Epidemiology of hepatitis D virus infection in Europe: Is it vanishing?

Co-infection with hepatitis delta virus (HDV) is a challenging health care problem worldwide, estimated to occur in approximately 5%-10% of patients with chronic hepatitis B virus (HBV) infection. While HBV prevalence is decreasing globally, the prevalence of HDV infection is rising in some parts mainly due to injection drug use, sexual transmission and immigration from high endemicity areas. Eastern Europe and the Mediterranean are among the regions with high rates of endemicity for HDV and the immigration from high endemicity areas to Central and Western Europe has changed the HDV epidemiology. We aimed to review the prevalence of HDV infection in Europe. A paucity of publication appears in many European countries. Prevalence studies from some countries are old dated and some other countries did not report any prevalence studies. The studies are accumulated in few countries. Anti-HDV prevalence is high in Greenland, Norway, Romania, Sweden and Italy. Belgium, France, Germany, Spain, Switzerland, Turkey and United Kingdom reported decreasing prevalences. Among cirrhotic HBV patients, Germany, Italy and Turkey reported higher rates of HDV. The studies including centres across the Europe reported that HIV-HBV coinfected individuals have higher prevalence of HDV infection. The immigrants contribute the HDV infection burden in Greece, Italy, and Spain in an increasing rate. Previous studies revealed extremely high rates of HDV infection in Germany, Greece, Italy and Sweden. The studies report a remarkably high prevalence of hepatitis delta among HIV/HBV-coinfected individuals, individuals who inject drugs, immigrants and severe HBV infected patients across Europe. The HDV infection burden still appears to be significant. In the lack of an effective HDV therapy, prevention strategies and active screening of HBV/HDV appear as the most critical interventions for reducing the burden of liver disease related to HDV infection in Europe.

Safety of anticoagulation use for treatment of portal vein thrombosis in liver cirrhosis and its effect on hospital-based outcomes: an insight from a US nationwide database.

BACKGROUND AND AIM: Anticoagulation use for portal vein thrombosis (PVT) in patients with advanced liver disease is controversial. We investigated the effect of anticoagulation on outcomes in patients with PVT with cirrhosis. METHODS: We reviewed National Inpatient Sample data from 2016 to 2018 to identify patients with PVT. Our outcomes were in-hospital mortality, variceal bleeding, hepatic encephalopathy, acute kidney injury (AKI), hepatorenal syndrome (HRS), spontaneous bacterial peritonitis (SBP), sepsis and hospital resource utilisation. RESULTS: We included 60 505 patients with PVT, out of whom 6.63% (4015) were on anticoagulation. The overall mortality in the anticoagulation group was 2.12% compared with 9.72% in the no anticoagulation group. The adjusted odds of mortality were low in the anticoagulation group (adjusted OR (AOR) 0.27, 95% CI 0.15 to 0.46, p<0.001). Patients on anticoagulation had 29% lower odds of variceal bleeding (AOR 0.71, 95% CI 0.53 to 0.96, p=0.03). Lower odds of HRS (AOR 0.56, 95% CI 0.37 to 0.85, p=0.01) and AKI (AOR 0.57, 95% CI 0.48 to 0.69, p<0.001) were also seen in the anticoagulation group. Patients in the anticoagulation group also showed lower odds of SBP (AOR 0.62, 95% CI 0.43 to 0.89, p=0.01) and sepsis (AOR 0.57, 95% CI 0.35 to 0.93, p=0.03). Anticoagulation use resulted in shorter hospital stay by 1.15 days (adjusted length of stay -1.15, 95% CI -1.51 to -0.79, p<0.001). The mean difference in total hospital charges between the anticoagulation and the no anticoagulation group was -$20 034 (95% CI -$27 077 to -$12 991, p<0.001). CONCLUSION: Our analysis found that anticoagulation use is safe and associated with better outcomes in patients with PVT with advanced liver disease.

Ex vivo human bile duct radiofrequency ablation with a bipolar catheter.

