No abstract

Treatment options for refractory hepatic encephalopathy (HE) are limited. Patients who fail medical management may harbor large portosystemic shunts (PSSs) which are possible therapeutic targets. This study aims to describe patient selection, effectiveness, and safety of percutaneous PSS embolization in those with medically refractory HE. A retrospective evaluation of consecutive adult patients with medically refractory HE referred for PSS embolization at a tertiary center was performed (2003–2015). Patient data collected included the type of HE, medications, Model for End-Stage Liver Disease (MELD) score, shunt type, embolization approach, and materials used. Outcomes of interest were immediate (7 days), intermediate (1–4 months), and longer-term (6–12 months) effectiveness and periprocedural safety. Effectiveness was determined based on changes in hospitalization frequency, HE medications, and symptoms. Twenty-five patients with large PSS were evaluated for shunt embolization. Five were excluded due to high MELD scores (n = 1), comorbid conditions (n = 1), or technical considerations (n = 3). Of 20 patients who underwent embolization, 13 had persistent and 7 had recurrent HE; 100% (20/20) achieved immediate improvement. Durable benefit was achieved in 100% (18/18) and 92% (11/12) at 1–4 and 6–12 months, respectively. The majority (67%; 8/12) were free from HE-related hospitalizations over 1 year; 10% developed procedural complications, and all resolved. Six developed new or worsening ascites. In conclusion, PSS embolization is a safe and effective treatment strategy that should be considered for select patients with medically refractory HE.

Background and aims COVID-19 pandemic lockdown and restrictions had significant disruption to patient care. We aimed to evaluate the impact of COVID-19 restrictions on hospitalizations of patients with alcoholic and non-alcoholic cirrhosis as well as alcoholic hepatitis (AH) in Alberta, Canada. Methods We used validated international clinical classification (ICD-9 and ICD-10) coding algorithms to identify liver-related hospitalizations for non-alcoholic cirrhosis, alcoholic cirrhosis, and AH in the province of Alberta between March 2018 and September 2020. We used the provincial inpatient discharge and laboratory databases to identify our cohorts. We used elevated ALT or AST, elevated international normalized ratio (INR) or bilirubin to identify AH patients. We compared COVID-19 restrictions (April-September 2020) to prior study periods. Joinpoint regression was used to evaluate the temporal trends among the three cohorts. Results We identified 2,916 hospitalizations for non-alcoholic cirrhosis, 2,318 hospitalizations for alcoholic cirrhosis, and 1,408 AH hospitalizations during our study time. The in-hospital mortality rate was stable in relation to the pandemic for alcoholic cirrhosis and AH. However, non-alcoholic cirrhosis patients had lower in-hospital mortality rate post March 2020 (8.5% vs. 11.5%, p =0.033). There was a significant increase in average monthly admission in the AH cohort (22.1/ 10,000 admissions during the pandemic vs. 11.6/10,000 admissions prior to March 2020, p<0.001). Conclusion Pre- and during COVID-19 monthly admission rates were stable for non-alcoholic and alcoholic cirrhosis, however, there was a significant increase in AH admissions. As alcohol sales surged during the pandemic, future impact on alcoholic liver disease could be detrimental.

A greater decline in TC, LDL-C and HDL was observed in CHB carriers receiving TDF compared with ETV. These data may influence anti-viral choice in CHB carriers at risk for CVD.

Background The burden of cirrhosis on the healthcare system is substantial and growing. Our objectives were to estimate the readmission rates and hospitalization costs as well as to identify risk factors for 90‐day readmission in patients with cirrhosis. Methods We conducted a weighted analysis of the 2014 Nationwide Readmission Database to identify adult patients with cirrhosis‐related complications in the United States and assessed readmission rates at 30, 60 and 90 days post‐index hospitalization. Predictors of 90‐day readmissions were identified using weighted regression models adjusting for patient and hospital characteristics; the national estimate of hospitalization costs was also calculated. Results Of the 58 954 patients admitted with cirrhosis‐related complications in 2014, 14 910 (25%) were readmitted within 90 days because of cirrhosis‐related complications. The main causes of readmission were ascites (56%), hepatic encephalopathy (47%) and bleeding oesophageal varices (9%). Independent predictors of 90‐day readmissions were male sex (adjusted OR [aOR]: 1.08, 95% CI, 1.04‐1.13), age <60 (aOR: 1.27, 95% CI, 1.22‐1.32), privately insured (aOR: 0.74, 95% CI, 0.70‐0.77), having ≥3 comorbid conditions (aOR: 1.27, 95% CI, 1.14‐1.42) and being discharged against medical advice (aOR: 1.41, 95% CI, 1.25‐1.59). The weighted cumulative national cost estimate of the index admission was $1.8 billion, compared to $0.5 billion for readmission. Conclusions A quarter of patients admitted with cirrhosis‐related complications were readmitted within 90 days, representing a significant economic burden related to readmission of this population. Interventions and resource allocations to reduce readmission rates among cirrhotic patients is critical.

