Efficacy and safety of laparoscopic Heller's myotomy versus pneumatic dilatation for achalasia: A systematic review and meta-analysis of randomized controlled trials.

BACKGROUND AND OBJECTIVES: Achalasia has several treatment modalities. We aim to compare the efficacy and safety of laparoscopic Heller myotomy (LHM) with those of pneumatic dilatation (PD) in adult patients suffering from achalasia. METHODS: We searched Cochrane CENTRAL, PubMed, Web of Science, SCOPUS and Embase for related clinical trials about patients suffering from achalasia. The quality appraisal and assessment of risk of bias were conducted with GRADE and Cochrane's risk of bias tool, respectively. Homogeneous and heterogeneous data was analyzed under fixed and random-effects models, respectively. RESULTS: The pooled analysis of 10 studies showed that PD was associated with a higher rate of remission at three months, one year, three years and five years (RR = 1.25 [1.09, 1.42] (p = 0.001); RR = 1.13 [1.05, 1.20] (p = 0.0004); RR = 1.48 [1.19, 1.82] (p = 0.0003); RR = 1.49 [1.18, 1.89] (p = 0.001)), respectively. LHM was associated with lower number of cases suffering from adverse events, dysphagia and relapses (RR = 0.50 [0.25, 0.98] (p = 0.04); RR = 0.33 [0.16, 0.71] (p = 0.004); RR = 0.38 [0.15, 0.97] (p = 0.04)), respectively. There is no significant difference between both groups regarding the lower esophageal pressure, perforations, remission rate at two years, Eckardt score after one year and reflux. CONCLUSION: PD had higher remission rates than LHM at three months, one year and three years, but not at two years or five years. More research is needed to determine whether PD has a significant advantage over LHM in terms of long-term remission rates.

Efficacy and safety of terlipressin and albumin vs. noradrenaline and albumin in adult patients with hepatorenal syndrome: A systematic review and meta-analysis.

INTRODUCTION AND OBJECTIVES: Hepatorenal syndrome (HRS) is a serious complication of cirrhosis treated with various medications. We aim to evaluate terlipressin and albumin's effectiveness and safety compared to albumin and noradrenaline in adult hepatorenal disease patients. MATERIALS AND METHODS: Clinical trials from four databases were included. Cochrane's approach for calculating bias risk was utilized. We rated the quality evaluation by Grading of Recommendations Assessment, Development, and Evaluation (GRADE). We included the following outcomes: serum creatinine (mg/dl), urine output (ml/24 h), mean arterial pressure (mmHg), reversal rate of HRS, mortality rate, blood plasma renin activity (ng/ml/h), plasma aldosterone concentration (pg/ml), urine sodium (mEq/l), and creatinine clearance (ml/min). RESULTS: Our analysis of nine clinical studies revealed that the noradrenaline group was associated with higher creatinine clearance (MD = 4.22 [0.40, 8.05]), (P = 0.03). There were no significant differences in serum creatinine levels (MD = 0.03 [-0.07, 0.13]), urinary sodium (MD = -1.02 [-5.15, 3.11]), urine output (MD = 32.75 [-93.94, 159.44]), mean arterial pressure (MD = 1.40 [-1.17, 3.96]), plasma renin activity (MD = 1.35 [-0.17, 2.87]), plasma aldosterone concentration (MD = 55.35 [-24.59, 135.29]), reversal rate of HRS (RR = 1.15 [0.96, 1.37]), or mortality rate (RR = 0.87 [0.74, 1.01]) between the two groups (p-values > 0.05). CONCLUSIONS: Noradrenaline is a safe alternative medical therapy for HRS.

Factors Associated with Survival of Hepatocellular Carcinoma (HCC) Patients at a Safety Net Hospital in Arizona without On-Site Liver Transplant Program.

BACKGROUND: With the rising incidence of hepatocellular carcinoma (HCC), ongoing efforts should be focused on providing equitable and state-of-the-art care to patients. PURPOSE: The aim of this study was to determine the survival of patients with HCC seen at a high-proportion Safety Net Hospital (h-SNH), where loco-regional therapy and hepatology services are available and liver transplantation (LT) is referred to outside facilities. PATIENTS AND METHODS: A retrospective cohort study was conducted on all patients with HCC seen at Valley Wise Health Center (VWHC) over a ten-year period. Clinical variables, treatment modalities, survival duration, hospice, and LT referrals of 161 patients were collected from the medical records. Survival analysis was used to determine the relationship of clinically relevant variables and survival among patients with HCC. A Log rank test was used to compare univariate variables. A Cox regression analysis was used to compare and control for multiple variables. RESULTS: Of the 161 patients included in the study, 33% were uninsured. The median age was 59 (21 to >89) years with 47% Hispanic, 31% Caucasian, 15% African American and 7% other races included for the analysis. The median survival for the cohort was 20.1 months. In the multivariate model, insurance status, final MELD, tumor within the Milan criteria and having received treatment for HCC were associated with survival. Surveillance for HCC was associated with HCC in the univariate analysis, but not in the multivariable model. Thirty percent of patients were referred for LT and 1.25% of the entire cohort received it. CONCLUSION: Despite the availability of treatment modalities available for HCC at VWHC and the option of liver transplantation for appropriate candidates at outside centers, OS was less than reported from programs with on-site liver transplant programs. Reasons for lower survival in centers without liver transplant programs should be further studied.