BACKGROUND: Management of the primary and secondary tumors of the bile ducts still remains as a major clinical challenge. Radiofrequency (RF) ablation (RFA) of these tumors is feasible but the effect of RF energy on the human common bile duct (CBD) and surrounding tissues has not been investigated. This pilot study aimed to determine the relationship between RF energy and the depth of ablation in the normal human CBD. METHODS: The study was performed on fresh ex vivo human biliary-pancreatic tissue which had been resected for a pancreatic cyst or mass. The study was conducted within 15 min after resection. A bipolar Habib RFA catheter was placed into the middle of the intact CBD, and three different (5, 7, 10 W) power settings were applied over a 90-s period by an RF generator. Gross and histological examinations were performed. The depth of coagulation necrosis in CBD and the effect of RFA on CBD wall and surrounding pancreas tissue were determined by microscopic examination. RESULTS: The study included eight tissue samples. 5 W power was applied to three sites and RFA caused only focal epithelial necrosis limited to the CBD mucosa. 7 and 10 W were applied to five sites and coagulation necrosis occurred in all cases. Microscopically, necrosis was transmural, involved accessory bile duct glands, and extended to the surrounding pancreatic tissue in four of these cases. Macroscopically, RFA resulted in circumferential white-yellowish color change extending approximately 2 cm of the CBD. CONCLUSION: Bipolar RF energy application with 5 W resulted in limited ablation on CBD wall. However, 7 and 10 W generated tissue necrosis which extended through the CBD wall and into surrounding pancreas tissue. Endoscopic biliary RFA is an effective technique for local biliary tissue ablation but the use of high energy may injure surrounding tissue.

Endoscopic submucosal resection of gastric subepithelial lesions smaller than 20 mm: a comparison of saline solution-assisted snare and cap band mucosectomy techniques.

BACKGROUND AND AIMS: Application of endoscopic submucosal resection (ESMR) in the management of gastric subepithelial lesions (GSLs) less than 20 mm is gradually increasing because it allows diagnosis and treatment at the same operative session. In this study, we compare and evaluate the benefits of ESMR with an endoscopic cap band mucosectomy technique or saline solution-assisted snare technique in GSLs smaller than 20 mm. METHODS: This was a retrospective analysis of a prospectively maintained database used at 2 academic tertiary care centers. A total of 63 patients (34 females, mean age 52 years) with endoscopically resected GSLs were included in this study. RESULTS: The mean tumor size determined by EUS was 12.3 mm (range, 5-20 mm). Sixty-seven percent of the GSLs were localized in the antrum in all groups. The endoscopic cap band mucosectomy technique was used to resect 32 (50.8%) GSLs, whereas 31 (49.2%) were resected with the saline solution-assisted snare technique. The en bloc resection rates were 97% for the saline solution-assisted snare technique and 100% for the endoscopic cap band mucosectomy. Intraoperative bleeding occurred in 1 of 31 patients (3.2%) when ESMR was performed with the saline solution-assisted snare technique. Postoperative bleeding was seen in 1 of 32 patients (3.1%) who underwent the endoscopic cap band mucosectomy technique. CONCLUSIONS: In GSLs smaller than 20 mm, ESMR with saline solution-assisted snare or endoscopic cap band mucosectomy techniques is safe, the adverse event rate is low, accurate diagnosis is achieved, and treatment with en bloc resection is provided in a single session. Given similar success and adverse event rates, saline solution-assisted ESMR may be the preferred technique because of its lower cost advantages.

The Presence of Genetic Mutations at Key Loci Predicts Progression to Esophageal Adenocarcinoma in Barrett's Esophagus.

