Pro-adrenomedullin in acute decompensation of liver cirrhosis: relationship with acute-on-chronic liver failure and short-term survival

Abstract

Background and aim: Acute-on-chronic liver failure (ACLF) is characterized by the presence of acute decompensation (AD) of cirrhosis, organ failures, and high short-term mortality rates. In present study, we explored whether Pro-adrenomedullin (Pro-ADM), a biomarker of sepsis, is a potential marker of outcome in patients admitted for AD or ACLF and whether it might be of additional value to conventional prognostic scoring systems in these patients.

Methods: 332 consecutive patients with AD of cirrhosis were prospectively enrolled. Pro-ADM was measured for all patients at baseline. Cox regression analysis was used to evaluate the impact of pro-ADM on short-term survival and developing ACLF during hospital stay.

Results: Serum pro-ADM levels were significantly high in non-survivors (p?<?.001) and showed significant correlation with ALT (r?=?0.181, p?=?.001), INR (r?=?0.144, p?=?.009), TB (r?=?0.368, p?<?.001), Creatinine (r?=?0.145, p?=?.004), MELD score (r?=?0.334, p =?<.001) and CLI-C OF score (r?=?0.375, p=?<.001). Serum pro-ADM at admission was shown to be a predictor of 28-day mortality independently of MELD and CLIF-C OF scores. Prognostic models incorporating pro-ADM achieved high C index for predicting 28-day mortality in AD patients of cirrhosis. Moreover, baseline pro-ADM was found to be predictive of ACLF development during hospital stay.

Conclusions: Serum pro-ADM levels correlate with multiorgan failure and are independently associated with short-term survival and ACLF development in patients admitted for AD or ACLF.     

Establishment of a predictive model for outcomes in patients with severe acute pancreatitis by nucleated red blood cells combined with Charlson complication index and APACHE II score

Background/AimsNucleated red blood cell (NRBC) is an immature red blood cell, which can appear in the peripheral blood of newborns but not in normal adults. However, in the presence of hemorrhage, severe hypoxia, or severe infection, NRBCs may exist in adult blood and are associated with prognosis. The aims of this study were to establish a predictive model for the outcome of patients with severe acute pancreatitis (SAP) based on NRBCs.Materials and MethodsData from 92 patients with SAP were retrospectively collected for the study. We used chi-square automatic interaction detection (CHAID) to explore a prediction model of mortality in patients with SAP by NRBCs.ResultsDuring the 90-day follow-up, 11 participants (12.0%) died. The NRBC-positive rate of nonsurvivors was much higher than survivors (90.9% vs. 23.5%). Charlson Comorbidity Index (CCI), Acute Physiology and Chronic Health Evaluation II (APACHE II), Ranson score, and serum C-reactive protein were higher in nonsurvivors (5.0, 29.0, 6.0, and 140.0 g/L) than survivors (3.0, 13.0, 4.0, and 54.7 g/L). A CHAID model including NRBC, CCI, APACHE II score, and Ranson score showed that NRBCs differentiated well between nonsurvivors and survivors. All patients with SAP survived when they had a negative test result for NRBCs and CCI was below 7. All patients died when they had a positive test result for NRBCs and APACHE II score exceeded 30. Among patients whose NRBC test result was positive and APACHE II score was below 30, if the Ranson score was less than 5, the mortality rate was only 5.6%, whereas the mortality rate was 66.7% if the Ranson score exceeded 5. A validated population of 32 patients showed that the accuracy of the prediction model was 100%.ConclusionNRBC combined with CCI, APACHE II, and Ranson score can predict 90-day mortality of patients with SAP.     

