Sarcopenia in hepatocellular carcinoma: Current knowledge and future directions.

Liver cancer is the second most occurring cancer worldwide and is one of the leading causes of cancer-related deaths. Hepatocellular carcinoma (HCC) is the most common (80%-90%) type among malignant liver cancers. Sarcopenia occurs very early in HCC and can predict and provide an opportunity to improve muscle health before engaging in the treatment options such as loco-regional, systemic, and transplant management. Multiple prognostic stating systems have been developed in HCC, such as Barcelona Clinic Liver Cancer, Child-Pugh score and Albumin-Bilirubin grade. However, the evaluation of patients' performance status is a major limitation of these scoring systems. In this review, we aim to summarize the current knowledge and recent advances about the role of sarcopenia in cirrhosis in general, while focusing specifically on HCC. Additionally, the role of sarcopenia in predicting clinical outcomes and prognostication in HCC patients undergoing loco-regional therapies, liver resection, liver transplantation and systematic therapy has been discussed. A literature review was performed using databases PubMed/MEDLINE, EMBASE, Cochrane, Web of Science, and CINAHL on April 1, 2021, to identify published reports on sarcopenia in HCC. Sarcopenia can independently predict HCC-related mortality especially in patients undergoing treatments such as loco-regional, surgical liver transplantation and systemic therapies. Basic research is focused on evaluating a balance of anabolic and catabolic pathways responsible for muscle health. Early clinical studies have shown promising results in methods to improve sarcopenia in HCC which can potentially increase prognosis in these patients. As sarcopenia occurs very early in HCC, it can predict and provide an opportunity to improve muscle health before engaging in the treatment options such as loco-regional, systemic, and transplant management. Further, sarcopenia measurement can obviate the confounding caused by the abdominal ascites in these patients. The use of sarcopenia can add to the existing scoring systems to better prognosticate the HCC.

Endoscopic ultrasound guided liver biopsy: Recent evidence.

Liver biopsy (LB) is an essential tool in diagnosing, evaluating and managing various diseases of the liver. As such, histopathological results are critical as they establish or aid in diagnosis, provide information on prognosis, and guide the appropriate selection of medical therapy for patients. Indications for LB include evaluation of persistent elevation of liver chemistries of unclear etiology, diagnosis of chronic liver diseases such as Wilson's disease, autoimmune hepatitis, small duct primary sclerosing cholangitis, work up of fever of unknown origin, amyloidosis and more. Traditionally, methods of acquiring liver tissue have included percutaneous LB (PCLB), transjugular LB (TJLB) or biopsy taken surgically via laparotomy or laparoscopy. However, traditional methods of LB may be inferior to newer methods. Additionally, PCLB and TJLB carry higher risks of adverse events and complications. More recently, endoscopic ultrasound guided LB (EUS-LB) has evolved as an alternative method of tissue sampling that has proven to be safe and effective, with limited adverse events. Compared to PC and TJ routes, EUS-LB may also have a greater diagnostic yield of tissue, be superior for a targeted approach of focal lesions, provide higher quality images and allow for greater patient comfort. These advantages have contributed to the increased use of EUS-LB as a technique for obtaining liver tissue. Herein, we provide a review of the recent evidence of EUS-LB for liver disease.

Noninvasive serum models to predict significant liver related events in chronic hepatitis C.

AIM: We aim to compare 20 noninvasive fibrosis scores (NIFS), derived from routine blood tests, for predicting significant liver-related adverse events (SLRE) in patients with chronic hepatitis C (CHC) after anti-viral treatment (AVT) with the goal to identify independent predictors for these outcomes. METHODS: From 1605 patients who received AVT (pegylated interferon and ribavirin) from January 2002 to June 2014, 20 NIFS were calculated from routine blood tests prior to AVT. Areas under the receiver-operating characteristic curve (AUROC) were calculated for each of these NIFS for predicting non-response to AVT and development of SLRE on follow-up. RESULTS: Mean age was 41.9 ± 9.7 years, and patients were predominantly genotype 4 (65%). After AVT, there were 1089 (67.8%) responders, 482 (30%) non-responders and 34 (2.1%) relapsers. After median follow-up of 6580.5 patient-years, 60 (3.8%) had SLRE, 52 (3.2%) had decompensation, and 11 (0.7%) had hepatocellular carcinoma (HCC). The predictive accuracy of NIFS and liver biopsy (LB) for non-response to AVT was low. FIB-4, FibroQ and King score showed high accuracy for predicting adverse events. For predicting decompensation, HCC and SLRE, FibroQ (0.881), King score (0.905) and FibroQ (0.877) had the highest AUROC, respectively. On multivariate analysis, independent predictors for treatment non-response (age, ALT, GGT, platelet count), HCC (albumin, GGT) and SLRE (albumin, GGT, platelet count) were identified. CONCLUSIONS: Some simple pretreatment blood parameters and NIFS showed high accuracy for predicting development of SLRE post treatment. Application of these simple scores can improve assessment of long-term liver prognosis for CHC.