OBJECTIVES: Risk stratification in Barrett's esophagus (BE) is challenging. We evaluated the ability of a panel of genetic markers to predict progression to high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC). METHODS: In this case-control study, we assessed a measure of genetic instability, the mutational load (ML), in predicting progression to HGD or EAC. Cases had nondysplastic BE or low-grade dysplasia (LGD) at baseline and developed HGD/EAC ≥1 year later. Controls were matched 2:1, had nondysplastic BE or LGD, and no progression at follow-up. Formalin-fixed, paraffin-embedded tissue was microdissected for the epithelium. Loss of heterozygosity (LOH) and microsatellite instability (MSI) were assessed. ML was calculated from derangements in 10 genomic loci. High-clonality LOH mutations were assigned a value of 1, low-clonality mutations were assigned a value of 0.5, and MSI 0.75 at the first loci, and 0.5 for additional loci. These values were summed to the ML. Receiver operator characteristic (ROC) curves were created. RESULTS: There were 69 patients (46 controls and 23 cases). Groups were similar in age, follow-up time, baseline histology, and the number of microdissected targets. Mean ML in pre-progression biopsies was higher in cases (2.21) than in controls (0.42; P<0.0001). Sensitivity was 100% at ML ≥0.5 and specificity was 96% at ML ≥1.5. Accuracy was highest at 89.9% for ML ≥1. ROC curves for ML ≥1 demonstrated an area under the curve (AUC) of 0.95. CONCLUSIONS: ML in pre-progression BE tissue predicts progression to HGD or EAC. Although further validation is necessary, ML may have utility as a biomarker in endoscopic surveillance of BE.

Evaluation of bipolar radiofrequency ablation for occluded self-expandable metal stents in the bile duct: in vivo and in vitro study.

BACKGROUND AND AIMS: Endobiliary radiofrequency ablation (RFA) has been used to treat occluded self-expandable metal stents (SEMSs). The aim of this study was to determine the characteristics of bipolar RFA in occluded SEMSs using both in vivo and in vitro models. METHODS: For the in vivo study, uncovered SEMSs were deployed in the bile ducts of three pigs; another pig was used as the control. RFA was performed at 10 W for 90 seconds. The bile duct was examined for histological changes. For the in vitro simulation of tissue ingrowth in SEMSs, RFA at 10 W for 30 seconds was performed on SEMS-occlusion polyacrylamide-gel phantoms. RESULTS: The ablation depth was markedly reduced in the stented porcine bile duct. RFA of uncovered SEMS-occlusion gel phantoms resulted in early termination of RFA when the coagulated area contacted the SEMS. This phenomenon was not observed in RFA of the covered SEMS-occlusion gel phantoms. CONCLUSIONS: The presence of SEMSs attenuated the effect of bipolar endobiliary RFA. Tumorous tissue outside the SEMS is unlikely to be affected.

Outcome of patients with positive heparin-platelet factor-4 antibodies: A retrospective multi-institutional observational study.

Studies show increased mortality with positive heparin-platelet factor-4 (H-PF4) antibodies, especially in hemodialysis patients. We aimed to compare mortality and thrombosis in hospitalized patients with positive, equivocal and negative H-PF4 antibody results. Information was collected on these patients using a multi-institutional retrospective electronic medical record review. Patients tested for H-PF4 antibodies by commercial ELISA during the years 2006 to 2010 were identified. We compared 30-day, 90-day and 1-year mortality in patients with negative, equivocal and positive H-PF4 test and evaluated the relationship between H-PF4 status and rate of thrombosis. Four hundred and seventeen patients had ELISA testing for H-PF4 antibodies. Forty-four patients had equivocal (optical density value 0.4-0.9) and 21 had positive (value 1) H-PF4 antibody test. There were no statistically significant differences in mortality between patients with negative, equivocal and positive results at all three time points (p = 0.22, 0.27 and 0.38, respectively) even after excluding patients with thrombosis (p = 0.22, 0.24 and 0.31, respectively). Age and Charlson score were associated with increased 30-day, 90-day and 1 year mortality. Odds ratio of having thrombosis was 23.1 for positive vs. equivocal results (p < 0.001); however, there was no statistically significant difference between equivocal vs. negative results (p = 0.22). Our results revealed no association between H-PF4 status and mortality, as well as no difference in 1-year survival between the positive and negative groups.

Evaluation of radiofrequency ablation using the 1-Fr wire electrode in the porcine pancreas, liver, gallbladder, spleen, kidney, stomach, and lymph nodes: A pilot study.

