Improving prognostication in patients with hepatocellular carcinoma undergoing loco-regional therapy using pre- and post-locoregional therapy scores.

BACKGROUND: Many scoring systems have been proposed for predicting survival in patients with hepatocellular carcinoma (HCC) undergoing locoregional therapy (LRT). We aimed to study the role of the NIACE score, hepatoma arterial embolization prognostic score (HAP), and ABCR score in predicting transplant-free survival (TFS) in these patients. METHODS: In this retrospective multicenter study of a United States Veteran cohort who underwent LRT, NIACE, HAP, and ABCR scores were calculated, and their predictive accuracy for TFS within different modified BCLC (mod-BCLC) stages was analyzed. RESULTS: 180 subjects underwent LRT between January-2012 and March-2019 were followed till January-2022, mean age 65.6 ± 6.3 years, model for end-stage liver disease -sodium (MELD-Na) score (at first LRT) 14.1 ± 6.7. A total of 43.9%, 35%, and 21.1% of patients had mod-BCLC A, B, and C stage disease, respectively. A total of 76.7% underwent transarterial embolization (TAE), 6.1% underwent ablation, and 17.2% underwent transarterial radioembolization (TARE) as the first intervention and were followed for a median of 576.5 patient-years. The NIACE score, HAP score, and ABCR scores differentiated patients within mod-BCLC stages A and B into groups with significant differences in TFS. In the stratified analysis of those undergoing only TAE, all three scores identified subgroups with significantly different TFS. CONCLUSION: In patients with HCC undergoing LRT, the mod-BCLC stages have subgroups with variable overall TFS. The NIACE score, HAP score, and ABCR score identified differential prognoses is within mod-BCLC stages and characterized subgroups with different TFS following LRT (TAE). Integration of these scoring systems into treatment decisions would help to improve prognostication within respective mod-BCLC groups, which may help with more customized treatment allocation.

Safety and Efficacy of Endoscopic Full Thickness Resection of Upper Gastrointestinal Lesions Using a Full Thickness Resection Device: A Systematic Review and Meta-analysis.

INTRODUCTION: Endoscopic full-thickness resection (EFTR) is a promising technique that allows for a minimally invasive resection of mucosal and submucosal lesions in the gastrointestinal (GI) tract. The data regarding the efficacy and safety of performing EFTR of upper GI lesions using a full-thickness resection device (FTRD) is limited. Hence, we performed a systematic review and meta-analysis of the studies that evaluated this technique. METHODS: We performed a comprehensive systematic search of multiple electronic databases and conference proceedings that reported outcomes of EFTR using the FTRD system. The weighted pooled rates of technical success, complete (R0) resection, adverse events (AE), and residual or recurrent lesions were analyzed with 95% CI using the random effects model. RESULTS: Eight studies with a total of 139 patients who underwent EFTR of upper GI lesions were included in the study. The pooled, weighted rate of technical success was 88.2% (95% CI: 81.4-92.7%, I2 : 0). The R0 resection rate was 70.7% (95% CI: 62.5-77.8%, I2 : 0). Overall AE rates were 22.1% (95% CI: 15.8-30.1%, I2 : 0), however, most of the AEs were minor. Of the patients who had follow-up endoscopies, the residual and/or recurrent lesion rate was 6.1% (95% CI: 2.4-14.4%, I2 : 0). Heterogeneity in the analysis was low. CONCLUSIONS: EFTR using the FTRD seems to be effective and safe with acceptable R0 resection rates and low recurrence rates. Further prospective studies are required to validate our results and to compare various modalities of endoscopic resection with this single-step EFTR device.

The Environmental Impact of Gastrointestinal Procedures: A Prospective Study of Waste Generation, Energy Consumption, and Auditing in an Endoscopy Unit.

