Albumin-bilirubin score in non-malignant liver diseases should be properly validated

The albumin-bilirubin(ALBI)score to assess the risk of decompensation in patients with initially compensated cirrhosis may improve their prognostic evaluation.This letter critically evaluates the research,which utilizes the ALBI score to forecast decompensation in cirrhosis patients over a three-year period.This score was initially developed to assess liver function in hepatocellular carcinoma,its prognostic utility for non-malignant liver diseases has now been explored,recognizing decompensation as a pivotal event that significantly affects patient’s survival.Some concerns regarding the methodology of this research may be raised,particularly the exclusive use of radiological diagnosis,potentially including patients without definite cirrhosis and thus skewing the decompensation risk assessment.The reported predominance of variceal bleeding as a decompensating event conflicts with established literature,that often reports ascites as the initial decompensation manifestation.The letter highlights the absence of details on esophageal varices and their management,which could introduce bias in evaluating the ALBI score's predictive power.Furthermore,the letter points out the small sample size of patients with high-risk ALBI grades,potentially compromising the score's validity in this context.We suggest prospective future research to investigate the dynamic changes in the ALBI score over time to reinforce the validity of the ALBI score as a predictor of decompensation in non-malignant liver disease.

Esophageal testing: What we have so far

Gastroesophageal reflux disease(GERD) is a common disorder of the gastrointestinal tract. In the last few decades, new technologies have evolved and have been applied to the functional study of the esophagus, allowing for the improvement of our knowledge of the pathophysiology of GERD. High-resolution manometry(HRM) permits greater understanding of the function of the esophagogastric junction and the risks associated with hiatal hernia. Moreover, HRM has been found to be more reproducible and sensitive than conventional water-perfused manometry to detect the presence of transient lower esophageal sphincter relaxation. Esophageal 24-h p H-metry with or without combined impedance is usually performed in patients with negative endoscopy and reflux symptoms who have a poor response to anti-reflux medical therapy to assess esophageal acid exposure and symptom-reflux correlations. In particular, esophageal 24-h impedance and p H monitoring can detect acid and non-acid reflux events. Endo FLIP is a recent technique poorly applied in clinical practice, although it provides a large amount of information about the esophagogastric junction. In the coming years, laryngopharyngeal symptoms could be evaluated with up and coming non-invasive or minimally invasive techniques, such as pepsin detection in saliva or pharyngeal p H-metry. Future studies are required of these techniques to evaluate their diagnostic accuracy and usefulness, although the available data are promising.

Pre-operative clinical and instrumental factors as antireflux surgery outcome predictors

Gastroesophageal reflux disease(GERD) is nowadays a highly prevalent, chronic condition, with 10% to 30% of Western populations affected by weekly symptoms. Many patients with mild reflux symptoms are treated adequately with lifestyle modifications, dietary changes, and low-dose proton pump inhibitors(PPIs). For those with refractory GERD poorly controlled with daily PPIs, numerous treatment options exist. Fundoplication is currently the most commonly performed antireflux operation for management of GERD. Outcomes described in current literature following laparoscopic fundoplication indicate that it is highly effective for treatment of GERD; early clinical studies demonstrate relief of symptoms in approximately 85%-90% of patients. However it is still unclear which factors, clinical or instrumental, are able to predict a good outcome after surgery. Virtually all demographic, esophagogastric junction anatomic conditions, as well as instrumental(such as presence of esophagitis at endoscopy, or motility patterns determined by esophageal high resolution manometry or reflux patterns determined by means of pH /impedance-pH monitoring) and clinical features(such as typical or atypical symptoms presence) of patients undergoing laparoscopic fundoplication for GERD can be factors associated with symptomatic relief. With this in mind, we sought to review studies that identified the factors that predict outcome after laparoscopic total fundoplication.

Barrett's esophagus in 2016: From pathophysiology to treatment

Esophageal complications caused by gastroesophageal reflux disease(GERD)include reflux esophagitis and Barrett’s esophagus(BE).BE is a premalignant condition with an increased risk of developing esophageal adeno-carcinoma(EAC).The carcinogenic sequence may progress through several steps,from normal esophageal mucosa through BE to EAC.A recent advent of functional esophageal testing(particularly multichannel intraluminal impedance and pH monitoring)has helped to improve our knowledge about GERD pathophysiology,including its complications.Those findings(when properly confirmed)might help to predict BE neoplastic progression.Over the last few decades,the incidence of EAC has continued to rise in Western populations.However,only a minority of BE patients develop EAC,opening the debate regarding the cost-effectiveness of current screening/surveillance strategies.Thus,major efforts in clinical and research practice are focused on new methods for optimal risk assessment that can stratify BE patients at low or high risk of developing EAC,which should improve the cost effectiveness of screening/surveillance programs and consequently significantly affect health-care costs.Furthermore,the area of BE therapeutic management is rapidly evolving.Endoscopic eradication therapies have been shown to be effective,and new therapeutic options for BE and EAC have emerged.The aim of the present review article is to highlight the status of screening/surveillance programs and the current progress of BE therapy.Moreover,we discuss the recent introduction of novel esophageal pathophysiological exams that have improved the knowledge of the mechanisms linking GERD to BE.

Alginate controls heartburn in patients with erosive and nonerosive reflux disease

AIM:To evaluate the effect of a novel alginate-based compound,Faringel,in modifying reflux characteristics and controlling symptoms.METHODS:In this prospective,open-label study,40 patients reporting heartburn and regurgitation with proven reflux disease(i.e.,positive impedance-pH test/evidence of erosive esophagitis at upper endoscopy) underwent 2 h impedance-pH testing after eating a refluxogenic meal.They were studied for 1 h under basal conditions and 1 h after taking 10 mL Faringel.In both sessions,measurements were obtained in right lateral and supine decubitus positions.Patients also completed a validated questionnaire consisting of a 2-item 5-point(0-4) Likert scale and a 10-cm visual analogue scale(VAS) in order to evaluate the efficacy of Faringel in symptom relief.Tolerability of the treatment was assessed using a 6-point Likert scale ranging from very good(1) to very poor(6).RESULTS:Faringel decreased significantly(P < 0.001),in both the right lateral and supine decubitus positions,esophageal acid exposure time [median 10(25th75th percentil 6-16) vs 5.8(4-10) and 16(11-19) vs 7.5(5-11),respectively] and acid refluxes [5(3-8) vs 1(1-1) and 6(4-8) vs 2(1-2),respectively],but increased significantly(P < 0.01) the number of nonacid reflux events compared with baseline [2(1-3)vs 3(2-5) and 3(2-4) vs 6(3-8),respectively].Percentage of proximal migration decreased in both decubitus positions(60% vs 32% and 64% vs 35%,respectively;P < 0.001).Faringel was significantly effective in controlling heartburn,based on both the Likert scale [3.1(range 1-4) vs 0.9(0-2);P < 0.001] and VAS score [7.1(3-9.8) vs 2(0.1-4.8);P < 0.001],but it had less success against regurgitation,based on both the Likert scale [2.6(1-4) vs 2.2(1-4);P = not significant(NS)] and VAS score [5.6(2-9.6) vs 3.9(1-8.8);P = NS].Overall,the tolerability of Faringel was very good 5(2-6),with only two patients reporting modest adverse events(i.e.,nausea and bloating).CONCLUSION:Our findings demonstrate that Faringel is well-tolerated and effective in reducing heartburn by modifying esophageal acid exposure time,number of acid refluxes and their proximal migration.