OBJECTIVES: The frequency of detecting asymptomatic incidental lesions of the pancreas is increasing. A substantial number of these lesions are either malignant or premalignant, thus mandating pancreatic resection. A less invasive treatment option may be feasible for selected patients. Endoscopic ultrasound-guided radiofrequency ablation (RFA) may be offered as a treatment option for these patients. The objective of this study was to evaluate the performance characteristics of monopolar RFA using a 1-Fr wire electrode in the porcine pancreas, liver, gallbladder, spleen, kidney, stomach, and lymph nodes. METHODS: Six Yorkshire pigs were used for this study. The internal organs were accessed after a midline laparotomy. Manual monopolar RFAs were performed over a 90-second period using a wide range of power settings (3, 4, 5, 10, 15, and 25 W). The pancreas was exposed at all power settings; the other organs were exposed at power settings of 3, 4, 5, and 10 W. The maximum diameter of coagulative necrosis was measured. RESULTS: In all study animals, RFA was performed in the target organs without difficulty. Only the pancreas showed definite coagulative necrosis. The maximum diameter of coagulative necrosis (8.0±1.7 mm) was achieved at 5 W. No definite coagulative necrosis was noted in the other organs. CONCLUSIONS: Monopolar RFA using a 1-Fr wire electrode resulted in coagulative necrosis in the porcine pancreas. RFA in higher power settings resulted in relatively homogeneous necrosis. At a given power setting, the RFA effect is likely to be differ according to electrical properties of the target tissue. This article is protected by copyright. All rights reserved.

mAb Das-1 is specific for high-risk and malignant intraductal papillary mucinous neoplasm (IPMN).

OBJECTIVE: Intraductal papillary mucinous neoplasm (IPMN) consists of four epithelial subtypes that correlate with histological grades and risks for malignant transformation. mAb Das-1 is a monoclonal antibody against a colonic epithelial phenotype that is reactive to premalignant conditions of the upper GI tract. We sought to assess the ability of mAb Das-1 to identify IPMN with high risk of malignant transformation. DESIGN: mAb Das-1 reactivity was evaluated in 94 patients with IPMNs by immunohistochemistry. Lesional fluid from 38 separate patients with IPMN (n=27), low-grade non-mucinous cystic neoplasms (n=7) and pseudocysts (n=4) was analysed by ELISA and western blot. RESULTS: Immunohistochemistry-Normal pancreatic ducts were non-reactive and low-grade gastric-type IPMN (IPMN-G) (1/17) and intermediate-grade IPMN-G (1/23) were minimally reactive with mAb Das-1. In contrast, mAb Das-1 reactivity was significantly higher in high-risk/malignant lesions (p<0.0001) including: intestinal-type IPMN with intermediate-grade dysplasia (9/10); high-grade dysplasia of gastric (4/7), intestinal (12/12), oncocytic (2/2) and pancreatobiliary types (2/2); and invasive tubular (8/12), colloid (7/7) and oncocytic (2/2) carcinoma. The sensitivity and specificity of mAb Das-1 for high-risk/malignant IPMNs were 85% and 95%, respectively. Lesional fluid-Samples from low- and intermediate-grade IPMN-G (n=9), and other low-grade/benign non-mucinous lesions demonstrated little reactivity with mAb Das-1. Conversely, cyst fluid from high-risk/malignant IPMNs (n=18) expressed significantly higher reactivity (p<0.0001). The sensitivity and specificity of mAbDas-1 in detecting high-risk/malignant IPMNs were 89% and 100%, respectively. CONCLUSIONS: mAb Das-1 reacts with high specificity to tissue and cyst fluid from high-risk/malignant IPMNs and thus may help in preoperative clinical risk stratification.

Peritoneal seeding in intraductal papillary mucinous neoplasm of the pancreas patients who underwent endoscopic ultrasound-guided fine-needle aspiration: the PIPE Study.