Red cell distribution width to serum albumin ratio as an early prognostic marker for severe acute pancreatitis: A retrospective study

Background and study aimsThe ability to predict severe acute pancreatitis (SAP) at an early stage is crucial for reducing the associated complications and mortality. In this study, we compared the ratio of red cell distribution width to albumin (RDW-to-ALB) using predictive scoring systems, such as the Ranson score, BISAP, and MCTSI, to develop a simple and accurate method of predicting SAP.Patients and methodsWe included 212 patients with mild acute pancreatitis (MAP) and 89 with SAP between January 2013 and December 2018. The differences in the general characteristics and biochemical analysis as well as the various predictive scores were compared between the two groups. We evaluated the sensitivity and specificity between the RDW-to-ALB ratio, RDW, ALB, and multiple predictive scores in patients with early acute pancreatitis (AP) by using the receiver operating characteristic (ROC) curve.ResultsThe RDW-to-ALB ratio (%) of patients with SAP was higher than that of patients with MAP (0.43 ± 0.08 vs. 0.32 ± 0.04, p < 0.001). Patients with SAP had higher Ranson, BISAP, and MCTSI scores than those with MAP. The ROC curve revealed that, when the RDW-to-ALB ratio (%) was >0.36, the sensitivity and specificity of the predicted SAP were 80.0% and 80.7%, respectively. Further statistical analysis found that the RDW-to-ALB ratio and Ranson, BISAP, and MCTSI scores were consistent in predicting SAP effectiveness (P > 0.05).ConclusionsThe RDW-to-ALB ratio has a promising predictive power for SAP, and its effectiveness is comparable with those of Ranson, BISAP, and MCTSI scores.     

Choledocholithiasis in elderly patients with gallbladder in situ - is ERCP sufficient?

Abstract

Introduction: Along with increased life expectancy, the proportion of elderly patients with choledocholithiasis will increase and with this, the need for endoscopic cholangiopancreatography (ERCP). Current recommendations suggest laparoscopic cholecystectomy in all patients with choledocholithiasis to prevent biliary events. However, adherence to these recommendations is low, especially in older patients.

Methods: Retrospective study that included non-cholecystectomized patients aged >?=75 years who underwent ERCP for choledocholithiasis from 2013–2016 (n?=?131). A new biliary event was defined as the need for a new ERCP, cholecystitis, cholangitis or gallstone pancreatitis.

Aim: The aim of this study was to compare the outcomes of new biliary events and mortality in cholecystectomized vs non-cholecystectomized patients after ERCP.

Results: Cholecystectomy was performed in 22% of the patients (92% laparoscopic). The post-cholecystectomy complication rate was 13% and the mortality rate was 7%. During the follow-up period (669?±?487 days) a new biliary event occurred in 20% of patients - 10% new ERCP, 9% cholecystitis, 9% cholangitis and 2% pancreatitis. Cholecystectomized patients had fewer events (7% vs 24%, p?=?.048) and longer time to event (p?=?.016). There was no statistically significant difference in all-cause mortality (14% vs 27%, p?=?.13), mortality related to lithiasis (0% vs 9%, p?=?.11) or time to mortality from all causes (p?=?.07) and related to biliary events (p?=?.07).

Conclusions: In this group of elderly patients, cholecystectomy after ERCP prevented the occurrence of new biliary events but resulted in a non-statistically significant difference in mortality.     

Evaluation of clinical prognostic factors for interstitial pneumonia in anti-MDA5 antibody-positive dermatomyositis patients

Objectives: We retrospectively investigated clinical prognostic factors for interstitial pneumonia (IP) in anti-melanoma differentiation-associated gene 5 (MDA5) antibody (Ab)-positive dermatomyositis (DM) patients.

Methods: Subjects comprised 18 patients with anti-MDA5 Ab-positive DM-IP (9 survivors; 9 deaths).

Results: Initial serum albumin levels, ferritin levels, and ground-glass opacity (GGO) scores in the right middle lobes were significantly higher in the death group than in the survivor group (p?=?.033, .013, and .005, respectively). Initial alveolar-arterial oxygen gradient (P[A-a]O₂) was also higher in the death group than in the survivor group (p?=?.064). Initial serum ferritin, P[A-a]O₂, and right middle lobe GGO score were found to significantly relate to death. Survival rates after 24 weeks were significantly lower among patients with an initial ferritin level of ≥450?ng/mL (25%), P[A-a]O₂ of ≥30?mmHg (31%), and a right middle lobe GGO score of ≥2 (11%) than each of the others (p?=?.006, .020, and .002, respectively).

Conclusions: An initial serum ferritin level of ≥450?ng/mL, P[A-a]O₂ of ≥30?mmHg, and right middle lobe GGO score of ≥2 (GGO ≥5% of the lobe) were identified as poor prognostic factors for anti-MDA5 Ab-positive DM-IP patients.     

