Background and aims: Acute-on-chronic liver failure (ACLF) is a frequent syndrome associated with high mortality. The aims of the present study are: a) comparing the Chronic Liver Failure Consortium (CLIF-C) ACLF Model for End-Stage Liver Disease (MELD), MELD Sodium (MELD-Na) and Child-TurcottePugh (CTP) scores for prediction of short/medium term mortality; b) identifying ACLF prevalence in patients admitted to the ward; and c) comparing mortality between non-ACLF/ACLF.Methods: Retrospective cohort study of 177 patients admitted to the Gastroenterology ward for acute decompensation of cirrhosis.Results: We included 132 males. Alcohol was the cirrhosis cause/co-factor in 79.7% of cases. Infection was present in 40.7%. At admission, 19.8% of patients presented ACLF and 7.9% developed it during hospitalization (overall prevalence was 27.7%). ACLF grade 1 was diagnosed in 55.1% of the ACLF patients; grade 2, in 42.8%, and grade 3, in 2.0%. Infection (p < 0.001) and hepatic encephalopathy (p = 0.004) were more prevalent and C-reactive protein and leukocyte counts were higher in ACLF patients. ACLF 28 and 90-day mortality was 45.8% and 60.4%, respectively. The CLIF-C ACLF score was significantly superior to CTP, MELD, MELD-Na in predicting 28-day (AUROC 0.799 ± 0.078, 95% CI 0.637-0.891) and 90-day mortality (AUROC 0.828 ± 0.063, 95% CI 0.705-0.952).Conclusion: ACLF is highly prevalent in the ward. The new CLIF scores identify high mortality cirrhotic patients admitted to the ward and are better than their predecessors to predict ACLF patients' short/medium term mortality.

Clinical nutrition is emerging as a major area in gastroenterology practice. Most gastrointestinal disorders interfere with digestive physiology and compromise nutritional status. Refeeding syndrome (RS) may increase morbidity and mortality in gastroenterology patients. Literature search using the keywords "Refeeding Syndrome", "Hypophosphatemia", "Hypomagnesemia" and "Hypokalemia". Data regarding definition, pathophysiology, clinical manifestations, risk factors, management and prevention of RS were collected. Most evidence comes from case reports, narrative reviews and scarse observational trials. RS results from the potentially fatal shifts in fluid and electrolytes that may occur in malnourished patients receiving nutritional therapy. No standard definition is established and epidemiologic data is lacking. RS is characterized by hypophosphatemia, hypomagnesemia, hypokalemia, vitamin deficiency and abnormal glucose metabolism. Oral, enteral and parenteral nutrition may precipitate RS. Awareness and risk stratification using NICE criteria is essential to prevent and manage malnourished patients. Nutritional support should be started using low energy replacement and thiamine supplementation. Correction of electrolytes and fluid imbalances must be started before feeding. Malnourished patients with inflammatory bowel disease, liver cirrhosis, chronic intestinal failure and patients referred for endoscopic gastrostomy due to prolonged dysphagia present high risk of RS, in the gastroenterology practice. RS should be considered before starting nutritional support. Preventive measures are crucial, including fluid and electrolyte replacement therapy, vitamin supplementation and use of hypocaloric regimens. Gastroenterology patients must be viewed as high risk patients but the impact of RS in the outcome is not clearly defined in current literature.

-Background -Protein-calorie malnutrition is common in chronic liver disease (CLD) but adequate clinical tools for nutritional assessment are not defined. Objective -In CLD patients, it was aimed: 1. Characterize protein-calorie malnutrition; 2. Compare several clinical, anthropometric and functional tools; 3. Study the association malnutrition/CLD severity and malnutrition/outcome. Methods -Observational, prospective study. Consecutive CLD ambulatory/hospitalised patients were recruited from 01-03-2012 to 31-08-2012, studied according with age, gender, etiology, alcohol consumption and CLD severity defined by Child-Turcotte-Pugh. Nutritional assessment used subjective global assessment, anthropometry, namely body-mass index (BMI), triceps skinfold, mid upper arm circumference, mid arm muscular circumference and handgrip strength. Patients were followed during two years and survival data was recorded. Results -A total of 130 CLD patients (80 men), aged 22-89 years (mean 60 years) were included. Most suffered from alcoholic cirrhosis (45%). Hospitalised patients presented more severe disease (P<0.001) and worst nutritional status defined by BMI (P=0.002), mid upper arm circumference (P<0.001), mid arm muscular circumference (P<0.001), triceps skinfold (P=0.07) and subjective global assessment (P<0.001). A third presented deficient/low handgrip strength. Alcohol consumption (P=0.03) and malnutrition detected by BMI (P=0.03), mid upper arm circumference (P=0.001), triceps skinfold (P=0.06), mid arm muscular circumference (P=0.02) and subjective global assessment (P<0.001) were associated with CLD severity. From 25 patients deceased during follow-up, 17 patients were severely malnourished according with triceps skinfold. Malnutrition defined by triceps skinfold predicted mortality (P<0.001). Conclusion -Protein-calorie malnutrition is common in CLD patients and alcohol plays an important role. Triceps skinfold is the most efficient anthropometric parameter and is associated with mortality. Nutritional assessment should be considered mandatory in the routine care of CLD patients.