BACKGROUND AND STUDY AIMS: There have been concerns about peritoneal seeding after endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of mucinous pancreatic cystic lesions. The aims of this study were to determine the frequency of postoperative peritoneal seeding in patients with intraductal papillary mucinous neoplasm (IPMN) who had undergone pre-operative EUS-FNA and to compare it with that of patients with IPMN who had surgery with no pre-operative tissue sampling. PATIENTS AND METHODS: A total of 175 patients who had undergone resection of IPMNs with pre-operative EUS-FNA (EUS-FNA group) were analyzed and compared with 68 patients who had undergone resection with no pre-operative tissue sampling (No Sampling group). Patient characteristics, pathology, and frequency of peritoneal seeding after surgery were analyzed and compared. Peritoneal seeding was diagnosed based on pathology or image findings. RESULTS: The two groups were comparable with respect to sex, age, follow-up duration, involvement of the pancreatic head, involvement of the main duct, grade of dysplasia, and size of histologically proven branch-duct IPMNs. Four patients (2.3 %) with invasive IPMN developed peritoneal seeding in the EUS-FNA group, whereas three (4.4 %, two with invasive IPMN and one with high-grade dysplasia) developed peritoneal seeding in the No Sampling group (P  = 0.403). No peritoneal seeding was noted during surgery in these cases. Except for one patient in the EUS-FNA group, no spillage occurred during resection in these patients. CONCLUSIONS: In this cohort of patients undergoing resection of IPMN, the difference in the frequency of peritoneal seeding in the EUS-FNA group and the No Sampling group was not significant.

Characterization of epithelial subtypes of intraductal papillary mucinous neoplasm of the pancreas with endoscopic ultrasound and cyst fluid analysis.

BACKGROUND AND STUDY AIMS: Intraductal papillary mucinous neoplasm (IPMN) consists of four epithelial subtypes. There are limited data on the endoscopic ultrasound (EUS) findings and/or cyst fluid analysis of the epithelial subtypes. The objective of this study was to determine whether there are differences in EUS and cyst fluid characteristics (carcinoembryonic antigen [CEA] concentration and cytology) among the subtypes. PATIENTS AND METHODS: The study cohort consisted of 85 patients (median age 68 years, 40 men) with resected and histologically confirmed branch-duct or mixed-type IPMNs who underwent preoperative EUS-guided fine-needle aspiration between 1999 and 2010 for the evaluation of pancreatic cysts. EUS and cyst fluid characteristics were analyzed retrospectively and correlated with the subtypes. RESULTS: The numbers of evaluated cystic lesions were 1 in 79 patients, 2 in 5 patients, and 3 in 1 patient. Of 92 IPMNs analyzed, gastric-type IPMNs were the most common (n = 68, 73.9 %), followed by intestinal (n = 17, 18.5 %), oncocytic (n = 5, 5.4 %), and pancreatobiliary subtypes (n = 2, 2.2 %). Gastric-type IPMNs were significantly smaller (cutoff 30 mm; P = 0.002), and less likely than other subtypes to have a mass lesion or mural nodule (P = 0.046) on EUS. Cyst fluid CEA concentration varied among the subtypes (median concentrations for gastric, intestinal, oncocytic, and pancreatobiliary types 619.8, 83.0, 5.1, and 270.0 ng/mL, respectively; P = 0.012). The presence of neoplastic epithelial cells (P = 0.624) and extracellular mucin (P = 0.208) on cytology had no association with subtypes. CONCLUSIONS: Gastric-type IPMNs, the most common subtype, are characterized by high concentrations of cyst fluid CEA, small cyst diameter, and low risk EUS imaging features.

Use of proton pump inhibitors improves outcomes in mild acute pancreatitis: A nationwide cohort study.

