Early predictors of corticosteroid response in acute severe autoimmune hepatitis: a nationwide multicenter study.

BACKGROUND AND AIMS: To assess whether corticosteroids improve prognosis in patients with AS-AIH, and to identify factors at therapy initiation and during therapy predictive of the response to corticosteroids. METHODS: This was a retrospective cohort study including all patients with AS-AIH admitted to 13 tertiary centres from January 2002 to January 2019. The composite primary outcome was death or liver transplantation within 90 days of admission. Kaplan-Meier and Cox regression methods were used for data analysis. RESULTS: Of 242 consecutive patients enrolled (mean age [SD] 49.7 [16.8] years), 203 received corticosteroids. Overall 90-day transplant-free survival was 61.6% (95% confidence interval [CI] 55.4-67.7). Corticosteroids reduced the risk of a poor outcome (adjusted hazard ratio [HR] 0.25; 95% CI 0.2-0.4), but this treatment failed in 30.5%. An internally validated nomogram composed of older age, MELD, encephalopathy and ascites at the initiation of corticosteroids accurately predicted the response (C-index 0.82; [95% CI 0.8-0.9]). In responders, MELD significantly improved from days 3 to 14 but remained unchanged in non-responders. MELD on day 7 with a cut-off of 25 (sensitivity 62.5%[95% CI: 47.0-75.8]; specificity 95.2% [95% CI: 89.9-97.8]) was the best univariate predictor of the response. Prolonging corticosteroids did not increase the overall infection risk (adjusted HR 0.75; 95% CI 0.3-2.1). CONCLUSION: Older patients with high MELD, encephalopathy or ascites at steroid therapy initiation and during treatment are unlikely to show a favourable response and so prolonged therapy in these patients, especially if they are transplantation candidates, should be avoided.

Noninvasive Prediction of Outcomes in Autoimmune Hepatitis-Related Cirrhosis.

The value of noninvasive tools in the diagnosis of autoimmune hepatitis (AIH)-related cirrhosis and the prediction of clinical outcomes is largely unknown. We sought to evaluate (1) the utility of liver stiffness measurement (LSM) in the diagnosis of cirrhosis and (2) the performance of the Sixth Baveno Consensus on Portal Hypertension (Baveno VI), expanded Baveno VI, and the ANTICIPATE models in predicting the absence of varices needing treatment (VNT). A multicenter cohort of 132 patients with AIH-related cirrhosis was retrospectively analyzed. LSM and endoscopies performed at the time of cirrhosis diagnosis were recorded. Most of the patients were female (66%), with a median age of 54 years. Only 33%-49% of patients had a LSM above the cutoff points described for the diagnosis of AIH-related cirrhosis (12.5, 14, and 16 kPa). Patients with portal hypertension (PHT) had significantly higher LSM than those without PHT (15.7 vs. 11.7 kPa; P = 0.001), but 39%-52% of patients with PHT still had LSM below these limits. The time since AIH diagnosis negatively correlated with LSM, with longer time being significantly associated with a lower proportion of patients with LSM above these cutoffs. VNT was present in 12 endoscopies. The use of the Baveno VI, expanded Baveno VI criteria, and the ANTICIPATE model would have saved 46%-63% of endoscopies, but the latter underpredicted the risk of VNT. Conclusions: LSM cutoff points do not have a good discriminative capacity for the diagnosis of AIH-related cirrhosis, especially long-term after treatment initiation. Noninvasive tools are helpful to triage patients for endoscopy.

Endoscopy-Related Bleeding and Thromboembolic Events in Patients on Direct Oral Anticoagulants or Vitamin K Antagonists.