Acute pancreatitis in elderly patients: a single-center retrospective evaluation of clinical outcomes

Introduction: Acute pancreatitis (AP) incidence in the elderly population has increased in the last years. However, the role of age as influencing factor on the AP clinical course is still debated.

Methods: We reviewed clinical records of consecutive patients admitted with diagnosis of AP. Patients were divided in elderly (≥65 years) and non-elderly (<65 years). Primary endpoint was comparison of overall mortality. Secondary endpoint included ICU admission, in-hospital length of stay (LOS) and surgical procedures.

Results: We enrolled 352 elderly and 532 non-elderly patients. A higher mortality rate (7.4% vs 1.9%; p?<?.001), ICU admission rate (18.9% vs 6.3%; p?<?.001) and prolonged length of hospital stay (9 (6–14) vs 7 (5–11.7) days; p?=?.01) were registered in the ≥65 years group. Multivariate analysis identified age (OR: 3.5; 95% CI:1.645–7.555; p?=?.001), a higher Ranson score at admission (OR: 5.52; 95% CI:1.11–27.41; p<.001) and necrotic pancreatitis (OR: 8.6; 95% CI:2.46–30.27; p?=?.001) as independent predictors of mortality. Conversely age and necrotic pancreatitis were independent risk factors for higher LOS and ICU admission.

Conclusions: Patients with AP and age ≥65 years have a higher mortality, ICU admission and prolonged LOS. Early recognition and prompt treatment are key elements to improve outcomes in this population.     

Impact of nitroglycerin and glucagon administration on selective common bile duct cannulation and prevention of post-ERCP pancreatitis

Objective: Easy common bile duct (CBD) cannulation is associated with low complication rate. This study aimed to investigate the potential impact of nitroglycerin and glucagon administration on selective CBD cannulation and prevention of post-ERCP pancreatitis.

Methods: A prospective single center, double–blind randomized study in which a total of 455 patients were randomly assigned to CBD cannulation by receiving 6 puffs (2.4?mg) sublingual nitroglycerin and glucagon 1?mg intravenously (n?=?227, group A) or 6 puffs sterile water and 20?mg hyoscine-n-butyl bromide intravenously (n?=?228, group B). After ERCP, patients were followed for the development of drugs’ side-effects and post-ERCP complications.

Results: There were no statistically significant differences between the two groups regarding demographic data and ERCP findings. Success rate of selective CΒD cannulation was 95.15% in group A versus 82.29% in group B (p?<?.001). Time required for CBD cannulation was 2.82?±?2.31?min in group A versus 4.27?±?3.84?min in group B (p?=?.021). Needle-knife papillotomy was used in 11 (4.85%) patients of group A and 39 (17.11%) patients of group B (p?=?.001). The frequency of post-ERCP pancreatitis was significantly lower in group A than in group B (3.08% versus 7.46%, p?=?.037). No difference was observed between the two groups with regard to the occurrence of post-procedure hemorrhage. There was no procedure-related mortality; no adverse event related to the combination regimen was observed.

Conclusions: Combined nitroglycerin and glucagon administration achieves a high selective CBC cannulation rates with concomitant reduction of post-ERCP pancreatitis incidence. However, further relative large-scale studies are needed to confirm our findings before definite conclusions can be drawn (Clinical trial registration number: NT: 4321).     

SAF score and mortality in NAFLD after up to 41 years of follow-up

Background and aims: A new score for the histological severity of nonalcoholic fatty liver disease (NAFLD), called SAF (Steatosis, Activity and Fibrosis) has been developed. We aimed to evaluate the impact of this score on overall mortality.

Methods: We used data from 139 patients with biopsy-proven NAFLD. All biopsies were graded according to the SAF scoring system and disease severity was classified as mild, moderate or severe. Causes of death were extracted from a national, population-based register. A Cox regression model, adjusted for sex, body mass index (BMI) and diabetes mellitus type 2, was applied.