Previous studies showed a potential anti-inflammatory effect of proton pump inhibitors (PPI) as well as possible inhibition of pancreatic secretion. This presents the question of their possible use in acute pancreatitis (AP). Current clinical evidence does not address the role of PPI and the present review for possible therapeutic use and safety is lacking. Therefore, our study aims to address the role of PPI in the management of AP and their association with the different outcomes of AP. We queried the Diamond Network through TriNetX-Research Network. This network included 92 healthcare organizations. Patients with mild AP with Bedside Index of Severity in Acute Pancreatitis (BISAP) score of Zero regardless of etiology were divided into 2 cohorts; 1st cohort included patients on PPI, and 2nd cohort included patients not on any PPI. Patients with BISAP score equal to or more than 1 or on PPI prior to the study date were excluded. Two well-matched cohorts were created using 1:1 propensity-scored matching model between cohorts. We compared the incidence of intensive care unit admission, mortality, and other associated complications. A total of 431,571 patients met the inclusion criteria. Of those, 32.9% (n = 142,062) were on PPI, and 67% (n = 289,509) were not on any PPI. After propensity matching, the sample included 115,630 patients on PPI vs 115,630 patients not on PPI. The PPI group had a lower rate of mortality (3.7% vs 4.4%, P < .001), a lower rate of intensive care unit admission (3.9% vs 5.5%, P < .001), a lower rate of necrotizing pancreatitis (1.1% vs 1.9%, P < .001), a lower rate of Hospital-Acquired Pneumonia (3.6% vs 4.9%, P < .001), a lower rate of respiratory failure (2.8% vs 4.2%, P < .001), and a lower rate of acute kidney injury (6.9% vs 10.1%, P < .001). There was no statistical difference in the rate of Clostridium difficile infection between the 2 cohorts (0.9% vs 0.8%, P = .5). The use of PPI in mild AP with a BISAP-score of zero is associated with reduced pancreatitis-related complications and improved mortality. Prospective studies are needed to confirm these findings.

The Use of Pre-Endoscopic Metoclopramide Does Not Prevent the Need for Repeat Endoscopy: A U.S. Based Retrospective Cohort Study.

BACKGROUND: Peptic ulcer disease (PUD) can cause upper gastrointestinal bleeding (UGIB), often needing esophagogastroduodenoscopy (EGD). Second-look endoscopies verify resolution, but cost concerns prompt research on metoclopramide's efficacy compared to erythromycin. METHODS: We analyzed the Diamond Network of TriNetX Research database, dividing UGIB patients with PUD undergoing EGD into three groups: metoclopramide, erythromycin, and no medication. Using 1:1 propensity score matching, we compared repeat EGD, post-EGD transfusion, and mortality within one month in two study arms. RESULTS: Out of 97,040 patients, 11.5% received metoclopramide, 3.9% received erythromycin, and 84.6% received no medication. Comparing metoclopramide to no medication showed no significant difference in repeat EGD (10.1% vs. 9.7%, p = 0.34), transfusion (0.78% vs. 0.86%, p = 0.5), or mortality (1.08% vs. 1.08%, p = 0.95). However, metoclopramide had a higher repeat EGD rate compared to erythromycin (9.4% vs. 7.5%, p = 0.003), with no significant difference in transfusion or mortality. CONCLUSIONS: The need to repeat EGD was not decreased with pre-EGD use of metoclopramide. If a prokinetic agent is to be used prior to EGD, erythromycin shows superior reduction in the need of repeat EGD as compared to metoclopramide.

Epigastric Pain and Dysphagia in a 36-Year-Old Man Due to Primary Esophageal Small Cell Carcinoma.

BACKGROUND Small cell carcinoma is an aggressive malignant neuroendocrine tumor that most commonly occurs in the lung. Primary small cell carcinoma of the esophagus (PSCCE) is rare and is an aggressive malignancy with poor prognosis and no clear management guidelines. This report describes the case of a 36-year-old man presenting with epigastric pain, dysphagia, and melena due to a primary esophageal small cell carcinoma. CASE REPORT A 36-year-old presented to the Emergency Department (ED) with epigastric pain associated with food intake. Initial workup was unremarkable, and a presumed clinical diagnosis of reflux esophagitis and peptic strictures was made, prompting empiric treatment with anti-secretory therapies. Despite these therapies, he presented to the emergency room with progressively worsening dysphagia. Endoscopic examination (EGD) revealed a large necrotic mass, and computed tomography (CT) imaging revealed liver metastasis. Biopsies from both the liver and esophageal masses confirmed small cell carcinoma. His clinical course was complicated by a broncho-esophageal fistula, leading to massive hemoptysis, necessitating intubation. Unfortunately, his condition deteriorated rapidly, and he chose to pursue hospice care. He died 3 months after his initial presentation. CONCLUSIONS This report has presented a rare case of primary esophageal small cell carcinoma and our approach to management. We highlight the importance of early diagnosis, supported by histopathology, and the need for management guidelines.

