Institute of Liver and Biliary Sciences

Aortic fistulas represent rare but life-threatening communications between the aorta and the adjacent structures, most commonly the gastrointestinal tract. They are classified as primary, arising spontaneously in the setting of a native, diseased aorta, or secondary to prior aortic surgery or endovascular repair. Clinical presentation is often variable and nonspecific—ranging from gastrointestinal bleeding, sepsis, abdominal pain to hemodynamic collapse—making imaging pivotal for diagnosis. Computed tomography angiography is the preferred imaging modality. Imaging features such as visualization of the fistula tract and active contrast extravasation into the fistulized hollow organ are definitive signs of aortic fistulas, but are rarely encountered. On the contrary, nonspecific indirect imaging features such as loss of fat planes and/or ectopic foci of gas are more frequently seen. Prompt recognition of these indirect imaging features is crucial, as delayed diagnosis significantly increases mortality. This review article summarizes the types, clinical features, and imaging findings of aortic fistulas, emphasizing the radiologist’s pivotal role in timely detection and management of aortic fistulas.

Acute-on-chronic liver failure (ACLF) is a complex syndrome characterized by acute hepatic decompensation superimposed on pre-existing chronic liver disease or cirrhosis that is associated with acute worsening of portal hypertension, increased risk of infection, organ dysfunction and high short-term mortality. This Review provides a comprehensive update on definitions, pathophysiological mechanisms, clinical presentation and management of ACLF. The severe hepatic injury in ACLF triggers systemic inflammation, which is driven by damage-associated molecular patterns, gut-derived microbial products, and immunometabolic and functional dysregulation. Immune dysfunction can range from hyperinflammation and hypercytokinaemia to immune paresis, which in turn predisposes patients to infection and organ failure. The principles of ACLF management prioritize ameliorating the acute hepatic insult, managing portal hypertension, preventing organ failure and optimizing patients who are eligible for liver transplantation. Emerging options include novel therapies targeting immune modulation and liver regeneration, therapeutic plasma exchange and artificial liver support systems. Well-defined criteria for prompt interventions and selection of patients for transplantation within the first week after diagnosis — the ‘golden window’ — have improved outcomes of liver transplantation in patients with ACLF. The Kyoto ACLF Consensus reflects global efforts on unifying definitions, simplifying treatment end points, refining prediction tools, and filling the void of targeted non-transplantation interventions to improve outcomes in patients with ACLF; however, large knowledge gaps remain and further research is needed. Acute-on-chronic liver failure (ACLF) is a complex syndrome characterized by acute hepatic decompensation superimposed on pre-existing chronic liver disease or cirrhosis. This Review provides an update on definitions, pathophysiological mechanisms, clinical presentation and management of ACLF.

INTRODUCTION:Artificial intelligence (AI) and digital pathology have the potential to augment liver biopsy interpretation in MAFLD in clinical practice and trials assessment. However, attitudes and barriers to its implementation have not been systematically explored. METHODS:A survey focusing on conventional liver histology, digital pathology and its AI applications in MAFLD/MASH was conducted among hepatologists and liver pathologists in the Asia Pacific region. RESULTS:AI-assisted digital pathology is perceived to be a valuable addition to existing histological reporting in MAFLD/MASH. Defined standards for application and validation of AI models are important priorities for their implementation. CONCLUSION:There is consensus among clinical experts in the Asia Pacific that AI-assisted histological assessment is useful in MAFLD/MASH interpretation. However, there remain important challenges to the adoption of these technologies into routine clinical workflows.

Identification of inferior pancreaticoduodenal artery (IPDA) on multi detector CT (MDCT) abdomen in relation to nearby vessels can guide its early ligation during pancreaticoduodenectomy (PD). Patients undergoing PD from March, 2022, to April, 2024, underwent 3D reconstruction of the vessels on MDCT and the distance between the root of the left renal vein (LRV), origin of superior mesenteric artery (SMA) and middle colic artery (MCA), and the origin of IPDA were estimated. Among 46 patients (standard PD and PD by early ligation of IPDA in 23 patients each) after exclusion, IPDA was identified intra-operatively within 1 cm and 5 mm of anticipated location as determined by 3D reconstructed MDCT from the root of LRV in 93.3

Transient elastography of liver and spleen, along with platelet count, identify cirrhosis patients with esophageal varices needing treatment (VNT). Inflammation can drive rapid rise in portal pressure and development and progression of varices in acute-on-chronic liver failure (ACLF) patients. We aimed at developing a non-invasive model to predict VNT in ACLF patients. Baseline liver stiffness measurement (LSM) and spleen stiffness measurement (SSM) were done using Fibroscan 630 Expert and esophagogastroduodenoscopy was performed to detect VNT. Varices with red color signs or large size were considered VNT. A model was developed and validated. Decision curve analysis (DCA) was used to assess net benefit (NB) of model at different threshold probabilities. Of the 216 patients analyzed (males 95.4