BACKGROUND & AIMS: Gastrointestinal (GI) endoscopy procedures are critical for screening, diagnosis, and treatment of a variety of GI disorders. However, like the procedures in other medical disciplines, they are a source of environmental waste generation and energy consumption. METHODS: We prospectively collected data on total waste generation, energy consumption, and the role of intraprocedural inventory audit of a single tertiary care academic endoscopy unit over a 2-month period (May-June 2022). Detailed data on items used were collected, including procedure type (esophagogastroduodenoscopy or colonoscopy), accessories, intravenous tubing, biopsy jars, linen, and personal protective equipment use. Data on endoscope reprocessing-related waste generation and energy use in the endoscopy unit (equipment, lights, and computers) were also collected. We used an endoscopy staff-guided auditing and review of the items used during procedures to determine potentially recyclable items going to landfill waste. The waste generated was stratified into biohazardous, nonbiohazardous, or potentially recyclable items. RESULTS: A total of 450 consecutive procedures were analyzed for total waste management (generation and reprocessing) and energy consumption. The total waste generated during the study period was 1398.6 kg (61.6% directly going to landfill, 33.3% biohazard waste, and 5.1% sharps), averaging 3.03 kg/procedure. The average waste directly going to landfill was 219 kg per 100 procedures. The estimated total annual waste generation approximated the size of 2 football fields (1-foot-high layered waste). Endoscope reprocessing generated 194 gallons of liquid waste per day, averaging 13.85 gallons per procedure. Total energy consumption in the endoscopy unit was 277.1 kW·h energy per day; for every 100 procedures, amounting to 1200 miles of distance traveled by an average fuel efficiency car. The estimated carbon footprint for every 100 GI procedures was 1501 kg carbon dioxide (CO2) equivalent (= 1680 lbs of coal burned), which would require 1.8 acres of forests to sequester. The recyclable waste audit and review demonstrated that 20% of total waste consisted of potentially recyclable items (8.6 kg/d) that could be avoided by appropriate waste segregation of these items. CONCLUSIONS: On average, every 100 GI endoscopy procedures (esophagogastroduodenoscopy/colonoscopy) are associated with 303 kg of solid waste and 1385 gallons of liquid waste generation, and 1980 kW·h energy consumption. Potentially recyclable materials account for 20% of the total waste. These data could serve as an actionable model for health systems to reduce total waste generation and decrease landfill waste and water waste toward environmentally sustainable endoscopy units.

The Influence of Obesity on Acute Pancreatitis Hospitalizations: Does Body Mass Index Matter?

OBJECTIVE: To identify the influence of body mass index (BMI) on Acute Pancreatitis (AP) hospitalizations in the United States (US). METHODS: The National Inpatient Sample was utilized to identify normal weight, overweight and obese AP hospitalizations in the US from 2016-2019 based on BMI. Hospitalization characteristics and outcomes were compared. RESULTS: Between 2016-2019, there were 314,215 (74.7%) obese, 27,005 (6.4%) overweight and 79,380 (18.9%) normal weight AP hospitalizations. Obese AP hospitalizations were younger (51.5 vs 56.5 years, p < 0.0001) compared to the normal weight cohort. However, normal weight AP hospitalizations had a higher proportion of Blacks and Asians compared to the obese subgroup. We also noted a higher all-cause inpatient mortality for normal weight AP hospitalizations (3.4% vs 2.8% vs 1.8%, p < 0.0001) compared to the overweight and obese cohorts, respectively. Furthermore, normal weight AP hospitalizations had a higher proportion of patients with pancreatic pseudocyst formation and pancreatic necrosis compared to the overweight and obese cohorts. The mean length of stay (5.8 vs 8.2 days, p < 0.0001) and mean total healthcare costs ($66,742 vs $82,319, p < 0.0001) were lower for obese compared to normal weight AP hospitalizations. CONCLUSIONS: Normal weight AP hospitalizations had higher inpatient mortality and complications compared to obese hospitalizations.

Role of Advanced Gastrointestinal Endoscopy in the Comprehensive Management of Neuroendocrine Neoplasms.