Characterization of Cardiac Dysfunction by Echocardiography in Early Severe Acute Pancreatitis.

OBJECTIVE: Persistent organ failure is a feature of severe acute pancreatitis (SAP) and the leading cause of death. Although usually defined by hypotension, cardiovascular dysfunction (CD) in early SAP has not been well characterized. We aim to characterize CD in patients with SAP and hypotension and determine its impact on clinical outcome. METHODS: Patients with SAP and hypotension were studied to define the frequency, nature, and prognostic significance of CD characterized by echocardiography and classified as systolic, diastolic, or combined dysfunction. RESULTS: Of the 72 patients (median age, 41 years, 44 men), 10 (14%) had percutaneous drain placement, 12 (17%) underwent surgery, and 14 (19%) died. Persistent hypotension was present in 58 (81%) and transient hypotension in 14 (19%) patients. Cardiovascular dysfunction was present in 47 (65%) patients: 28 (60%) with diastolic dysfunction, 8 (17%) with systolic dysfunction, and 11 (23%) with combined dysfunction. Left ventricular end diastolic volume, stroke volume index, cardiac index, and diastolic dysfunction correlated with mortality on univariate analysis. CONCLUSIONS: Two thirds of patients with early SAP and hypotension had cardiac dysfunction, which was most commonly diastolic dysfunction. A better understanding of the nature of cardiac dysfunction in this setting may allow more accurate diagnosis, prognostication, and management.

Endoscopic ultrasound in the diagnosis and management of carcinoma pancreas.

Endoscopic ultrasound (EUS) has become an important component in the diagnosis and treatment of carcinoma pancreas. With the advent of advanced imaging techniques and tissue acquisition methods the role of EUS is becoming increasingly important. Small pancreatic tumors can be reliably diagnosed with EUS. EUS guided fine needle aspiration establishes diagnosis in some cases. EUS plays an important role in staging of carcinoma pancreas and in some important therapeutic methods that include celiac plexus neurolysis, EUS guided biliary drainage and drug delivery. In this review we attempt to review the role of EUS in diagnosis and management of carcinoma pancreas.

Clinical Application of AIMS65 Scores to Predict Outcomes in Patients with Upper Gastrointestinal Hemorrhage.

BACKGROUND/AIMS: To evaluate the ability of the recently proposed albumin, international normalized ratio (INR), mental status, systolic blood pressure, age >65 years (AIMS65) score to predict mortality in patients with acute upper gastrointestinal bleeding (UGIB). METHODS: AIMS65 scores were calculated in 251 consecutive patients presenting with acute UGIB by allotting 1 point each for albumin level <30 g/L, INR >1.5, alteration in mental status, systolic blood pressure ≤90 mm Hg, and age ≥65 years. Risk stratification was done during the initial 12 hours of hospital admission. RESULTS: Intensive care unit (ICU) admission, endoscopic therapy, or surgery were required in 51 patients (20.3%), 64 (25.5%), and 12 (4.8%), respectively. The predictive accuracy of AIMS65 scores ≥2 was high for blood transfusion (area under the receiver operator characteristic curve [AUROC], 0.59), ICU admission (AUROC, 0.61), and mortality (AUROC, 0.74). The overall mortality was 10.3% (n=26), and was 3%, 7.8%, 20%, 36%, and 40% for AIMS65 scores of 0, 1, 2, 3, and 4, respectively; these values were significantly higher in those with scores ≥2 (30.9%) than in those with scores <2 (4.5%, p<0.001). CONCLUSIONS: AIMS65 is a simple, accurate, non-endoscopic risk score that can be applied early (within 12 hours of hospital admission) in patients with acute UGIB. AIMS65 scores ≥2 predict high in-hospital mortality.

Endoscopic ultrasound guided drainage of pancreatic fluid collections: Assessment of the procedure, technical details and review of the literature.

