepatocellular carcinoma and their correlation with radiological characteristics.

BACKGROUND: Alpha-fetoprotein (AFP), a commonly used biomarker for hepatocellular carcinoma (HCC), is normal in up to one-third of patients. AIM: To evaluate the diagnostic performance of des-gamma-carboxy-prothrombin (DCP) alone and in combination with AFP. METHODS: In this study, 202 patients with radiologically proven HCC were enrolled, and their DCP and AFP levels were evaluated for their diagnostic performance. RESULTS: The mean age of the enrolled patients was 58.5 years; 72.0% were male. DCP was elevated in 86.6% (n = 175) of all patients, 100.0% (n = 74) of patients with portal vein thrombus, and 87.4% (n = 111) of patients with multicentric HCC. AFP was elevated in 64.3% (n = 130) of all the patients, 74% (n = 55) of the patients with portal vein thrombus, and 71.6% (n = 91) of the patients with multicentric HCC (P = 0.030, 0.001, and 0.015, respectively). In tumors less than 2 cm in size (n = 46), DCP was increased in 32 (69.5%) patients, and AFP was increased in 25 (54.3%) patients (P = 0.801). There was good pairing between DCP and AFP for HCCs of 2 cm size or larger (P < 0.001); however, the pairing among tumors < 2 cm size was not significant (P = 0.210). In 69 of the patients (34.1%), only one of the tumor markers was positive; DCP was elevated alone in 57/202 (28.2%) of all patients, and AFP alone was elevated in 12/202 (5.9%) of the patients. The areas under receiver operating characteristic curves (AUROC) for tumors > 2 cm was 0.74 for DCP and 0.59 for AFP; combining both markers resulted in an AUROC of 0.73. For tumors < 2 cm, the AUROC was 0.25 for DCP and 0.40 for AFP. CONCLUSION: DCP, as an individual marker, had a better diagnostic performance in many cases of HCC. Hence, DCP may replace AFP as the primary HCC biomarker.

Is there a need for universal double reflex testing of HBsAg-positive individuals for hepatitis D infection?

Hepatitis D virus (HDV) can infect HBsAg-positive individuals, causing rapid fibrosis progression, early decompensation, increased hepatocellular carcinoma risk, and higher mortality than hepatitis B virus (HBV) mono-infection. Most countries lack high-quality HDV prevalence data, and the collection techniques employed often bias published data. In recent meta-analyses, HDV prevalence in HBsAg-positive patients reaches 5%-15% and is even significantly higher in endemic areas. Since HBV vaccination programs were implemented, HDV prevalence has decreased among younger populations. However, owing to immigrant influx, it has increased in some Western countries. The current practice of HDV screening in HBsAg-positive individuals is stepwise, based on physician's discretion, and limited to at-risk populations and may require numerous visits. Double reflex testing, which includes anti-HDV testing in all HBsAg-positive individuals and then HDV RNA testing for anti-HDV-positive ones, is uncommon. Reflex testing can identify more HDV infection cases and link identified patients to further care and follow-up. Moreover, laboratory-based double reflex screening is less biased than physician-led testing. Therefore, healthcare providers should learn about reflex testing, and federal and provincial hepatitis control programs should implement laboratory-based double reflex testing to obtain reliable HDV prevalence estimates. The test's cost-effectiveness depends on the number of HBV-positive patients screened to identify one HDV-positive patient. Such testing may be viable in areas with low HBsAg but high HDV prevalence. However, its economic impact on areas with low HDV prevalence needs further study.

National guidelines for the diagnosis and treatment of hilar cholangiocarcinoma.

