BACKGROUND While varices and variceal bleeds are well-known and feared complications of advanced cirrhosis and portal hypertension,omental variceal bleed are a rare sequala even in patients with known esophageal or ga...BACKGROUND While varices and variceal bleeds are well-known and feared complications of advanced cirrhosis and portal hypertension,omental variceal bleed are a rare sequala even in patients with known esophageal or gastric varices.While rare,omental varices pose a risk for hemoperitoneum if ruptured,which is a lifethreatening complication with high mortality rates despite surgical intervention.CASE SUMMARY This report reviews the case of a patient 36-year-old female with alcohol related cirrhosis decompensated by ascites,but no history of varices admitted for hemorrhagic shock from spontaneous rupture of omental varices requiring emergency surgery.She underwent the first documented successful orthotopic liver transplantation the same admission.CONCLUSION This case report and literature review stresses the importance of early consideration and identification of intraabdominal variceal sources in cirrhotic patients with refractory shock.展开更多
BACKGROUND Rebleeding after recovery from esophagogastric variceal bleeding(EGVB)is a severe complication that is associated with high rates of both incidence and mortality.Despite its clinical importance,recognized p...BACKGROUND Rebleeding after recovery from esophagogastric variceal bleeding(EGVB)is a severe complication that is associated with high rates of both incidence and mortality.Despite its clinical importance,recognized prognostic models that can effectively predict esophagogastric variceal rebleeding in patients with liver cirrhosis are lacking.AIM To construct and externally validate a reliable prognostic model for predicting the occurrence of esophagogastric variceal rebleeding.METHODS This study included 477 EGVB patients across 2 cohorts:The derivation cohort(n=322)and the validation cohort(n=155).The primary outcome was rebleeding events within 1 year.The least absolute shrinkage and selection operator was applied for predictor selection,and multivariate Cox regression analysis was used to construct the prognostic model.Internal validation was performed with bootstrap resampling.We assessed the discrimination,calibration and accuracy of the model,and performed patient risk stratification.RESULTS Six predictors,including albumin and aspartate aminotransferase concentrations,white blood cell count,and the presence of ascites,portal vein thrombosis,and bleeding signs,were selected for the rebleeding event prediction following endoscopic treatment(REPET)model.In predicting rebleeding within 1 year,the REPET model ex-hibited a concordance index of 0.775 and a Brier score of 0.143 in the derivation cohort,alongside 0.862 and 0.127 in the validation cohort.Furthermore,the REPET model revealed a significant difference in rebleeding rates(P<0.01)between low-risk patients and intermediate-to high-risk patients in both cohorts.CONCLUSION We constructed and validated a new prognostic model for variceal rebleeding with excellent predictive per-formance,which will improve the clinical management of rebleeding in EGVB patients.展开更多
BACKGROUND Esophageal and gastric variceal bleeding is a catastrophic complication of portal hypertension,most commonly caused by cirrhosis of various etiologies.Although a considerable body of research has been condu...BACKGROUND Esophageal and gastric variceal bleeding is a catastrophic complication of portal hypertension,most commonly caused by cirrhosis of various etiologies.Although a considerable body of research has been conducted in this area,the complexity of the disease and the lack of standardized treatment strategies have led to fragmented findings,insufficient information,and a lack of systematic investigation.Bibliometric analysis can help clarify research trends,identify core topics,and reveal potential future directions.Therefore,this study aims to use bibliometric methods to conduct an in-depth exploration of research progress in this field,with the expectation of providing new insights for both clinical practice and scientific research.AIM To evaluate research trends and advancements in esophagogastric variceal bleeding(EGVB)over the past twenty years.METHODS Relevant publications on EGVB were retrieved from the Web of Science Core Collection.VOSviewer,Pajek,CiteSpace,and the bibliometrix package were then employed to perform bibliometric visualizations of publication volume,countries,institutions,journals,authors,keywords,and citation counts.RESULTS The analysis focused on original research articles and review papers.From 2004 to 2023,a total of 2097 records on EGVB were retrieved.The number of relevant publications has increased significantly over the past two decades,especially in China and the United States.The leading contributors in this field,in terms of countries,institutions,authors,and journals,were China,Assistance Publique-Hôpitaux de Paris,Bosch Jaime,and World Journal of Gastroenterology,respectively.Core keywords in this field include portal hypertension,management,liver cirrhosis,risk,prevention,and diagnosis.Future research directions may focus on optimizing diagnostic methods,personalized treatment,and multidisciplinary collaboration.CONCLUSION Using bibliometric methods,this study reveals the developmental trajectory and trends in research on EGVB,underscoring risk assessment and diagnostic optimization as the core areas of current focus.The study provides an innovative and systematic perspective for this field,indicating that future research could center on multidisciplinary collaboration,personalized treatment approaches,and the development of new diagnostic tools.Moreover,this work offers practical research directions for both the academic community and clinical practice,driving continued advancement in this domain.展开更多
Gastrointestinal(GI)bleeding is a critical and potentially life-threatening condition frequently observed in the intensive care unit(ICU).This literature review consolidates current insights on the epidemiology,etiolo...Gastrointestinal(GI)bleeding is a critical and potentially life-threatening condition frequently observed in the intensive care unit(ICU).This literature review consolidates current insights on the epidemiology,etiology,management,and outcomes of GI bleeding in critically ill patients.GI bleeding remains a significant concern,especially among patients with underlying risk factors such as coagulopathy,mechanical ventilation,and renal failure.Managing GI bleeding in the ICU requires a multidisciplinary approach,including resuscitation,endoscopic intervention,pharmacologic therapy,and sometimes surgical procedures.Even with enhanced management strategies,GI bleeding in the ICU is associated with considerable morbidity and mortality,particularly when complicated by multi-organ failure.This review reiterates the need for adequate resuscitation and interventions in managing GI bleeding in critically ill patients,aiming to enhance survival rates and improve the quality of care within the ICU setting.展开更多
A recent study by Peng et al developed a predictive model for first-instance secondary esophageal variceal bleeding in cirrhotic patients by integrating clinical and multi-organ radiomic features.The combined radiomic...A recent study by Peng et al developed a predictive model for first-instance secondary esophageal variceal bleeding in cirrhotic patients by integrating clinical and multi-organ radiomic features.The combined radiomic-clinical model demonstrated strong predictive capabilities,achieving an area under the curve of 0.951 in the training cohort and 0.930 in the validation cohort.The results highlight the potential of noninvasive prediction models in assessing esophageal variceal bleeding risk,aiding in timely clinical decision-making.Additionally,manual delineation of regions of interest raises the risk of observer bias despite efforts to minimize it.The study adjusted for clinical covariates,while some potential confounders,such as socioeconomic status,alcohol use,and liver function scores,were not included.Additionally,an imbalance in cohort sizes between the training and validation groups may reduce the statistical power of validation.Expanding the validation cohort and incorporating multi-center external validation would improve generalizability.Future studies should focus on incorporating long-term patient outcomes,exploring additional imaging modalities,and integrating automated segmentation techniques to refine the predictive model.展开更多
BACKGROUND Endoscopic variceal band ligation(EVBL)represents a pivotal treatment in the prophylaxis of esophageal varices bleeding in patients with cirrhosis,but in some cases a single session of EVBL is unable to era...BACKGROUND Endoscopic variceal band ligation(EVBL)represents a pivotal treatment in the prophylaxis of esophageal varices bleeding in patients with cirrhosis,but in some cases a single session of EVBL is unable to eradicate esophageal varices completely,and a control endoscopy after 2-4 weeks is required to assess eradication and/or the need for another band ligation.Liver stiffness measurement(LSM)is being increasingly used as a screening non-invasive tool to predict varices according to Baveno VII criteria.However,to date,there are no instruments able to non-invasively predict the outcome of EVBL.AIM To identify non-invasive predictors of varices eradication(VE)after EVBL through multiparametric ultrasound(US).Secondary aim was to develop a prediction model of successful variceal eradication based on non-invasive parameters.METHODS We prospectively enrolled consecutive cirrhotic patients intolerant or with contraindications to beta-blockers undergoing EVBL for bleeding prophylaxis.Patients underwent multiparametric US with LSM,spleen stiffness measurement(SSM)and dynamic contrastenhanced US(DCE-US)on liver parenchyma and portal vein,at baseline(T0)and one month(T1)after EVBL.Each US parameter and their variations from baseline were correlated with VE evaluated by control endoscopy performed at T1.RESULTS We enrolled 41 patients(median age 64 years,75.6%males).At T128 patients(68.3%)reached VE,whereas 13(31.7%)required a second EVBL.Patients who achieved VE showed a significant decrease in SSM(P=0.018),and a significant increase in peak enhancement,area under the curve and wash-in rate of both liver parenchyma and portal vein after treatment(P<0.001).Statistically significant differences between the two groups of patients were incorporated in a multivariate analysis and used to develop three prediction models.CONCLUSION A multimodal US approach based on DCE-US parameters,LSM and SSM might become a reliable predictor of VE and a useful non-invasive alternative to endoscopy.展开更多