SARS-CoV-2 Infection Is an Independent Risk Factor for Decompensation in Cirrhosis Patients.

BACKGROUND: SARS-CoV-2 causes varied gastrointestinal symptoms. Cirrhosis patients face higher mortality rates from it, especially those with decompensated cirrhosis. This study examines SARS-CoV-2's impact on decompensation in previously compensated cirrhotic patients. METHODS: We analyzed the Global Collaborative Network, comprising 98 healthcare organizations across sixteen countries, using TriNetX's deidentified research database. Compensated cirrhosis patients were split into two groups: one with SARS-CoV-2-positive patients and another testing negative. Using a 1:1 propensity score matching model based on baseline characteristics and comorbidities, we created comparable cohorts. We then assessed decompensation, mortality, and GI bleed at 1 and 3 months. RESULTS: Out of 252,631 identified compensated cirrhosis patients, 27.3% (69,057) tested SARS-CoV-2-positive, while 72.6% (183,574) remained negative. Post PSM, 61,963 patients were in each group. SARS-CoV-2-positive patients showed significantly higher decompensation rates (4.4% vs. 1.9% at 1 month; 6% vs. 2.6% overall). Rates of complications, like ascites, SBP, HE, and HRS, increased notably. Mortality (2.5% vs. 1.7% at 1 month; 3.6% vs. 2.7% at 3 months) and GI bleed (1.3% vs. 0.9% at 1 month; 1.9% vs. 1.2% at 3 months) were also elevated in SARS-CoV-2 patients. CONCLUSIONS: SARS-CoV-2 increases decompensation over 2-fold in compensated cirrhosis patients and raises mortality and increases rates of complications at 1 and 3 months.

The Use of Glucagon-like Peptide-1 Receptor Agonists in Patients with Type 2 Diabetes Mellitus Does Not Increase the Risk of Pancreatic Cancer: A U.S.-Based Cohort Study.

BACKGROUND: GLP-1 RAs are widely used for T2DM treatment due to their cardiorenal and metabolic benefits. This study examines the risk of pancreatic cancer with GLP-1 RA use in patients with T2DM. METHODS: We analyzed TriNetX's deidentified research database using the U.S. Collaborative Network comprising 62 healthcare organizations across the U.S.A. Patients with T2DM were split into two cohorts: one receiving GLP-1 RAs, and one not receiving GLP-1 RAs. We excluded patients with known risk factors for pancreatic cancer, including pancreatic cysts, a personal or family history of BRCA1, BRCA2, CDKN2A, KRAS, MEN1, MLH1, MSH2, NOTCH1, PALB2, PMS2, and PRSS1S genes, family history of pancreatic cancer, and VHL syndrome. Using a 1:1 propensity score-matching model based on baseline characteristics and comorbidities, we created comparable cohorts. We then compared the rate of pancreatic cancer between the two cohorts at a 7-year interval. RESULTS: Out of 7,146,015 identified patients with T2DM, 10.3% were on a GLP-1 RA and 89.7% were not. Post-PSM, 721,110 patients were in each group. Patients on GLP-1 RAs had a 0.1% risk compared to a 0.2% risk of pancreatic cancer in the 7-year timeframe. CONCLUSION: The use of GLP-1 RAs in patients with type 2 diabetes mellitus (T2DM) does not appear to substantially elevate the risk of pancreatic cancer; in fact, it may potentially exert a protective effect.

Type V gastric ulcer: An unusual etiology of gastrosplenic fistula associated with upper gastrointestinal bleeding.

Type V gastric ulcer is an unusual etiology of gastrosplenic fistula (GSF). Prompt diagnosis and early embolization of splenic vessels prior to esophagogastroduodenoscopy and surgical resection is crucial.

Safety of DOACs in patients with Child-Pugh Class C cirrhosis and atrial fibrillation.