Frequency and Associated Risk Factors of Hepatitis B Virus and Hepatitis C Virus Infections in Children at a Hepatitis Prevention and Treatment Clinic in Lahore, Pakistan.

Objective This study evaluated the frequency of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection and the associated horizontal risk factors in children being screened for viral hepatitis in Lahore, Pakistan. Methods Children aged 15 years or younger who were brought to a specialized outpatient viral hepatitis clinic affiliated with a tertiary hospital in Lahore, Pakistan, for viral hepatitis screening from March 2017 to March 2018 were enrolled. Children were screened for HBV and HCV infection by enzyme-linked immunosorbent assay; if results were positive, HBV and HCV concentrations were quantitatively assayed by polymerase chain reaction. Children positive for HBV or HCV infection were matched with 100 controls of the same age and sex. All subjects completed a questionnaire on viral infection and its associated risk factors. Results During the study period, 3500 children living in the Punjab Province of Pakistan were screened for HBV and HCV infection. Of these children, 28 (0.8%) were positive for HBV and 66 (1.88%) were positive for HCV. A comparison of the 94 (2.68%) children positive for HBV or HCV with 100 controls identified several risk factors associated with infection. Unexpectedly, ten (35.7%) of the 28 HBV-positive children were born of HBV-negative mothers and had been fully vaccinated for HBV during infancy. Conclusion The frequency of HCV infection was higher than that of HBV infection among Pakistani children aged ≤15 years. Several horizontal risk factors were found to cause viral hepatitis. Several children born of HBV-negative mothers and vaccinated for HBV during infancy later developed HBV infection.

Molecular epidemiology and genotype distribution of hepatitis C in Pakistan; a multicenter cross-sectional study.

Pakistan has second highest burden of hepatitis C virus (HCV) infected patients in the World. Little is known about the molecular epidemiology and risk factors for prevailing HCV genotypes in Pakistan. Considering this a multicenter cross-sectional study was conducted at 23different viral hepatitis control and prevention centers. A total of 175,897 patients were registered and screened for HCV, out of which 73,180 (41.6%) were found positive on Architect screening test. The screened positive patients were sequentially tested on RT-PCR; where 41,241 (56.35%) were detected positive. Molecular characterization results showed genotype 3 (73.9%) as the most prevalent type, followed by genotype 1 (9.7%), and genotype 4 (0.3%) was isolated for the first time in Pakistan. On regression analysis; risk factors associated with genotype 3 and 1 included; age group of 30-50 years, rural residence, exposure to >10 injections, barber shaving, circumcision by barbers, and low literacy rate. Phylogenetic analysis based on genotypes identified in this study and sequences isolated from Pakistan in last 10 years demonstrated that genotype 3 and 1 are endemic locally in Punjab province. The high prevalence rate of HCV is a threat for a generalized epidemic and genetic recombination with such variability of genotypes identified here is an alarming condition. More focused attention and resources should be spent in awareness of the population to prevent the spread of HCV among high risk population.

Imaging-Negative Hepatocellular Carcinoma Presents as an Intrabiliary Mass.

Hepatocellular carcinoma (HCC) is the second most common cause of cancer-related death and one of the most prevalent cancers worldwide. HCC prognosis remains poor with an average survival rate between 6 and 12 months. Obstructive jaundice, as a main clinical feature, is uncommon in HCC. HCC with bile duct invasion is much rarer than HCC with vascular invasion. We present a case where a patient's HCC was diagnosed by endoscopic retrograde cholangiopancreatography and digital cholangioscopy because his HCC manifested as an obstructing lesion in the intrahepatic duct, but not in the liver.

Clinical characteristics of antimitochondrial antibody-positive patients at a safety net health care system in Arizona.

BACKGROUND AND AIMS: To assess whether aspartate aminotransferase (AST), alanine aminotransferase (ALT) and alkaline phosphatase (AP) levels can predict the diagnosis of primary biliary cholangitis (PBC) or any other diagnoses and whether PBC occurs either simultaneously or independently of other liver diseases among antimitochondrial antibody (AMA)-positive patients. METHODS: Demographic and clinical variables were assessed in 90 AMA-positive patients with and without liver biopsies. These patients were further categorised as having a diagnosis of PBC, overlap syndrome or 'not established with a diagnosis of PBC'. Receiver operating characteristic curves were constructed to determine the thresholds of liver enzymes that predict these three diagnoses. RESULTS: The 48 patients with liver biopsies were more frequently female and had significantly higher AP levels compared with the non-liver biopsy group. Based on liver biopsy findings, 12, 12 and 22 patients were assigned a diagnosis of PBC, overlap syndrome with autoimmune hepatitis and PBC and 'not established diagnosis of PBC', respectively. Seven of 12 patients classified as PBC had AP level of ˂200 IU. AST, ALT and AP levels were significant predictors of a diagnosis of overlap syndrome compared with the rest of the patients; however, these tests were not discriminatory between diagnoses of PBC and 'not established with PBC'. Findings of fatty liver and bile duct injury on liver biopsies were not significantly associated with any liver test pattern. CONCLUSIONS: As the liver test pattern did not correlate with the liver biopsy findings of PBC or other non-PBC diagnoses in AMA-positive patients at risk for other disease, a liver biopsy and/or non-invasive liver assessment along with serum liver tests should be interpreted to complete liver evaluation.