A consensus meeting of national experts from all major national hepatobiliary centres in the country was held on May 26, 2023, at the Pakistan Kidney and Liver Institute & Research Centre (PKLI & RC) after initial consultations with the experts. The Pakistan Society for the Study of Liver Diseases (PSSLD) and PKLI & RC jointly organised this meeting. This effort was based on a comprehensive literature review to establish national practice guidelines for hilar cholangiocarcinoma (hCCA). The consensus was that hCCA is a complex disease and requires a multidisciplinary team approach to best manage these patients. This coordinated effort can minimise delays and give patients a chance for curative treatment and effective palliation. The diagnostic and staging workup includes high-quality computed tomography, magnetic resonance imaging, and magnetic resonance cholangiopancreatography. Brush cytology or biopsy utilizing endoscopic retrograde cholangiopancreatography is a mainstay for diagnosis. However, histopathologic confirmation is not always required before resection. Endoscopic ultrasound with fine needle aspiration of regional lymph nodes and positron emission tomography scan are valuable adjuncts for staging. The only curative treatment is the surgical resection of the biliary tree based on the Bismuth-Corlette classification. Selected patients with unresectable hCCA can be considered for liver transplantation. Adjuvant chemotherapy should be offered to patients with a high risk of recurrence. The use of preoperative biliary drainage and the need for portal vein embolisation should be based on local multidisciplinary discussions. Patients with acute cholangitis can be drained with endoscopic or percutaneous biliary drainage. Palliative chemotherapy with cisplatin and gemcitabine has shown improved survival in patients with irresectable and recurrent hCCA.

Expert consensus on the diagnosis and treatment of end-stage liver disease complicated by infections.

End-stage liver disease (ESLD) is a life-threatening clinical syndrome and when complicated with infection the mortality is markedly increased. In patients with ESLD, bacterial or fungal infection can induce or aggravate the occurrence or progression of liver decompensation. Consequently, infections are among the most common complications of disease deterioration. There is an overwhelming need for standardized protocols for early diagnosis and appropriate management for patients with ESLD complicated by infections. Asia Pacific region has the largest number of ESLD patients, due to hepatitis B and the growing population of alcohol and NAFLD. Concomitant infections not only add to organ failure and high mortality but also to financial and healthcare burdens. This consensus document assembled up-to-date knowledge and experience from colleagues across the Asia-Pacific region, providing data on the principles as well as evidence-based current working protocols and practices for the diagnosis and treatment of patients with ESLD complicated by infections.

Asian Pacific Association for the Study of the Liver clinical practice guidelines on liver transplantation.

Liver transplantation is a highly complex and challenging field of clinical practice. Although it was originally developed in western countries, it has been further advanced in Asian countries through the use of living donor liver transplantation. This method of transplantation is the only available option in many countries in the Asia-Pacific region due to the lack of deceased organ donation. As a result of this clinical situation, there is a growing need for guidelines that are specific to the Asia-Pacific region. These guidelines provide comprehensive recommendations for evidence-based management throughout the entire process of liver transplantation, covering both deceased and living donor liver transplantation. In addition, the development of these guidelines has been a collaborative effort between medical professionals from various countries in the region. This has allowed for the inclusion of diverse perspectives and experiences, leading to a more comprehensive and effective set of guidelines.

Saccharomyces cerevisiae for abdominal pain and discomfort in irritable bowel syndrome patients.

Background: Irritable Bowel Syndrome (IBS) leads to significant impairment of health-related quality of life, for the alleviation of which, the efficacy of available therapies is modest. Limited data is available on the role of Saccharomyces cerevisiae in treating patients with IBS. Methods: Thirty patients with IBS as per Rome-IV criteria, visiting our outpatient department from March 2021 to October 2021, were given capsule Saccharomyces cerevisiae 500 mg twice daily for four weeks. Evaluation for abdominal pain symptoms was done every week and the patient's compliance was assessed. IBS Quality of Life (QOL) questionnaires were filled at baseline and after four weeks of treatment. The QOL and pain scales were adjusted to 0-100 for statistical analysis. Results: Seventeen patients (56.7%) were males. The age range was 21-72 years (mean ± SD: 39. 63 ± 14.32), out of which 18(60%) patients were 20-40 years old. Body Mass Index (BMI) ranged from 18-33 (25.33 ± 4.09), and 17 (56.67%) were overweight or obese. Sixteen patients had constipation predominant (53.3%), nine had diarrhea-predominant (30%), and five had mixed-type (16.7%) IBS. There was an improvement in the pain score from 63.81 at week 0 (W0) to 20.48 at the end of week 4 (W4) (p<0.001). An improvement was noted in all the eight categories of IBS QOL questionnaire, i.e., dysphoria (p<0.001), interference with activity (p<0.001), body image (p<0.001), health worry (p<0.001), food avoidance (p<0.001), social reaction (p<0.001), sexual function (p<0.001) and relationships (p<0.001). There was an overall improvement in QOL score from a mean of 24.68 at baseline to 58.09 at the end of the study duration (p<0.001). The improvement in the pain score showed a positive correlation with the improvement in quality of life (p<0.001). Conclusion: Treatment with Saccharomyces cerevisiae improved the pain and quality of life in patients with IBS and it appears to be a promising option for alleviating symptoms in these patients.

