Annals of hepatology最新文献

Introduction and Objectives

Hepatic encephalopathy (HE) is a common and serious complication of cirrhosis, associated with high morbidity and mortality. Ammonia and inflammation are the main triggers of HE. The use of L-ornithine-L-aspartate (LOLA) provides precursor substances for glutamine synthesis in perivenous cells, accelerating ammonia detoxification.

This study aims to evaluate the efficacy and safety of intravenous L-ornithine-L-aspartate (LOLA) in patients with grade III-IV hepatic encephalopathy (HE).

Materials and Patients

Retrospective and analytical study of patients with grade III-IV hepatic encephalopathy (HE).

All patients received intravenous LOLA 50 g for up to 48 hours, excluding those with renal failure. Descriptive statistics with measures of central tendency and dispersion were performed. Improvement was considered when HE regressed by at least one grade, and adverse events were evaluated.

Results

A total of 32 patients were included, with a mean age of 55 years ± 9.6. There were 13 females (40.6%) and 19 males (59.4%). Eight patients (25%) were classified as Child-Pugh B, while 24 patients (75%) were classified as Child-Pugh C. The mean MELD score was 19.03 ± 6.08, and the mean MELD NA score was 7.19 ± 7.19. The most common etiology was alcohol-related (43.8%), followed by MAFLD (29.1%) and viral (9.5%). All patients had grade III hepatic encephalopathy. The precipitating factors were sepsis (53%), hemorrhage (25%), constipation (12.5%), diuretics (6.3%), and electrolyte imbalance (3.1%). A total of 24 patients (75%) responded to the treatment, while 8 patients (25%) did not. Nineteen patients were found to have some degree of acute-on-chronic liver failure (ACLF). No adverse events were reported.

Conclusions

The use of intravenous LOLA for the treatment of grade III-IV hepatic encephalopathy iseffective and safe. These results support the use of LOLA as a therapeutic option in the management of hepatic encephalopathy in this patient population.

Introduction and Objectives

Liver transplantation is the optimal treatment in patients with irreversible liver damage. The principal complication of a transplant is ischemia-reperfusion injury (I/R), which induces primary graft rejection. Treatment with plant extracts prior to I/R has decreased the severity of this injury due to their potential anti-inflammatory and antioxidant activity. A plant that presents potential antioxidant activity is Flourensia cernua (Fc). The objective was to evaluate the hepatoprotective effect of Flourensia cernua against the damage induced by ischemia-reperfusion in Wistar rats.

Materials an Patients

42 mixed Wistar rats were sorted into 7 groups (n=6). Fc was administered (200 mg/kg/, p.o/5 days) followed by I/R clamping of the left portal triad producing 1hr of 70% ischemia and 2 or 24hrs of reperfusion. Biochemical and oxidative stress biomarkers, proinflammatory cytokine and gene expression were determined. Ethics Committee approval under HI17-00002 registry and PAICYT 152-CS-2022 financing. The research group declares no conflict of interest.

Results

The I/R groups with 2 (IR2hr) and 24 hour (IR24hr) reperfusion displayed significantly elevated ALT and AST concentrations vs. Sham (SH); only FcIR2hr significantly decreased these enzymes (Figure 1). The remaining biochemical parameters did not show any significant differences between the groups. IR2hr group induced a statistically significant alteration of oxidative stress biomarkers, Fc counteracted these effects, with a decrease of malondialdehyde(MDA) and an increase of reduced glutathione (GSH) and the superoxide dismutase(SOD) (Figure 2). The gene expression of NFκβ was increased in IR2hr group, the treatment with F. cernua counteracted this increase. TNF-α was significantly increased in the IR2hr group and decreased in the treatment group.

Conclusions

I/R is a widely studied injury model, capable of inducing pathological changes in several spheres, not unlike the observed results in the present study; the hydroalcoholic extract of Fc displayed anti-inflammatory and antioxidant activity at 200mg/kg, it was not toxic and proved to be hepatoprotective against I/R.

