An excerpt of AASLD practice guidance on risk stratification and management of portal hypertension and varices in cirrhosis （2023） / 临床肝胆病杂志

This Practice Guidance intends to coalesce best practice recommendations for the identification of portal hypertension （PH）， for prevention of initial hepatic decompensation， for the management of acute variceal hemorrhage （AVH）， and for reduction of the risk of recurrent variceal hemorrhage in chronic liver disease. The most significant changes in the current Guidance relate to recognition of the concept of compensated advanced chronic liver disease， codification of methodology to use noninvasive assessments to identify clinically significant PH （CSPH）， and endorsement of a change in paradigm with the recommendation of early utilization of nonselective beta-blocker therapy when CSPH is identified. The updated guidance further explores potential future pharmacotherapy options for PH， clarifies the role of preemptive transjugular intrahepatic portosystemic shunt in AVH， discusses more recent data related to the management of cardiofundal varices， and addresses new topics such as portal hypertensive gastropathy and endoscopy prior to transesophageal echocardiography and antineoplastic therapy.

Excerpts of European Association for the Study of the Liver Clinical Practice Guidelines on Acute-on-chronic Liver Failure in 2023 / 胃肠病学

Acute-on-chronic liver failure(ACLF),which was first described in 2013,is a severe form of acutely decompensated cirrhosis characterized by the existence of organ system failure(s)and a high risk of short-term mortality.ACLF is caused by an excessive systemic inflammatory response triggered by precipitants that are clinically apparent(e.g.,confirmed microbial infection with sepsis,severe alcohol-related hepatitis)or not.Since the description of ACLF,some important studies have suggested that patients with ACLF may benefit from liver transplantation and should therefore be urgently stabilized for transplantation by receiving appropriate etiological treatment and comprehensive management,including support of organ systems in the intensive care unit(ICU).The goal of the present clinical practice guidelines is to provide the most reliable evidence available to assist the clinical decision-making process in the management of patients with ACLF,to make triage decisions(ICU vs.no ICU),to identify and manage acute precipitants,to identify organ systems that require support or replacement,to define potential criteria for futility of intensive care,and it also provides suggestions for identifying potential indications for liver transplantation.

Exerpts of European Association for the Study of the Liver clinical practice guidelines on acute-on-chronic liver failure in 2023 / 中华消化杂志

Acute-on-chronic liver failure (ACLF), which was first described in 2013, is a severe form of acutely decompensated cirrhosis characterised by the existence of organ system failure(s) and a high risk of short-term mortality. ACLF is caused by an excessive systemic inflammatory response triggered by precipitants that are clinically apparent (e.g., comfirmed microbial infection with sepsis, severe alcohol-related hepatitis) or not. Since the description of ACLF, some important studies have suggested that patients with ACLF may benefit from liver transplantation and should therefore be urgently stabilized for transplantation by receiving appropriate etiological treatment and comprehesive management, including support of organ systems in the intensive care unit (ICU). The goal of the present clinical practice guidelines is to provide the most reliable evidence available to assist the clinical decision-making process in the management of patients with ACLF, to make triage decisions (ICU vs. no ICU), to identify and manage acute precipitants, to identify organ systems that require support or replacement, to define potential criteria for futility of intensive care, and it also provides suggestions for identifying potential indications for liver transplantation.

Excerpts of European Association for the Study of the Liver clinical practice guidelines on the management of liver diseases in pregnancy (2023) / 中华消化杂志

Liver diseases in pregnancy comprise both gestational liver disorders and acute and chronic hepatic disorders occurring coincidentally in pregnancy. Whether pregnancy-related or not, liver diseases in pregnancy are associated with a significant risk of maternal and fetal morbidity and mortality. Thus, the European Association for the Study of Liver invited a panel of experts to develop clinical practice guidelines aimed at providing recommendations, based on the best available evidence, for the management of liver disease in pregnancy for hepatologists, gastroenterologists, obstetric physicians, general physicians, obstetricians, training specialists and other healthcare professionals who provide care for this patient population.

An Excerpt of 2022 European Association for the Study of the Liver Clinical Practice Guidelines on the Management of Hepatic Encephalopathy / 胃肠病学

In 2022, the European Association for the Study of the Liver clinical practice guidelines on the management of hepatic encephalopathy (HE) present evidence ⁃ based answers to a set of relevant questions, which formulated in participant, intervention, comparison, and outcome (PICO) format on the definition, diagnosis, differential diagnosis and treatment of HE. This excerpt does not cover the pathophysiology of HE and does not cover all available treatment options. It presents the readers with translations and summarizations of the above mentioned recommendations. The methods through which it was developed and any information relevant to its interpretation are also provided.