BACKGROUND Budd-Chiari syndrome(BCS)is caused by obstruction of the hepatic veins or suprahepatic inferior vena cava,leading to portal hypertension and the development of gastroesophageal varices(GEVs),which are assoc...BACKGROUND Budd-Chiari syndrome(BCS)is caused by obstruction of the hepatic veins or suprahepatic inferior vena cava,leading to portal hypertension and the development of gastroesophageal varices(GEVs),which are associated with an increased risk of bleeding.Existing risk models for variceal bleeding in cirrhotic patients have limited applicability to BCS due to differences in pathophysiology.Radiomics,as a noninvasive technique,holds promise as a tool for more accurate prediction of bleeding risk in BCS-related GEVs.AIM To develop and validate a personalized risk model for predicting variceal bleeding in BCS patients with GEVs.METHODS We retrospectively analyzed clinical data from 444 BCS patients with GEVs in two centers.Radiomic features were extracted from portal venous phase computed tomography(CT)scans.A training cohort of 334 patients was used to develop the model,with 110 patients serving as an external validation cohort.LASSO Cox regression was used to select radiomic features for constructing a radiomics score(Radscore).Univariate and multivariate Cox regression identified independent clinical predictors.A combined radiomics+clinical(R+C)model was developed using stepwise regression.Model performance was assessed using the area under the receiver operating characteristic curve(AUC),calibration plots,and decision curve analysis(DCA),with external validation to evaluate generalizability.RESULTS The Radscore comprised four hepatic and six splenic CT features,which predicted the risk of variceal bleeding.Multivariate analysis identified invasive treatment to relieve hepatic venous outflow obstruction,anticoagulant therapy,and hemoglobin levels as independent clinical predictors.The R+C model achieved C-indices of 0.906(training)and 0.859(validation),outperforming the radiomics and clinical models alone(AUC:training 0.936 vs 0.845 vs 0.823;validation 0.876 vs 0.712 vs 0.713).DCA showed higher clinical net benefit across the thresholds.The model stratified patients into low-,medium-and high-risk groups with significant differences in bleeding rates(P<0.001).An online tool is available at https://bcsvh.shinyapps.io/BCS_Variceal_Bleeding_Risk_Tool/.CONCLUSION We developed and validated a novel radiomics-based model that noninvasively and conveniently predicted risk of variceal bleeding in BCS patients with GEVs,aiding early identification and management of high-risk patients.展开更多
The Sengstaken-Blakemore tube(SB tube),introduced in the 1950s,was a pivotal device for managing acute gastrointestinal(GI)bleeding,particularly from esophageal varices.This multi-lumen tube,featuring esophageal and g...The Sengstaken-Blakemore tube(SB tube),introduced in the 1950s,was a pivotal device for managing acute gastrointestinal(GI)bleeding,particularly from esophageal varices.This multi-lumen tube,featuring esophageal and gastric balloons,applied mechanical pressure to control bleeding and provided a temporary solution until more definitive treatments could be employed.It was historically significant in resource-limited settings where advanced endoscopic options were unavailable,enabling patient stabilization and transfer to specialized centers.However,the advent of GI endoscopy and its increased availability has rendered the SB tube obsolete.SB tubes are associated with complications,including esophageal perforation,aspiration pneumonia,and gastric ulceration.Additionally,the tube can cause significant discomfort,and its migration may lead to inadequate.Techniques such as endoscopic variceal ligation and endoscopic sclerotherapy offer superior precision,efficacy,and safety for managing variceal bleeding.Improved hospital transfer protocols now facilitate prompt endoscopic or surgical interventions,reducing the need for temporary measures like the SB tube.Additionally,advancements in pharmacological treatments,including vasoactive drugs,reliance on mechanical compression devices.While the SB tube remains an important historical artifact,its role in current medical practice reflecting safer and more effective treatment options in emergency GI care.This review discusses the declining role of the Sengstaken-Blakemore tube and its replacement by current intervention methods.展开更多
BACKGROUND Cirrhosis is a progressive condition characterized by fibrosis that can lead to severe complications and increased mortality.The mac-2 binding protein glyco-sylation isomer(M2BPGi)is a prominent biomarker f...BACKGROUND Cirrhosis is a progressive condition characterized by fibrosis that can lead to severe complications and increased mortality.The mac-2 binding protein glyco-sylation isomer(M2BPGi)is a prominent biomarker for predicting hepatocellular carcinoma(HCC)and cirrhosis-induced esophageal varices(EV).AIM To investigate thresholds of M2BPGi associated with HCC,EV,and decomp-ensation in patients with cirrhosis.METHODS This was a prospective study.A total of 153 patients with cirrhosis who met the inclusion criteria were enrolled.The patients were diagnosed with HCC and EV according to the Baveno VII and European Association for the Study of the Liver guidelines.Baseline serum M2BPGi levels were assessed along with other routine tests.The data analysis aimed to determine the cutoff values of M2BPGi for pre-dicting EV and HCC.RESULTS In the study 85.6%of patients were Child-Pugh B and C.M2BPGi mean cutoff index was 7.1±3.7,showing no significant etiological differences.However,M2BPGi levels varied significantly among Child-Pugh classes,EV classifications,and between patients with and without HCC(P<0.01).M2BPGi cutoff values for predicting HCC,EV,and decompensated cirrhosis were 6.50,6.64,and 5.25,respectively.Mul-tivariate analysis confirmed M2BPGi as an independent risk factor for EV[adjusted odds ratio(aOR):1.3,95%CI:1.08-1.64]and liver decompensation(aOR:2.11,95%CI:1.37-3.83).Area under the curve of M2BPGi for HCC differ-entiation was 0.71.An algorithm combining alpha-fetoprotein(AFP)and M2BPGi detected 26 of 28 HCC cases with 98.04%accuracy vs 10 cases by AFP alone.CONCLUSION Serum M2BPGi predicted cirrhosis complications,including decompensation and varices,especially in HCC.Combined with AFP,it enhanced HCC detection.Future liver biopsy studies are needed for tissue confirmation.展开更多
BACKGROUND Acute variceal bleeding(AVB)represents a life-threatening complication in hepatocellular carcinoma(HCC)patients undergoing systemic therapy,mainly including immune checkpoint inhibitors(ICIs)and antivascula...BACKGROUND Acute variceal bleeding(AVB)represents a life-threatening complication in hepatocellular carcinoma(HCC)patients undergoing systemic therapy,mainly including immune checkpoint inhibitors(ICIs)and antivascular drugs used alone or in combination.The pathogenesis of AVB in this population may involve tumor-related factors,treatment-induced effects,or progression of underlying portal hypertension.Identifying high-risk factors for AVB is crucial for the management of this patient population.AIM To develop and validate a risk prediction model for AVB occurrence in cirrhotic HCC patients receiving ICI-based systemic therapy.METHODS This retrospective study analyzed 286 HCC patients(2021-2022)receiving ICIs(mono-/combination therapy),randomly split into training(n=184)and validation(n=102)cohorts.In the training cohort,bleeding vs nonbleeding groups were compared for general information,etiological data,laboratory indicators,tumor staging,systemic treatment drugs,variceal bleeding history,and endoscopic treatment history.Risk factors for AVB were identified and used to establish a logistic regression model for predicting bleeding,which was further validated in the validation cohort.RESULTS The bleeding group had significantly higher proportions of patients with platelet count≥100×10^(9)/L,alphafetoprotein≥400 ng/mL,tumor diameter≥5 cm,portal vein tumor thrombosis,ascites,bleeding history,prior endoscopic treatment,albumin-bilirubin grade level 2-3,fibrosis-4 index(FIB-4)≥4.57,and prognostic nutritional index<45 compared to the non-bleeding group.Multivariate analysis identified tumor diameter≥5 cm,portal vein thrombosis,bleeding history,and elevated FIB-4 as independent risk factors for bleeding(P<0.05).A predictive model based on these factors showed good discrimination,with area under the receiver operating characteristic curve values of 0.861(training)and 0.816(validation).CONCLUSION A history of pre-ICI bleeding significantly increases recurrent bleeding risk,necessitating close monitoring.The FIB-4 fibrosis model,combined with tumor features,can also serve as a predictive factor for bleeding.展开更多