Background: Anticoagulation (AC) is used for stroke prevention in atrial fibrillation (AF). Direct Oral Anticoagulants (DOACs) are safe in patients with AF without cirrhosis, they are hardly studied in patients with advanced cirrhosis. Our study evaluates the safety and outcomes of DOACs in patients with Child-Pugh class C cirrhosis (CPC). Methods: We queried TriNetX Database. Patients with CPC and AF were divided into three cohorts: patients on DOACs, no AC, and warfarin. Three study arms were created using a 1:1 propensity score matching system (PSM). Results: Totally 16 029 patients met the inclusion criteria. Of those, 20.2% (n = 3235) were on DOACs, 47.1% (n = 7552) were not on AC, and 32.7% (n = 5242) were on warfarin. First arm comparing AC versus no AC, a statistically significant benefit was identified in 3-year mortality risk (47% vs 71%, P < 0.0001) and transplant status (17% vs 5%, p < 0.0001) with AC. However, no significant difference was identified regarding intracranial hemorrhage and GI bleeding risk. Second arm comparing patients on DOACs versus no AC, we identified mortality benefit (40% vs 72%, P < 0.0001) and a higher transplant rate (9% vs 3.2%, P < 0.0001) with DOACs. Intracranial hemorrhage rates (6% vs 4%, P = 0.03) were higher in patients on DOACs. Third arm comparing patients on DOACs versus Warfarin, a statistically significant lower risk of intracranial hemorrhage (6.6% vs 8.7%, P = 0.004) and GI bleed (2% vs 2.4%, P < 0.0001) were identified in patients on DOACs. Conclusion: Anticoagulation is safe in patients with CPC with AF and may provide a mortality benefit. DOACs are a safer alternative to warfarin.

Controlled swine bile duct ablation with a bipolar radiofrequency catheter.

BACKGROUND: Radiofrequency (RF) power is capable of ablation of neoplastic tissue arising from Barrett's esophagus. Endoscopic catheter bipolar RF ablation is a new technique for ablation of neoplastic tissue in the bile duct. OBJECTIVE: To determine the effect of RF power on bile duct and solid organ histology. DESIGN: Nonsurvival animal study. SETTING: Academic center. PATIENTS: This study involved 4 Yorkshire farm swine. INTERVENTION: After we made a midline laparotomy incision, a bipolar RF catheter was placed with 3 power (5, 7, 10 W) and voltage settings (66, 132, 190 V) in the bile duct and solid organs (liver, spleen, kidney, and pancreas). Gross and histologic examinations were performed. MAIN OUTCOME MEASUREMENTS: Depth of ablation in the bile duct wall, characteristics of the ablation in the solid organs. RESULTS: An endoscopic bipolar RF catheter produced incomplete (bile duct), patchy ablation (pancreas) with 5 watts, intramural (bile duct) or confluent ablation with 7 watts, and transmural (bile duct) ablation at 10 W. The depth of ablation in the bile duct was 0.9 ± 0.3, 1.5 ± 0.2, 2.3 ± 0.6 mm at 5, 7, and 10 W, respectively (analysis of variance; P = .02). Histologic ablation was not achieved in the liver, although gross changes were seen. LIMITATIONS: Animal study, normal bile duct. CONCLUSION: RF energy applied to the bile duct or solid organs resulted in controlled ablation with a linear relationship between the depth of ablation in the bile duct and RF power.

Mushroom Sign: Complete Esophageal Obstruction After Esophageal Variceal Band Ligation With Successful Removal of Variceal Band.

Esophageal varices due to portal hypertension are treated with endoscopic variceal band ligation (EVBL), a minimally invasive procedure with potential complications, such as pain, bleeding, and stricture formation. Rarely, complete esophageal obstruction can occur secondary to edema of the mucosa. Most cases can be managed conservatively, but intervention is necessary for severe symptoms with a risk for aspiration and airway compromise. Since EVBL is such a common procedure, it is important for clinicians to be aware of this rare but severe complication. An 80-year-old woman presented with severe dysphagia and chest discomfort after a recent EVBL. Esophagogastroduodenoscopy revealed esophageal mucosal edema and complete obstruction of the esophageal lumen. The band was removed with a loop cutter with subsequent balloon dilation to relieve the obstruction.