Neuroendocrine neoplasms (NENs), also called neuroendocrine tumors (NETs), are relatively uncommon, heterogenous tumors primarily originating in the gastrointestinal tract. With the improvement in technology and increasing use of cross-sectional imaging and endoscopy, they are being discovered with increasing frequency. Although traditionally considered indolent tumors with good prognoses, some NENs exhibit aggressive behavior. Timely diagnosis, risk stratification, and management can often be a challenge. In general, small NENs without local invasion or lymphovascular involvement can often be managed using minimally invasive advanced endoscopic techniques, while larger lesions and those with evidence of lymphovascular invasion require surgery, systemic therapy, or a combination thereof. Ideal management requires a comprehensive and accurate understanding of the stage and grade of the tumor. With the recent advancements, a therapeutic advanced endoscopist can play a pivotal role in diagnosing, staging, and managing this rare condition. High-definition white light imaging and digital image enhancing technologies like narrow band imaging (NBI) in the newer endoscopes have improved the diagnostic accuracy of traditional endoscopy. The refinement of endoscopic ultrasound (EUS) over the past decade has revolutionized the role of endoscopy in diagnosing and managing various pathologies, including NENs. In addition to EUS-directed diagnostic biopsies, it also offers the ability to precisely assess the depth of invasion and lymphovascular involvement and thus stage NENs accurately. EUS-directed locoregional ablative therapies are increasingly recognized as highly effective, minimally invasive treatment modalities for NENs, particularly pancreatic NENs. Advanced endoscopic resection techniques like endoscopic submucosal dissection (ESD), endoscopic submucosal resection (EMR), and endoscopic full-thickness resection (EFTR) have been increasingly used over the past decade with excellent results in achieving curative resection of various early-stage gastrointestinal luminal lesions including NENs. In this article, we aim to delineate NENs of the different segments of the gastrointestinal (GI) tract (esophagus, gastric, pancreatic, and small and large intestine) and their management with emphasis on the endoscopic management of these tumors.

The Role of EUS in Advanced Endoscopic Procedures and Therapeutics-Advancing the Field to Greater Heights.

Endoscopic ultrasound (EUS) provides high-resolution and real-time visualization of various layers of the gastrointestinal (GI) tract and beyond by combining ultrasound technology with endoscopic visualization [...].

Clinical Outcomes and Complications for Achalasia Patients Admitted After Per-Oral Endoscopic Myotomy.

Background: Per-oral endoscopic myotomy (POEM) is a rapidly emerging minimally invasive procedure for management of achalasia. Same-day discharge after POEM is safe and feasible; however, some patients may need hospitalization. We aimed to identify characteristics and outcomes for achalasia patients requiring hospitalizations after POEM in the United States (US). Methods: The US National Inpatient Sample was utilized to identify all adult achalasia patients who were admitted after POEM from 2016 to 2019. Hospitalization characteristics and clinical outcomes were highlighted. Results: From 2016 to 2019, we found that 1,885 achalasia patients were admitted after POEM. There was an increase in the total number of hospitalizations after POEM from 380 in 2016 to 490 in 2019. The mean age increased from 54.2 years in 2016 to 59.3 years in 2019. Most POEM-related hospitalizations were for the 65 - 79 age group (31.8%), females (50.4%), and Whites (68.4%). A majority (56.2%) of the study population had a Charlson Comorbidity Index of 0. The Northeast hospital region had the highest number of POEM-related hospitalizations. Most of these patients (88.3%) were eventually discharged home. There was no inpatient mortality. The mean length of stay decreased from 4 days in 2016 to 3.2 days in 2019, while the mean total healthcare charge increased from $52,057 in 2016 to $65,109 in 2019. Esophageal perforation was the most common complication seen in 1.3% of patients. Conclusion: The number of achalasia patients needing hospitalization after POEM increased. There was no inpatient mortality conferring an excellent safety profile of this procedure.

Peptic ulcer disease in non-alcoholic fatty liver disease hospitalizations: A new challenge on the horizon in the United States.