An Excerpt of 2022 European Association for the Study of the Liver Clinical Practice Guidelines on the Management of Cystic Liver Diseases / 胃肠病学

The advent of enhanced radiological imaging techniques has facilitated the diagnosis of cystic liver lesions. Concomitantly, the evidence base supporting the management of these diseases has matured over the last decades. As a result, comprehensive clinical guidance on the subject matter is warranted. This guideline covers the diagnosis and management of hepatic cysts, mucinous cystic neoplasms of the liver, polycystic liver disease, caroli disease, caroli syndrome, biliary hamartomas and peribiliary cysts. On the basis of in⁃depth review of the relevant literature, this guideline provides recommendations to navigate clinical dilemmas followed by supporting text. The recommendations are graded according to the Oxford Centre for Evidence⁃based Medicine system and categorized as "weak" or "strong". This guideline aims to provide the best available evidence to aid the clinical decision⁃making process in the diagnosis and treatment of patients with cystic liver diseases, and presents the readers with translations and summarizations of the above mentioned recommendations.

Application status and future prospect of transjugular intrahepatic portosystemic shunt in gastroesophageal variceal bleeding in liver cirrhosis / 临床肝胆病杂志

Gastroesophageal variceal bleeding is the life-threating complication of cirrhotic portal hypertension, and transjugular intrahepatic portosystemic shunt (TIPS) is an effective therapy for portal hypertension-related complications. TIPS can be used for the prevention of first-time bleeding in patients with recurrent or intractable ascites. TIPS should be performed as early as possible for patients at a high risk of acute variceal bleeding (Child-Pugh class C 7 points with active bleeding on endoscopy or hepatic venous pressure > 20 mmHg). TIPS is an effective salvage therapy for acute variceal bleeding with failure after standard treatment, and is also a second-line option for preventing variceal rebleeding.

An excerpt of 2022 European Association for the Study of the Liver clinical practice guidelines on the management of hepatic encephalopathy / 中华消化杂志

In 2022, the European Association for the Study of the Liver clinical practice guideline on the management of hepatic encephalopathy (HE) present evidence-based answers to a set of relevant questions, which formulated in participant, intervention, comparison and outcome (PICO) format on the definition, diagnosis, differential diagnosis and treatment of HE. The document does not cover the pathophysiology of HE and does not cover all available treatment options. We present the readers with translations and summarizations of the above mentioned recommendations. The methods through which it was developed and any information relevant to its interpretation are also provided.

An excerpt of 2022 European Association for the Study of the Liver clinical practice guidelines on the management of cystic liver diseases / 中华消化杂志

The advent of enhanced radiological imaging techniques has facilitated the diagnosis of cystic liver lesions. Concomitantly, the evidence base supporting the management of these diseases has matured over the last decades. As a result, comprehensive clinical guidance on the subject matter is warranted. This guideline covers the diagnosis and management of hepatic cysts, mucinous cystic neoplasms of the liver, biliary hamartomas, polycystic liver disease, caroli disease, caroli syndrome, biliary hamartomas and peribiliary cysts. On the basis of in-depth review of the relevant literature, this guideline provide recommendations to navigate clinical dilemmas followed by supporting text. The recommendations are graded according to the Oxford Centre for Evidence-Based Medicine system and categorized as "weak" or "strong" . This guideline aims to provide the best available evidence to aid the clinical decision-making process in the management of patients with cystic liver disease, and presents the readers with translations and summarizations of the above mentioned recommendations.

Changes in gut microbiota after transjugular intrahepatic portosystemic shunt in cirrhotic patients with mild hepatic encephalopathy in different prognosis groups / 临床肝胆病杂志

