Three year experience of Upper Gastrointestinal Endoscopic procedures at a tertiary care hospital of South Punjab

Introduction: Endoscopy has become a necessity in diagnosing gastrointestinal (GI) disorders. The objective of our study was to evaluate the different indications and findings of upper GI endoscopy. Methods: This retrospective analysis was undertaken at department of Gastroenterology, Nishtar Hospital Multan. Records of all upper GI endoscopic procedures from 1st January 2018 till 31st December 2020 were evaluated. Results: A total 3299 upper GI endoscopic procedures were perfumed during the three-year time period. Mean age was 47 years. Majority of patients were males. Almost 48% of patients belonged to the middle-aged group. The most common indication was upper GI bleeding (57%), followed by dyspepsia (15%). The most common finding was esophageal varices (43%), followed by portal gastropathy (26%) and gastritis (16%). Conclusion: This study concludes that the majority of endoscopies are being undertaken as a result of complications of cirrhosis and portal hypertension. Keywords: Endoscopy, audit, indications, findings

Three year experience of Upper Gastrointestinal Endoscopic procedures at a tertiary care hospital of South Punjab

Introduction: Endoscopy has become a necessity in diagnosing gastrointestinal (GI) disorders. The objective of our study was to evaluate the different indications and findings of upper GI endoscopy. Methods: This retrospective analysis was undertaken at department of Gastroenterology, Nishtar Hospital Multan. Records of all upper GI endoscopic procedures from 1st January 2018 till 31st December 2020 were evaluated. Results: A total 3299 upper GI endoscopic procedures were perfumed during the three-year time period. Mean age was 47 years. Majority of patients were males. Almost 48% of patients belonged to the middle-aged group. The most common indication was upper GI bleeding (57%), followed by dyspepsia (15%). The most common finding was esophageal varices (43%), followed by portal gastropathy (26%) and gastritis (16%). Conclusion: This study concludes that the majority of endoscopies are being undertaken as a result of complications of cirrhosis and portal hypertension.

Gut Dysbiosis and Hemodynamic Changes as Links of the Pathogenesis of Complications of Cirrhosis

Background. Hemodynamic changes (hyperdynamic circulation) and gut dysbiosis are observed in cirrhosis. It was suggested that gut dysbiosis contributes to the development of hyperdynamic circulation, which aggravates the course of cirrhosis. The aim is to test this hypothesis.Methods. The cross-sectional observational study included 47 patients with cirrhosis. Stool microbiome was assessed using 16S rRNA gene sequencing. Echocardiography with a simultaneous assessment of blood pressure and heart rate was performed. Hemodynamic parameters were calculated. Results. Hyperdynamic circulation was found in 34% of patients. Patients with hyperdynamic circulation had higher incidences of clinically significant ascites (p=0.018), overt hepatic encephalopathy (p=0.042), hypoalbuminemia (p=0.011), hypoprothrombinemia (p=0.019), systemic inflammation (p=0.002), and severe hyperbilirubinemia (p=0.042) than patients without hyperdynamic circulation. The abundance of Proteobacteria (p=0.012), Enterobacteriaceae (p=0.008), Bacilli (p=0.027), Streptococcaceae (p=0.044), Lactobacillaceae (p=0.034), Enterococcaceae (p=0.046), and Fusobacteria (p=0.026) increased and the abundance of Bacteroidetes (p=0.049) and Erysipelotrichia (p=0.029) decreased in the gut microbiome of patients with hyperdynamic circulation compared to patients without hyperdynamic circulation. The systemic vascular resistance value negatively correlated with the abundance of Proteobacteria (r=-0.423; p=0.003), Enterobacteriaceae (r=-0.417; p=0.004), and Fusobacteria (r=-0.401; p=0.005). Heart rate was negatively correlated with the abundance of Bacteroidetes (r=-0.453; p=0.001). The cardiac output value was positively correlated with the abundance of Proteobacteria (r=0.402; p=0.003), Enterobacteriaceae (r=0.424; p=0.003), Fusobacteria (r=0.281; p=0.049), and Bacilli (r=0.314; p=0.031), and negatively correlated with the abundance of Bacteroidetes (r=-0.313; p=0.032) and Erysipelotrichia (r=-0.329; p=0.024). Conclusion. Gut dysbiosis is associated with hyperdynamic circulation, which is associated with a number of complications of cirrhosis.

Prevention of Cirrhosis Complications: Looking for Potential Disease Modifying Agents

The current therapeutic strategies for the management of patients with cirrhosis rely on the prevention or treatment of specific complications. The removal of the causative agents (i.e., viruses or alcohol) prevents decompensation in the vast majority of patients with compensated cirrhosis. In contrast, even when etiological treatment has been effective, a significant proportion of patients with decompensated cirrhosis remains at risk of further disease progression. Therefore, therapies targeting specific key points in the complex pathophysiological cascade of decompensated cirrhosis could represent a new approach for the management of these severely ill patients. Some of the interventions currently employed for treating or preventing specific complications of cirrhosis or used in other diseases (i.e., poorly absorbable oral antibiotics, statins, albumin) have been proposed as potential disease-modifying agents in cirrhosis (DMAC) since clinical studies have shown their capacity of improving survival. Additional multicenter, large randomized clinical trials are awaited to confirm these promising results. Finally, new drugs able to antagonize key pathophysiological mechanisms are under pre-clinical development or at the initial stages of clinical assessment.