Results: At baseline 35 patients presented with mild or moderate disease respectively, and 69 patients with severe disease. During follow-up (median 25.3 years, range 1.7–40.8) 74 patients died, 11 in the mild group (31%), 18 in the moderate group (51%) and 45 in the severe group (65%), p?=?.002. Compared to patients with mild disease, patients with moderate disease did not have a significant increase in overall mortality (HR 1.83, 95%CI 0.89–3.77, p?=?.10). Patients with severe disease had a significant increase in mortality (HR 2.65, 95%CI 1.19–5.93, p?=?.017). However, when adjusting for fibrosis stage, significance was lost (HR 1.85, 95%CI 0.76–4.54, p?=?.18). NASH, defined as per the FLIP algorithm, was not associated with mortality compared to not having NASH (HR 1.46, 95%CI 0.74–2.90, p?=?.28).

Conclusions: After adjustment for fibrosis, the SAF score was not associated with increased mortality in NAFLD. This finding should be corroborated in larger cohorts with similar follow-up time.     

Association of five-factor score with the mortality in Japanese patients with polyarteritis nodosa

Aim: To determine mortality and its predictive factors in Japanese patients with polyarteritis nodosa (PAN).

Methods: This retrospective single-center study determined the mortality of 18 patients with PAN who were admitted to Juntendo University Hospital from 1994 to 2016. The variables at baseline, including patient demographics, clinical characteristics, and treatment, were analyzed for their association with mortality.

Results: The median age of onset was 57.0 years. The 1-year survival rate was 100% (16/16) and the 5-year survival rate was 80.0% (8/10). The relationship between mortality, as defined by the survival rate and each variable was evaluated by Cox univariate analysis. A higher 2009 five-factor score (FFS) was associated with increased mortality, with a hazard ratio of 2.34 (p?=?.04). Analysis of the secondary outcome of relapse-free survival time revealed an association with rapid progressive renal failure, Birmingham Vasculitis Activity Score (BVAS), the 1996 FFS, and the 2009 FFS, with hazard ratios of 7.28 (p?=?.048), 1.26 (p?=?.02), 2.32 (p?=?.03), and 1.82 (p?=?.04), respectively.

Conclusion: We investigated mortality, relapse-free survival, and their predictive factors in Japanese patients with PAN. The BVAS and the 1996 FFS at diagnosis may be prognostic factors for relapse-free survival, and the 2009 FFS at diagnosis may be a prognostic factor for both mortality and relapse-free survival.     

Prognostic value of lectin pathway molecules and complement proteins in ascitic fluid and blood in patients with liver cirrhosis

Background and aim: Patients with liver cirrhosis and ascites have a poor prognosis with increased risk of infection related death, as advanced stages of cirrhosis are associated with immunodeficiency. We aimed to investigate immunologically active molecules in ascitic fluid and blood and their potential association to survival.

Materials and methods: In an exploratory pilot study; blood and ascitic fluid from 34 patients with liver cirrhosis of different etiology were analyzed for pattern recognition molecules (ficolin-1, ficolin-2, ficolin-3 and MBL) and complement proteins (C4 and C3). An observational follow-up study (minimum 17 months) was conducted to assess the association to all-cause mortality or liver transplantation.

Results: Ficolin-1, ficolin-2, MBL, C4 and C3 in ascitic fluid and ficolin-1, C4 and C3 in blood were significantly (p?=?.001–.027) lower in patients with Child-Pugh stage C (n?=?16, 47%) compared to Child-Pugh stage B cirrhosis (n?=?18, 53%). In multivariate COX-regression analysis low levels of ficolin-1(p?=?.036) and C3 (p?=?.025) in ascitic fluid and C4(p?=?.005) and C3 (p?=?.032) in serum were associated with all-cause mortality or liver transplantation independent of Child-Pugh score.

Conclusion: Levels of lectin-complement pathway molecules in ascitic fluid and blood are lower in patients with more advanced stage of cirrhosis. Low C4 and C3 in serum and C3 and ficolin-1 in ascitic fluid are risk factors for all-cause mortality or liver transplantation independently of liver function in patients with cirrhosis and ascites.     