Gastric variceal(GV)bleeding remains a life-threatening complication of portal hypertension,with ongoing debate regarding the optimal endoscopic therapy.Conventional endoscopic cyanoacrylate injection(ECI)is effective...Gastric variceal(GV)bleeding remains a life-threatening complication of portal hypertension,with ongoing debate regarding the optimal endoscopic therapy.Conventional endoscopic cyanoacrylate injection(ECI)is effective but limited by the risk of ectopic embolism,particularly in the presence of gastrorenal shunts.Clip-assisted ECI(clip-ECI)has emerged as a novel modification designed to reduce embolic risk while maintaining hemostatic efficacy.We appraised the recent study by Xiong et al,which compared clip-ECI with endoscopic ultrasoundguided coil and cyanoacrylate injection in 108 propensity-matched patients with cardiofundal varices and shunts.Both techniques demonstrated comparable efficacy,with obliteration rates exceeding 90%and similar one-year rebleeding rates.Importantly,no embolic events were reported.These findings are consistent with prior studies,including multicenter cohorts and a recent randomized controlled trial,which highlight clip-ECI as a safe,effective,and efficient technique,with advantages of shorter procedure times,fewer sessions,and lower costs.While endoscopic ultrasound(EUS)-guided therapy offers precision in expert hands,clip-ECI provides a practical,accessible alternative,particularly in resource-limited settings.Larger prospective studies with standardized definitions and cost-effectiveness analyses are needed to refine treatment algorithms.Clip-ECI represents a promising“flow-control assisted”strategy and a real-world alternative to EUS-based therapies for GV.展开更多
BACKGROUND Relative changes in the prevalence of gastrointestinal(GI)diseases have been reported worldwide over the past decades.However,data on changing trends of upper GI diseases remain scarce in sub-Saharan Africa...BACKGROUND Relative changes in the prevalence of gastrointestinal(GI)diseases have been reported worldwide over the past decades.However,data on changing trends of upper GI diseases remain scarce in sub-Saharan Africa.This study examines the shifting patterns of upper GI endoscopic findings over 35 years in Ethiopia.AIM To analyze trends in upper GI endoscopic findings over two distinct time periods,35 years apart,in Ethiopia.METHODS We extracted findings from 8412 upper GI endoscopies performed between 2016 and 2024 at a tertiary referral center in Addis Ababa,Ethiopia.Patient characteristics,indications,and endoscopic findings were analyzed using descriptive statistics and presented in tables,map and graphs.These findings were compared to 10000 procedures conducted between 1979 and 1994.Key endoscopic findings were identified,and percentage changes in disease prevalence were calculated.RESULTS Between the two study periods,the male-to-female ratio of patients undergoing upper GI endoscopy shifted from 2:1 to 1.4:1,while the median patient age increased from 36 to 40 years.The proportion of patients older than 50 years doubled(14.6%to 30.2%),and referrals from outside Addis Ababa increased from 33%to 57%.The prevalence of peptic ulcer disease and its complications decreased from 46.2%to 9.5%.Conversely,gastroesophageal varices increased from 9.5%to 21.8%,and upper GI malignancies rose from 3.6%to 18.8%.CONCLUSION This study sheds light on critical epidemiological shifts in upper GI diseases in Ethiopia,with a decline in peptic ulcer disease and a rise in portal hypertensive lesions and malignancies which have important public health implications.These findings underscore the need for increased awareness,improved clinical practices,enhanced resource allocation,and expanded access to early diagnosis and treatment of prevailing conditions.Preventive strategies targeting immunization and treatment of viral hepatitis,schistosomiasis,and Helicobacter pylori infection are urgently needed.展开更多
Esophagogastric variceal bleeding is a common and severe complication of cirr-hotic portal hypertension.Hepatic venous pressure gradient measurement and esophagogastroduodenoscopy are the diagnostic gold standards for...Esophagogastric variceal bleeding is a common and severe complication of cirr-hotic portal hypertension.Hepatic venous pressure gradient measurement and esophagogastroduodenoscopy are the diagnostic gold standards for portal hyper-tension and esophagogastric variceal bleeding,respectively.With advancements in artificial intelligence in medicine,non-invasive diagnostic methods are in-creasingly replacing traditional invasive procedures,permitting more rational and personalized patient care.This review summarizes the formation and diagnosis of portal hypertension,as well as the primary prophylaxis,secondary prophylaxis,and management of acute esophagogastric variceal bleeding.This study also highlights the latest progress in artificial intelligence in the diagnosis and treat-ment of portal hypertension and esophagogastric varices.展开更多
Advanced endoscopic methods like endoscopic ultrasound(EUS)have recently been applied for the management of complications related to cirrhosis.This includes novel techniques to measure portal pressure gradients,esopha...Advanced endoscopic methods like endoscopic ultrasound(EUS)have recently been applied for the management of complications related to cirrhosis.This includes novel techniques to measure portal pressure gradients,esophageal,gastric,and ectopic varices management,and EUS-assisted treatment of liver tumors.Management of liver tumors has seen significant changes in recent years,and many minimally invasive procedures have been approved,especially in the management of liver cell carcinoma.These are specialized procedures and are performed only in patients with cirrhosis in specialized centers.There are concerns for complications in patients with cirrhosis due to their increased risk of bleeding and the altered hemostatic milieu.This minireview summarizes the recent evidence on using EUS in the management of cirrhosis-related complications.展开更多
BACKGROUND The high rebleeding rate and severe adverse events have raised concerns regarding the safety of endoscopic cyanoacrylate as a conventional treatment for gastric variceal hemorrhage.Clip-assisted endoscopic ...BACKGROUND The high rebleeding rate and severe adverse events have raised concerns regarding the safety of endoscopic cyanoacrylate as a conventional treatment for gastric variceal hemorrhage.Clip-assisted endoscopic cyanoacrylate injection(Clip-CYA)and endoscopic ultrasound-guided coil and cyanoacrylate injection(EUS-CG)are two currently used modalities.There are limited data comparing the two techniques.AIM To compare the efficacy,safety,and procedural characteristics of Clip-CYA vs EUS-CG for treatment of gastric varices(GVs)with spontaneous portosystemic shunts.METHODS Between April 2019 and August 2023,162 patients with GVs and concomitant gastrorenal or splenorenal shunts who underwent either Clip-CYA or EUS-CG at our center were included.After 1:2 propensity score matching,108 patients were included in the final analysis.The evaluated outcomes included the amount of cyanoacrylate,eradication of GVs,cyanoacrylate embolization,all-cause rebleeding,operating time and endoscopic therapy costs.RESULTS Of the 108 patients,72(male,83.3%;mean age,56.2±10.8 years)received Clip-CYA,and 36(male,72.2%;mean age,59.1±10.7 years)received EUS-CG.The amount of cyanoacrylate used,rates of obliteration of GVs and all-cause rebleeding were similar between the two groups(2.0±1.1 mL vs 2.0±0.6 mL,P=0.913;91.7%vs 94.4%,P=0.603;and 23.6%vs 19.4%,P=0.623,respectively).No cyanoacrylate embolization occurred in either group.Compared with EUS-CG,Clip-CYA was associated with significantly shorter operating times(24.0±9.9 minutes vs 47.1±21.0 minutes,P<0.001)and lower endoscopic therapy costs(7523.4±5719.4 Chinese yuan vs 11153.7±7679.1 Chinese yuan,P=0.007).These advantages persisted in the subgroup analysis of patients whose GVs had a maximum diameter>3 cm or>4 cm.CONCLUSION Compared with EUS-CG,Clip-CYA of GVs appears to be a safe procedure with shorter operating times and lower endoscopic therapy costs.展开更多
BACKGROUND Shwachman-Diamond syndrome(SDS)is a rare genetic disorder that affects multiple organs,primarily the liver.Most patients are diagnosed during infancy or early childhood.As they grow older,the majority of af...BACKGROUND Shwachman-Diamond syndrome(SDS)is a rare genetic disorder that affects multiple organs,primarily the liver.Most patients are diagnosed during infancy or early childhood.As they grow older,the majority of affected children may experience spontaneous remission,and cases of cirrhosis in adults are rarely reported.CASE SUMMARY A 36-year-old male patient presented with massive ascites.Laboratory tests revealed pancytopenia and a serum-ascites albumin gradient greater than 1.1 g/dL.An abdominal computed tomography scan demonstrated cirrhosis,splenomegaly,pancreatic fat infiltration,and a substantial accumulation of peritoneal fluid.Gastroscopy identified esophageal varices.Liver stiffness measurement indicated a value of 32.7 kPa.Based on the results of auxiliary examinations,common causes of cirrhosis were excluded,and a mutation in the Shwachman-Bodian-Diamond syndrome gene was ultimately identified through whole-exome sequencing.The patient was diagnosed with cirrhosis secondary to SDS.Following the correction of hypoalbuminemia and administration of diuretics,the patient's ascites resolved.CONCLUSION Patients with liver cirrhosis who also exhibit pancreatic fat infiltration and pancytopenia necessitate further exon testing to exclude the possibility of SDS.展开更多