Introduction and Objectives

The hepatitis A and hepatitis E viruses are organisms that stand out for their high resistance to acid and alkaline media, as well as to freezing temperatures. Despite presenting an approximate mortality of 1% for both viruses, a seroprevalence of up to 81.3% has been reported in previous decades, so it is important to know the current epidemiological status of both diseases.

Materials and Patients

Cross-sectional, descriptive, prospective and observational study. Individuals over 18 years of age were recruited, who were studying or had the degree of gastroenterologists at the Hospital de Especialidades Centro Médico Nacional Siglo XXI, in a period of time between June 01 and June 30, 2023. Blood samples were collected for detection of immunoglobulin G against hepatitis A and hepatitis E viruses and a demographic questionnaire was conducted to each of the participants.

Results

23 individuals were recruited, 60.9% men (n=14) and 39.1% women (n=9), with a median age of 29 years, 13.0% corresponding to individuals from Mexico City (n= 3) and 86.9% from other states of the Mexican Republic (n=20). A seroprevalence of 17.3% (n=4) and 4.3% (n=1) was reported for hepatitis A virus and hepatitis E virus, respectively.

Conclusions

There is a lower seroprevalence for hepatitis A and hepatitis E viruses than reported, so it is vitally important to take preventive measures in populations at risk of infection, such as health personnel.

Introduction and Objectives

MAFLD is a highly prevalent cause of chronic liver disease, present in 70% of overweight people, 70% of diabetics, and 90% of morbidly obese people. It is the hepatic manifestation of the metabolic syndrome, defined by the presence of central obesity, insulin resistance, hyperlipidemia, hyperglycemia, and hypertension. The development of liver fibrosis is secondary to several factors, steatosis being one of them. To evaluate the correlation of steatosis with hepatic fibrosis in patients with metabolic syndrome using transition elastography.

Materials and Patients

Patients older than 18 years who met MALFD criteria were included, transition elastography was performed to calculate CAP and kilopascals, steatosis degree and fibrosis degree were calculated according to the myfibroscan application, for statistical analysis Pearson's bivariate correlations were used between CAP and kilopascal values. The association between the degree of steatosis and fibrosis was performed using the chi-square test. Was considered significant at p < 0.05.

Results

94 patients were included, 20 men (21.3%), 74 women (78.7%), mean age 40.5 ± 10.02, CAP 300.6 ± 63.4, kilopascals 6.4 ± 2.7, steatosis grade S0: 8, S1: 8, S2: 20, S3: 58, degree of fibrosis F0: 58, F1: 14, F2:14, F3: 6, F4:2. The correlation between CAP and kilopascals was moderate and significant RHO=0.343 P =0.001. A significant association was found between the degree of steatosis and that of fibrosis chi-square (12) =25.1, p=0.015. The proportions were 50% (S0:F0), 16% (S1:F3), 50% (S2:F3), 100% (S3:F4).

Conclusions

The correlation between steatosis and fibrosis is moderate, implying that there are other factors that influence the development of fibrosis and its progression, so metabolic control and other factors in patients with MALFD are highly relevant to prevent fibrosis progression.

Introduction and Objectives

To present a 70-year-old female with type 2 diabetes and a history of multiple episodes of cholecystitis within Bouveret's Syndrome.

Materials and Patients

70-year-old female with type 2 diabetes and a history of multiple episodes of cholecystitis refusing surgical treatment. She was admitted to the emergency department due to a clinical picture of 10 days of evolution characterized by severe abdominal pain localized in the right hypochondrium that was exacerbated after food intake. Symptoms included nausea, vomiting and malaise. Physical examination revealed a Glasgow score of 15 points, cardiopulmonary normal, abdomen tenderness on palpation, increased peristaltic sounds, and negative Murphy and Blumberg signs with no evidence of peritoneal irritation. Rest normal. Leukocytes 17.1, neutrophils 15.4, hemoglobin 12.3, platelets 45.000, glucose 614, BUN 54, urea 117, creatinine 3.3, AST 82, ALT 52, LDH 264, alkaline phosphatase 155, total bilirubin 0.56, albumin 1.9, gamma glutamyl transpeptidase 99, serum electrolytes normal. Urine tests with ketones and arterial blood gases with metabolic acidosis. Management for diabetic ketoacidosis was started with poor clinical progression and, worsening of abdominal pain and absence of bowel movements. Abdominal ultrasound showed a hepatic image in segment IVa with defined borders; it measured 47 × 38 millimeters, suggestive of a biloma. The gallbladder had heterogeneous content with multiple stones and acute lithiasic cholecystitis. The CT identified a stone in the first and second portions of the duodenum, biliary ilium and a cholecystoduodenal fistula.

