Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update

More than five decades after it was originally conceptualized as rescue therapy for patients with intractable variceal bleeding,the transjugular intrahepatic portosystemic shunt(TIPS)procedure continues to remain a focus of intense clinical and biomedical research.By the impressive reduction in portal pressure achieved by this intervention,coupled with its minimally invasive nature,TIPS has gained increasing acceptance in the treatment of complications of portal hypertension.The early years of TIPS were plagued by poor long-term patency of the stents and increased incidence of hepatic encephalopathy.Moreover,the diversion of portal flow after placement of TIPS often resulted in derangement of hepatic functions,which was occasionally severe.While the incidence of shunt dysfunction has markedly reduced with the advent of covered stents,hepatic encephalopathy and instances of early liver failure continue to remain a significant issue after TIPS.It has emerged over the years that careful selection of patients and diligent post-procedural care is of paramount importance to optimize the outcome after TIPS.The past twenty years have seen multiple studies redefining the role of TIPS in the management of variceal bleeding and refractory ascites while exploring its application in other complications of cirrhosis like hepatic hydrothorax,portal hypertensive gastropathy,ectopic varices,hepatorenal and hepatopulmonary syndromes,non-tumoral portal vein thrombosis and chylous ascites.It has also been utilized to good effect before extrahepatic abdominal surgery to reduce perioperative morbidity and mortality.The current article aims to review the updated literature on the status of TIPS in the management of patients with liver cirrhosis.

One disease, many faces-typical and atypical presentations of SARS-CoV-2 infection-related COVID-19 disease

Since the appearance of the novel coronavirus(severe acute respiratory syndrome-coronavirus-2)and related coronavirus disease 2019(COVID-19)in China in December 2019,a very high number of small and large patient series have been published in literature from around the world.Even though the classical presentation of COVID-19 is one with respiratory symptoms with or without pneumonia that can be self-limiting or evolve into severe respiratory distress syndrome with multiple organ failure,and secondary bacterial sepsis,a large body of evidence suggests a plethora of other types of clinical presentation.In this exhaustive review,we reviewed all of the published literature on COVID-19 to identify different types of clinical presentations affecting various organ systems,to provide an in-depth analysis that may prove useful for clinicians and health-workers on the frontline,battling the severe pandemic.

Modulating the Intestinal Microbiota:Therapeutic Opportunities in Liver Disease

Gut microbiota has been demonstrated to have a significant impact on the initiation,progression and development of complications associated with multiple liver diseases.Notably,nonalcoholic fatty liver diseases,including nonalcoholic steato-hepatitis and cirrhosis,severe alcoholic hepatitis,primary scle-rosing cholangitis and hepatic encephalopathy,have strong links to dysbiosis–or a pathobiological change in the microbiota.In this review,we provide clear and concise discussions on the human gut microbiota,methods of identifying gut microbiota and its functionality,liver diseases that are affected by the gut microbiota,including novel associations under research,and provide current evidence on the modulation of gut microbiota and its effects on specific liver disease conditions.

Outcomes and Toxicology of Herbal Drugs in Alcoholic Hepatitis-A Single Center Experience from India

Background and Aims:We aimed to study clinical out-comes and liver biopsy features of alcoholic hepatitis(AH)patients on complementary and alternative medicines(CAMs)and to analyze the retrieved drugs for chemical and toxic components linked to drug-induced liver injury.Methods:We retrospectively assessed clinical,biochemical and liver bi-opsy features of AH patients on CAM with drug-induced liver injury(AH-CAM,n=27)and compared them to a control group(classical AH,n=29)on standard of care.Patients without liver biopsy evaluation and other causes for liver dis-ease were excluded.Samples of the CAMs(n=42)from pa-tients were retrieved and assessed for chemical and toxins.Results:All were males,and significantly worse clinical pre-sentation,biochemical severity,and liver disease scores were notable in patients with AH-CAM.Traditional Ayurve-dic-polyherbal formulations were the most commonly used CAM.On liver histology,varying grades of severe-necrosis,severe hepatocellular,canalicular,cholangiolar cholestasis with predominant lymphocytic-portal-inflammation and varying grades of interface-hepatitis were noted in AH-CAM.Analysis of CAMs revealed presence of heavy metals up to 100,000 times above detectable range and adulter-ants,such as antibiotics,chemotherapy agents,nonsteroi-dal anti-inflammatory drugs,alcohols,antidepressants,anxiolytics,and recreational drugs.On follow up,a signifi-cantly higher number of patients with AH on CAM died at end of 1,3-and-6-months compared to controls(37%vs.83%,29%vs.62%,18%vs.52%respectively;p<0.001).Conclusions:Patients with AH and CAM-related drug-induced liver injury have extremely poor short-term survival in the absence of liver transplantation compared to those patients with AH on evidence-based management.Early transplant referral and educating on and curbing of CAM use in severe liver disease through strict monitoring of unregulated traditional health practices can help ease the burden of liver-related death.