BACKGROUND Patients with decompensated liver cirrhosis suffering from esophagogastric variceal bleeding(EGVB)face high mortality.AIM To investigate the risk factors for EGVB in patients with liver cirrhosis and establ...BACKGROUND Patients with decompensated liver cirrhosis suffering from esophagogastric variceal bleeding(EGVB)face high mortality.AIM To investigate the risk factors for EGVB in patients with liver cirrhosis and establish a diagnostic nomogram.METHODS Patients with liver cirrhosis who met the inclusion criteria were randomly divided into training and validation cohorts in a 6:4 ratio in this retrospective research.Univariate analysis,least absolute shrinkage and selection operator regression,and multivariate analysis were employed to establish the nomogram model.Calibration curve,the area under the receiver operating characteristic curve(AUC),and decision curve analysis(DCA)were applied to assess the discrimination,accuracy,and clinical practicability of the nomogram,respectively.RESULTS A total of 1115 patients were enrolled in this study.The nomogram was established based on white blood cells(P<0.001),hemoglobin(P<0.001),fibrinogen(P<0.001),total bilirubin(P=0.007),activated partial thromboplastin time(P=0.002),total bile acid(P=0.012),and ascites(P=0.006).The calibration curve indicated that the actual observation results were in good agreement with the prediction results of the model.The AUC values of the diagnostic model were 0.861 and 0.859 in the training and validation cohorts,respectively,which were higher than that of the aspartate aminotransferase-to-platelet ratio index,fibrosis index based on 4 factors,and aspartate aminotransferase-to-alanine aminotransferase ratio.Additionally,DCA indicated that the net benefit value of the model was higher than that of the other models.CONCLUSION This research constructed and validated a nomogram with perfect performance for predicting EGVB events in patients with liver cirrhosis,which could help clinicians with timely diagnosis,individualized treatment,and follow-up.展开更多
BACKGROUND Hepatitis C virus(HCV)infection remains a major public health issue in Egypt,with a high prevalence of genotype 4.Direct-acting antivirals(DAAs)achieve>95%sustained virologic response(SVR),but their impa...BACKGROUND Hepatitis C virus(HCV)infection remains a major public health issue in Egypt,with a high prevalence of genotype 4.Direct-acting antivirals(DAAs)achieve>95%sustained virologic response(SVR),but their impact on variceal rebleeding in genotype 4 cirrhotic patients is underexplored.This study evaluated the association between DAA therapy and variceal rebleeding in Egyptian patients with HCV-related cirrhosis.AIM To evaluate the association between DAA therapy and variceal rebleeding in Egyptian patients with HCV-related cirrhosis.METHODS A multicenter retrospective cohort study included HCV genotype 4 cirrhotic patients from five Egyptian centers with a first variceal bleeding episode.Patients were divided into DAA-treated(Group A)and non-treated(Group B)groups and followed for 5 years.Propensity score matching(PSM),Cox regression,and competing risk analysis were adjusted for confounders.RESULTS DAA treatment significantly reduced variceal rebleeding(HR 2.57;95%CI:1.39-4.72;P=0.002),ascites development over 5 years(6.8%vs 27.1%,P=0.006),and hepatic dysfunction progression.During treatment,it improved liver function[lower model for end-stage liver disease(MELD),stable Child-Pugh class]and reduced complications.All Group A patients achieved SVR by PCR,while Group B remained HCV-positive,likely contributing to the observed reductions in rebleeding and hepatic decompensation.These benefits persisted over 5 years,with longer survival without rebleeding(4.5 years vs 3.2 years),lower MELD(7 vs 12,P<0.001),and reduced hepatic decompensation(Child-Pugh progression:5.1%vs 35.6%,P<0.001).At 5 years,the DAA group had better liver function(higher albumin,lower international normalized ratio,improved platelets),while the non-DAA group worsened.PSM confirmed these findings(HR:0.45,95%CI:0.27-0.75,P=0.002),and competing risk analysis showed sustained protection(sub-distribution HR:0.44,95%CI:0.26-0.74,P=0.002).Endoscopy revealed variceal regression with DAA but progression in the non-DAA group.DAA therapy significantly reduced variceal rebleeding,hepatic decompensation,and mortality(8.5%vs 20.3%,P=0.045),with survival benefits linked to SVR.Additionally,it was associated with improved survival,with a lower 5-year mortality rate in the DAA group(8.5%vs 20.3%,P=0.045).The protective effect of DAA therapy remained consistent across multivariable Cox regression,time-dependent modeling,and competing risk analyses.CONCLUSION DAA treatment in HCV-related cirrhosis significantly reduces variceal rebleeding,ascites development,and hepatic dysfunction progression.The 5-year follow-up data demonstrate sustained improvements in liver function and hematologic parameters,underscoring the long-term benefits of DAA therapy.展开更多
BACKGROUND Severe esophagogastric varices(EGVs)significantly affect prognosis of patients with hepatitis B because of the risk of life-threatening hemorrhage.Endoscopy is the gold standard for EGV detection but it is ...BACKGROUND Severe esophagogastric varices(EGVs)significantly affect prognosis of patients with hepatitis B because of the risk of life-threatening hemorrhage.Endoscopy is the gold standard for EGV detection but it is invasive,costly and carries risks.Noninvasive predictive models using ultrasound and serological markers are essential for identifying high-risk patients and optimizing endoscopy utilization.Machine learning(ML)offers a powerful approach to analyze complex clinical data and improve predictive accuracy.This study hypothesized that ML models,utilizing noninvasive ultrasound and serological markers,can accurately predict the risk of EGVs in hepatitis B patients,thereby improving clinical decisionmaking.AIM To construct and validate a noninvasive predictive model using ML for EGVs in hepatitis B patients.METHODS We retrospectively collected ultrasound and serological data from 310 eligible cases,randomly dividing them into training(80%)and validation(20%)groups.Eleven ML algorithms were used to build predictive models.The performance of the models was evaluated using the area under the curve and decision curve analysis.The best-performing model was further analyzed using SHapley Additive exPlanation to interpret feature importance.RESULTS Among the 310 patients,124 were identified as high-risk for EGVs.The extreme gradient boosting model demonstrated the best performance,achieving an area under the curve of 0.96 in the validation set.The model also exhibited high sensitivity(78%),specificity(94%),positive predictive value(84%),negative predictive value(88%),F1 score(83%),and overall accuracy(86%).The top four predictive variables were albumin,prothrombin time,portal vein flow velocity and spleen stiffness.A web-based version of the model was developed for clinical use,providing real-time predictions for high-risk patients.CONCLUSION We identified an efficient noninvasive predictive model using extreme gradient boosting for EGVs among hepatitis B patients.The model,presented as a web application,has potential for screening high-risk EGV patients and can aid clinicians in optimizing the use of endoscopy.展开更多
Portal hypertension(PH)is a major complication of chronic liver disease,often leading to serious clinical consequences such as variceal bleeding,ascites,and splenomegaly.The current gold standard for PH diagnosis,name...Portal hypertension(PH)is a major complication of chronic liver disease,often leading to serious clinical consequences such as variceal bleeding,ascites,and splenomegaly.The current gold standard for PH diagnosis,namely,hepatic venous pressure gradient measurement,is invasive and not widely available.Transient elastography has emerged as a non-invasive alternative for assessing liver stiffness(LS),and recent studies have highlighted the potential role of splenic stiffness(SS)in evaluating PH severity.This narrative review summarizes the available evidence on the utility of splenic transient elastography in assessing PH.We evaluated its diagnostic accuracy,technical challenges,and clinical applications,particularly in distinguishing between cirrhotic PH(CPH)and noncirrhotic PH(NCPH).A comprehensive literature search was conducted using the PubMed database,focusing on studies that assess splenic elastography in the diagnosis and prognosis of PH.This review compares splenic elastography with other non-invasive imaging modalities,including MR elastography and shearwave elastography.Additionally,we examined the role of SS using elastography in predicting the presence of esophageal varices and its potential impact on reducing the need for endoscopic screening.Studies have demonstrated that splenic elastography correlates well with PH severity,with cut-off values ranging between 45 kPa and 50 kPa for significant PH detection.Splenic elastography,when combined with platelet count and LS measurements,improves diagnostic accuracy and risk stratification for the occurrence of variceal bleeding.Despite its clinical promise,technical challenges such as patient positioning,body habitus,and probe selection remain key limitations.Notably,splenic elastography may be particularly useful in diagnosing NCPH,where LS remains normal but PH is present.Splenic transient elastography is a valuable adjunct in the non-invasive assessment of PH.Its ability to predict varices,differentiate between CPH and NCPH,and reduce unnecessary endoscopies suggests that it should be incorporated into routine hepatology practice.Future research should focus on refining SS cut-offs,evaluating its cost-effectiveness,and integrating splenic elastography into clinical guidelines for PH management.展开更多
文摘BACKGROUND While varices and variceal bleeds are well-known and feared complications of advanced cirrhosis and portal hypertension,omental variceal bleed are a rare sequala even in patients with known esophageal or gastric varices.While rare,omental varices pose a risk for hemoperitoneum if ruptured,which is a lifethreatening complication with high mortality rates despite surgical intervention.CASE SUMMARY This report reviews the case of a patient 36-year-old female with alcohol related cirrhosis decompensated by ascites,but no history of varices admitted for hemorrhagic shock from spontaneous rupture of omental varices requiring emergency surgery.She underwent the first documented successful orthotopic liver transplantation the same admission.CONCLUSION This case report and literature review stresses the importance of early consideration and identification of intraabdominal variceal sources in cirrhotic patients with refractory shock.