Secondary Sclerosing Cholangitis During Pregnancy.

We report a case of secondary sclerosing cholangitis that manifested itself during pregnancy. A tentative diagnosis of intrahepatic cholestasis of pregnancy was considered, but after her third delivery, a liver biopsy and imaging, as well as review of past records, confirmed the diagnosis of secondary sclerosing cholangitis. Maternal and fetal outcomes of primary sclerosis cholangitis have been reported, and this case highlights the importance of considering other diseases besides the benign intrahepatic cholestasis of pregnancy as a cause of cholestasis in pregnancy.

Helicobacter pylori prevalence and histopathological findings in dyspeptic patients.

BACKGROUND: Helicobacter pylori (H. pylori) colonizes in half of the population of developed and nearly all inhabitants of developing countries. The infection is characterized by gastritis but can present more complicated disease states. We intended to report prevalence of H. pylori infection by histopathology and presence of gastritis, activity, atrophy and intestinal metaplasia in dyspeptic patients of Islamabad, Pakistan. METHODS: Ninety four patients identified to be dyspeptic on the basis of Rome-III criteria were included in the study and diagnosed for H. pylori status by Histopathology. The grading and severity of gastritis was documented as nil, mild, moderate or severe, based on the Sydney system. Activity was recorded as present when an increase in the number of neutrophils was observed. Atrophic changes and intestinal metaplasia were also determined. RESULTS: Eighty three out of total 94 (88.3%) patients were positive for H. pylori on histopathology. Out of total 94 patients, chronic gastritis was observed in 89 (94.6%), evidence of activity was found in 37 (39.4%), atrophic changes were observed in 66 (70%) and intestinal metaplasia was present in 4 (4.3%) patients. CONCLUSION: H. pylori infection in dyspeptic patients of Islamabad appears to be more related with gastritis.

Endoscopic ultrasound with biopsy of omental mass for cholangiocarcinoma diagnosis in cirrhosis.

In this report, a patient had a previous diagnosis of cholangiocarcinoma with an extended cholecystectomy. Three years later, he was evaluated for recurrent ascites. The patient had several large volume paracentesis, without evidence of malignant cells. Subsequently, endoscopic ultrasound (EUS) with fine needle aspiration (FNA) of both lymph and omental nodules was utilized. While the lymph nodes were negative for malignancy, the omental nodule was interrogated with multiple antibodies and was found to be positive for neoplasia. EUS with FNA can safely be used in patients with cirrhosis to spare the patient invasive evaluation such as exploratory laparotomy (ex-lap) for diagnosis and staging of cholangiocarcinoma.

Continuous peritoneal drainage of large-volume ascites.

BACKGROUND: With the increasing population of individuals with cirrhosis, many of whom are not liver transplant candidates, large volume paracentesis as a medical therapy for ascites resistant to diuretic therapy has become increasingly utilized. AIM: To determine the safety and efficacy of continuous peritoneal drainage of large-volume ascites in Child Class-C cirrhosis. Subjects with no current clinical or laboratory findings of spontaneous bacterial ascites were studied. Each had a complete medical evaluation to document the etiology and severity of their liver disease as well as the identification of any confounding medical illness. A triple-phase abdominal CT of the abdomen was obtained in each individual to rule out any hepatoma. Upon completion of the above, a pericardiocentesis catheter was placed in the abdomen using the Seldinger technique and the ascites was drained continuously (to gravity) until no additional ascitic fluid could be removed or the total time of drainage was 72 h. The patient's weight, volume of ascitic fluid removed, ascitic fluid cell counts, ascitic fluid cultures, complete blood count and comprehensive metabolic profile were obtained immediately before and after the peritoneal catheter was removed. RESULTS: HCV cirrhosis accounted for 12 cases and alcoholic liver disease accounted for 8 cases (half the total of 40 cases), with 6 other diseases accounting for the remaining half. The ascitic fluid was drained continuously for 2.5 ± 0.08 days, with a removal of 13.3 ± 0.5 l of ascitic fluid. No clinically significant change in the serum creatinine or ascitic fluid cells count occurred as a result of the procedure. The adverse effects of the procedure were minimal. 63% of the patients experienced some mild discomfort at the catheter insertion site, or local abdominal pain just prior to the removal of the catheter. Two patients developed a small abdominal wall hematoma that required no therapy. No patients experienced peritoneal hemorrhage, infection or renal dysfunction. CONCLUSION: (1) Continuous large-volume peritoneal drainage by gravity is safe and effective; (2) if the procedure is limited 72 h, no cases of ascitic fluid contamination/infection occur; and (3) it reduces the time between subsequent paracentesis based upon historical data.