BACKGROUND: Peptic ulcer disease (PUD) is frequently seen in patients with liver cirrhosis. However, current literature lacks data on PUD in non-alcoholic fatty liver disease (NAFLD) hospitalizations. AIM: To identify trends and clinical outcomes of PUD in NAFLD hospitalizations in the United States. METHODS: The National Inpatient Sample was utilized to identify all adult (≥ 18 years old) NAFLD hospitalizations with PUD in the United States from 2009-2019. Hospitalization trends and outcomes were highlighted. Furthermore, a control group of adult PUD hospitalizations without NAFLD was also identified for a comparative analysis to assess the influence of NAFLD on PUD. RESULTS: The total number of NAFLD hospitalizations with PUD increased from 3745 in 2009 to 3805 in 2019. We noted an increase in the mean age for the study population from 56 years in 2009 to 63 years in 2019 (P < 0.001). Racial differences were also prevalent as NAFLD hospitalizations with PUD increased for Whites and Hispanics, while a decline was observed for Blacks and Asians. The all-cause inpatient mortality for NAFLD hospitalizations with PUD increased from 2% in 2009 to 5% in 2019 (P < 0.001). However, rates of Helicobacter pylori (H. pylori) infection and upper endoscopy decreased from 5% in 2009 to 1% in 2019 (P < 0.001) and from 60% in 2009 to 19% in 2019 (P < 0.001), respectively. Interestingly, despite a significantly higher comorbidity burden, we observed lower inpatient mortality (2% vs 3%, P = 0.0004), mean length of stay (LOS) (11.6 vs 12.1 d, P < 0.001), and mean total healthcare cost (THC) ($178598 vs $184727, P < 0.001) for NAFLD hospitalizations with PUD compared to non-NAFLD PUD hospitalizations. Perforation of the gastrointestinal tract, coagulopathy, alcohol abuse, malnutrition, and fluid and electrolyte disorders were identified to be independent predictors of inpatient mortality for NAFLD hospitalizations with PUD. CONCLUSION: Inpatient mortality for NAFLD hospitalizations with PUD increased for the study period. However, there was a significant decline in the rates of H. pylori infection and upper endoscopy for NAFLD hospitalizations with PUD. After a comparative analysis, NAFLD hospitalizations with PUD had lower inpatient mortality, mean LOS, and mean THC compared to the non-NAFLD cohort.

In older patients receiving aspirin, H pylori eradication reduced hospitalization or death due to peptic ulcer bleeding at 2.5 y.

SOURCE CITATION: Hawkey C, Avery A, Coupland CAC, et al; HEAT trialists. Helicobacter pylori eradication for primary prevention of peptic ulcer bleeding in older patients prescribed aspirin in primary care (HEAT): a randomised, double-blind, placebo-controlled trial. Lancet. 2022;400:1597-1606. 36335970.

Endoscopic versus surgical management for colonic volvulus hospitalizations in the United States.

BACKGROUND/AIMS: Colonic volvulus (CV), a common cause of bowel obstruction, often requires intervention. We aimed to identify hospitalization trends and CV outcomes in the United States. METHODS: We used the National Inpatient Sample to identify all adult CV hospitalizations in the United States from 2007 to 2017. Patient demographics, comorbidities, and inpatient outcomes were highlighted. Outcomes of endoscopic and surgical management were compared. RESULTS: From 2007 to 2017, there were 220,666 CV hospitalizations. CV-related hospitalizations increased from 17,888 in 2007 to 21,715 in 2017 (p=0.001). However, inpatient mortality decreased from 7.6% in 2007 to 6.2% in 2017 (p<0.001). Of all CV-related hospitalizations, 13,745 underwent endoscopic intervention, and 77,157 underwent surgery. Although the endoscopic cohort had patients with a higher Charlson comorbidity index, we noted lower inpatient mortality (6.1% vs. 7.0%, p<0.001), mean length of stay (8.3 vs. 11.8 days, p<0.001), and mean total healthcare charge ($68,126 vs. $106,703, p<0.001) compared to the surgical cohort. Male sex, increased Charlson comorbidity index scores, acute kidney injury, and malnutrition were associated with higher odds of inpatient mortality in patients with CV who underwent endoscopic management. CONCLUSION: Endoscopic intervention has lower inpatient mortality and is an excellent alternative to surgery for appropriately selected CV hospitalizations.