基金Supported by National Natural Science Foundation of China,No.81874390 and No.81573948Shanghai Natural Science Foundation,No.21ZR1464100+1 种基金Science and Technology Innovation Action Plan of Shanghai Science and Technology Commission,No.22S11901700the Shanghai Key Specialty of Traditional Chinese Clinical Medicine,No.shslczdzk01201.
文摘BACKGROUND Rebleeding after recovery from esophagogastric variceal bleeding(EGVB)is a severe complication that is associated with high rates of both incidence and mortality.Despite its clinical importance,recognized prognostic models that can effectively predict esophagogastric variceal rebleeding in patients with liver cirrhosis are lacking.AIM To construct and externally validate a reliable prognostic model for predicting the occurrence of esophagogastric variceal rebleeding.METHODS This study included 477 EGVB patients across 2 cohorts:The derivation cohort(n=322)and the validation cohort(n=155).The primary outcome was rebleeding events within 1 year.The least absolute shrinkage and selection operator was applied for predictor selection,and multivariate Cox regression analysis was used to construct the prognostic model.Internal validation was performed with bootstrap resampling.We assessed the discrimination,calibration and accuracy of the model,and performed patient risk stratification.RESULTS Six predictors,including albumin and aspartate aminotransferase concentrations,white blood cell count,and the presence of ascites,portal vein thrombosis,and bleeding signs,were selected for the rebleeding event prediction following endoscopic treatment(REPET)model.In predicting rebleeding within 1 year,the REPET model ex-hibited a concordance index of 0.775 and a Brier score of 0.143 in the derivation cohort,alongside 0.862 and 0.127 in the validation cohort.Furthermore,the REPET model revealed a significant difference in rebleeding rates(P<0.01)between low-risk patients and intermediate-to high-risk patients in both cohorts.CONCLUSION We constructed and validated a new prognostic model for variceal rebleeding with excellent predictive per-formance,which will improve the clinical management of rebleeding in EGVB patients.
基金Supported by the National Natural Science Foundation of China,No.81874390 and No.81573948Shanghai Natural Science Foundation,No.21ZR1464100+1 种基金Science and Technology Innovation Action Plan of Shanghai Science and Technology Commission,No.22S11901700the Shanghai Key Specialty of Traditional Chinese Clinical Medicine,No.shslczdzk01201.
文摘BACKGROUND Esophageal and gastric variceal bleeding is a catastrophic complication of portal hypertension,most commonly caused by cirrhosis of various etiologies.Although a considerable body of research has been conducted in this area,the complexity of the disease and the lack of standardized treatment strategies have led to fragmented findings,insufficient information,and a lack of systematic investigation.Bibliometric analysis can help clarify research trends,identify core topics,and reveal potential future directions.Therefore,this study aims to use bibliometric methods to conduct an in-depth exploration of research progress in this field,with the expectation of providing new insights for both clinical practice and scientific research.AIM To evaluate research trends and advancements in esophagogastric variceal bleeding(EGVB)over the past twenty years.METHODS Relevant publications on EGVB were retrieved from the Web of Science Core Collection.VOSviewer,Pajek,CiteSpace,and the bibliometrix package were then employed to perform bibliometric visualizations of publication volume,countries,institutions,journals,authors,keywords,and citation counts.RESULTS The analysis focused on original research articles and review papers.From 2004 to 2023,a total of 2097 records on EGVB were retrieved.The number of relevant publications has increased significantly over the past two decades,especially in China and the United States.The leading contributors in this field,in terms of countries,institutions,authors,and journals,were China,Assistance Publique-Hôpitaux de Paris,Bosch Jaime,and World Journal of Gastroenterology,respectively.Core keywords in this field include portal hypertension,management,liver cirrhosis,risk,prevention,and diagnosis.Future research directions may focus on optimizing diagnostic methods,personalized treatment,and multidisciplinary collaboration.CONCLUSION Using bibliometric methods,this study reveals the developmental trajectory and trends in research on EGVB,underscoring risk assessment and diagnostic optimization as the core areas of current focus.The study provides an innovative and systematic perspective for this field,indicating that future research could center on multidisciplinary collaboration,personalized treatment approaches,and the development of new diagnostic tools.Moreover,this work offers practical research directions for both the academic community and clinical practice,driving continued advancement in this domain.
文摘Gastrointestinal(GI)bleeding is a critical and potentially life-threatening condition frequently observed in the intensive care unit(ICU).This literature review consolidates current insights on the epidemiology,etiology,management,and outcomes of GI bleeding in critically ill patients.GI bleeding remains a significant concern,especially among patients with underlying risk factors such as coagulopathy,mechanical ventilation,and renal failure.Managing GI bleeding in the ICU requires a multidisciplinary approach,including resuscitation,endoscopic intervention,pharmacologic therapy,and sometimes surgical procedures.Even with enhanced management strategies,GI bleeding in the ICU is associated with considerable morbidity and mortality,particularly when complicated by multi-organ failure.This review reiterates the need for adequate resuscitation and interventions in managing GI bleeding in critically ill patients,aiming to enhance survival rates and improve the quality of care within the ICU setting.
文摘A recent study by Peng et al developed a predictive model for first-instance secondary esophageal variceal bleeding in cirrhotic patients by integrating clinical and multi-organ radiomic features.The combined radiomic-clinical model demonstrated strong predictive capabilities,achieving an area under the curve of 0.951 in the training cohort and 0.930 in the validation cohort.The results highlight the potential of noninvasive prediction models in assessing esophageal variceal bleeding risk,aiding in timely clinical decision-making.Additionally,manual delineation of regions of interest raises the risk of observer bias despite efforts to minimize it.The study adjusted for clinical covariates,while some potential confounders,such as socioeconomic status,alcohol use,and liver function scores,were not included.Additionally,an imbalance in cohort sizes between the training and validation groups may reduce the statistical power of validation.Expanding the validation cohort and incorporating multi-center external validation would improve generalizability.Future studies should focus on incorporating long-term patient outcomes,exploring additional imaging modalities,and integrating automated segmentation techniques to refine the predictive model.
