Cirrhotic patients and older people

The global population is aging,and so the number of older cirrhotic patients is increasing.Older patients are characterised by a risk of frailty and comorbidities,and age is a risk factor for mortality in cirrhotic patients.The incidence of nonalcoholic fatty liver disease as an aetiology of cirrhosis is increasing,while that of chronic viral hepatitis is decreasing.Also,cirrhosis is frequently idiopathic.The management of portal hypertension in older cirrhotic patients is similar to that in younger patients,despite the greater risk of treatment-related adverse events of the former.The prevalence of hepatocellular carcinoma increases with age,but its treatment is unaffected.Liver transplantation is generally recommended for patients<70 years of age.Despite the increasing prevalence of cirrhosis in older people,little data are available and few recommendations have been proposed.This review suggests that comorbidities have a considerable impact on older cirrhotic patients.

Ribavirin:Past,present and future

Before the advent of direct acting antiviral agents(DAAs) ribavirin, associated to pegylated-interferon played a crucial role in the treatment of chronic hepatitis C, preventing relapses and breakthroughs. In the present era of new potent DAAs, a place is still devoted to the drug. Ribavirin associated with sofosbuvir alone is efficient in the treatment of most cases of G2 infected patients. All options currently available for the last difficult-to-treat cirrhotic G3 patients contain ribavirin. Reducing treatment duration to 12 wk in G1 or G4 cirrhotic compensated patients is feasible thanks to ribavirin. Retreating patients with acquired anti NS5 A resistance-associated variants using ribavirin-based strategies could be useful. The addition of ribavirin with DAAs combinations however, leads to more frequent but mild adverse events especially in cirrhotic patients. Preliminary data with interferon-free second generation DAAs combinations without ribavirin suggest that future of the drug is jeopardized even in difficult-totreat patients: The optimization of ribavirin dosage according to an early monitoring of blood levels has been suggested to be relevant in double therapy with peginterferon or sofosbuvir but not with very potent combinations of more than two DAAs.

Obscure bleeding colonic duplication responds to proton pump inhibitor therapy

We report the case of a 17-year-old male admitted to our academic hospital with massive rectal bleeding.Since childhood he had reported recurrent gastrointestinal bleeding and had two exploratory laparotomies 5and 2 years previously.An emergency abdominal computed tomography scan,gastroscopy and colonoscopy,performed after hemodynamic stabilization,were considered normal.High-dose intravenous proton pump inhibitor(PPI)therapy was initiated and bleeding stopped spontaneously.Two other massive rectal bleeds occurred 8 h after each cessation of PPI which led to a hemostatic laparotomy after negative gastroscopy and small bowel capsule endoscopy.This showed long tubular duplication of the right colon,with fresh blood in the duplicated colon.Obscure lower gastrointestinal bleeding is a difficult medical situation and potentially life-threatening.The presence of ulcerated ectopic gastric mucosa in the colonic duplication explains the partial efficacy of PPI therapy.Obscure gastrointestinalbleeding responding to empiric anti-acid therapy should probably evoke the diagnosis of bleeding ectopic gastric mucosa such as Meckel’s diverticulum or gastrointestinal duplication,and gastroenterologists should be aware of this potential medical situation.

Anti-hepatitis C virus drugs and kidney

Hepatitis C virus(HCV) mainly targets the liver but can also induce extrahepatic manifestations. The kidney may be impacted via an immune mediated mechanism or a cytopathic effect. HCV patients are clearly at a greater risk of chronic kidney disease(CKD) than uninfected patients are, and the presence of CKD increases mortality. Interferon-based therapies and ribavirin are difficult to manage and are poorly effective in endstage renal disease and hemodialysis. These patients should be given priority treatment with new direct anti-viral agents(DAAs) while avoiding peginterferon and ribavirin. The first results were convincing. To aid in the correct use of these drugs in patients with renal insufficiency, their pharmacokinetic properties and potential renal toxicity must be known. The renal toxicity of these new drugs was not a safety signal in clinical trials, and the drugs are generally efficient in these frail populations. These drugs are usually well tolerated, but recent cohort studies have demonstrated that these new regimens may be associated with renal side effects, especially when using sofosbuvir combinations. HCV, renal diseases and comorbidities are intimately linked. The close monitoring of renal function is required, particularly for at-risk patients(transplanted, HIV-coinfected, CKD, hypertensive or diabetic patients). New DAA regimens, which will soon be approved, will probably change the landscape.