A Comparative Analysis of Bleeding Peptic Ulcers in Hospitalizations With and Without End-Stage Renal Disease.

Background: End-stage renal disease (ESRD) patients are highly susceptible to peptic ulcer bleeding (PUB). We aimed to assess the influence of ESRD status on PUB hospitalizations in the United States (USA). Methods: We analyzed the National Inpatient Sample to identify all adult PUB hospitalizations in the USA from 2007 to 2014, which were divided into two subgroups based on the presence or absence of ESRD. Hospitalization characteristics and clinical outcomes were compared. Furthermore, predictors of inpatient mortality for PUB hospitalizations with ESRD were identified. Results: Between 2007 and 2014, there were 351,965 PUB hospitalizations with ESRD compared to 2,037,037 non-ESRD PUB hospitalizations. PUB ESRD hospitalizations had a higher mean age (71.6 vs. 63.6 years, P < 0.001), and proportion of ethnic minorities i.e., Blacks, Hispanics, and Asians compared to the non-ESRD cohort. We also noted higher all-cause inpatient mortality (5.4% vs. 2.6%, P < 0.001), rates of esophagogastroduodenoscopy (EGD) (20.7% vs. 19.1%, P < 0.001), and mean length of stay (LOS) (8.2 vs. 6 days, P < 0.001) for PUB ESRD hospitalizations compared to the non-ESRD cohort. After multivariate logistic regression analysis, Whites with ESRD had higher odds of mortality from PUB compared to Blacks. Furthermore, the odds of inpatient mortality from PUB decreased by 0.6% for every 1-year increase in age for hospitalizations with ESRD. Compared to the 2011 - 2014 study period, the 2007 - 2010 period had 43.7% higher odds (odds ratio (OR): 0.696, 95% confidence interval (CI): 0.645 - 0.751) of inpatient mortality for PUB hospitalizations with ESRD. Conclusions: PUB hospitalizations with ESRD had higher inpatient mortality, EGD utilization, and mean LOS compared to non-ESRD PUB hospitalizations.

The Role of Red Cell Distribution Width as a Prognostic Marker in Chronic Liver Disease: A Literature Review.

Liver disease is one of the leading public health problems faced by healthcare practitioners regularly. As such, there has been a search for an inexpensive, readily available, non-invasive marker to aid in monitoring and prognosticating hepatic disorders. Recently, red blood cell distribution width (RDW) has been found to be associated with various inflammatory conditions with implications for its use as a potential marker for assessing disease progression and prognosis in multiple conditions. Multiple factors effect red blood cell production whereby a dysfunction in any process can lead to anisocytosis. Furthermore, a chronic inflammatory state leads to increased oxidative stress and produces inflammatory cytokines causing dysregulation and increased intracellular uptake and use of both iron and vitamin B12, which leads to a reduction in erythropoiesis causing an increase in RDW. This literature review reviews in-depth pathophysiology that may lead to an increase in RDW and its potential correlation with chronic liver diseases, including hepatitis B, hepatitis C, hepatitis E, non-alcoholic fatty liver disease, autoimmune hepatitis, primary biliary cirrhosis, and hepatocellular carcinoma. In our review, we examine the use of RDW as a prognostic and predictive marker for hepatic injury and chronic liver disease.

Racial disparities in endoscopic retrograde cholangiopancreatography (ERCP) utilization in the United States: are we getting better?