文摘BACKGROUND Endoscopic variceal band ligation(EVBL)represents a pivotal treatment in the prophylaxis of esophageal varices bleeding in patients with cirrhosis,but in some cases a single session of EVBL is unable to eradicate esophageal varices completely,and a control endoscopy after 2-4 weeks is required to assess eradication and/or the need for another band ligation.Liver stiffness measurement(LSM)is being increasingly used as a screening non-invasive tool to predict varices according to Baveno VII criteria.However,to date,there are no instruments able to non-invasively predict the outcome of EVBL.AIM To identify non-invasive predictors of varices eradication(VE)after EVBL through multiparametric ultrasound(US).Secondary aim was to develop a prediction model of successful variceal eradication based on non-invasive parameters.METHODS We prospectively enrolled consecutive cirrhotic patients intolerant or with contraindications to beta-blockers undergoing EVBL for bleeding prophylaxis.Patients underwent multiparametric US with LSM,spleen stiffness measurement(SSM)and dynamic contrastenhanced US(DCE-US)on liver parenchyma and portal vein,at baseline(T0)and one month(T1)after EVBL.Each US parameter and their variations from baseline were correlated with VE evaluated by control endoscopy performed at T1.RESULTS We enrolled 41 patients(median age 64 years,75.6%males).At T128 patients(68.3%)reached VE,whereas 13(31.7%)required a second EVBL.Patients who achieved VE showed a significant decrease in SSM(P=0.018),and a significant increase in peak enhancement,area under the curve and wash-in rate of both liver parenchyma and portal vein after treatment(P<0.001).Statistically significant differences between the two groups of patients were incorporated in a multivariate analysis and used to develop three prediction models.CONCLUSION A multimodal US approach based on DCE-US parameters,LSM and SSM might become a reliable predictor of VE and a useful non-invasive alternative to endoscopy.
基金Supported by Natural Science Foundation of Henan Province,China,No.232300420232Henan Provincial Key Research and Development Project,No.231111313500.
文摘BACKGROUND Budd-Chiari syndrome(BCS)is caused by obstruction of the hepatic veins or suprahepatic inferior vena cava,leading to portal hypertension and the development of gastroesophageal varices(GEVs),which are associated with an increased risk of bleeding.Existing risk models for variceal bleeding in cirrhotic patients have limited applicability to BCS due to differences in pathophysiology.Radiomics,as a noninvasive technique,holds promise as a tool for more accurate prediction of bleeding risk in BCS-related GEVs.AIM To develop and validate a personalized risk model for predicting variceal bleeding in BCS patients with GEVs.METHODS We retrospectively analyzed clinical data from 444 BCS patients with GEVs in two centers.Radiomic features were extracted from portal venous phase computed tomography(CT)scans.A training cohort of 334 patients was used to develop the model,with 110 patients serving as an external validation cohort.LASSO Cox regression was used to select radiomic features for constructing a radiomics score(Radscore).Univariate and multivariate Cox regression identified independent clinical predictors.A combined radiomics+clinical(R+C)model was developed using stepwise regression.Model performance was assessed using the area under the receiver operating characteristic curve(AUC),calibration plots,and decision curve analysis(DCA),with external validation to evaluate generalizability.RESULTS The Radscore comprised four hepatic and six splenic CT features,which predicted the risk of variceal bleeding.Multivariate analysis identified invasive treatment to relieve hepatic venous outflow obstruction,anticoagulant therapy,and hemoglobin levels as independent clinical predictors.The R+C model achieved C-indices of 0.906(training)and 0.859(validation),outperforming the radiomics and clinical models alone(AUC:training 0.936 vs 0.845 vs 0.823;validation 0.876 vs 0.712 vs 0.713).DCA showed higher clinical net benefit across the thresholds.The model stratified patients into low-,medium-and high-risk groups with significant differences in bleeding rates(P<0.001).An online tool is available at https://bcsvh.shinyapps.io/BCS_Variceal_Bleeding_Risk_Tool/.CONCLUSION We developed and validated a novel radiomics-based model that noninvasively and conveniently predicted risk of variceal bleeding in BCS patients with GEVs,aiding early identification and management of high-risk patients.
文摘The Sengstaken-Blakemore tube(SB tube),introduced in the 1950s,was a pivotal device for managing acute gastrointestinal(GI)bleeding,particularly from esophageal varices.This multi-lumen tube,featuring esophageal and gastric balloons,applied mechanical pressure to control bleeding and provided a temporary solution until more definitive treatments could be employed.It was historically significant in resource-limited settings where advanced endoscopic options were unavailable,enabling patient stabilization and transfer to specialized centers.However,the advent of GI endoscopy and its increased availability has rendered the SB tube obsolete.SB tubes are associated with complications,including esophageal perforation,aspiration pneumonia,and gastric ulceration.Additionally,the tube can cause significant discomfort,and its migration may lead to inadequate.Techniques such as endoscopic variceal ligation and endoscopic sclerotherapy offer superior precision,efficacy,and safety for managing variceal bleeding.Improved hospital transfer protocols now facilitate prompt endoscopic or surgical interventions,reducing the need for temporary measures like the SB tube.Additionally,advancements in pharmacological treatments,including vasoactive drugs,reliance on mechanical compression devices.While the SB tube remains an important historical artifact,its role in current medical practice reflecting safer and more effective treatment options in emergency GI care.This review discusses the declining role of the Sengstaken-Blakemore tube and its replacement by current intervention methods.
文摘BACKGROUND Cirrhosis is a progressive condition characterized by fibrosis that can lead to severe complications and increased mortality.The mac-2 binding protein glyco-sylation isomer(M2BPGi)is a prominent biomarker for predicting hepatocellular carcinoma(HCC)and cirrhosis-induced esophageal varices(EV).AIM To investigate thresholds of M2BPGi associated with HCC,EV,and decomp-ensation in patients with cirrhosis.METHODS This was a prospective study.A total of 153 patients with cirrhosis who met the inclusion criteria were enrolled.The patients were diagnosed with HCC and EV according to the Baveno VII and European Association for the Study of the Liver guidelines.Baseline serum M2BPGi levels were assessed along with other routine tests.The data analysis aimed to determine the cutoff values of M2BPGi for pre-dicting EV and HCC.RESULTS In the study 85.6%of patients were Child-Pugh B and C.M2BPGi mean cutoff index was 7.1±3.7,showing no significant etiological differences.However,M2BPGi levels varied significantly among Child-Pugh classes,EV classifications,and between patients with and without HCC(P<0.01).M2BPGi cutoff values for predicting HCC,EV,and decompensated cirrhosis were 6.50,6.64,and 5.25,respectively.Mul-tivariate analysis confirmed M2BPGi as an independent risk factor for EV[adjusted odds ratio(aOR):1.3,95%CI:1.08-1.64]and liver decompensation(aOR:2.11,95%CI:1.37-3.83).Area under the curve of M2BPGi for HCC differ-entiation was 0.71.An algorithm combining alpha-fetoprotein(AFP)and M2BPGi detected 26 of 28 HCC cases with 98.04%accuracy vs 10 cases by AFP alone.CONCLUSION Serum M2BPGi predicted cirrhosis complications,including decompensation and varices,especially in HCC.Combined with AFP,it enhanced HCC detection.Future liver biopsy studies are needed for tissue confirmation.
基金Supported by Tianjin Key Medical Discipline(Specialty)Construction Project,No.TJYXZDXK-034AHebei Province 2025 Traditional Chinese Medicine Scientific Research Project Plan,No.T2025008.
文摘BACKGROUND Acute variceal bleeding(AVB)represents a life-threatening complication in hepatocellular carcinoma(HCC)patients undergoing systemic therapy,mainly including immune checkpoint inhibitors(ICIs)and antivascular drugs used alone or in combination.The pathogenesis of AVB in this population may involve tumor-related factors,treatment-induced effects,or progression of underlying portal hypertension.Identifying high-risk factors for AVB is crucial for the management of this patient population.AIM To develop and validate a risk prediction model for AVB occurrence in cirrhotic HCC patients receiving ICI-based systemic therapy.METHODS This retrospective study analyzed 286 HCC patients(2021-2022)receiving ICIs(mono-/combination therapy),randomly split into training(n=184)and validation(n=102)cohorts.In the training cohort,bleeding vs nonbleeding groups were compared for general information,etiological data,laboratory indicators,tumor staging,systemic treatment drugs,variceal bleeding history,and endoscopic treatment history.Risk factors for AVB were identified and used to establish a logistic regression model for predicting bleeding,which was further validated in the validation cohort.RESULTS The bleeding group had significantly higher proportions of patients with platelet count≥100×10^(9)/L,alphafetoprotein≥400 ng/mL,tumor diameter≥5 cm,portal vein tumor thrombosis,ascites,bleeding history,prior endoscopic treatment,albumin-bilirubin grade level 2-3,fibrosis-4 index(FIB-4)≥4.57,and prognostic nutritional index<45 compared to the non-bleeding group.Multivariate analysis identified tumor diameter≥5 cm,portal vein thrombosis,bleeding history,and elevated FIB-4 as independent risk factors for bleeding(P<0.05).A predictive model based on these factors showed good discrimination,with area under the receiver operating characteristic curve values of 0.861(training)and 0.816(validation).CONCLUSION A history of pre-ICI bleeding significantly increases recurrent bleeding risk,necessitating close monitoring.The FIB-4 fibrosis model,combined with tumor features,can also serve as a predictive factor for bleeding.
