Graphical abstract

Assessment of MRI parameters in a single scan session. Higher liver T 1 and reduced liver perfusion with increasing disease severity and clinical outcomes. Reduced renal cortex T 1 linked to disease severity and clinical outcomes.

Current guidelines recommend that all cirrhotic patients should undergo screening endoscopy at diagnosis to identify patients with varices at high risk of bleeding who will benefit from primary prophylaxis. This approach places a heavy burden upon endoscopy units and the repeated testing over time may have a detrimental effect on patient compliance. Noninvasive identification of patients at highest risk for oesophageal varices would limit investigation to those most likely to benefit. Upper GI endoscopy is deemed to be the gold standard against which all other tests are compared, but is not without its limitations. Multiple studies have been performed assessing clinical signs and variables relating to liver function, variables relating to liver fibrosis, and also to portal hypertension and hypersplenism. Whilst some tests are clearly preferable to patients, none appear to be as accurate as upper GI endoscopy in the diagnosis of oesophageal varices. The search for noninvasive tests continues.

Background and aimsCurrent creatine-based criteria for defining acute kidney injury (AKI) are validated in general hospitalised patients but their application to cirrhotics (who are younger and have reduced muscle mass) is less certain. We aimed to evaluate current definitions of AKI (acute kidney injury network (AKIN) criteria) in a population of cirrhotic patients and correlate this with outcomes.MethodsWe prospectively identified patients with AKI and clinical, radiological or histological evidence of cirrhosis. We compared them with a control group with evidence of cirrhosis and no AKI.Results162 cirrhotic patients were studied with a mean age of 56.8±14 years. They were predominantly male (65.4%) with alcoholic liver disease (78.4%). 110 patients had AKI: 44 stage 1, 32 stage 2 and 34 stage 3. They were well matched in age, sex and liver disease severity with 52 cirrhotics without AKI. AKI was associated with increased mortality (31.8% vs 3.8%, p<0.001). Mortality increased with each AKI stage; 3.8% in cirrhotics without AKI, 13.5% stage 1, 37.8% stage 2 and 43.2% stage 3 (p<0.001 for trend). Worsening liver disease (Child–Pugh class) correlated with increased mortality: 3.1% class A, 23.6% class B and 32.8% class C (p=0.006 for trend). AKI was associated with increased length of stay: median 6.0 days (IQR 4.0–8.75) versus 16.0 days (IQR 6.0–27.5), p<0.001. Multivariate analysis identified AKI and Child–Pugh classes B and C as independent factors associated with mortality.ConclusionsThe utility of AKIN criteria is maintained in cirrhotic patients. Decompensated liver disease and AKI appear to be independent variables predicting death in cirrhotics.

OVERVIEW DefinitionEnteral tube feeding is the delivery of nutritionally complete feed directly into the stomach or small intestine via a tube. INDICATIONSEnteral tube feeding is indicated in any patient who cannot meet their nutritional requirements by oral intake and who has a functioning and accessible gastrointestinal tract. It can be administered either into the stomach or directly into the small intestine (usually the jejunum). Table 1 shows examples of when enteral feeding is indicated. RoutesThe following options are available:• Nasogastric tube • Nasojejunal tube • Gastrostomy• Percutaneous endoscopic gastrostomy (PEG)• Radiological inserted gastrostomy (RIG)• Surgical • Jejunostomy• Endoscopic (PEJ or PEGJ)• Radiological • Surgical NASOGASTRIC TUBESNasogastric tubes (NGTs) are recommended for those requiring tube feeding for no longer than 4-6 weeks. Enteral tube feeding in adultsABSTRACT Enteral tube feeding is usually a relatively straightforward method of nutritional support, and should be facilitated by a multiprofessional team. For short-term use (<4 weeks) a fine bore feeding nasogastric tube is indicated but if longer term feeding is required then a gastrostomy is appropriate, usually inserted endoscopically (a percutaneous endoscopic gastrostomy tube). The most common serious complication of a nasogastric tube is not identifying a misplaced tube within the lungs: there are clear recommendations from the National Patient Safety Agency as to how to check tube placement. Nasojejunal tubes are required in patients with gastroparesis. Tube blockage is common and is prevented by careful and regular flushing.Diarrhoea is the most complication of feeding and is often related to other medication. Clinicians need an algorithm for systematically dealing with such a problem. Refeeding syndrome may occur in malnourished patients and is characterised by low levels of potassium, phosphate, and/or magnesium, as well as disorders of water and salt balance. Identifying the at-risk patient with careful monitoring is crucial. The most commonly encountered problem with a NGT is inadvertent removal, either by the patient or by accident, e.g. snagged on clothing or vomiting. If this is a recurring problem and feeding is still required, either a PEG can be considered or a 'nasal loop' or bridle can be attached, thereby making accidental removal far less likely -18% for bridled tubes compared to 63% for nonbridled tubes in one study -with the bridled group more likely to meet their recommended nutritional requirements. Bridle systems are commercially available and, although their unit cost is relatively high, this is more than offset by the avoidance of repeated NGT placements +/-X-rays to verify placement. For other complications of both NGTs and nasojejunal tubes see Table 2. KEYWORDS complications, enteral tube feeding, gastrostomy, nasoenteral tubes DECLARATION OF INTERESTS No conflict of interests declared NASOJEJUNAL TUBESSpecifically designed self-propelling nasojejunal tubes such as the Bengmark tube (Nutricia,...