Role of Alanine Transaminase and Transient Elastography in Categorising Nonalcoholic Fatty Liver Disease Subgroups.

OBJECTIVE: To investigate the association of alanine transaminase (ALT) with transient elastography grades to define various nonalcoholic fatty liver disease (NAFLD) groups for disease status. STUDY DESIGN: Cross-sectional, descriptive study. Place and Duration of the Study: Gastroenterology Outpatient Clinic, Ziauddin Hospital, from January to December 2022. METHODOLOGY: This study included 194 NAFLD patients. Demographic data, body mass index, enzymes, and transient elastography (TE) findings were recorded. NAFLD patients were categorised as nonalcoholic fatty liver (NAFL), nonalcoholic steatohepatitis (NASH), steatofibrosis (significant fibrosis F2-F3 with normal ALT), and cirrhosis using TE grades. RESULTS: The median age of the patients was 44 [IQR 18.25] years; 146 (75.3%) were males. Out of 194 NAFLD patients, 21 (10.8%) were NAFL, 116 (59.8%) were NASH, 14 (7.2%) showed steatofibrosis, and 43 (22.2%) were cirrhotic. On transient elastography, the majority were with S3 steatosis (n=107, 55.2%) and 59 (30.2%) had F0-F1 fibrosis. There was a statistically significant difference in the mean rank of age, ALT, AST, and GGT levels within 4 groups of NAFLD (p <0.001). Most of the patients with all the stages of fibrosis had increased ALT levels (p=0.034). CONCLUSION: This study concluded that a combination of ALT levels and transient elastography findings could be considered for differentiating uncomplicated steatosis from NASH, steatofibrosis, and cirrhosis, hence limiting the use of liver biopsy. This may prove a reliable way to measure the severity of the disease. KEY WORDS: Nonalcoholic fatty liver disease, Cirrhosis, Transient elastography.

An Insight Into the Factors Affecting the Prevalence and Natural History of Hepatitis D.

Epidemiological studies and recent metanalyses addressing hepatitis D have reported a wide variation in the prevalence of the disease. Between 4.5% to 15% of all hepatitis B surface antigen (HBsAg) positive patients are thought to harbor the hepatitis D virus. The emergent variation in prevalence can be attributed to several factors. Unsurprisingly, published literature shows that the prevalence of the disease is higher in areas where aggregate viral hepatitis infections are endemic and amongst groups with high-risk practices facilitating the horizontal transfer. Meanwhile, the natural history of the disease is influenced by the genotype of the virus, the hepatitis D virus (HDV) RNA levels, HBV-HDV codominance, HBsAg titers, HBV genotype, nutritional status, HIV co-infection, and prior treatment. Together these factors contribute to the accelerated development of fibrosis and the increased risk of hepatocellular carcinoma. Superinfection with genotype 1 results in rapid progression to cirrhosis with lower rates of remission. Genotype 3 follows an aggressive course but shows a good response to interferon therapy. Other genotypes have better outcomes. The course of the disease leading to these outcomes can be tracked by HDV-specific models integrating clinical surrogate markers and epidemiological factors such as age, region, alanine aminotransferase (ALT), gamma-glutamyl transferase, albumin, platelets and cholinesterase, and liver stiffness.

Water stress effects on stay green and chlorophyll fluorescence with focus on yield characteristics of diverse bread wheats.