文摘Gastric variceal(GV)bleeding remains a life-threatening complication of portal hypertension,with ongoing debate regarding the optimal endoscopic therapy.Conventional endoscopic cyanoacrylate injection(ECI)is effective but limited by the risk of ectopic embolism,particularly in the presence of gastrorenal shunts.Clip-assisted ECI(clip-ECI)has emerged as a novel modification designed to reduce embolic risk while maintaining hemostatic efficacy.We appraised the recent study by Xiong et al,which compared clip-ECI with endoscopic ultrasoundguided coil and cyanoacrylate injection in 108 propensity-matched patients with cardiofundal varices and shunts.Both techniques demonstrated comparable efficacy,with obliteration rates exceeding 90%and similar one-year rebleeding rates.Importantly,no embolic events were reported.These findings are consistent with prior studies,including multicenter cohorts and a recent randomized controlled trial,which highlight clip-ECI as a safe,effective,and efficient technique,with advantages of shorter procedure times,fewer sessions,and lower costs.While endoscopic ultrasound(EUS)-guided therapy offers precision in expert hands,clip-ECI provides a practical,accessible alternative,particularly in resource-limited settings.Larger prospective studies with standardized definitions and cost-effectiveness analyses are needed to refine treatment algorithms.Clip-ECI represents a promising“flow-control assisted”strategy and a real-world alternative to EUS-based therapies for GV.
文摘BACKGROUND Relative changes in the prevalence of gastrointestinal(GI)diseases have been reported worldwide over the past decades.However,data on changing trends of upper GI diseases remain scarce in sub-Saharan Africa.This study examines the shifting patterns of upper GI endoscopic findings over 35 years in Ethiopia.AIM To analyze trends in upper GI endoscopic findings over two distinct time periods,35 years apart,in Ethiopia.METHODS We extracted findings from 8412 upper GI endoscopies performed between 2016 and 2024 at a tertiary referral center in Addis Ababa,Ethiopia.Patient characteristics,indications,and endoscopic findings were analyzed using descriptive statistics and presented in tables,map and graphs.These findings were compared to 10000 procedures conducted between 1979 and 1994.Key endoscopic findings were identified,and percentage changes in disease prevalence were calculated.RESULTS Between the two study periods,the male-to-female ratio of patients undergoing upper GI endoscopy shifted from 2:1 to 1.4:1,while the median patient age increased from 36 to 40 years.The proportion of patients older than 50 years doubled(14.6%to 30.2%),and referrals from outside Addis Ababa increased from 33%to 57%.The prevalence of peptic ulcer disease and its complications decreased from 46.2%to 9.5%.Conversely,gastroesophageal varices increased from 9.5%to 21.8%,and upper GI malignancies rose from 3.6%to 18.8%.CONCLUSION This study sheds light on critical epidemiological shifts in upper GI diseases in Ethiopia,with a decline in peptic ulcer disease and a rise in portal hypertensive lesions and malignancies which have important public health implications.These findings underscore the need for increased awareness,improved clinical practices,enhanced resource allocation,and expanded access to early diagnosis and treatment of prevailing conditions.Preventive strategies targeting immunization and treatment of viral hepatitis,schistosomiasis,and Helicobacter pylori infection are urgently needed.
基金Supported by the National Natural Science Foundation of China,No.81970533the Natural Science Foundation of Shandong Province,No.ZR2022ZD21.
文摘Esophagogastric variceal bleeding is a common and severe complication of cirr-hotic portal hypertension.Hepatic venous pressure gradient measurement and esophagogastroduodenoscopy are the diagnostic gold standards for portal hyper-tension and esophagogastric variceal bleeding,respectively.With advancements in artificial intelligence in medicine,non-invasive diagnostic methods are in-creasingly replacing traditional invasive procedures,permitting more rational and personalized patient care.This review summarizes the formation and diagnosis of portal hypertension,as well as the primary prophylaxis,secondary prophylaxis,and management of acute esophagogastric variceal bleeding.This study also highlights the latest progress in artificial intelligence in the diagnosis and treat-ment of portal hypertension and esophagogastric varices.
文摘Advanced endoscopic methods like endoscopic ultrasound(EUS)have recently been applied for the management of complications related to cirrhosis.This includes novel techniques to measure portal pressure gradients,esophageal,gastric,and ectopic varices management,and EUS-assisted treatment of liver tumors.Management of liver tumors has seen significant changes in recent years,and many minimally invasive procedures have been approved,especially in the management of liver cell carcinoma.These are specialized procedures and are performed only in patients with cirrhosis in specialized centers.There are concerns for complications in patients with cirrhosis due to their increased risk of bleeding and the altered hemostatic milieu.This minireview summarizes the recent evidence on using EUS in the management of cirrhosis-related complications.
基金Supported by the National Natural Science Foundation of China,No.82200664the Clinical Research Program of The First Affiliated Hospital,Zhejiang University School of Medicine,No.BL2025023.
文摘BACKGROUND The high rebleeding rate and severe adverse events have raised concerns regarding the safety of endoscopic cyanoacrylate as a conventional treatment for gastric variceal hemorrhage.Clip-assisted endoscopic cyanoacrylate injection(Clip-CYA)and endoscopic ultrasound-guided coil and cyanoacrylate injection(EUS-CG)are two currently used modalities.There are limited data comparing the two techniques.AIM To compare the efficacy,safety,and procedural characteristics of Clip-CYA vs EUS-CG for treatment of gastric varices(GVs)with spontaneous portosystemic shunts.METHODS Between April 2019 and August 2023,162 patients with GVs and concomitant gastrorenal or splenorenal shunts who underwent either Clip-CYA or EUS-CG at our center were included.After 1:2 propensity score matching,108 patients were included in the final analysis.The evaluated outcomes included the amount of cyanoacrylate,eradication of GVs,cyanoacrylate embolization,all-cause rebleeding,operating time and endoscopic therapy costs.RESULTS Of the 108 patients,72(male,83.3%;mean age,56.2±10.8 years)received Clip-CYA,and 36(male,72.2%;mean age,59.1±10.7 years)received EUS-CG.The amount of cyanoacrylate used,rates of obliteration of GVs and all-cause rebleeding were similar between the two groups(2.0±1.1 mL vs 2.0±0.6 mL,P=0.913;91.7%vs 94.4%,P=0.603;and 23.6%vs 19.4%,P=0.623,respectively).No cyanoacrylate embolization occurred in either group.Compared with EUS-CG,Clip-CYA was associated with significantly shorter operating times(24.0±9.9 minutes vs 47.1±21.0 minutes,P<0.001)and lower endoscopic therapy costs(7523.4±5719.4 Chinese yuan vs 11153.7±7679.1 Chinese yuan,P=0.007).These advantages persisted in the subgroup analysis of patients whose GVs had a maximum diameter>3 cm or>4 cm.CONCLUSION Compared with EUS-CG,Clip-CYA of GVs appears to be a safe procedure with shorter operating times and lower endoscopic therapy costs.
文摘BACKGROUND Shwachman-Diamond syndrome(SDS)is a rare genetic disorder that affects multiple organs,primarily the liver.Most patients are diagnosed during infancy or early childhood.As they grow older,the majority of affected children may experience spontaneous remission,and cases of cirrhosis in adults are rarely reported.CASE SUMMARY A 36-year-old male patient presented with massive ascites.Laboratory tests revealed pancytopenia and a serum-ascites albumin gradient greater than 1.1 g/dL.An abdominal computed tomography scan demonstrated cirrhosis,splenomegaly,pancreatic fat infiltration,and a substantial accumulation of peritoneal fluid.Gastroscopy identified esophageal varices.Liver stiffness measurement indicated a value of 32.7 kPa.Based on the results of auxiliary examinations,common causes of cirrhosis were excluded,and a mutation in the Shwachman-Bodian-Diamond syndrome gene was ultimately identified through whole-exome sequencing.The patient was diagnosed with cirrhosis secondary to SDS.Following the correction of hypoalbuminemia and administration of diuretics,the patient's ascites resolved.CONCLUSION Patients with liver cirrhosis who also exhibit pancreatic fat infiltration and pancytopenia necessitate further exon testing to exclude the possibility of SDS.