The relationship between social support and health-related quality of life in patients with antiphospholipid (hughes) syndrome

Objective: Antiphospholipid (Hughes) syndrome (APS) is recognised as a systemic autoimmune disease defined by recurrent thromboembolic events and/or pregnancy morbidity. Little is known about the psychological burden of this long-term condition. This study aims to explore the relationship between social support and health-related quality of life (HRQoL) in patients with APS.

Methods: A total of 270 patients with a clinical diagnosis of APS participated in a cross-sectional online questionnaire survey. Data included demographics, disease-related information, social support and HRQoL.

Results: Both perceived and ideal social support were associated with HRQoL in APS. Patients reported receiving insufficient social support. Perceived emotional support was related to physical functioning (B?=?7.77, p?=?.006, 95% CI: 2.25, 13.29); perceived instrumental support was associated with bodily pain (B?=?17.52, p? .001, 95% CI: 11.15, 23.90) and perceived informational support with physical and social functioning (B?=??6.30, p?=?.05, 95% CI: ?12.52, ?0.08; B?=?8.06, p?=?.02, 95% CI: 1.17, 14.94). Ideal emotional support was related to physical and social functioning (B?=?5.80, p?=?.04, 95% CI: 0.26, 11.34; B?=?7.53, p?=?.04, 95% CI: 0.55, 14.51); ideal instrumental support was associated with mental health (B?=?4.73, p?=?.03, 95% CI: 0.38, 9.07) and ideal informational support with vitality (B?=?5.85, p?=?.01, 95% CI: 1.23, 10.46).

Conclusion: Social support was linked to HRQoL in patients with APS. Insufficient social support was associated with limitations in various HRQoL domains. Increasing social support especially through provision of disease-specific education might contribute to improving HRQoL in patients with APS. Patient-tailored interventions addressing psychosocial aspects of living with APS are needed to improve patients’ psychological and physical status.     

Audit of patients with severe acute pancreatitis admitted to an intensive care unit

Background

Severe acute pancreatitis (SAP) is a disease with high morbidity and mortality. We undertook a study of patients with SAP admitted to the intensive care unit (ICU) of a tertiary referral hospital.

Methods

Between 2002 and 2007, 50 patients with SAP were admitted in our intensive care unit (ICU). Data were collected from their medical records and their clinical profile, course and outcome were retrospectively analyzed. Patients were categorized into survivor and nonsurvivor groups, and were further classified based on interventions such as percutaneous drainage and surgical necrosectomy.

Results

SAP contributed 5?% of total ICU admissions during the study period. Median age of survivors (n?=?20) was 34 against 44?years in nonsurvivors (n?=?30). Median Acute Physiology and Chronic Health Evaluation (APACHE) II score in nonsurvivors was 16.5 (8?C32) vs. 12.5 (5?C20) in survivors (p?=?0.002). Patients with APACHE II score ??12 had mortality >80?% compared to 23?% with score <12 (p?<?0.001). Median Sequential Organ Failure Assessment (SOFA) scores on admission and on days 3, 7, 14, and 21 were significantly higher in nonsurvivors compared to survivors (p?<?0.05). Mean (SD) intraabdominal pressure was 23 (3.37) mmHg in nonsurvivors vs. 19.05 (2.51) in survivors (p?<?0.05). Patients with renal failure had significant mortality (p?<?0.001). Length of ICU stay, requirement for vasopressor, total parenteral nutrition, and the amount of blood and blood product transfusions differed significantly between patients with and without intervention.

Conclusions

APACHE II and SOFA scores and other clinical data correlated with outcome in SAP admitted to ICU.     

CECDAIic – a new useful tool in pan-intestinal evaluation of Crohn’s disease patients in the era of mucosal healing

Abstract

Background: Pan-intestinal capsule endoscopy (Pan-CE) has been used to assess both the small and large bowel inflammation in Crohn’s disease (CD) patients in a single examination. The capsule endoscopy Crohn’s disease activity index (CECDAI) was initially developed to measure mucosal disease activity in the small bowel, although in 2018, it was extended to the colon for standardization of inflammatory activity (CECDAIic). The aim of this study was to apply the CECDAIic in a cohort of CD patients that underwent Pan-CE to evaluate the inter-observer agreement and the correlation between this score and inflammatory parameters.