Results

Bouveret syndrome was diagnosed by performing a duodenoscopy in which a fistulous orifice with bile outlet was observed, posteriorly removing the stone with no complications during the procedure. Image-guided drainage of the biloma was performed with a multipurpose catheter placement with total resolution. Diabetic ketoacidosis was treated under usual measures, observing a general and important improvement in the patient.

Conclusions

Bouveret syndrome is a rare clinical entity and its simultaneous appearance with an acute episode of diabetic ketoacidosis is rarely described in the literature. Only 6% of patients with cholecystoenteric fistulas develop a clinical picture of intestinal obstruction, with duodenal obstruction being the less frequent (<5%).

Introduction and Objectives

Hepatocellular carcinoma (HCC) is the most common malignant tumor in patients with advanced cirrhosis, posing a significant challenge to the healthcare system. Treatment involves a multidisciplinary approach; however, advanced disease limits the available options. Effectiveness and outcomes can differ depending on the stage of the disease, the patient's functional reserve, and other factors. This study aims to describe the clinical characteristics, staging, treatment, and outcomes of patients with HCC at a third-level hospital

Materials and Patients

A retrospective, descriptive study of HCC patients. Demographic variables, treatment received according to the Barcelona Clinic Liver Cancer (BCLC) staging system, and treatment response according to the Response Evaluation Criteria in Solid Tumors (RECIST) were evaluated. Descriptive statistics with measures of central tendency and dispersion were performed.

Results

The study included 50 patients (20 females, 30 males; mean age 62 ±8). Etiology of cirrhosis: MAFLD (19), alcohol-related (14), Hepatitis C (11), and other causes (6). The average MELD score was 12.5 ±6.22, and the MELD-Na score was 14.7 ±5.44. BCLC staging: A (9), B (28), C (4), D (9). Eligible for treatment (30), categorized as Child-Pugh A(2), B(22), C(6). Radiological treatment (21) included Transarterial Chemoembolization (TACE) in 13 cases, ablation (4), and a combination TACE/Ablation (4). Medical treatment with Lenvatinib (1). Combination of medical and radiological treatments (3). TACE followed by transplantation (4), and transplantation alone (1). Treatment response evaluation: Complete response (4), partial response (9), stable disease (7), and progression (8). The 3-month mortality rate was 8.3%.

Conclusions

In our group, most of the patients were males, with a relatively equal distribution between compensated and decompensated cirrhosis. MAFLD was the most prevalent etiology, and a significant portion of cases presented at an intermediate stage (BCLC B), qualifying them as candidates for treatment. The response rates to treatment were 13% for complete response and 30% for partial response. Furthermore, the calculated mortality rate at 3 months was relatively low.

Introduction and Objectives

The microbial communities’ control is crucial to maintaining homeostasis of gut-liver axis; clinical evidence demonstrates disruptions of microbiota-gut-liver in individuals with Metabolic-associated fatty liver disease (MAFLD). Foods rich in fiber and polyphenols have been associated with an improvement in microbiota diversity, indexand miRNAs expression. The aim of this study was to evaluate the effect of a supplementation with a mixture of Mexican foods (MexMix): Opuntia ficus indica (nopal), Theobroma cacao (cocoa) and Acheta domesticus (crickets) on gut-liver axis in a MAFLD mice model.

Materials and Patients

Thirty C57BL/6J mice were divided into three groups: 1) control: normal diet. 2) HF: high fat diet (60%) and fructose/sucrose water 3) MexMix: HF diet up to week 10, followed by HF diet supplemented with 6.7% nopal, 8.7% cocoa, and 8.7% cricket for 8 weeks.