MAIN CONCLUSION: The study provided an insight toward better understanding of stay-green mechanisms for drought tolerance improvement and identified that synthetic-derived wheats proved as a promising germplasm for improved tolerance against water stress. Stay-green (SG) trait is considered to be related with the ability of wheat plants to maintain photosynthesis and CO2 assimilation. The present study explored the interaction of water stress with SG expression through physio-biochemical, agronomic and phenotypic responses among diverse wheat germplasm comprising of 200 synthetic hexaploids, 12 synthetic derivatives, 97 landraces and 16 conventional bread wheat varieties, for 2 years. The study established that variation of SG trait existed in the studied wheat germplasm and there was positive association between SG trait and tolerance to water stress. The relationship of SG trait with chlorophyll content (r = 0.97), ETR (r = 0.28), GNS (r = 0.44), BMP (r = 0.34) and GYP (r = 0.44) was particularly promising under water stress environment. Regarding chlorophyll fluorescence, the positive correlation of фPSII (r = 0.21), qP (r = 0.27) and ETR (r = 0.44) with grain yield per plant was noted. The improved ΦPSII and Fv/Fm of PSII photochemistry resulted in the high photosynthesis activity in SG wheat genotypes. Regarding relative water content and photochemical quenching coefficient, synthetic-derived wheats were better by maintaining 20.9, 9.8 and 16.1% more RWC and exhibiting 30.2, 13.5 and 17.9% more qP when compared with landraces, varieties and synthetic hexaploids, respectively, under water stress environment. Synthetic derived wheats also exhibited relatively more SG character with good yield and were more tolerant to water stress in terms of grain yield, grain weight per plant, better photosynthetic performance through chlorophyll fluorescence measurement, high leaf chlorophyll and proline content, and hence, may be used as novel sources for breeding drought tolerant materials. The study will further facilitate research on wheat leaf senescence and will add to better understanding of SG mechanisms for drought tolerance improvement.

Point of Care Testing for SARS-COV-2 Antibodies before doing Endoscopy.

Objectives: COVID-19 has taken the world by storm, creating much disparity among both healthcare and non-healthcare centres regarding the provision of services. The purpose of our study was to see the prevalence of the SARS-COV-2 exposure in the asymptomatic patients undergoing the endoscopic procedure, already triaged based on history and examination. Methods: Total 207 patients were enrolled during a time period of five months during October 2020 to April 2021 at Dr. Ziauddin Hospital Clifton campus, Karachi. In this prospective observational study patients undergoing endoscopic procedures were included after taking informed consent. The patients who already tested positive for COVID-19 by PCR were excluded. Patients were tested for Covid serology by immunochromatographic rapid serology test (ICT). Standard Operating Procedures for dealing with endoscopy patients during the COVID era were followed in all patients irrespective of antibody status. Result: Total number of patients included was 207; males were 121 (58.5%). The mean age was 48.5 ± 17.55 (range 13 to 92). Forty eight patients (23.2%) were positive for either antibody suggesting exposure to the COVID-19 virus. Out of these combined IgM and IgG positivity was seen in 24 (11.5%), IgM mono antibody positivity was seen in 7 (3.38%) and 17 (8.21%) of the study population tested positive for IgG only. 15 out of 46 (32.6%) patients with chronic liver disease in the cohort were seropositive for COVID antibodies. Conclusion: About one-fourth of the patients undergoing the endoscopic procedure were tested positive for COVID antibodies of which a significant percentage had chronic liver disease. It stresses the need of observing standard precautions to prevent the spread of infection during these procedures, especially in the vulnerable population.

Incidence and predisposing factors for de novo post-COVID-19 irritable bowel syndrome.

OBJECTIVE: Postinfectious irritable bowel syndrome (IBS) is a known entity. We evaluated the incidence of post-COVID-19 IBS in patients discharged from the hospital and analyzed its correlation with the clinical and laboratory parameters, and treatment during the hospital stay. METHODS: Three hundred three COVID-19 hospitalized patients without prior history of IBS were prospectively followed after their discharge and were evaluated as per Rome-IV criteria for IBS. RESULTS: One hundred seventy-eight patients were males (58.7%). The age range was 17-95 years (mean ± SD, 55.9 ± 15.8). A total of 194 (64%) had mild COVID-19, 74 (24.4%) had moderate COVID-19, whereas 35 (11.6%) had severe COVID-19 infection. Sixteen (5.3%) patients had concomitant GI symptoms during COVID-19 infection. IBS symptoms were found to be present in 32 (10.6%) patients, out of which 17 (53.13%) had diarrhea-predominant, 10 (31.25%) had constipation-predominant, and five (15.62%) had mixed-type IBS. Post-COVID-19 IBS was more common in the female sex (P < 0.001), concomitant GI symptoms with COVID-19 (P < 0.001), oxygen requirement (P = 0.015), deranged liver function tests at the time of admission (P = 0.002), high procalcitonin (P = 0.013), high C-reactive protein levels (P = 0.035); whereas negative correlation was found with remdesivir treatment (P = 0.047). After performing regression analysis, female sex (P < 0.001), oxygen requirement during hospital stay (P = 0.016), GI symptoms during COVID-19 infection (P < 0.001), and high procalcitonin levels (P = 0.017) were independently associated with post-COVID-19 IBS. CONCLUSION: GI symptoms during active COVID-19 infection increase the chances of developing post-COVID-19 IBS. The risk of developing post-COVID-19 IBS increases in female patients, those requiring oxygen and having high procalcitonin levels during COVID-19 infection.

