Natural history of covert hepatic encephalopathy: An observational study of 366 cirrhotic patients

AIM To explore the natural history of covert hepatic encephalopathy(CHE) in absence of medication intervention.METHODS Consecutive outpatient cirrhotic patients in a Chinese tertiary care hospital were enrolled and evaluated for CHE diagnosis. They were followed up for a mean of 11.2 ± 1.3 mo. Time to the first cirrhosis-related complications requiring hospitalization, including overt HE(OHE), resolution of CHE and death/transplantation, were compared between CHE and no-CHE patients. Predictors for complication(s) and death/transplantation were also analyzed.RESULTS A total of 366 patients(age: 47.2 ± 8.6 years, male: 73.0%) were enrolled. CHE was identified in 131 patients(35.8%). CHE patients had higher rates of death and incidence of complications requiring hospitalization, including OHE, compared to unimpaired patients. Moreover, 17.6% of CHE patients developed OHE, 42.0% suffered persistent CHE, and 19.8% of CHE spontaneously resolved. In CHE patients, serum albumin < 30 g/L(HR = 5.22, P = 0.03) was the sole predictor for developing OHE, and blood creatinine > 133 μmol/L(HR = 4.75, P = 0.036) predicted mortality. Child-Pugh B/C(HR = 0.084, P < 0.001) and OHE history(HR = 0.15, P = 0.014) were predictors of spontaneous resolution of CHE.CONCLUSION CHE exacerbates, persists or resolves without medication intervention in clinically stable cirrhosis. Triage of patients based on these predictors will allow for more cost-effect management of CHE.

Fecal microbiota transplantation as an effective initial therapy for pancreatitis complicated with severe Clostridium difficile infection:A case report

BACKGROUND Moderately severe acute pancreatitis (MSAP) is a critical form of acute pancreatitis that is related with high morbidity and mortality.Severe Clostridium difficile infection (sCDI) is a serious and rare nosocomial diarrheal complication,especially in MSAP patients.Fecal microbiota transplantation (FMT) is a highly effective treatment for refractory and recurrent CDI (rCDI).However,knowledge regarding the initial use of FMT in patients suffering from sCDI is limited.CASE SUMMARY Here,we report an MSAP patient complicated with sCDI who was treated by FMT as a first-line therapy.The patient was a 51-year-old man who suffered from diarrhea in his course of acute pancreatitis.An enzyme immunoassay was performed to detect toxins,and the result was positive for toxin-producing C.difficile and toxin B and negative for C.difficile ribotype 027.The colonoscopy revealed pseudomembranous colitis.Due to these findings,sCDI was our primary consideration.Because the patient provided informed consent for FMT treatment,we initially treated the patient by FMT rather than metronidazole.Diarrhea resolved within 5 d after FMT.The patient remained asymptomatic,and the follow-up colonoscopy performed 40 d after discharge showed a complete recovery.Our case is the first reported in China.CONCLUSION This case explores the possibilities of initially using FMT to treat severe CDI.Moreover,FMT may become a critical component of the treatment for severe CDI in MSAP patients.