Healthy sexual function is important to maintain a good quality of life but is frequently impaired in patients with cirrhosis. The degree of sexual dysfunction appears to be linked with the degree of hepatic dysfunction. In men, sexual dysfunction can be related to the hyperestrogenism of portal hypertension and/or to decreased testosterone resulting from testicular dysfunction. In women, suppression of the hypothalamic–pituitary–gonadal axis appears to be a principal contributor, with no significant effect of portal hypertension. There is also a huge psychological barrier to break through as there is a component of depression in many patients with cirrhosis. Sexual dysfunction is often underdiagnosed in the cohort with cirrhosis. Management of sexual disorders in patients with cirrhosis can be challenging as they are often multifactorial. A multidisciplinary approach is key in managing these patients. We review the current literature on the pathogenesis of sexual dysfunction in patients with cirrhosis and propose a stepwise algorithm to better manage these patients.

Portal vein thrombosis (PVT) can contribute to significant morbidity and mortality; in patients with cirrhosis, this can make transplant more technically challenging. Additionally, the clot may extend further into the mesenteric and splenic veins, and disturbance of the hepatic blood flow may lead to faster progression of the cirrhosis. Development of PVT is associated with local risk factors, and many patients have associated systemic prothrombotic factors. Anticoagulation in noncirrhotic patients should be initiated at diagnosis, using low-molecular-weight heparin overlapping with vitamin K antagonists. Cirrhotic patients with PVT should be screened for varices and then anticoagulated with low-molecular-weight heparin for at least a 6-month period. All patients should be assessed for triggering factors and tumors, as well as systemic prothrombotic factors. Newer evidence suggests that prophylactic anticoagulation in patients with cirrhosis may have a role in clinical management with decreased incidence of PVT and improved survival; further study is needed.

Background Functional bowel disorders (FBDs) are the most common gastrointestinal problems managed by physicians. We aimed to assess the burden of chronic symptomatic FBDs on ambulatory care delivery in the United States and evaluate patterns of treatment. Methods Data from the National Ambulatory Medical Care Survey were used to estimate annual rates and associated costs of ambulatory visits for symptomatic irritable bowel syndrome (IBS), chronic functional abdominal pain, constipation, or diarrhea. The weighted proportion of visits associated with pharmacologic and non-pharmacologic (stress/mental health, exercise, diet counseling) interventions were calculated, and predictors of treatment strategy were evaluated in multivariable multinomial logistic regression. Results From 2007-2015, ∼36.9 million [95% CI, 31.4-42.4] weighted visits in non-federal patients for chronic symptomatic FBDs were sampled. There was an annual weighted average of 2.7 million [95% CI, 2.3-3.2] visits for symptomatic IBS/chronic abdominal pain, 1.0 million [95% CI, 0.8-1.2] visits for chronic constipation, and 0.7 million [95% CI, 0.5-0.8] visits for chronic diarrhea. Pharmacologic therapies were prescribed in 49.7% [95% CI, 44.7%-54.8%] of visits, compared to non-pharmacologic interventions in 19.8% [95% CI, 16.0%-24.2%] of visits ( P < .001). Combination treatment strategies were more likely to be implemented by primary care physicians and in patients with depression or obesity. The direct annual cost of ambulatory clinic visits alone for chronic symptomatic FBDs is ∼$358 million USD [95% CI, $233-482 million]. Conclusions The management of chronic symptomatic FBDs is associated with considerable health care resource utilization and cost. There may be an opportunity to improve comprehensive FBD management as fewer than 1 in 5 ambulatory visits include non-pharmacologic treatment strategies.