The emergence of the COVID-19 pandemic, which started in Wuhan in 2019 changed the world and created several challenges to healthcare services. In preparation for expected increased numbers of patients with severe respiratory failure, many hospitals across the globe have intentionally reduced non-emergent procedures and hospitalizations to assure that initially scarce personal protective equipment was available and to preserve the different levels of hospital capacity. During this period, some studies reported reduced numbers of hospital admissions across different areas -from cirrhosis to heart failure [1][2][3][4] . In Portugal, the first case and subsequent beginning of the pandemic were recorded with an average delay of one month compared to other neighboring western European countries, thus allowing health authorities and medical departments to delineate strategies to deal with both COVID-19 and non-COVID-19 patients. Whether these strategies have influenced admissions for patients with decompensation of cirrhosis is poorly documented.We report trends in hospitalizations in a tertiary, academic, high volume center by using the electronic health record system and hospital discharge database. We analysed the hospitalizations for decompensated cirrhosis from March 2, when the first patient with confirmed COVID-19 in Portugal was seen in our emergency department, to the end of the state of emergency, on May 2,2020. We compared the trends in decompensated cirrhosis hospitalizations with those observed in the same period in the years 2015-2019 to account for the potential for residual confounding based on seasonal trends in decompensated cirrhosis hospitalizations.Hospitalizations in adult patients with a principal diagnosis of cirrhosis based on ICD codes were included. Liver transplanted patients were excluded. Demographic, clinical and laboratory data pertaining to hospitalizations for decompensated cirrhosis were retrospectively analysed.During this period there were 40 admissions due to decompensated cirrhosis, a number that was not significantly different from that observed in the same time period in previous years (median 38 admissions, ranging from 34 in 2015 to 42 in 2019). There was no variability in week-to-week hospitalizations for decompensated cirrhosis. 27 patients (93%) were male, the median age was 61.5 years (range 41-75). Aetiology of cirrhosis was alcohol in 80%, viral hepatitis in 15% and autoimmune hepatitis in 2.5%. 17.5% had previously diagnosed hepatocellular carcinoma.Reason for admission was encephalopathy in 55% of patients, ascites in 12.5% and variceal bleeding in 10%. There were no significant differences in reason for admission compared to 2015-2019 (encephalopathy in 37.8% of patients, variceal bleeding in 12.8%
Bullous pemphigoid is a rare autoimmune dermatologic disease that usually occurs in the elderly. Mucous membrane lesions occur in about 10–35% of patients and are almost always limited to the oral mucous membrane. Esophageal involvement is very rare (4% of cases) and usually presents with chest pain, dysphagia, and odynophagia, though patients are frequently asymptomatic. We report the case of newly diagnosed bullous pemphigoid in a 76-year-old man with a past medical history of dementia. He presented with cutaneous manifestations but also severe gastrointestinal bleeding due to extensive esophageal involvement. Although bullous pemphigoid is mainly a skin disease, mucous membrane lesions should not be overlooked as they are associated with an even poorer outcome. A high index of suspicion for esophageal involvement is needed as its presentation can be fatal, as with our patient.
Hepatobiliary manifestations are common in inflammatory bowel disease (IBD), with 30% of patients presenting abnormal liver tests and 5% developing chronic liver disease. They range from asymptomatic elevated liver tests to life-threatening disease and usually follow an independent course from IBD. The pathogenesis of liver manifestations or complications and IBD can be closely related by sharing a common auto-immune background (in primary sclerosing cholangitis, IgG4-related cholangitis, and autoimmune hepatitis), intestinal inflammation (in portal vein thrombosis and granulomatous hepatitis), metabolic impairment (in non-alcoholic fatty liver disease or cholelithiasis), or drug toxicity (in drug induced liver injury or hepatitis B virus infection reactivation). Their evaluation should prompt a full diagnostic workup to identify and readily treat all complications, improving management and outcome.
The global pandemic of coronavirus disease 2019 (COVID-19) changed dramatically all priorities on medical society and created several challenges for clinicians caring for patients with liver diseases. We performed a comprehensive review about how COVID-19 can affect the liver, the influence of liver diseases on the risk of developing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and COVID-19 severity and also some strategies to overcome all the challenges clinicians have to face in the management of patients with liver diseases in a period of time when all the focus turned on COVID-19. We analyze the relationship between COVID-19 and non-alcoholic fatty liver disease, alcoholic liver disease, viral hepatitis, autoimmune liver disease, cirrhosis, hepatocellular carcinoma and liver transplantation, as well as the approach to SARS-CoV-2 vaccination.
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