Methods: The videos were read and scored using the CECDAIic by three independent experienced operators, blinded to the results of the standard workup. Statistical analysis was performed with SPSS^®, using Kendall’s coefficient to evaluate the inter-observer agreement. Spearman correlation (r_s) was used to access the correlation between the score and inflammatory biomarkers.

Results: Included 22 patients, 59.1% males with mean age of 30.7?±?11.1 years. The median CECDAIic score was 9.17 (0–37). The overall CECDAIic score Kendall coefficient was 0.94, demonstrating a statistically significant (p?<?.001) and excellent agreement between the three observers. In addition, we found a very good correlation between CECDAIic and calprotectin (r_s?=?0.82; p?=?.012) and a moderate correlation with C-reactive protein (CRP, r_s?=?0.50; p?=?.019).

Conclusions: CECDAIic is a new score with excellent inter-observer agreement and strong correlation with calprotectin levels.     

Nasobiliary drainage can reduce the incidence of post-ERCP pancreatitis after papillary large balloon dilation plus endoscopic biliary sphincterotomy: a randomized controlled trial

Background and aims: Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis can be reduced following endoscopic papillary balloon dilation with the placement of an endoscopic nasobiliary drainage (ENBD) catheter. The aim of this study was to determine whether the placement of an ENBD reduces the risk of post-ERCP pancreatitis following endoscopic papillary large balloon dilation together with endoscopic biliary sphincterotomy.

Methods: A total of 160 patients with bile duct stones were randomly assigned (1:1) to an ENBD group or no-ENBD group. The primary outcome of this study was the incidence of post-ERCP pancreatitis. The secondary outcome was the incidence of post-ERCP hyperamylasemia.

Results: In total, 160 patients were randomized, and 155 were found to be eligible for the analysis. The two groups were similar regarding clinical and demographic factors as well as patient- and procedure-related risk factors for post-ERCP pancreatitis. Post-ERCP pancreatitis developed in 9 patients, that is, 8/77 (10.4%) of the control group and 1/78 (1.28%) of the ENBD group (p?=?.018; per protocol analysis). Intention to treat analysis also revealed that ENBD reduced the rate of post-ERCP pancreatitis (8/80 (10%) in the control group vs. 1/80 (1.25%) the ENBD group (p?=?.034)). Multivariate regression analysis identified not undergoing ENBD as an independent risk factor for post-ERCP pancreatitis (ENBD compared with no-ENBD: OR 0.087, 95% CI 0.011–0.734; p?=?.025).

Conclusion: This study demonstrated that placement of an ENBD was effective and safe for the prevention of post-ERCP pancreatitis in patients undergoing endoscopic papillary large balloon dilation together with endoscopic biliary sphincterotomy.     

Changing management of gallstone-related disease in pregnancy – a retrospective cohort analysis

Objectives: Gallstone-related disease is the second most common non-obstetric cause, following appendicitis, for acute abdomen in pregnancy. This study aimed to investigate treatment strategies, changes over time and outcome.

Materials and methods: All consecutive patients with symptomatic gallstone-related disease during pregnancy admitted to Skane University hospital in Lund and Malmö 2001–2015 were analysed retrospectively. Information regarding the patient, pregnancy and fetus/child was recorded. The material was analysed by dividing it into two equal time periods and by comparing conservative management and surgical intervention.

Results: We included 96 patients with 97 pregnancies. The age was 30 (26–34) years and BMI 28 (24–31). Median length of pregnancy at first admission was 23 (13–31) weeks. The three most common diagnoses were biliary colic (n?=?63), cholecystitis (n?=?22) and acute pancreatitis (n?=?16). Conservative treatment was practiced in 62 (64%) patients and intervention in 35 (36%). Conservatively treated patients were admitted later during pregnancy (week 26 (20–33) versus 17 (10–22), p?<?.001). Surgically treated patients had a longer total length of stay (all admissions) than conservatively treated patients (p?=?.001), less readmissions (p?=?.001) and equal birth outcome. Surgical intervention was more common in the later time period (48% versus 22%, p?=?.011). Of the conservatively treated patients, 56% were subjected to surgical intervention within 2 years after delivery.