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Palabras clave:Esclerosis lateral amiotrófi ca. Nutrición. Gastrostomía. PEG. ResumenIntroducción: la disfagia es común en pacientes con esclerosis lateral amiotrófi ca (ELA) y pude resultar en desnutrición. Se recomienda la gastrostomía endoscópica (PEG) cuando la alimentación oral no es más segura. Este trabajo tiene como objetivo evaluar la efi cacia y seguridad de la alimentación por PEG en la mejora de los parámetros nutricionales y de pronóstico en pacientes con ELA. Métodos: estudio observacional y retrospectivo que utilizó los registros clínicos de pacientes con ELA referidos para gastrostomía. Se recogieron datos sobre la edad, el género y la mortalidad. Se registró el NRS 2002, el índice de masa corporal (IMC), la albúmina sérica, la transferrina y el colesterol total en el momento de PEG (T0) y después de 3 meses (T3). Resultados: fueron recolectados los datos de 37 pacientes con ELA (18 hombres/19 mujeres), con edades comprendidas entre 43-88 años (media: 69 años). Todos los pacientes presentaron NRS 2002 ≥ 3 puntos. En promedio, los pacientes fueron sometidos a gastrostomía 11 meses después del diagnóstico. No hubo complicaciones mayores del procedimiento. La media de supervivencia después del diagnóstico de ELA fue de 22,2 meses. La tasa de mortalidad a los 3 meses fue de 21,6%, con una supervivencia media de 1,.2 meses después de PEG. Los niveles de albúmina, transferrina y colesterol aumentaron de T0 a T3, sin embargo sin alcanzar signifi cación estadística. Mayores niveles de albúmina (R = 0,3) y de transferrina séricas (R = 0,4) en el momento de PEG tienden a estar correlacionados positivamente con una supervivencia más larga. El IMC medio fue similar en los dos momentos, pero valores iniciales más altos están asociados con un mejor pronóstico (R2 = 0,39, p < 0,05). Conclusiones: PEG es una técnica segura y efi caz para la nutrición enteral y se debe considerar temprano en pacientes con ELA y disfagia. Un mayor IMC predice una mayor supervivencia. La asociación entre proteínas séricas más altas y la supervivencia debe ser confi rmada en estudios posteriores. AbstractBackground: Dysphagia is common in amyotrophic lateral sclerosis (ALS) and may result in malnutrition. Endoscopic gastrostomy (PEG) is recommended when oral feeding is unsafe. This work aims to assess the effectiveness and safety of PEG feeding on improving nutritional and prognostic parameters in ALS patients. Methods: Observational and retrospective study using records from ALS patients referred for gastrostomy. Age, gender and mortality data were collected. NRS 2002, body mass index (BMI), serum albumin, transferrin and total cholesterol were recorded at the time of PEG (T0) and repeated after 3 months (T3). The evolution of these parameters was analysed and compared to survival. Results: Data from 37 ALS patients (18 men/19 women) aged 43-88 years (mean: 69 years). All patients presented NRS 2002 ≥ 3 points. On average, patients underwent gastrostomy 11 months after diagnosis. No major procedural complications occurred. Mean sur...

Background: Digestive tumours are among the leading causes of morbidity and mortality. Many cancer patients cannot maintain oral feeding and develop malnutrition. The authors aim to: review the endoscopic, radiologic and surgical techniques for nutritional support in cancer patients; address the strategies for nutritional intervention according to the selected technique; and establish a decision-making algorithm to define the best approach in a specific tumour setting. Summary: This is a narrative non-systematic review based on an electronic search through the medical literature using PubMed and UpToDate. The impossibility of maintaining oral feeding is a major cause of malnutrition in head and neck (H&N) cancer, oesophageal tumours and malignant gastric outlet obstruction. Tube feeding, endoscopic stents and gastrojejunostomy are the three main nutritional options. Nasal tubes are indicated for short-term enteral feeding. Percutaneous endoscopic gastrostomy (PEG) is the gold standard when enteral nutrition is expected for more than 3-4 weeks, especially in H&N tumour and oesophageal cancer patients undergoing definite chemoradiotherapy. A gastropexy push system may be considered to avoid cancer seeding. Radiologic and surgical gastrostomy are alternatives when an endoscopic approach is not feasible. Postpyloric nutrition is indicated for patients intolerant to gastric feeding and may be achieved through nasoenteric tubes, PEG with jejunal extension, percutaneous endoscopic jejunostomy and surgical jejunostomy. Oesophageal and enteric stents are palliative techniques that allow oral feeding and improve quality of life. Surgical or EUS-guided gastrojejunostomy is recommended when enteric stents fail or prolonged survival is expected. Nutritional intervention is dependent on the technique chosen. Institutional protocols and decision algorithms should be developed on a multidisciplinary basis to optimize nutritional care. Conclusions: Gastroenterologists play a central role in the nutritional support of cancer patients performing endoscopic techniques that maintain oral or enteral feeding. The selection of the most effective technique must consider the cancer type, the oncologic therapeutic program, nutritional aims and expected patient survival.

Low albumin, transferrin and cholesterol were predictors of a poor survival. PEG improves low albumin and transferrin, serum markers of malnutrition and poor outcome. PEG should be considered on an individual basis in patients with moderate-severe dementia when risk of malnutrition and aspiration is present.

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