BACKGROUND: We identified trends of inpatient therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in the United States (US), focusing on outcomes related to specific patient demographics. METHODS: The National Inpatient Sample was utilized to identify all adult inpatient ERCP in the US between 2007-2018. Trends of utilization and adverse outcomes were highlighted. P-values ≤ 0.05 were considered statistically significant. RESULTS: We noted a rising trend for total inpatient ERCP in the US from 126,921 in 2007 to 165,555 in 2018 (p = 0.0004), with a significant increase in utilization for Blacks, Hispanics, and Asians. Despite an increasing comorbidity burden [Charlson Comorbidity Index (CCI) score ≥ 2], the overall inpatient mortality declined from 1.56% [2007] to 1.46% [2018] without a statistically significant trend (p = 0.14). Moreover, there was a rising trend of inpatient mortality for Black and Hispanic populations, while a decline was noted for Asians. After a comparative analysis, we noted higher rates of inpatient mortality for Blacks (2.4% vs 1.82%, p = 0.0112) and Hispanics (1.17% vs 0.83%, p = 0.0052) at urban teaching hospitals between July toand September compared to the October to June study period; however, we did not find a statistically significant difference for the Asian cohort (1.9% vs 2.10%, p = 0.56). The mean length of stay (LOS) decreased from 7 days in 2007 to 6 days in 2018 (p < 0.0001), while the mean total hospital charge (THC) increased from $48,883 in 2007 to $85,909 in 2018 (p < 0.0001) for inpatient ERCPs. Compared to the 2015-2018 study period, we noted higher rates of post-ERCP pancreatitis (27.76% vs 17.25%, p < 0.0001) from 2007-2014. CONCLUSION: Therapeutic ERCP utilization and inpatient mortality were on the rise for a subset of the American minority population, including Black and Hispanics.

Production and possible reduction of greenhouse gases produced during GI endoscopy activity: a systematic review of available literature.

BACKGROUND AND AIMS: Greenhouse gases (GHGs) that trap heat in the atmosphere are composed of carbon dioxide (CO2), methane, nitrous oxide and fluorinated gases (synthetic hydrofluorocarbons, perfluorocarbons and nitrogen trifluoride). In the USA, the health sector accounts for 8.5% of total GHG emissions. The primary objective of this systematic review was to critically analyse the carbon emissions data from GI endoscopic activity. DESIGN: The GI endoscopy carbon cycle was evaluated at preprocedural, intraprocedural and postprocedural levels. We performed a systematic literature search of articles published on these issues until 30 June 2022 and discussed these available data on endoscopy unit GHG carbon cycle, barriers to reduce GHG emissions and potential solutions. The inclusion criteria were any full-text articles (observational, clinical trials, brief communications, case series and editorials) reporting waste generation from GI endoscopy. Abstracts, news articles and conference proceedings were excluded. RESULTS: Our search yielded 393 records in PubMed, 1708 in Embase and 24 in Google Scholar. After application of inclusion and exclusion factors, we focused on 9 fulllength articles in detail, only 3 of them were cross-sectional studies (all from the USA), the others reviews or position statements. Therefore, the quality of the studies could not be assessed due to heterogeneity in definitions and amount of emissions. CONCLUSIONS: Recognition of carbon emissions generated by GI endoscopy activity is critical. Although multiple limitations exists for quantification of these emission, there is an urgent need for collecting proper data as well as examining novel methods for reduction of these emissions for a sustainable endoscopic practices in the future.

COVID-19 and the liver: a narrative review of the present state of knowledge.

Novel corona virus disease (COVID-19) is an ongoing pandemic that has spread across the globe. The virus primarily infects type-2 pneumocytes in alveoli and causes lung disease, with severity ranging from mild pneumonia to acute respiratory distress syndrome. The virus also invades gastrointestinal epithelial cells, hepatocytes, and biliary epithelial cells. Derangement of liver function tests is noted in about one third of patients and appears to correlate with more severe disease. There are multiple mechanisms by which the virus can cause liver injury; immune-mediated inflammation and direct viral cytotoxicity are believed to be the predominant mechanisms. Liver injury appears to be transient, usually recovering with resolution of illness. Limited available studies and experience from prior corona virus pandemics seem to suggest that immunosuppressed patients have similar outcomes compared to non-immunosuppressed patients. Age and comorbid conditions seem to influence outcome, irrespective of immune status. Additionally, patients with preexisting comorbid conditions are more prone to acquire infection and should strictly adhere to travel and social distancing advisories. Telemedicine should be utilized to provide uninterrupted care for patients with liver disease, and clinic or hospital visits should be advised only in sick patients with advanced liver disease. In conclusion, liver dysfunction is not uncommon in COVID-19, it generally improves with resolution of disease, and patients with chronic liver disease (CLD) need continued follow up, uninterrupted by the ongoing pandemic, preferably in virtual clinic settings.