Endoscopic ultrasound (EUS) guided drainage of pancreatic fluid collections (PFC) has become increasingly popular and become first line management option in many centers. Use of therapeutic echoendoscopes has greatly increased the applicability of EUS guided transmural drainage. Drainage is indicated in symptomatic PFCs, PFC related infection, bleed, luminal obstruction, fistulization and biliary obstruction. EUS guided transmural drainage of PFCs is preferred in patients with non bulging lesions, portal hypertension, bleeding tendency and in those whom conventional drainage has failed. In the present decade significant progress has been made in minimally invasive endoscopic techniques. There are newer stent designs, access devices and techniques for more efficient drainage of PFCs. In this review, we discuss the EUS guided drainage of PFCs in acute pancreatitis.

Noninvasive biomarkers FibroTest and ActiTest versus liver biopsy in chronic hepatitis C patients: the Middle East experience.

BACKGROUND: The aim of this study was to compare noninvasive biomarkers, FibroTest and ActiTest in predicting fibrosis stage and inflammation grade in chronic hepatitis C (CHC) patients with liver biopsy (LB). METHODS: In 107 patients with CHC, levels of six serum biomarkers (alanine aminotransferase, γ-glutamyl transpeptidase, total bilirubin, haptoglobin, apolipoprotein, α-2 macroglobulin) were determined at the time of LB. LB was evaluated by Metavir score for fibrosis and inflammation. Voluntary blood donors (n=106) were taken as controls for the study. RESULTS: Fibrosis estimated by Fibrotest was significantly higher in patients compared to control group. The observed area under the receiver operating characteristic curve (AUROC) for advanced fibrosis (F3, F4) adjusted according to the observed difference between advanced and non-advanced fibrosis prevalence (DANA) was 0.80 (0.69-0.88) and the AUROC for cirrhosis (F4) was 0.94 (0.86-0.98). ActiTest AUROC for moderate to severe activity (A2A3) was 0.72 (0.61-0.81), and for severe activity (A3) was 0.88 (0.78-0.93). The diagnostic values in the group of good quality biopsy (n=41) showed Fibrotest AUROC (DANA-adjusted): for advanced fibrosis 0.90 (0.72-0.99); for cirrhosis 0.93 (0.76-0.98); and ctiTest AUROC: for moderate/severe activity 0.86 (0.67-0.94); and for severe activity 0.90 (0.76-0.93). There was good concordance between FibroTest and LB (with discordance for two or more stages in <20% for advanced fibrosis and <10% for cirrhosis) and between ActiTest and LB. Specificity for FibroTest and ActiTest in the control population were 95% and 100% respectively. CONCLUSIONS: Fibrotest and ActiTest had high observed and standardized diagnostic values for predicting fibrosis and activity respectively.

Endoscopic ultrasound-guided fine-needle aspiration of the adrenal glands: analysis of 21 patients.

BACKGROUND/AIMS: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) cytology of adrenal masses helps in etiological diagnosis. The aim of this study was to evaluate the diagnostic yield of EUS-FNA of adrenal masses in cases where other imaging methods failed and/or were not feasible. METHODS: Twenty-one consecutive patients with adrenal masses, in whom adrenal FNA was performed because conventional imaging modalities failed and/or were not feasible, were prospectively evaluated over a period of 3 years. RESULTS: Of the 21 patients (mean age, 56±12.2 years; male:female ratio, 2:1), 12 had pyrexia of unknown origin and the other nine underwent evaluation for metastasis. The median lesion size was 2.4×1.6 cm. Ten patients were diagnosed with tuberculosis (shown by the presence of caseating granulomas [n=10] and acid-fast bacilli [n=4]). Two patients had EUS-FNA results suggestive of histoplasmosis. The other patients had metastatic lung carcinoma (n=6), hepatocellular carcinoma (n=1), and adrenal lipoma (n=1) and adrenal myelolipoma (n=1). EUS results were not suggestive of any particular etiology. No procedure-related adverse events occurred. CONCLUSIONS: EUS-FNA is a safe and effective method for evaluating adrenal masses, and it yields diagnosis in cases where tissue diagnosis is impossible or has failed using conventional imaging modalities.

Hypotension in the first week of acute pancreatitis and APACHE II score predict development of infected pancreatic necrosis.