BACKGROUND & AIMS: Few prospective studies have assessed the safety of direct oral anticoagulants (DOACs) in elective endoscopy. Our primary aim was to compare the risks of endoscopy-related gastrointestinal bleeding and thromboembolic events in patients on DOACs or vitamin K antagonists (VKAs) in this setting. Secondarily, we examined the impact of the timing of anticoagulant resumption on the risk of delayed bleeding in high-risk therapeutic procedures. METHODS: We conducted a multicenter, prospective, observational study from January 2018 to March 2020 of 1602 patients on oral anticoagulants (1004 on VKAs and 598 on DOACs) undergoing 1874 elective endoscopic procedures. Our primary outcomes were 90-day thromboembolic events and 30-day endoscopy-related gastrointestinal bleeding. The inverse probability of treatment weighting propensity score method was used for baseline covariate adjustment. RESULTS: The 2 groups had similar risks of endoscopy-related gastrointestinal bleeding (VKAs vs DOACs, 6.2% vs 6.7%; adjusted odds ratio [OR], 1.05; 95% CI, 0.67-1.65) and thromboembolic events (VKAs vs DOACs, 1.3% vs 1.5%; adjusted OR, 0.90; 95% CI, 0.34-2.38). In high bleeding risk procedures (n = 747), delayed anticoagulant resumption (> 48 hours or 24-48 hours vs < 24 hours) did not reduce the risk of postprocedural bleeding (10.3%, 9%, and 5.8%, respectively; adjusted P = .43). Hot and cold snare polypectomy were the most frequent high-risk interventions (41.8% and 39.8%, respectively). CONCLUSION: In a prospective study of patients on DOACs or VKAs undergoing elective endoscopy, endoscopy-related bleeding and thromboembolic events showed similar risk. Our study suggests that early anticoagulant resumption is safe in most patients, but more data are needed for advanced high-risk therapeutic procedures.

Modificaciones en las características de los ingresos hospitalarios por cirrosis descompensada en la era de los antivirales de acción directa frente al virus de la hepatitis C / No disponible

INTRODUCCIÓN: el desarrollo de los regímenes libres de interferón, basados en antivirales de acción directa (AADs), ha supuesto una revolución en el tratamiento de la infección por el virus de la hepatitis C (VHC). OBJETIVO: conocer si han existido cambios en las características de los ingresos hospitalarios por cirrosis descompensada desde la introducción de los AADs. MÉTODOS: se recogieron de forma prospectiva todos los ingresos hospitalarios por cirrosis descompensada en dos periodos: octubre/12-octubre/14 (P-I) y julio/16-julio/18 (P-II). Se registraron variables demográficas y clínicas y se utilizaron los métodos estadísticos habituales para su análisis. RESULTADOS: se registraron 746 ingresos (347 en P-I y 399 en P-II). Los pacientes del P-I fueron más jóvenes (59 vs. 63 años; p = 0,034), mientras que la proporción de ingresos por cirrosis-VHC fue inferior en el P-II (15,8 % vs. 21,6 %; p = 0,041). No hubo diferencias significativas en la proporción de ingresos por otras etiologías de la cirrosis entre ambos periodos. Analizando los ingresos por cirrosis-VHC, los pacientes del P-II tuvieron menos frecuentemente infección viral activa (57,1 vs. 97,3 %; p = 0,001) y en ellos coexistía con mayor frecuencia un consumo excesivo de alcohol (55,5 % vs. 30,7 %; p = 0,003), mientras que la coinfección con VIH fue menos frecuente (1,6 % vs. 10,7 %; p = 0,039). CONCLUSIONES: la proporción de ingresos por cirrosis descompensada ocasionada por el VHC ha descendido en torno a un 30 % desde la introducción de los AADs. Además, las características de los pacientes que ingresan por complicaciones de la cirrosis relacionada con el VHC han cambiado desde la aplicación de los regímenes libres de interferón

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Changes in the characteristics of hospital admissions due to decompensated cirrhosis in the era of direct-acting antivirals against hepatitis C virus.