Conclusions: We found that intervention was more common in the later time period, with good results concerning safety, and less readmissions. A majority of the conservatively treated patients had surgical intervention within two years after delivery. Our results support surgical intervention in pregnancy.     

Hepatocellular carcinoma surveillance with liver imaging is not associated with improved survival

Abstract

Objective: International guidelines recommend hepatocellular carcinoma (HCC) surveillance with ultrasound in high-risk patients with chronic liver diseases. However, there is low-strength evidence about the effects on mortality. The aim of our study was to assess the impact of surveillance on the clinical course and survival of HCC patients seen at a tertiary referral center in Germany.

Material and methods: We retrospectively evaluated the data of 401 HCC patients, who presented to our clinic between 1997 and 2015. Two groups were compared regarding patient and disease outcomes: one group included patients who received at least two ultrasound examinations for surveillance purposes prior to first diagnosis (n?=?111). The other group consisted of patients with HCC at first presentation without foregoing HCC surveillance (n?=?290).

Results: Median follow-up in the surveillance group was 76?months (range 4–310?months). Patients in the surveillance group had smaller median tumor sizes (3.5?cm vs. 4.5?cm; p?<?.001), fulfilled more often Milan criteria (64% vs. 42%; p?<?.001) and received more often liver transplantation (27% vs. 9%, p?<?.001) when compared with the non-surveillance group. However, HCC surveillance was not associated with an improved survival (14?months in the surveillance group vs. 12?months in the non-surveillance group, p?=?.375), hazard ratio regarding overall mortality for the surveillance group: 0.80 (95% CI: 0.62–1.04, p?=?.09).

Conclusions: HCC surveillance with ultrasound led to the detection of earlier disease stages but was not significantly associated with improved survival. Further prospective and long-term studies are needed to clarify benefits and harms of HCC surveillance programs on mortality.     

Comparison of clinical characteristics and outcomes of spontaneous bacterial peritonitis and culture negative neutrocytic ascites

Objective: Ascitic fluid infections (AFI) in cirrhotic patients can be classified into two groups: spontaneous bacterial peritonitis (SBP) and culture-negative neutrocytic ascites (CNNA). The aim of this study was to compare the clinical characteristics and outcomes of the two groups of patients with AFI.

Methods: We retrospectively reviewed the medical records of cirrhotic patients with AFI. We evaluated demographic data, clinical presentations of AFI, laboratory findings, liver function, and mortality rates.

Results: Between January 2005 and December 2014, 533 patients with AFI were evaluated; 259 (48.6%) had SBP and 274 (51.4%) CNNA. Ascites neutrophil count (4410/mm³ versus 1046/mm³, p?<?.001) and the blood culture positive rate (38.1% versus 20.1%, p?<?.001) were higher in the SBP group, which also had a higher MELD score (24.29 versus 22.05, p?=?.004). Seven-day mortality was higher in the SBP group (9.4% versus 4.5%, p?=?.027) but there was no significant difference in 30-day (22.1% versus 17.5%) or 90-day mortality rate (36.1% versus 36.4%).

Conclusions: Patients in the SBP group had a higher MELD score, ascites neutrophil count, and positive blood culture rate. Although seven-day mortality rate was higher in the SBP group, the 30-day and 90-day mortality rates were similar in the two groups.     

Psychiatric symptoms among patients with acute abdominal pain

Abstract

Background: Abdominal pain is a common cause of visits to emergency facilities. It is related to psychiatric disorders in primary care, but it is unclear if this also holds in emergency departments.

Objective: Is to explore potential differences between diagnostic groups in patients with acute abdominal pain in an emergency ward regarding concurrent somatic-and psychiatric symptoms, ‘Length of stay’ (LOS) and perceived health.

Method: The patients (N?=?137) were divided into three groups; organic dyspepsia, specific abdominal diagnoses, and non-specific abdominal pain. The Prime-MD results for extra gastrointestinal symptoms (outside the gastrointestinal tract), psychiatric symptoms, frequency of symptoms, self-reported health, and LOS within the month before admittance were compared between the diagnostic groups.