Results

The MexMix animals showed a significantly decreased in body weight, visceral and epididymal fat, adipocyte size, triglycerides, insulin, leptin, and PAI-1; while adiponectin levels increased. Using 16S rRNA gene sequencing, MexMix increased phylogenetic diversity, Firmicutes abundance, and enrichment of 10 beneficial genera, including Lachnospiraceae, Ruminococcaceae, Akkermansia, and Eubacterium_coprostanoligenes_group. In the gut, MexMix supplementation significantly increased SCFAs concentration, intestinal crypts depth, Ocln and Cldn1 expression, and decreased Il6 and Tnf-a expression. In liver, MexMix significantly reduced steatosis and Tnfa expression. Besides, MexMix increased nuclear translocation of NFR2 and, in consequence, a higher hepatic expression of Cat and Sod. MexMix also decreased hepatic expression of miRNA-34a, miRNA-103, and miRNA-33a.

Conclusions

Synchronous supplementation with three nutraceuticals, nopal, cacao, and cricket, produced better results compared to previous studies where foods were administered individually. MexMix demonstrated its efficacy as a prebiotic, promoting the growth of beneficial genera and improving intestinal health. These findings indicate that MexMix has the potential to serve as a therapeutic approach for treating MAFLD in patients, as well as other conditions associated with excessive consumption of fats and sugars.

Introduction and Objectives

Alcoholic hepatitis (AH) is an acute liver inflammation associated with excessive alcohol consumption. The pharmacological treatment for AH is corticosteroids. There is a study that has proposed calculating the Lille model on day 4 (Lille-4), which apparently has comparable accuracy to the Lille model calculated on day 7 (Lille-7). However, this finding has not been validated. Therefore our objective is to determine if Lille-4 is equivalent to Lille-7 in predicting 28-day mortality in patients with probable severe alcoholic hepatitis (AH) as defined by the 2016 consortium criteria sponsored by NIAAA.

Materials and Patients

Observational, prospective, ambidirectional, analytical cohort study conducted from January 2010 to April 2023. We collected clinical and biochemical variables upon admission, calculated Lille models, assessed response and 28-day mortality. Comparative analyses were performed based on survival versus mortality. Sensitivity, specificity, PPV, NPV, and accuracy of the models were calculated.

Results

A total of 327 patients were included, 297 (90.8%) being male. Mean age was 43.4±9.3 years. The 50th percentile for alcohol consumption was 320 g/day (5th-95th percentile: 100.8-662). At day 28, 207 patients (63.3%) died. Upon admission, the patients who died showed a significant difference compared to survivors in: Maddrey (90 [95%CI: 81-99] vs. 70 [95%CI:65-75]; p<0.0001); ABIC (8.8±1.8 vs. 8.1±1.3; p<0.0001); MELD (32±8 vs. 27±4; p<0.0001); MELD-Na (33±6 vs. 30±4; p<0.0001). Lille-7 model had an AUROC of 0.71 [0.65-0.77], where a value >0.45 had a sensitivity (S) of 78% and specificity (E) of 45% in predicting early mortality. Lille-4 model had an AUROC of 0.68 [0.63-0.74], where a value >0.45 had an S of 81% and E of 54% (Figure 1).

Conclusions

Lille-7 is the model with the highest accuracy, according to the obtained AUROC, for predicting early mortality in severe alcoholic hepatitis (AH). Therefore, the determination of total bilirubin should not be done prematurely (before day 7), and steroid therapy should be provided to patients for up to 7 days to classify treatment response.