Molecular and Physiological Evaluation of Bread Wheat (Triticum aestivum L.) Genotypes for Stay Green under Drought Stress.

Water availability is considered as the main limiting factor of wheat growth illuminating the need of cultivars best adapted to drought situations for better wheat production and yield. Among these, the stay-green trait is thought to be related to the ability of wheat plants to maintain photosynthesis and CO2 assimilation, and a detailed molecular understanding of this trait may help in the selection of high-yielding, drought-tolerant wheats. The current study, therefore, evaluated the physiological responses of the selected wheat genotypes under pot-induced water stress conditions through different field capacities. The study also focused on exploring the molecular mechanisms involved in drought tolerance conferred due to the stay-green trait by studying the expression pattern of the selected PSI-associated light-harvesting complex I (LHC1) and PSII-associated LHCII gene families related to pigment-binding proteins. The results revealed that the studied traits, including relative water content, membrane stability index and chlorophyll, were variably and negatively affected, while the proline content was positively enhanced in the studied wheats under water stress treatments. Molecular diagnosis of the selected wheat genotypes using the expression profile of 06 genes, viz. TaLhca1, TaLhca2, TaLhca3, TaLhcb1, TaLhcb4 and TaLhcb6 that encodes for the LHCI and LHCII proteins, indicated variable responses to different levels of drought stress. The results obtained showed the relation between the genotypes and the severity of the drought stress condition. Among the studied genotypes, Chirya-1 and SD-28 performed well with a higher level of gene expression under drought stress conditions and may be used in genetic crosses to enrich the genetic background of common wheat against drought stress.

Patients visiting gastroenterology clinics avoid giving honest history for COVID-19 related symptoms in the pre-clinic triage.

OBJECTIVE: To assess the discrepancy in terms of history related to coronavirus disease-2019 and symptoms given in the pre-clinic triage and to the doctor attending the patient in a gastroenterology clinic. METHODS: The observational study was conducted from September 2020 to January 2021 at the Gastroenterology outpatient department of Dr Ziauddin Hospital's Clifton unit in Karachi, and comprised all patients visiting the facility regardless of age and gender. Data was collected using a questionnaire that was first filled up by the receptionist outside the clinic and was then administered again once the patient entered the clinic. Discrepancy on the answers was then checked and associations were determined with clinical assessment. Data was analysed using SPSS 20. RESULTS: Of the 300 patients, 184(61.3%) were males and 116(38.6%) were females. The overall mean age was 55 ± 16.98 (range: 18-92 years). Discrepancy between pre-clinic and in-clinic self-reported data was significant for fever, cough, fatigue, headache, body ache, diarrhoea, sore throat, loss of sense of smell/taste, shortness of breath, and contact with someone positive for coronavirus disease-2019 was significant (p<0.05). CONCLUSIONS: Patients were found to be afraid of getting barred from seeing a consultant, had fear of hospital-based isolation or were in denial regarding the pandemic.

Acute variceal bleeding portends poor outcomes in patients with acute-on-chronic liver failure: a propensity score matched study from the APASL ACLF Research Consortium (AARC).