Results: There was a significant positive correlation between the number of physical extra gastrointestinal and psychiatric symptoms (p?<?.001), especially regarding anxiety (p?<?.001) and depression (p?=?.002). Patients with organic dyspepsia reported significantly more total (p?=?.016), extragastrointestinal (p?=?.026) (chest pain; p?=?.017, dizziness; p?=?.004, palpitations; p?=?.005, insomnia; p?=?.005 and worries; p?=?.001), and summarized anxiety and depression symptoms (p?=?.001–0.002) besides poorer general health (p?<?.001) compared to other abdominal conditions. Also, organic dyspepsia patients needed longer hospital stay than the non-specific abdominal group (p?=?.002) but similar to the specific abdominal disorders group.

Conclusion: Organic dyspepsia is accompanied by more co-occurring physical, anxiety and depression symptoms as well as poorer perceived health than other abdominal pain conditions and comparably increased LOS. This suggests that psychiatric consultations might be beneficial for diagnosing and treating psychiatric comorbidity in emergency care.     

Lifetime alcohol intake and pattern of alcohol consumption in patients with alcohol-induced pancreatitis in comparison with patients with alcohol use disorder

Objective: To examine lifetime drinking patterns in men and women with alcohol-induced pancreatitis (AIP) in comparison with patients with alcoholic use disorder (AUD) without pancreatic disease.

Methods: Alcohol consumption patterns were assessed using a validated questionnaire, the Lifetime Drinking History (LDH), during an outpatient visit. Patients diagnosed with AIP were matched for gender and age (+/? 5 years) with patients with AUD in addiction treatment.

Results: A total of 45 patients with AIP (35 males, 10 females) and 45 AUD patients were included. Alcohol consumption patterns were not significantly different between males and females with AIP and those with history of acute AIP and chronic pancreatitis (CP). Alcohol consumption patterns of AIP and AUD patients were similar in terms of onset age and duration of alcohol consumption, lifetime alcohol intake and drinks per drinking day. A higher proportion of binge drinking was found among patients with AUD than those with AIP (median 1.00 vs. 0.94, p?=?.01). Males with AUD had lower onset age (15 vs. 16 years, p?=?.03), higher total amount of spirits (35520 vs. 10450 drinks, p?=?.04) and higher proportion of binge drinking (1.00 vs. 0.97, p?=?.01) than males with AIP, whereas females with AIP and AUD had similar drinking patterns.

Conclusions: Alcohol drinking patterns and lifetime drinking history was similar in patients with AIP and patients with AUD. Males with AIP had lower total amount of spirits and lower proportion of binge drinking than those with AUD, suggesting the idiosyncratic etiology of AIP.     

Extracorporeal shock wave lithotripsy for pancreatic duct stones: an observational study

Abstract

Introduction: Previous studies suggest that fragmentation of pancreatic duct stones (PDS) using extracorporeal shock wave lithotripsy (ESWL) is associated with pain relief. However, the treatment may not be effective in certain subgroups.

Aim: To evaluate predictors of pain relief after ESWL in patients with chronic pancreatitis and PDS.

Methods: Retrospective study including patients with chronic pancreatitis undergoing ESWL for painful PDS. Analgesic use before and after the ESWL procedure was registered. We defined adequate pain relief after ESWL as ‘pain-free without analgesics or with use of weak analgesics as needed’. The study was approved by the Danish Data Protection Agency (approval number: AHH-2017-048).

Results: We included 81 patients (median age 58 years; 63% men; 68% alcoholic pancreatitis). Patients underwent one to seven ESWL procedures (mean 1.7). A concurrent ERCP was performed in 17%. All patients used analgesics before the ESWL procedure (68 used opioids). After ESWL, 43 still used opioids. Thirty-two patients achieved adequate pain relief. Univariable regression analysis showed that older age predicted adequate pain relief (OR 1.09;1.03–1.16; p?=?.002) as did location of the stone in the head or neck (OR 2.59;1.04–6.45; p?=?.041). In multivariable analysis, we found that the only two predictors of adequate pain relief were age (p?=?.002) and the location of the stones (p?=?.039).

Conclusion: After the ESWL, about four out of ten patients are pain-free without medication or able to manage their pain with weak analgesics. Age and the location of the stones may be considered when evaluating if patients are eligible for referral to ESWL.