ObjectiveTo investigate the changes in gut microbiota after transjugular intrahepatic portosystemic shunt (TIPS) in cirrhotic patients with mild hepatic encephalopathy (MHE) in different prognosis groups. MethodsA total of 28 MHE cirrhotic patients who were hospitalized and underwent TIPS in Xijing Hospital of Digestive Diseases from July 2016 to July 2017 were enrolled. Fecal samples and related clinical data were collected on days 1-3 before surgery and at 1 month after surgery. According to the prognosis after surgery, the patients were divided into none-hepatic encephalopathy (HE) group with 8 patients, MHE group with 12 patients, and overt hepatic encephalopathy (OHE) group with 8 patients. Fecal samples were analyzed by 16S rRNA sequencing to obtain the relative abundance of gut microbiota, and SPSS and R packages were used to analyze the biodiversity, postoperative changes, and differences in such changes of gut microbiota at the genus level between groups. The chi-square test was used for comparison of categorical data between groups; the Kruskal-Wallis H test was used for comparison of continuous data between three groups; the Bonferroni method was used for multiple comparisons of multiple samples; the Wilcoxon signed-rank test was used for comparison before and after surgery within each group. For microbiome beta-diversity analyses, a principal coordinate analysis (PCoA) was performed based on Bray-Curtis distance matrix, and the Adonis method (PerMANOVA) was used for comparison between groups. ResultsPCoA based on Bray-Curtis distance matrix showed that only the MHE group had a significant change in beta diversity after surgery (F=2.71, P=0.049). After surgery, the non-HE group had significant increases in the abundance of the native flora Dialister, Coprococcus, Ruminococcaceae_uncultured, Flavonifractor, and Clostridium_sensu_stricto_1 (Z=2.521, 2.1, 2.1, 2.1, and 1.96, all P＜0.05); the MHE group had significant reductions in the abundance of the harmful flora Granulicatella（Z=2.521,P=0.012）, Enterococcus（Z=2.51,P=0.012）, Streptococcus（Z=2.432,P=0.015）, and Rothia（Z=2.001,P=0.045） and significant increases in the abundance of Veillonella（Z=2.353,P=0.019） and Megasphaera（Z=1.955,P=0.05）; the OHE group only had a significant increase in the abundance of Veillonella after surgery (Z=2.38, P=0.017). There was a significant difference in the change in gut microbiota (postoperative abundance/preoperative abundance) between the non-HE group, the MHE group, and the OHE group ［2.00 (1.11-91.61) vs 1.21 (0.26-679) vs 0.09 (0.01-0.92), χ2=6.249, P=0.043］. ConclusionThere is a significant difference in the change in gut microbiota after TIPS between patients with different prognoses, and the increase in the abundance of native flora may have a certain influence on the remission of MHE.

Value of Modified Response Evaluation Criteria in Solid Tumors response in predicting the prognosis of patients with unresectable hepatocellular carcinoma patients after transarterial chemoembolization / 临床肝胆病杂志

ObjectiveTo investigate the association of Modified Response Evaluation Criteria in Solid Tumors (mRECIST) response with the prognosis of patients with unresectable hepatocellular carcinoma (HCC) after transarterial embolization (TACE). MethodsA retrospective analysis was performed for the clinical data of 190 patients with unresectable HCC who were consecutively admitted to Department of Liver Disease and Digestive Interventional Radiology, The First Affiliated Hospital of Air Force Medical University, and treated with TACE from January 2010 to December 2014. The mRECIST criteria were used to evaluate imaging response after TACE; the patients with complete response (CR) or partial response (PR) were enrolled as response group(n=89), and those with progressive disease (PD) or stable disease (SD) were enrolled as non-response group(n=101). The Kaplan-Meier method was used to calculate median survival time, and the log-rank test was used for comparison between groups; the Cox regression model was used to identify the influencing factors for prognosis. ResultsAccording to the mRECIST criteria, 39 patients (20.5%) achieved CR, 50 (26.3%) achieved PR, 67 (35.3%) had SD, and 34 (17.9%) had PD. The objective response rate based on mRECIST was 46.8% for the whole population. The response group had a significantly longer survival time than the non-response group, and the median survival time was 29.9 (95% confidence interval ［CI］: 25.0-34.8) months for the response group and 7.5 (95% CI: 5.7-9.3) months for the non-response group (P＜0.001). The multivariate analysis showed that mRECIST response (hazard ratio ［HR］=2.02, P＜0.001), hepatitis B (HR=4.03, P＜0.001), and portal invasion (HR=2.12, P=0.008) were independent risk factors for survival. ConclusionThe mRECIST response has a certain value in predicting the prognosis of patients with unresectable HCC after TACE.

Association between gut microbiota and hepatic encephalopathy in patients with liver cirrhosis / 临床肝胆病杂志

Hepatic encephalopathy (HE) is an important indicator of decompensated cirrhosis and is one of the most common causes of death. With the development of research on gut microbiota in patients with liver cirrhosis in recent years, the role of gut microbiota in the pathogenesis of HE has attracted wide attention. At present, next-generation sequencing has deepened the understanding of the composition and function of gut microbiota among researchers, and HE treatment targeting gut microbiota has achieved remarkable results. The research on gut microbiota helps to further clarify the pathogenesis of HE and may provide more treatment methods for patients with HE.