A global multicenter propensity-matched analysis of mortality risk and palliative care referral due to cirrhosis in hospitalized patients with COVID-19.

Background and Aim: A few recent studies identified cirrhosis as a risk factor for high mortality in patients with coronavirus disease-19 (COVID-19). Palliative care is less often involved in the management of cirrhosis. We analyzed a global multicenter database to study the risk of mortality and palliative care referrals in patients with COVID-19 and cirrhosis. Methods: A federated cloud-based network (TriNetX) data from 50 health-care organizations across the globe were analyzed retrospectively. Patients with COVID-19 aged from 18 years to 90 years were identified between January 20, 2020, and November 16, 2020. Results: A total of 1969 patients (Group A) with COVID-19 and cirrhosis and 169,257 patients with COVID-19 alone (Group B) were studied. The two groups had a similar occurrence of other comorbid diseases. In a propensity-matched analysis, the mortality rate in Group A (8.9%) was significantly higher than Group B (5.6%), hazard ratio (95% confidence interval) for mortality with cirrhosis was 1.59 (1.26-1.99) (P = 0.01). The occurrence of palliative care referrals in Group A (4.1%) was significantly higher than Group B (2.0%), hazard ratio (95% confidence interval) with cirrhosis was 2.02 (1.39-2.94) (P = 0.01). Conclusion: Mortality rate and palliative care referrals were higher in patients with cirrhosis and COVID-19 compared to those with COVID-19 alone. This increased occurrence of palliative care referrals compared to the general trend in cirrhotic patients probably indicates increased awareness of COVID-19 as a life-threatening condition. Relevance for Patients: Cirrhosis should be identified as a high-risk condition that may require palliative care referral in hospitalized patients with COVID-19. Hospital resource utilization and cost-analysis modeling should anticipate the need for palliative care referrals as a significant outcome in patients with cirrhosis who are hospitalized with COVID-19.

The Conundrum of Obesity and Gastroparesis Hospitalizations: A Retrospective Comparative Analysis of Hospitalization Characteristics and Disparities Amongst Socioeconomic and Racial Backgrounds in the United States.

Background/Aims: We aim to assess the influence of obesity on gastroparesis (GP) hospitalizations in the United States (US). Methods: The National Inpatient Sample was analyzed from 2007-2017 to identify all adult hospitalizations with a primary discharge diagnosis of GP. They were subdivided based on the presence or absence of obesity (body mass index > 30). Hospitalization characteristics, procedural differences, all-cause inpatient mortality, mean length of stay (LOS), and mean total hospital charge (THC) were identified and compared. Results: From 2007-2017, there were 140 293 obese GP hospitalizations accounting for 13.75% of all GP hospitalizations in the US. Obese GP hospitalizations were predominantly female (76.11% vs 64.36%, P < 0.001) and slightly older (51.9 years vs 50.8 years, P < 0.001) compared to the non-obese cohort. Racial disparities were noted as Blacks (25.49% vs 22%, P < 0.001) had higher proportions of GP hospitalizations with obesity compared to the non-obese cohort. Furthermore, we noted higher rates of inpatient upper endoscopy utilization (6.05% vs 5.42%, P < 0.001), longer mean LOS (5.71 days vs 5.32 days, P < 0.001), and higher mean THC ($53 373 vs $45 040, P < 0.001) for obese GP hospitalizations compared to the non-obese group. However, obese GP hospitalizations had lower rates of inpatient mortality (0.92% vs 1.33%, P < 0.001), and need for nutritional support with endoscopic jejunostomy (0.25 vs 0.56%, P < 0.001) and total parenteral nutrition (1.46% vs 2.33%, P < 0.001) compared to the non-obese cohort. Conclusions: In the US, compared to non-obese, a higher proportion of obese GP hospitalizations were female and Blacks. Obese GP hospitalizations also had higher THC, LOS, and rates of upper endoscopy.

