Recent advances in diagnosis and management of chronic cholestatic liver diseases: expert consensus

Chronic cholestatic liver diseases (CCLD), primarily including primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC), are characterized by impaired bile flow, leading to systemic complications such as pruritus, jaundice, fat soluble vitamin deficiencies and progressive liver damage. Recent advances in diagnostics, particularly the use of non-invasive tests like FIB-4, APRI and transient elastography, have significantly improved the early detection and assessment of liver fibrosis. Ursodeoxycholic acid (UDCA) remains the cornerstone treatment for PBC, effectively improving biochemical markers and delaying disease progression. In contrast, the treatment options for PSC remain limited. Emerging therapies targeting bile acid synthesis and gut microbiota modulation are under investigation, offering potential future solutions for PSC. In the Indian clinical setting, other causes of intrahepatic cholestasis, such as alcoholic liver disease (ALD) and drug-induced liver injury (DILI), are more prevalent. ALD with cholestasis is seen in 10-30% of patients, while DILI, often driven by tuberculosis medications and complementary and alternative medicines, accounts for a significant proportion of cases. Infectious causes like hepatitis A and fibrosing cholestatic hepatitis in hepatitis C patients post-liver transplantation also contribute to the disease burden. Experts recommend ongoing UDCA use in cholestatic conditions, regular non-invasive fibrosis assessments, and further research into new pharmacological agents for both PBC and PSC

Full-thickness resection device (FTRD) for treatment of upper gastrointestinal tract lesions: the first international experience.

Background and study aims The Full-Thickness Resection Device (FTRD) provides a novel treatment option for lesions not amenable to conventional endoscopic resection techniques. There are limited data on the efficacy and safety of FTRD for resection of upper gastrointestinal tract (GIT) lesions. Patients and methods This was an international multicenter retrospective study, including patients who had an endoscopic resection of an upper GIT lesion using the FTRD between January 2017 and February 2019. Results Fifty-six patients from 13 centers were included. The most common lesions were mesenchymal neoplasms (n = 23, 41 %), adenomas (n = 7, 13 %), and hamartomas (n = 6, 11 %). Eighty-four percent of lesions were located in the stomach, and 14 % in the duodenum. The average size of lesions was 14 mm (range 3 to 33 mm). Deployment of the FTRD was technically successful in 93 % of patients (n = 52) leading to complete and partial resection in 43 (77 %) and 9 (16 %) patients, respectively. Overall, the FTRD led to negative histological margins (R0 resection) in 38 (68 %) of patients. A total of 12 (21 %) mild or moderate adverse events (AEs) were reported. Follow-up endoscopy was performed in 31 patients (55 %), on average 88 days after the procedure (IQR 68-138 days). Of these, 30 patients (97 %) did not have any residual or recurrent lesion on endoscopic examination and biopsy, with residual adenoma in one patient (3 %). Conclusions Our results suggest a high technical success rate and an acceptable histologically complete resection rate, with a low risk of AEs and early recurrence for FTRD resection of upper GIT lesions

Acute-on-Chronic Liver Failure (ACLF): The ‘Kyoto Consensus’-Steps From Asia

Acute-on-chronic liver failure (ACLF) is a condition associated with high mortality in the absence of liver transplantation. There have been various definitions proposed worldwide. The first consensus report of the working party of the Asian Pacific Association for the Study of the Liver (APASL) set in 2004 on ACLF was published in 2009, and the APASL ACLF Research Consortium (AARC) was formed in 2012. The AARC database has prospectively collected nearly 10,500 cases of ACLF from various countries in the Asia-Pacific region. This database has been instrumental in developing the AARC score and grade of ACLF, the concept of the \u27Golden Therapeutic Window\u27, the \u27transplant window\u27, and plasmapheresis as a treatment modality. Also, the data has been key to identifying pediatric ACLF. The European Association for the Study of Liver-Chronic Liver Failure (EASL CLIF) and the North American Association for the Study of the End Stage Liver Disease (NACSELD) from the West added the concepts of organ failure and infection as precipitants for the development of ACLF and CLIF-Sequential Organ Failure Assessment (SOFA) and NACSELD scores for prognostication. The Chinese Group on the Study of Severe Hepatitis B (COSSH) added COSSH-ACLF criteria to manage hepatitis b virus-ACLF with and without cirrhosis. The literature supports these definitions to be equally effective in their respective cohorts in identifying patients with high mortality. To overcome the differences and to develop a global consensus, APASL took the initiative and invited the global stakeholders, including opinion leaders from Asia, EASL and AASLD, and other researchers in the field of ACLF to identify the key issues and develop an evidence-based consensus document. The consensus document was presented in a hybrid format at the APASL annual meeting in Kyoto in March 2024. The \u27Kyoto APASL Consensus\u27 presented below carries the final recommendations along with the relevant background information and areas requiring future studies

Recent Endoscopic Ultrasound-Related Publications With Potential to Influence Clinical Practice

AbstractThe field of endoscopic ultrasound (EUS) has evolved significantly over the last two decades from being a tool of only diagnostic purpose to tissue acquisition and now therapeutic potential. There have been several important publications in the field of EUS in the last few years, which had a major impact in the clinical management of various gastrointestinal disorders. In this review, we discuss four such articles that in our opinion will significantly impact the role of EUS in treating various conditions. The first article is a randomized controlled trial comparing EUS-guided gall bladder drainage with percutaneous gall bladder drainage for high-risk acute cholecystitis. The second article is a randomized controlled trial comparing EUS versus minimally invasive surgery for necrotizing pancreatitis. The third article is a novel human study of EUS-guided portal pressure measurement in patients with portal hypertension. The last article is also a randomized controlled trial evaluating the role of rapid on-site evaluation for EUS-guided fine needle biopsy in solid pancreatic lesions.</jats:p

Endoscopic Management of a Complex Biliary Problem

Endoscopic interventions have become increasingly popular in the management of obstructive jaundice. In this case study, we present a case of complex Bismuth type 4 hilar stricture in an elderly lady presenting with obstructive jaundice. Complete endoscopic biliary drainage was accomplished successfully by placement of three metal stents – two with ERCP and one with Endoscopic Ultrasound (EUS) guided hepatico-gastrostomy. She developed cholecystitis later, which was successfully addressed by EUS guided gallbladder drainage using a cautery enhanced lumen apposing metal stent. Thus, a complete internal biliary drainage was achieved with endoscopic interventions

Endoscopic Sponge Vacuum Therapy for Large Infected Esophagus Pleural Fistula

AbstractA 50-year-old man with hypothyroidism was diagnosed with severe pneumonia secondary to the SARS-CoV-2 virus with an HRCT CORAD score of 18/25 in September 2020. From the records, the patient appeared to have developed spontaneous esophageal perforation. In view of his poor general condition, he was treated with endoscopic sponge vacuum therapy (EVT). EVT is a novel approach for treatment for a closed cavity. Also, very few studies exist in the literature in regard to this procedure.</jats:p