BACKGROUND: the development of interferon-free regimens, based on direct acting antivirals (DAAs) has revolutionized the treatment of hepatitis C virus (HCV) infection. AIMS: to determine if there have been changes in the characteristics of hospital admissions due to decompensated cirrhosis in a general hospital since the introduction of DAAs. PATIENTS AND METHODS: this was a prospective study of all hospital admissions due to decompensated cirrhosis during two periods: October 2012-October 2014 (P-I) and July 2016-July 2018 (P-II). Clinical and demographic variables were collected and standard statistical methods were used for the analysis. RESULTS: there were 746 hospital admissions; 347 in P-I and 399 in P-II. P-I patients were younger (59 vs 63 years; p = 0.034), while the proportion of admissions due to HCV-cirrhosis was lower in P-II (15.8 % vs 21.6 %; p = 0.041). There were no significant differences in the proportion of admissions due to other etiologies of cirrhosis between both periods. Patients in the P-II group presented an active viral infection (57.1 vs 97.3 %; p = 0.001) less frequently and had a higher rate of excessive alcohol consumption (55.5 vs 30.7 %; p = 0.003) when admitted, while HIV co-infection was less frequent (1.6 % vs 10.7 %; p = 0.039). CONCLUSION: the proportion of admissions due to decompensated HCV-related cirrhosis has decreased by almost 30 % since the introduction of the DAA. In addition, the characteristics of patients admitted have changed since the application of interferon-free regimens.

Eficacia y seguridad de la pinza disectora SB Knife(TM) Jr. en el tratamiento del divertículo de Zenker. Serie de casos / No disponible

INTRODUCCIÓN Y OBJETIVO: la pinza disectora SB Knife(TM) es un nuevo dispositivo endoscópico que se puede utilizar en el tratamiento del divertículo de Zenker, pero la experiencia es limitada. Nuestro objetivo fue evaluar la eficacia y seguridad del SB Knife(TM) en el tratamiento del divertículo de Zenker. MÉTODOS: estudio unicéntrico prospectivo en el que se incluyeron 16 pacientes entre mayo de 2017 y abril de 2019. Se evaluaron las complicaciones del procedimiento y la evolución clínica. RESULTADOS: la mediana de edad fue de 78 años y el 62,5% fueron varones. El 100% presentaba disfagia; el 43,8%, atragantamientos; el 31,3%, regurgitación; y el 6,3%, aspiraciones. La mediana de tamaño del divertículo fue de 20 mm y la mediana de seguimiento, 281 días. No hubo ninguna complicación intraprocedimiento y solo una posprocedimiento importante (microperforación). En todos los pacientes hubo mejoría inicial, pero en dos hubo recurrencia clínica que se trató con el mismo sistema con buen resultado. CONCLUSIONES: el SB Knife(TM) parece una opción segura y eficaz en el tratamiento del divertículo de Zenker

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Efficacy and safety of the SB Knife™ Jr. for the treatment of Zenker's diverticulum: a case series.

BACKGROUND AND AIMS: the stag-beetle knife is a new scissor-like endoscopic device that can be used for the treatment of Zenker's diverticulum, although experience is limited. The aim of this study was to evaluate the efficacy and safety of the SB Knife™ for the endoscopic treatment of Zenker's diverticulum. METHODS: a single-center prospective study of 16 patients was performed between May 2017 and April 2019. The rate of complications and symptom changes was evaluated. RESULTS: the median age was 78 years and 62.5% of the patients were male. All had dysphagia, 43.8% choking, 31.3% regurgitation and 6.3% respiratory symptoms. The median size of the diverticulum was 20 mm and the median follow-up was 281 days. There were no intra-procedure complications and only one major post-procedure complication was reported that was a microperforation. All patients had clinical improvement. Two patients had relapsing symptoms and were successfully treated with the same method. CONCLUSIONS: the SB Knife™ seems to be a safe and effective technique for the treatment of Zenker's diverticulum.

Hepatitis aguda C seronegativa: informe de dos casos / Acute seronegative hepatitis C: two case reports

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Acute seronegative hepatitis C: two case reports.

We present two cases of immunosuppressed patients diagnosed with acute hepatitis C (AHC) HCV-antibody negative by HCV-RNA testing. Delayed seroconversion in immunosuppressed patients may result in retarded diagnosis and treatment. Therefore, HCV-RNA testing should be part of the initial evaluation.