Spontaneous bacterial empyema in cirrhosis: A systematic review and meta-analysis.

BACKGROUND: Spontaneous bacterial empyema (SBE) occurs when a hepatic hydrothorax becomes infected and runs a course similar to spontaneous bacterial peritonitis (SBP). It remains underdiagnosed as patients with cirrhosis do not routinely undergo diagnostic thoracentesis. Current understanding is limited by small cohorts, while studies reporting its association with ascites/SBP are conflicting. AIM: To explore the incidence of SBE, to determine its association with ascites, and to summarize what is known regarding treatment and outcomes for patients with SBE. METHODS: Major databases were searched until June 2021. Outcomes include the incidence of SBE in pleural effusions, SBP in peritoneal fluid, and SBE in patients without ascites within our cohort of patients with cirrhosis. We performed a meta-analysis using a random-effects model with pooled proportions and 95% confidence intervals (CI). We assessed heterogeneity using I 2 and classic fail-safe to determine bias. RESULTS: Eight studies with 8899 cirrhosis patients were included. The median age ranged between 41.2 to 69.7 years. The majority of the patients were Child-Pugh B and C. Mean MELD score was 18.6 ± 8.09. A total of 1334 patients had pleural effusions and the pooled incidence of SBE was 15.6% (CI 12.6-19; I 2 50). Amongst patients diagnosed with SBE, the most common locations included right (202), left (64), and bilateral (8). Amongst our cohort, a total of 2636 patients had ascites with a pooled incidence of SBP of 22.2% (CI 9.9-42.7; I 2 97.8). The pooled incidence of SBE in patients with cirrhosis but without concomitant ascites was 9.5% (CI 3.6-22.8; I 2 82.5). CONCLUSION: SBE frequently occurs with concurrent ascites/SBP; our results suggest high incidence rates of SBE even in the absence of ascites. The pleura can be an unrecognized nidus and our findings support the use of diagnostic thoracentesis in patients with decompensated cirrhosis after exclusion of other causes of pleural effusion. Thoracentesis should be considered particularly in patients without ascites and when there is a high suspicion of infection. The need for diagnostic thoracentesis will continue to be important as rates of multi-drug resistant bacterial infections increase and antibiotic susceptibility information is required for adequate treatment.

Early prediction of post-ERCP pancreatitis by post-procedure amylase and lipase levels: A systematic review and meta-analysis.

Background and study aims Post-ERCP pancreatitis (PEP) is the most common complication attributed to the procedure, its incidence being approximately 9.7 %. Numerous studies have evaluated the predictive efficacy of post-procedure serum amylase and lipase levels but with varied procedure-to-test time intervals and cut-off values. The aim of this meta-analysis was to present pooled data from available studies to compare the predictive accuracies of serum amylase and lipase for PEP. Patients and methods A total of 18 studies were identified after a comprehensive search of various databases until June 2021 that reported the use of pancreatic enzymes for PEP. Results The sample size consisted of 11,790 ERCPs, of which PEP occurred in 764 (6.48 %). Subgroups for serum lipase and amylase were created based on the cut-off used for diagnosing PEP, and meta-analysis was done for each subgroup. Results showed that serum lipase more than three to four times the upper limit of normal (ULN) performed within 2 to 4 hours of ERCP had the highest pooled sensitivity (92 %) for PEP. Amylase level more than five to six times the ULN was the most specific serum marker with a pooled specificity of 93 %. Conclusions Our analysis indicates that a lipase level less than three times the ULN within 2 to 4 hours of ERCP can be used as a good predictor to rule out PEP when used as an adjunct to patient clinical presentation. Multicenter randomized controlled trials using lipase and amylase are warranted to further evaluate their PEP predictive accuracy, especially in high-risk patients.