Introduction and Objectives

The use of natural products without proper assessment is common and favored by the popularity of phytotherapeutics. The regulations related to the prescription and use of these products are scarce, which leads to their being widely used in self-medication. We present the clinical case of a woman who consumed piñalim and presented hepatotoxicity

Materials and Patients

A 29-year-old woman without significant history. She was admitted to the general surgery service for cholecystectomy. After preoperative evaluation, abnormalities in liver function tests (LFT) stood out, for which reason they intentionally asked about the consumption of alcohol, drugs, supplements or herbal and/or homeopathic products, referring to the daily consumption during the last year of PIÑALIM (red, green and white tea) in order to lose weight. Ultrasound of the liver and bile ducts reported: liver of normal shape, size and situation, with no evidence of solid or cystic lesions. Bile duct without dilatation. Gallbladder with a 5.6mm thick wall, without images suggestive of stones. The surgical report showed a lack of findings in the gallbladder and liver. The jaundice and altered LFT persisted in the postoperative period (mixed pattern); additional tests were performed: HBV-HCV-HAV-HIV viral panel: TORCH negative. Negative Tomography of the abdomen without relevant findings. ANA: Negative Until now, the only hepatotoxic agent identified (PIÑALIM) had already been suspended, so this behavior was maintained, avoiding the consumption of any drug. In the following control, the LFT maintained a downward trend, until normalizing 6 months after the definitive suspension of the infusion. (Table 1)

Results

After the definitive suspension of the tea, the LFT were normalized, thus concluding the direct relationship of the product by having a score on the CIOM/RUCAM scale of 9 (definitive cause of hepatotoxicity).

Conclusions

The report of hepatitis associated with infusions is becoming more frequent, it is important to raise awareness about our patients in the "non-safety" of natural products and in the medical team to alert about these products and avoid procedures unnecessary surgeries.

Introduction and Objectives

The prevalence of anemia after liver transplantation ranges from 4.3% to 28.2%. Causes that occur in the first two weeks include bleeding, sepsis, medications, and hemolysis. Immune hemolysis represents less than 1% of the cases and includes graft-versus-host disease and hemolysis associated with ABO incompatibility. We present a case of passenger lymphocyte syndrome as a cause of immune hemolytic anemia two weeks after a liver transplant.

Materials and Patients

A 43-year-old woman, blood group A+, with a history of HCV-related liver cirrhosis and BCLC-A hepatocellular carcinoma, was chosen for a liver transplant. Surgery was uneventful, requiring the transfusion of an O+ blood unit. The postoperative evolution was carried out without complications. On day 10, after the transplant, she presented a drop of 3 g/dL in hemoglobin, leukocytosis, elevated acute phase reactants, and mixed hyperbilirubinemia. An esophagogastroduodenoscopy and colonoscopy showed no active bleeding. The hemolysis profile showed a decrease in the haptoglobin value and an increase in DHL, negative Coombs, without schistocytes. An MRCP was requested, with no evidence of bile leakage or active bleeding. Because of the suspicion of hemolysis due to drugs, tacrolimus was changed to mycophenolate mofetil, and because of possible hemolysis due to sepsis, broad-spectrum antibiotic coverage was added without improvement. On day 14, there was a suspicion of transient lymphocyte syndrome. Isohemagglutinin levels were requested and became positive, and two O+ blood units were transfused. The following day, she presented a significant improvement in all laboratory parameters, and on day 20 she was discharged from the hospital without any abnormality in her laboratory parameters.

Results

In our management of hemolytic anemia after liver transplantation, two theories initially emerged: 1) Hemolysis due to tacrolimus, for which it was suspended and changed to mycophenolate mofetil, and 2) Hemolysis due to sepsis, due to leukocytosis and inflammation, initiating coverage with meropenem and vancomycin. But without improvement after both interventions. Finally, due to suspicion of transient lymphocyte syndrome, isohemagglutitins were requested and were positive, and after the transfusion of 2 O+ blood units, containing anti-A+ antibodies, she showed improvement, confirming the diagnosis.

Conclusions

In the passenger lymphocyte syndrome, there is a donor B lymphocyte production of antibodies causing a primary or secondary response to recipient erythrocytes. The incidence is higher in the heart-lung transplant, followed by liver transplantation. The risk also increases according to the donor-recipient ABO mismatch, being more common with group O donors and group A recipient (61%), followed by group O donors and group B recipients (22%). The clinical picture is characterized by