Diagnosis and Therapeutic Management of Liver Fibrosis by microRNA

Remarkable progress has been made in the treatment and control of hepatitis B and C viral infections. However, fundamental treatments for diseases in which liver fibrosis is a key factor, such as cirrhosis, alcoholic/nonalcoholic steatohepatitis, autoimmune hepatitis, primary biliary cholangitis, and primary sclerosing cholangitis, are still under development and remain an unmet medical need. To solve this problem, it is essential to elucidate the pathogenesis of liver fibrosis in detail from a molecular and cellular perspective and to develop targeted therapeutic agents based on this information. Recently, microRNAs (miRNAs), functional RNAs of 22 nucleotides, have been shown to be involved in the pathogenesis of liver fibrosis. In addition, extracellular vesicles called “exosomes” have been attracting attention, and research is being conducted to establish noninvasive and extremely sensitive biomarkers using miRNAs in exosomes. In this review, we summarize miRNAs directly involved in liver fibrosis, miRNAs associated with diseases leading to liver fibrosis, and miRNAs related to complications of cirrhosis. We will also discuss the efficacy of each miRNA as a biomarker of liver fibrosis and pathology, and its potential application as a therapeutic agent.

Gut Dysbiosis and Hemodynamic Changes as Links of the Pathogenesis of Complications of Cirrhosis

Background. Hemodynamic changes (hyperdynamic circulation) and gut dysbiosis are observed in cirrhosis. It was suggested that gut dysbiosis contributes to the development of hyperdynamic circulation, which aggravates the course of cirrhosis. The aim is to test this hypothesis.Methods. The cross-sectional observational study included 47 patients with cirrhosis. Stool microbiome was assessed using 16S rRNA gene sequencing. Echocardiography with a simultaneous assessment of blood pressure and heart rate was performed. Hemodynamic parameters were calculated. Results. Hyperdynamic circulation was found in 34% of patients. Patients with hyperdynamic circulation had higher incidences of clinically significant ascites (p=0.018), overt hepatic encephalopathy (p=0.042), hypoalbuminemia (p=0.011), hypoprothrombinemia (p=0.019), systemic inflammation (p=0.002), and severe hyperbilirubinemia (p=0.042) than patients without hyperdynamic circulation. The abundance of Proteobacteria (p=0.012), Enterobacteriaceae (p=0.008), Bacilli (p=0.027), Streptococcaceae (p=0.044), Lactobacillaceae (p=0.034), Enterococcaceae (p=0.046), and Fusobacteria (p=0.026) increased and the abundance of Bacteroidetes (p=0.049) and Erysipelotrichia (p=0.029) decreased in the gut microbiome of patients with hyperdynamic circulation compared to patients without hyperdynamic circulation. The systemic vascular resistance value negatively correlated with the abundance of Proteobacteria (r=-0.423; p=0.003), Enterobacteriaceae (r=-0.417; p=0.004), and Fusobacteria (r=-0.401; p=0.005). Heart rate was negatively correlated with the abundance of Bacteroidetes (r=-0.453; p=0.001). The cardiac output value was positively correlated with the abundance of Proteobacteria (r=0.402; p=0.003), Enterobacteriaceae (r=0.424; p=0.003), Fusobacteria (r=0.281; p=0.049), and Bacilli (r=0.314; p=0.031), and negatively correlated with the abundance of Bacteroidetes (r=-0.313; p=0.032) and Erysipelotrichia (r=-0.329; p=0.024). Conclusion. Gut dysbiosis is associated with hyperdynamic circulation, which is associated with a number of complications of cirrhosis.

Dorfman-Chanarin Syndrome: A Rare Cause of Metabolic Associated Fatty Liver Disease Related to Homozygosity of the Nonsense Mutation c.934C>T (p.R312*)

Metabolic associated fatty liver disease became the most common form of chronic liver disease, in the vast majority of the cases related to increased insulin resistance or metabolic dysregulation. Yet, other causes may be implied. We report the late diagnosis of Dorfman-Chanarin syndrome in a non-alcoholic steatohepatitis previously labeled cirrhotic middle-aged man, with consanguineous parents, complicated with hepatocellular carcinoma. Congenital ichthyosis, neurosensory hearing loss and elevated muscular enzymes hit on the track of Dorfman-Chanarin syndrome. The genetic analysis uncovered a first-time described homozygotic nonsense mutation in the <i>ABHD5</i> gene, responsible for coding the ABHD5 protein. The patient was successfully submitted to liver transplantation. Inborn errors of metabolism are a rare cause of metabolic associated fatty liver disease, but they need to be kept in consideration in all patients who present with atypical clinical features. This shall raise the awareness of physicians to rare forms of presentation since it may imply not only a different prognosis, but also other actions, like particular therapies as liver transplantation due to related complications of cirrhosis, or familial screening.

Major complications of cirrhosis: the nurse's role

Palle Bager explores the findings of an international review paper into complications arising from liver cirrhosis, with a focus on the role of specialist nursing care