Treating morbid obesity in cirrhosis: A quest of holy grail

The problem of obesity is increasing worldwide in epidemic proportions; the situation is similarly becoming more common in patients with cirrhosis which negatively affect the prognosis of disease and also makes liver transplantation difficult especially in the living donor liver transplantation setting where low graft to recipientweight ratio negatively affects survival. Treatment of obesity is difficult in cirrhosis due to difficulty in implementation of lifestyle measures, limited data on safety of anti-obesity drugs and high risk of surgery. Currently approved anti-obesity drugs have limited data in patients with cirrhosis. Bariatric surgery remains an option in selected compensated cirrhotic patients. Endoscopic interventions for obesity are emerging and are quite promising in patients with cirrhosis as these are minimally invasive. In present review, we briefly discuss various modalities of weight reduction in obese patients and their applicability in patients with cirrhosis.

To scan or not to scan:Use of transient elastography in an integrated health system

BACKGROUND Non-invasive tests,such as Fibrosis-4 index and transient elastography(com-monly FibroScan),are utilized in clinical pathways to risk stratify and diagnose non-alcoholic fatty liver disease(NAFLD).In 2018,a clinical decision support tool(CDST)was implemented to guide primary care providers(PCPs)on use of FibroScan for NAFLD.AIM To analyze how this CDST impacted health care utilization and patient outcomes.METHODS We performed a retrospective review of adults who had FibroScan for NAFLD indication from January 2015 to December 2017(pre-CDST)or January 2018 to December 2020(post-CDST).Outcomes included FibroScan result,laboratory tests,imaging studies,specialty referral,patient morbidity and mortality.RESULTS We identified 958 patients who had FibroScan,115 before and 843 after the CDST was implemented.The percentage of FibroScans ordered by PCPs increased from 33%to 67.1%.The percentage of patients diagnosed with early F1 fibrosis,on a scale from F0 to F4,increased from 7.8%to 14.2%.Those diagnosed with ad-vanced F4 fibrosis decreased from 28.7%to 16.5%.There were fewer laboratory tests,imaging studies and biopsy after the CDST was implemented.Though there were more specialty referrals placed after the CDST was implemented,multivariate analysis revealed that healthcare utilization aligned with fibrosis score,whereby patients with more advanced disease had more referrals.Very few patients were hospitalized or died.CONCLUSION This CDST empowered PCPs to diagnose and manage patients with NAFLD with appropriate allocation of care towards patients with more advanced disease.

Women’s health issues in solid organ transplantation:Breast and gynecologic cancers in the post-transplant population

The success of solid organ transplant has steadily improved which has led to a unique set of post-transplant issues.The rates of de novo cancer in the solid organ transplant recipient population are higher than those in the general population.There is growing evidence that breast and gynecologic cancers may have a higher mortality rate in post-transplant patients.Cervical and vulvovaginal cancers specifically have a significantly higher mortality in this population.Despite this increased mortality risk,there is currently no consistent standard in screening and identifying these cancers in post-transplant patients.Breast,ovarian and endometrial cancers do not appear to have significantly increased incidence.However,the data on these cancers remains limited.Further studies are needed to determine if more aggressive screening strategies would be of benefit for these cancers.Here we review the cancer incidence,mortality risk and current screening methods associated with breast and gynecologic cancers in the post-solid organ transplant population.

Insights into gastrointestinal manifestation of human immunodeficiency virus:A narrative review

Human immunodeficiency virus(HIV)modifies CD4-positive cells,resulting in immunodeficiency and a wide range of gastrointestinal(GI)manifestations.The burden of HIV-related GI illnesses has significantly evolved with the widespread use of antiretroviral therapy(ART).While ART has effectively reduced the occurrence of opportunistic infections,it has led to an increase in therapy-related GI illnesses.Common esophageal conditions in HIV patients include gastroesophageal reflux disease,idiopathic esophageal ulcers,herpes simplex virus,cytomegalovirus(CMV),and candidal esophagitis.Kaposi’s sarcoma,a hallmark of acquired immunodeficiency syndrome,may affect the entire GI system.Gastritis and peptic ulcer disease are also frequently seen in patients with HIV.Diarrhea,often linked to both opportunistic infections and ART,requires careful evaluation.Bloody diarrhea,often a sign of colitis caused by bacterial infections such as Shigella or Clostridium difficile,is prevalent.Small bowel lymphoma,although rare,is increasing in prevalence.Anorectal disorders,including proctitis,fissures,and anal squamous cell carcinoma,are particularly relevant in homosexual men,underlining the importance of timely diagnosis.This review comprehensively explores the epidemiology,pathogenesis,and treatment considerations for the various GI disorders associated with HIV,highlighting the importance of accurate diagnosis and effective treatment to improve outcomes for HIV-infected patients.

Management of Hepatitis C Post-liver Transplantation: a Comprehensive Review

Infection with hepatitis C virus (HCV) is a common cause of chronic liver disease,and HCV-related cirrhosis and hepatocellular carcinoma are the leading causes for liver transplantation in the Western world.Recurrent infection of the transplanted liver allograft is universal in patients with detectable HCV viremia at the time of transplant and can cause a spectrum of disease,ranging from asymptomatic chronic infection to an aggressive fibrosing cholestatic hepatitis.Recurrent HCV is more aggressive in the post-transplant population and is a leading cause of allograft loss,morbidity,and mortality.Historically,treatment of recurrent HCV has been limited by low rates of treatment success and high side effect profiles.Over the past few years,promising new therapies have emerged for the treatment of HCV that have high rates of sustained virological response without the need for interferon based regimens.In addition to being highly effective,these treatments have higher rates of adherence and a lower side effect profile.The purpose of this review is to summarize current therapies in recurrent HCV infection,to review the recent advances in therapy,and to highlight areas of ongoing research.

Hodgkin's lymphoma coexisting with liver failure secondary to acute on chronic hepatitis B

Acute on chronic liver failure(ACLF) is rarely the initial manifestation of a malignant process or precipitated by the initiation of anti-viral treatment with a nucleoside or nucleotide agent. We report an unusual case of ACLF temporally associated with initiation of Entecavir for treatment of chronic hepatitis B. Early Hodgkin's lymphoma(HL) was unmasked with initiation of the antiviral treatment which may have exacerbated ACLF. To the best of our knowledge, this has not been described in the literature. In reviewing our patients clinical course and liver autopsy, he developed a severe acute exacerbation of his chronic hepatitis B virus coinciding with the institution of antiviral therapy and the underlying HL perhaps modulating the overall degree of hepatic injury.