BACKGROUND AND AIMS: Limited data exist regarding outcomes of acute variceal bleeding (AVB) in patients with acute-on-chronic liver failure (ACLF), especially in those with hepatic failure. We evaluated the outcomes of AVB in patients with ACLF in a multinational cohort of APASL ACLF Research Consortium (AARC). METHODS: Prospectively maintained data from AARC database on patients with ACLF who developed AVB (ACLF-AVB) was analysed. This data included demographic profile, severity of liver disease, and rebleeding and mortality in 6 weeks. These outcomes were compared with a propensity score matched (PSM) cohort of ACLF matched for severity of liver disease (MELD, AARC score) without AVB (ACLF without AVB). RESULTS: Of the 4434 ACLF patients, the outcomes in ACLF-AVB (n = 72) [mean age-46 ± 10.4 years, 93% males, 66% with alcoholic liver disease, 65% with alcoholic hepatitis, AARC score: 10.1 ± 2.2, MELD score: 34 (IQR: 27-40)] were compared with a PSM cohort selected in a ratio of 1:2 (n = 143) [mean age-44.9 ± 12.5 years, 82.5% males, 48% alcoholic liver disease, 55.7% alcoholic hepatitis, AARC score: 9.4 ± 1.5, MELD score: 32 (IQR: 24-40)] of ACLF-without AVB. Despite PSM, ACLF patients with AVB had a higher baseline HVPG than without AVB (25.00 [IQR: 23.00-28.00] vs. 17.00 [15.00-21.75] mmHg; p = 0.045). The 6-week mortality in ACLF patients with or without AVB was 70.8% and 53.8%, respectively (p = 0.025). The 6-week rebleeding rate was 23% in ACLF-AVB. Presence of ascites [hazard ratio (HR) 2.2 (95% CI 1.03-9.8), p = 0.026], AVB [HR 1.9 (95% CI 1.2-2.5, p = 0.03)], and MELD score [HR 1.7 (95% CI 1.1-2.1), p = 0.001] independently predicted mortality in the overall ACLF cohort. CONCLUSION: Development of AVB confers poor outcomes in patients with ACLF with a high 6-week mortality. Elevated HVPG at baseline represents a potential risk factor for future AVB in ACLF.

Asian Pacific association for the study of liver (APASL) guidelines: hepatitis B virus in pregnancy.

Hepatitis B virus (HBV) infection still remains a major public health issue in the Asia-Pacific region. Most of the burden of HBV-related disease results from infections acquired in infancy through perinatal or early childhood exposure to HBV in Asia-Pacific. Hepatitis B during pregnancy presents unique management issues for both the mother and fetus. These APASL guidelines provide a comprehensive review and recommendations based on available evidence in the literature, for the management of females with HBV infection through every stage of pregnancy and postpartum. These also address the concerns, management challenges, and required follow-up of children born to hepatitis B-positive mothers.

Impact of compensated cirrhosis on survival in patients with acute-on-chronic liver failure.

BACKGROUND AND AIMS: Acute-on-chronic liver failure (ACLF) is considered a main prognostic event in patients with chronic liver disease (CLD). We analyzed the 28-day and 90-day mortality in ACLF patients with or without underlying cirrhosis enrolled in the ACLF Research Consortium (AARC) database. METHODS: A total of 1,621 patients were prospectively enrolled and 637 (39.3%) of these patients had cirrhosis. Baseline characteristics, complications and mortality were compared between patients with and without cirrhosis. RESULTS: Alcohol consumption was more common in cirrhosis than non-cirrhosis (66.4% vs. 44.2%, p < 0.0001), while non-alcoholic fatty liver disease/cryptogenic CLD (10.9% vs 5.8%, p < 0.0001) and chronic HBV reactivation (18.8% vs 11.8%, p < 0.0001) were more common in non-cirrhosis. Only 0.8% of patients underwent liver transplantation. Overall, 28-day and 90-day mortality rates were 39.3% and 49.9%, respectively. Patients with cirrhosis had a greater chance of survival compared to those without cirrhosis both at 28-day (HR = 0.48; 95% CI 0.36-0.63, p < 0.0001) and 90-day (HR = 0.56; 95% CI 0.43-0.72, p < 0.0001), respectively. In alcohol CLD, non-cirrhosis patients had a higher 28-day (49.9% vs. 23.6%, p < 0.001) and 90-day (58.4% vs. 35.2%, p < 0.001) mortality rate than cirrhosis patients. ACLF patients with cirrhosis had longer mean survival than non-cirrhosis patients (25.5 vs. 18.8 days at 28-day and 65.2 vs. 41.2 days at 90-day). Exaggerated systemic inflammation might be the reason why non-cirrhosis patients had a poorer prognosis than those with cirrhosis after ACLF had occurred. CONCLUSIONS: The 28-day and 90-day mortality rates of ACLF patients without cirrhosis were significantly higher than those with cirrhosis in alcoholic CLD. The presence of cirrhosis and its stage should be evaluated at baseline to guide for management. Thai Clinical Trials Registry, TCTR20191226002.