Transjugular intrahepatic portosystemic shunt for esophagogastric variceal bleeding in liver cirrhosis: intended population and timing / 中华肝脏病杂志

Esophagogastric variceal bleeding is a life-threatening complication of cirrhotic portal hypertension. Transjugular intrahepatic portosystemic shunt (TIPS) is an effective method for the treatment and prevention of esophagogastric variceal bleeding; however, right timing of TIPS and selection of appropriate candidates for TIPS are of vital importance in improving patients’ survival rate and reducing mortality rate. This article reviews the intended population and right timing of TIPS for the treatment and prevention of esophagogastric variceal bleeding in liver cirrhosis.

Radiological evaluation after treatment of hepatocellular carcinoma:criteria and application / 临床肝胆病杂志

An early and accurate response evaluation is essential for clinicians to decide whether to continue the treatment with current thera-peutic regimen or to make necessary changes.This article briefly introduces the development of response evaluation criteria for tumors,elab-orates on the application of radiological evaluation criteria in local interventional therapy or sorafenib treatment of hepatocellular carcinoma (HCC),compares the four radiological evaluation criteria,i.e.,World Health Organization (WHO)criteria,Response Evaluation Criteria in Solid Tumors (RECIST),European Association for the Study of Liver (EASL)criteria,and the modified RECIST (mRECIST),and thinks that EASL criteria and mRECIST are better than WHO criteria and RECIST and can predict the prognosis of HCC patients at earlier time points.

Long-term therapeutic effect of transjugular intrahepatic portosystemic shunt in patients with intractable cirrhotic ascites and prognostic factors / 临床肝胆病杂志

ObjectiveTo investigate the long-term therapeutic effect of transjugular intrahepatic portosystemic shunt (TIPS) in patients with intractable cirrhotic ascites and prognostic factors. MethodsA retrospective analysis was performed for the clinical data of 57 patients with intractable cirrhotic ascites who were received TIPS in our hospital from January 2009 to June 2014. Regular telephone follow-up was performed in all patients. Laboratory testing results and abdominal ultrasound and CT findings were examined. The improvement in ascites and survival were evaluated. The χ2 test was applied for comparison of categorical data between groups. The Kaplan-Meier method was used to calculate the cumulative probability of survival and other cumulative probabilities, the log-rank test was used for survival difference analysis, the Cox regression model was used to analyze prognostic factors, and the receiver operating characteristic curve(ROC) and the area under the curve(AUC) were used to determine the optimal cut-off values of prognostic factors. ResultsThe 1-year ascites remission rate after TIPS was 93%, and the 1- and 2-year survival rates were 60% and 43%, respectively. The multivariate Cox regression analysis showed that Child-Pugh score (HR=268, 95%CI: 1.009-1.594, P=0.042) and urea nitrogen (HR=1.143, 95%CI: 1034-1.264, P=0.009,) were predictive factors for 1-year survival rate after TIPS in patients with intractable cirrhotic ascites. The area under the ROC curve of Child-Pugh score was 0.699 (P=0011, 95%CI: 0.558-0.840), and the optimal cut-off value of Child-Pugh score was 8, with a sensitivity of 75% and a specificity of 67%. The Kaplan-Meier survival analysis demonstrated that the 1-year survival rates of patients with Child-Pugh scores of ≤8 and ＞8 were 82% and 38%, respectively (χ2=10.888, P=0.001). ConclusionTIPS is safe and effective in the treatment of intractable ascites, and Child-Pugh score ≤8 is a predictive factor for 1-year survival rate in such patients.

Research advances in non-cirrhotic portal hypertension / 临床肝胆病杂志

Although liver cirrhosis is the most common cause of portal hypertension (PH), about 20% of PH cases are caused by non-cirrhotic reasons, which are referred to as non-cirrhotic portal hypertension (NCPH), with a high incidence rate in developing countries. NCPH is a group of heterogeneous hepatic vascular diseases, including idiopathic portal hypertension (IPH) and extrahepatic portal vein obstruction (EHPVO), as well as the rare diseases in clinical practice such as Budd-Chiari syndrome, congenital hepatic fibrosis, and nodular regenerative hyperplasia. The patients with NCPH usually have the symptoms of portal hypertension, such as recurrent variceal bleeding and splenomegaly, but liver function is well preserved in these patients. At present, the diagnosis of NCPH lacks a universally accepted standard and remains a challenge. In clinical practice, the method of exclusion is usually applied for the diagnosis of HCPH, and liver biopsy is performed when necessary to make a confirmed diagnosis. This paper introduces the pathogenesis and pathological manifestations of IPH and EHPVO, as well as the selection of diagnostic methods and therapeutic strategies. If upper gastrointestinal bleeding can be effectively controlled, NCPH is considered to have a relatively good prognosis.