BACKGROUND: Hypotension and intestinal mucosal ischemia lead to bacterial translocation from the gut lumen into systemic circulation. AIM: The purpose of this study was to determine the strength of association between different types of organ failure (OF): hypotension (cardiovascular system failure), renal failure, respiratory failure, CNS failure and coagulopathy in the first week of acute pancreatitis (AP) and the subsequent development of infected pancreatic necrosis (IN). METHODS: Consecutive patients with AP were evaluated for OF and its severity in the first week of hospital admission. Modified multiple organ failure score (MOFS) was used to identify and grade severity of OF. MOFS of ≥2, lasting for more than 48 h was defined as OF. Occurrence of IN (isolation of bacteria in necrosectomy specimen or image guided fine needle aspiration of pancreatic necrosis) was compared between groups with and without OF. RESULTS: Of the 81 patients, mean age was 40.1 ± 14.4 years and 55 were males; 60 (74 %) patients had OF and 13 (16 %) patients had IN. Occurrence of IN was not significantly different between patients with OF (18.3 %) and without OF (14.3 %), p = 0.48. However IN occurred in 10 % of patients without and 33.7 % patients with hypotension, p = 0.01. The rest of the organ systems analyzed did not show any significant difference in occurrence of infected necrosis. On multivariate analysis independent predictors of occurrence of IN were hypotension (odds ratio, OR 2.5, p < 0.001) and APACHE II score at 24 h of hospital admission (OR 4.77, p < 0.001). CONCLUSION: Hypotension in the first week of AP and APACHE II score predict development of IN.

Reexamination of the relationship between the prevalence of hepatitis C virus and parenteral antischistosomal therapy among Egyptians resident in Qatar.

Egypt has the highest prevalence of recorded hepatitis C virus (HCV) worldwide, estimated nationally at 14.7%, which is attributed to extensive iatrogenic transmission during the era of parenteral antischistosomal therapy (PAT) mass-treatment campaigns. The objective of our study was to attempt to highlight to what extent HCV transmission is ongoing and discuss the possible risk factors. We studied the prevalence of HCV among 7.8% of Egyptians resident in Qatar in relation to age, socioeconomic status, and PAT and discuss the possible risk factors. HCV testing was conducted in 2,335 participants, and results were positive for 13.5%, and 8.5% for those aged below 35 years. The prevalence of HCV in the PAT-positive population was 23.7% (123 of 518, 95% confidence interval [CI] 20.2%-27.6%) compared with 11.2% in the PAT-negative group. Significantly higher HCV prevalence occurred in participants who were older than 50 years (23%, 95% CI 19.3%-27.1%) compared to those aged 45-50 years (19.3%, 95% CI 15.2%-23.8%), 35-45 years (11.1%, 95% CI 8.9%-13.7%), and less than 35 years (8.5%, 95% CI 6.8%-10.4%) (P<0.0001). Insignificant higher prevalence occurred in the low socioeconomic group (14.2%, 95% CI 11.3%-17.4%). Logistic regression analysis revealed that increasing age, history of PAT, bilharziasis, and praziquantel were common risk factors, but there was no relation with dental care. Host genetic predisposition seems to be a plausible underlying factor for susceptibility among Egyptians and intense ongoing infection.

Uncommon gastrointestinal complications of enteric fever in a non-endemic country.

Enteric fever is a systemic illness with varying presentation. It is an important infectious disease in developing countries and also in industrialized countries where many migrants reside. Enteric fever can result in complications in different organ systems and delay in identification and prompt treatment can be fatal. The important gastrointestinal complications of enteric fever include hepatitis, intestinal ulcers, bleeding and bowel perforation. We report three relatively uncommon complications of enteric fever in Qatar, a non-endemic country, ileal ulcer presenting with hematochezia; duodenal ulcer with polyserositis, cholestatic hepatitis and bone marrow suppression; enteric fever related peritonitis.

Abdominal and scrotal wall emphysema in a patient with severe ulcerative colitis.

Severe ulcerative colitis can be associated with bowel perforation. Bowel perforation rarely leads on to abdominal wall and scrotal wall emphysema. Bowel perforation in such cases can be spontaneous or iatrogenic (colonoscopy-related). We report a rare scenario where a patient presented with abdominal wall and scrotal emphysema after topical corticosteroid enema-induced traumatic rectal perforation. Topical corticosteroids were stopped immediately after identification of rectal perforation. The patient was managed conservatively with intravenous antibiotics. With this report we intend to sensitise clinicians and topical enema manufacturers regarding this rare complication.