Background Patient outcomes in gastric adenocarcinoma are poor due to late diagnosis. Detecting and treating at the premalignant stage has the potential to improve this. H. pylori is also a strong risk factor for this disease. Aims Primary aims were to assess the diagnostic accuracy of magnified narrow band imaging (NBI-Z) endoscopy and serology in detecting normal mucosa, H. pylori gastritis and gastric atrophy. Secondary aims were to compare the diagnostic accuracies of two classification systems using both NBI-Z and white light endoscopy with magnification (WLE-Z) and evaluate the interobserver agreement. Methods Patients were prospectively recruited. Images of gastric mucosa were stored with histology and serum for IgG H. pylori and Pepsinogen (PG) I/II ELISAs. Blinded expert endoscopists agreed on mucosal pattern. Mucosal images and serological markers were compared with histology. Kappa statistics determined inter-observer variability for randomly allocated images among four experts and four non-experts.

Methods We applied multiparametric MRI to assess changes in liver composition, perfusion and blood flow in 17 patients before direct-acting antiviral (DAA) therapy and after treatment completion (within 12 weeks of last DAA tablet swallowed). Results We observed changes in hepatic composition indicated by a reduction in both liver longitudinal relaxation time (T1, 35 ± 4 ms), transverse relaxation time (T2, 2.5 ± 0.8 ms; T2* 3.0 ± 0.7 ms), and liver perfusion (28.1 ± 19.7 ml/100 g/min) which we suggest are linked to reduced pro-inflammatory milieu, including interstitial oedema, within the liver. No changes were observed in liver or spleen blood flow, splenic perfusion, or superior mesenteric artery blood flow. Conclusion For the first time, our study has shown that treatment of HCV with DAAs in patients with cirrhosis leads to an acute reduction in liver T1, T2 and T2* and an increase in liver perfusion measured using MR parameters. The ability of MRI to characterise changes in the angio-architecture of patients with cirrhosis after intervention in the short term will enhance our understanding of the natural history of regression of liver disease and potentially influence clinical decision algorithms. Key Points • DAAs have revolutionised the treatment of hepatitis C and achieve sustained virological response in over 95% of patients, even with liver cirrhosis. • Currently available non-invasive measures of liver fibrosis are not accurate after HCV treatment with DAAs, this prospective single-centre study has shown that MRI can sensitively measure changes within the liver, which could reflect the reduction in inflammation with viral clearance. • The ability of MRI to characterise changes in structural and haemodynamic MRI measures in the liver after intervention will enhance our understanding of the progression/regression of liver disease and could potentially influence clinical decision algorithms.

Background Increased small bowel permeability leads to bacterial translocation, associated with significant morbidity and mortality. Biomarkers are needed to evaluate these changes in vivo, stratify an individual's risk, and evaluate the efficacy of interventions. MRI is an established biomarker of small bowel inflammation. Purpose To characterize changes in the small bowel with quantitative MRI measures associated with increased permeability induced by indomethacin. Study Type Prospective single‐center, double‐blind, two‐way crossover provocation study. Subjects A provocation cohort (22 healthy volunteers) and intrasubject reproducibility cohort (8 healthy volunteers). Field Strength/Sequence 2D balanced turbo field echo sequences to measure small bowel wall thickness, T2, and motility acquired at 3T. Assessment Participants were randomized to receive indomethacin or placebo prior to assessment. After a minimum 2‐week washout, measures were repeated with the alternative allocation. MR measures (wall thickness, T2, motility) at each study visit were compared to the reference standard 2‐hour lactulose/mannitol urinary excretion ratio (LMR) test performed by a lab technician. All analyses were performed blind. Statistical Tests Normality was tested (Shapiro–Wilk's test). Paired testing (Student's t‐test or Wilcoxon) determined the significance of paired differences with indomethacin provocation. Pearson's correlation coefficient compared significant measures with indomethacin provocation to LMR. Intrasubject (intraclass correlation) and interrater variability (Bland–Altman) were assessed. Results Indomethacin provocation induced a significant increase in LMR compared to placebo (P < 0.05) and a significant increase in small bowel T2 (0.12 seconds compared to placebo 0.07 seconds, P < 0.05). Small bowel wall thickness (P = 0.17) and motility (P = 0.149) showed no significant change. T2 and LMR were positively correlated (r = 0.68, P < 0.05). T2 measurements were robust to interobserver (intraclass correlation 0.89) and intrasubject variability (Bland–Altman bias of 0.005 seconds, 95% confidence interval [CI] –0.04 to +0.05 seconds, and 0.0006 seconds, 95% CI –0.05 to +0.06 seconds). Data Conclusion MR measures of small bowel wall T2 were significantly increased following indomethacin provocation and correlated with 2‐hour LMR test results. Level of Evidence 1 Technical Efficacy Stage 2