Embolization of spontaneous portosystemic shunt for cirrhotic patients with portal hypertension: a review of current status / 临床肝胆病杂志

Spontaneous portosystemic shunt (SPSS) has not yet drawn enough attention. The incidence of SPSS in cirrhotic patients is 38%-40%, and 46%-70% of cirrhotic patients with refractory encephalopathy show SPSS. Embolization of SPSS may be a safe and effective method for the treatment of refractory encephalopathy in patients with cirrhosis. The critical role of transjugular intrahepatic portosystemic shunt (TIPS) in the prevention and treatment of the complications of portal hypertension has been demonstrated. To further reduce portal pressure and prevent gastroesophageal variceal rebleeding, TIPS is essential for the treatment of cirrhotic patients with SPSS. Meanwhile, TIPS with SPSS embolization may reduce the post-TIPS complications, and the patients may benefit more from TIPS. Prospective randomized controlled trials are warranted to further confirm these findings.

Unilateral versus bilateral biliary drainage for malignant hilar obstruction: a systematic review and meta-analysis / 中华肝脏病杂志

<p><b>OBJECTIVE</b>To assess the efficacy and safety of bilateral versus unilateral biliary drainage in malignant hilar obstruction.</p><p><b>METHODS</b>Topically relevant studies,regardless of randomized or observational design, were searched for in PubMed, EmBase and the Cochrane Library database. Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated to compare the effect of the two treatments.</p><p><b>RESULTS</b>Three randomized trials and 7 observational studies were included, involving 894 patients with malignant hilar obstruction. The meta-analysis assessment of primary outcomes showed that the stent patency rate was better in bilateral drainage than in unilateral drainage (Rr=2.03,95% CI [1.16-3.56], P=0.01), but there were no significant differences in successful drainage rate (Rr=1.07,95% CI [0.97-1.18], P=0.20) and patient survival rate (Rr=-0.16,95% CI [-0.40-0.08], P=0.20). In the analysis of secondary outcomes,there were also no significant differences in the technical success rate (Rr=1.05,95% CI [0.98-1.17], P=0.34),the early complication rate (Rr=1.15, 95% CI [0.75-1.76], P=0.52), late complication rate (Rr=1.09,95% CI [0.75-1.60], P=0.60) and 30-day mortality rate (Rr=0.68,95% CI [0.38-1.23], P=0.20).</p><p><b>CONCLUSION</b>Although the cumulative stent patency was better for the bilateral than the unilateral drainage approach, based on the available data, there is not enough data to support bilateral drainage for malignant hilar obstruction. Well-designed randomized controlled trials are necessary to confirm it.</p>

Interventional treatment of liver metastases / 中华消化外科杂志

Liver is one of the most predilection sites of hematogenous metastasis of a variety of malignances,especially for gastrointestinal tumors.Surgical resection was the first choice for the treatment of liver metastases,while it could not apply to patients who had multiple metastatic lesions or other organs involvement.Interventional technique has been widely recognized for the advantages of minimal trauma,little pain,quick recovery and obvious efficacy.

Budd-Chiari syndrome and pregnancy / 临床肝胆病杂志

Budd-Chiari syndrome (BCS)is a rare liver disease,and there are mutual influences between BCS and pregnancy.The rela-tionship between BCS and pregnancy is systematically discussed,and the points we should pay attention to in the diagnosis and treatment of this disease are pointed out as follows:First,pregnancy is a risk factor for BCS;pregnant women with the clinical manifestations of portal hy-pertension and (or)inferior vena cava hypertension should be highly suspected of having BCS.Second,pregnancy is risky in BCS patients;pregnancy is allowable in BCS patients who have a stable condition after treatment,but they should be kept under rigorous surveillance dur-ing pregnancy and after delivery to avoid thrombosis recurrence.Third,BCS may lead to infertility in women;patients with unexplained in-fertility should be evaluated by abdominal ultrasound and computed tomography to clarify the diagnosis of BCS.