基金Supported by the National Natural Science Foundation of China,No.82270594the National Natural Science Foundation for Youths of China,No.82103151+1 种基金the Fundamental Research Funds for the Central Universities of Central South University,No.2022ZZTS0265the Graduate Research Innovation Project of Hunan Province,No.CX20220347.
文摘BACKGROUND Patients with decompensated liver cirrhosis suffering from esophagogastric variceal bleeding(EGVB)face high mortality.AIM To investigate the risk factors for EGVB in patients with liver cirrhosis and establish a diagnostic nomogram.METHODS Patients with liver cirrhosis who met the inclusion criteria were randomly divided into training and validation cohorts in a 6:4 ratio in this retrospective research.Univariate analysis,least absolute shrinkage and selection operator regression,and multivariate analysis were employed to establish the nomogram model.Calibration curve,the area under the receiver operating characteristic curve(AUC),and decision curve analysis(DCA)were applied to assess the discrimination,accuracy,and clinical practicability of the nomogram,respectively.RESULTS A total of 1115 patients were enrolled in this study.The nomogram was established based on white blood cells(P<0.001),hemoglobin(P<0.001),fibrinogen(P<0.001),total bilirubin(P=0.007),activated partial thromboplastin time(P=0.002),total bile acid(P=0.012),and ascites(P=0.006).The calibration curve indicated that the actual observation results were in good agreement with the prediction results of the model.The AUC values of the diagnostic model were 0.861 and 0.859 in the training and validation cohorts,respectively,which were higher than that of the aspartate aminotransferase-to-platelet ratio index,fibrosis index based on 4 factors,and aspartate aminotransferase-to-alanine aminotransferase ratio.Additionally,DCA indicated that the net benefit value of the model was higher than that of the other models.CONCLUSION This research constructed and validated a nomogram with perfect performance for predicting EGVB events in patients with liver cirrhosis,which could help clinicians with timely diagnosis,individualized treatment,and follow-up.
文摘BACKGROUND Hepatitis C virus(HCV)infection remains a major public health issue in Egypt,with a high prevalence of genotype 4.Direct-acting antivirals(DAAs)achieve>95%sustained virologic response(SVR),but their impact on variceal rebleeding in genotype 4 cirrhotic patients is underexplored.This study evaluated the association between DAA therapy and variceal rebleeding in Egyptian patients with HCV-related cirrhosis.AIM To evaluate the association between DAA therapy and variceal rebleeding in Egyptian patients with HCV-related cirrhosis.METHODS A multicenter retrospective cohort study included HCV genotype 4 cirrhotic patients from five Egyptian centers with a first variceal bleeding episode.Patients were divided into DAA-treated(Group A)and non-treated(Group B)groups and followed for 5 years.Propensity score matching(PSM),Cox regression,and competing risk analysis were adjusted for confounders.RESULTS DAA treatment significantly reduced variceal rebleeding(HR 2.57;95%CI:1.39-4.72;P=0.002),ascites development over 5 years(6.8%vs 27.1%,P=0.006),and hepatic dysfunction progression.During treatment,it improved liver function[lower model for end-stage liver disease(MELD),stable Child-Pugh class]and reduced complications.All Group A patients achieved SVR by PCR,while Group B remained HCV-positive,likely contributing to the observed reductions in rebleeding and hepatic decompensation.These benefits persisted over 5 years,with longer survival without rebleeding(4.5 years vs 3.2 years),lower MELD(7 vs 12,P<0.001),and reduced hepatic decompensation(Child-Pugh progression:5.1%vs 35.6%,P<0.001).At 5 years,the DAA group had better liver function(higher albumin,lower international normalized ratio,improved platelets),while the non-DAA group worsened.PSM confirmed these findings(HR:0.45,95%CI:0.27-0.75,P=0.002),and competing risk analysis showed sustained protection(sub-distribution HR:0.44,95%CI:0.26-0.74,P=0.002).Endoscopy revealed variceal regression with DAA but progression in the non-DAA group.DAA therapy significantly reduced variceal rebleeding,hepatic decompensation,and mortality(8.5%vs 20.3%,P=0.045),with survival benefits linked to SVR.Additionally,it was associated with improved survival,with a lower 5-year mortality rate in the DAA group(8.5%vs 20.3%,P=0.045).The protective effect of DAA therapy remained consistent across multivariable Cox regression,time-dependent modeling,and competing risk analyses.CONCLUSION DAA treatment in HCV-related cirrhosis significantly reduces variceal rebleeding,ascites development,and hepatic dysfunction progression.The 5-year follow-up data demonstrate sustained improvements in liver function and hematologic parameters,underscoring the long-term benefits of DAA therapy.
基金Supported by the Agency Natural Science Foundation of Fujian Province,China,No.2022J011285 and No.2023J011480.
文摘BACKGROUND Severe esophagogastric varices(EGVs)significantly affect prognosis of patients with hepatitis B because of the risk of life-threatening hemorrhage.Endoscopy is the gold standard for EGV detection but it is invasive,costly and carries risks.Noninvasive predictive models using ultrasound and serological markers are essential for identifying high-risk patients and optimizing endoscopy utilization.Machine learning(ML)offers a powerful approach to analyze complex clinical data and improve predictive accuracy.This study hypothesized that ML models,utilizing noninvasive ultrasound and serological markers,can accurately predict the risk of EGVs in hepatitis B patients,thereby improving clinical decisionmaking.AIM To construct and validate a noninvasive predictive model using ML for EGVs in hepatitis B patients.METHODS We retrospectively collected ultrasound and serological data from 310 eligible cases,randomly dividing them into training(80%)and validation(20%)groups.Eleven ML algorithms were used to build predictive models.The performance of the models was evaluated using the area under the curve and decision curve analysis.The best-performing model was further analyzed using SHapley Additive exPlanation to interpret feature importance.RESULTS Among the 310 patients,124 were identified as high-risk for EGVs.The extreme gradient boosting model demonstrated the best performance,achieving an area under the curve of 0.96 in the validation set.The model also exhibited high sensitivity(78%),specificity(94%),positive predictive value(84%),negative predictive value(88%),F1 score(83%),and overall accuracy(86%).The top four predictive variables were albumin,prothrombin time,portal vein flow velocity and spleen stiffness.A web-based version of the model was developed for clinical use,providing real-time predictions for high-risk patients.CONCLUSION We identified an efficient noninvasive predictive model using extreme gradient boosting for EGVs among hepatitis B patients.The model,presented as a web application,has potential for screening high-risk EGV patients and can aid clinicians in optimizing the use of endoscopy.
文摘Portal hypertension(PH)is a major complication of chronic liver disease,often leading to serious clinical consequences such as variceal bleeding,ascites,and splenomegaly.The current gold standard for PH diagnosis,namely,hepatic venous pressure gradient measurement,is invasive and not widely available.Transient elastography has emerged as a non-invasive alternative for assessing liver stiffness(LS),and recent studies have highlighted the potential role of splenic stiffness(SS)in evaluating PH severity.This narrative review summarizes the available evidence on the utility of splenic transient elastography in assessing PH.We evaluated its diagnostic accuracy,technical challenges,and clinical applications,particularly in distinguishing between cirrhotic PH(CPH)and noncirrhotic PH(NCPH).A comprehensive literature search was conducted using the PubMed database,focusing on studies that assess splenic elastography in the diagnosis and prognosis of PH.This review compares splenic elastography with other non-invasive imaging modalities,including MR elastography and shearwave elastography.Additionally,we examined the role of SS using elastography in predicting the presence of esophageal varices and its potential impact on reducing the need for endoscopic screening.Studies have demonstrated that splenic elastography correlates well with PH severity,with cut-off values ranging between 45 kPa and 50 kPa for significant PH detection.Splenic elastography,when combined with platelet count and LS measurements,improves diagnostic accuracy and risk stratification for the occurrence of variceal bleeding.Despite its clinical promise,technical challenges such as patient positioning,body habitus,and probe selection remain key limitations.Notably,splenic elastography may be particularly useful in diagnosing NCPH,where LS remains normal but PH is present.Splenic transient elastography is a valuable adjunct in the non-invasive assessment of PH.Its ability to predict varices,differentiate between CPH and NCPH,and reduce unnecessary endoscopies suggests that it should be incorporated into routine hepatology practice.Future research should focus on refining SS cut-offs,evaluating its cost-effectiveness,and integrating splenic elastography into clinical guidelines for PH management.
