Background: Alcohol-associated liver disease (ALD) is one of the leading indications for liver transplantation (LT). Excessive alcohol intake may cause severe alcoholic hepatitis (sAH) and trigger acute-on-chronic liver failure (ACLF). ACLF presence and its severity have an impact on sAH prognosis, increasing mortality and reducing steroid response. While post-LT survival rates are similar between ALD, including sAH and ACLF, and other etiologies, alcohol relapse (AR) remains a major concern. Moreover, factors influencing post-LT mortality and AR are still poorly defined, especially in alcohol-induced ACLF. This study aimed to compare overall survival (OS) and AR between alcohol-induced ACLF and AC and to identify predictors of post-LT mortality and AR.Materials & Methods: We retrospectively analyzed all patients transplanted for ALD at our center between January 2020 and December 2023. Patients were stratified in 3 groups: alcohol-induced ACLF (A), AC with abstinence before LT (B) and AC with ongoing alcohol consumption at LT (C). Data are expressed as percentages/mean ± SD and analyzed using Χ2/Fisher’s/ANOVA/Kruskal-Wallis tests. OS and AR were evaluated with Kaplan-Meier curves and predictors with Cox regression.Results: 161 patients were included: 21 in group A (14 ACLF-1, 5 ACLF-2, 2 ACLF-3), 117 in group B and 23 in group C. Mean follow-up was 31±16 months. Compared with B and C, group A patients were younger, had a lower Charlson Comorbidity Index, higher MELD score, shorter waiting-list time, and longer hospitalization and ICU stay. ∼50% of patients in group A were women. Group A also showed higher rejection (20%) and retransplantation (18.7%) rates. OS (Fig1) did not differ among groups (p=0.2). Most deaths occurred in the first year post-LT, mainly due to infections. In univariate analysis, hospitalization length (HR 1.03), ICU stay (HR 1.05) and caregiver presence (HR 0.37) correlated with OS, but only hospitalization length (HR 1.03) remained significant in multivariate analysis. AR differed significantly (p<0.0001) among groups (Fig2). Group A had the highest AR rate (38.2% at 1 and 2yrs, 53.7% at 3yrs), while Group B had the lowest (6.9% at 1yr, 10% at 2 and 3yrs). Early relapse (within the first year) was most common. <50% of patients had a harmful consumption. Age (HR 0.95) and enrollment in rehabilitation programs (HR 2.47) were associated with AR in univariate analysis, but not in multivariable analysis.Conclusions: OS rates provide evidence of long-term benefit in ACLF without differences between patients transplanted for alcoholic ACLF and those transplanted for AC, regardless of pre-LT abstinence. Although abstinence correlates with a lower risk of AR, it should not be the sole eligibility criterion for LT in patients with active alcohol use. Our focus must shift from pre-LT abstinence to identifying factors associated with a high risk of AR and optimizing interventions to minimize post-LT AR.

To report a case of advanced hepatocellular carcinoma (HCC) complicated by tumor rupture, successfully downstaged with combined oncolytic immunotherapy (Pexa-Vec) and a PD-1 inhibitor (Nivolumab), ultimately enabling liver transplantation (LT). This report highlights the potential role of immune checkpoint inhibitors (ICIs) as bridging therapy in otherwise ineligible patients. A 54-year-old male with HCV-related cirrhosis presented with multifocal, unresectable HCC (BCLC C) complicated by hemoperitoneum. Surgery was not indicated. He was enrolled in a Phase I/IIa trial of intralesional Pexa-Vec and intravenous Nivolumab (240 mg every 14 days). Percutaneous biopsies confirmed Edmondson–Steiner grade 2 HCC. Clinical, laboratory, and imaging follow-up were performed throughout therapy. Pre-transplant screening was performed after 4 years of stable disease. The patient received three intralesional Pexa-Vec injections and 93 cycles of Nivolumab over four years, with only mild, transient adverse events. Imaging showed stable disease without extrahepatic spread. Pre-LT evaluation confirmed preserved liver function (Child-Pugh A5, ECOG 0). Immunotherapy was suspended 12 weeks before LT, and LT was performed successfully in September 2023. Post-transplant follow-up (24 months) revealed no recurrence of HCC or graft rejection. HCV was eradicated with direct-acting antivirals. Explant pathology showed complete necrosis in injected nodules and regressive changes in other lesions. ICIs alone or in combination with oncolytic immunotherapy may serve as novel downstaging strategies in advanced, ruptured HCC. Successful LT with long-term disease-free survival challenges traditional concerns about peritoneal seeding. Larger studies are required to define optimal patient selection, timing, and safety of pre-transplant ICIs. A 54-year-old man with advanced, ruptured liver cancer had an unexpectedly stable course over four years while receiving immunotherapy and an oncolytic virus. He later underwent a liver transplant and remains cancer-free two years later, illustrating the unpredictable nature of some severe liver cancer cases. Not applicable.

Background and Aim: Metabolic dysfunction-associated steatotic liver disease (MASLD) and Heart failure (HF) are rapidly growing clinical challenges. MASLD affects approximately 25% of adults worldwide and associates with a higher risk of HF. Early myocardial dysfunction, as reflected by reduced left ventricular global longitudinal strain (LVGLS) often precedes the decline in ejection fraction (EF). Understanding the relation between MASLD and impaired systolic function may provide insights for HF prevention. Our study aimed to investigate the association between MASLD and LVGLS in patients without overt cardiovascular disease.Method: We retrospectively evaluated 58 patients with MASLD and no history of heart disease, followed at our outpatient clinic; of these 32 underwent 2D transthoracic echocardiography with speckle-tracking analysis of myocardial strain in all cardiac chambers. Diastolic dysfunction was defined as mitral E/E’ > 9, systolic dysfunction as LVGLS > –17.5%. Severe liver steatosis and significant stiffness were defined as CAP > 290 dB/m and LSM > 7 kPa, respectively. Informed consent was obtained for all participants.Results: A total of 58 patients were included (mean age 59.4 ±1 0.3 years; 48.3 % female). The mean BMI was 30.5 ± 4.6 kg/m². The most frequent comorbidities were arterial hypertension (60.3 %) and dyslipidemia (79.3 %). Hepatic steatosis was distributed as mild (10.3 %), moderate (15.5 %), and severe (36.2 %). Among the 32 patients who underwent echocardiography, the mean LVGLS was – 16.9 ± 4.0. Patients with severe steatosis showed significantly less negative LVGLS values compared to those without severe steatosis (- 15.4 vs - 18.7; p = 0.024); all patients had normal values of EF. Patients with LSM ≥ 7 kPa had less negative LVGLS compared to those with < 7 kPa (-16.5 vs - 17.7), although the difference was not statistically significant (p = 0.49). Metabolic parameters (glycemia, cholesterol, insulin) were not significantly associated to LVGLS.Conclusions: MASLD patients with severe steatosis have a significantly high frequency of impaired LVGLS, independent of age, sex, and conventional cardiovascular risk factors. LVGLS deterioration appears early in MASLD, before ejection fraction declines. Our findings support echocardiographic screening for heart failure in all patients with liver steatosis and MASLD screening for all cardiac patients.

Background & Aims: The prognostic impact of asymptomatic pulmonary hypertension (PulH) in compensated cirrhosis remains unclear, particularly following the 2022 ESC/ERS guidelines that lowered the diagnostic mPAP threshold to >20 mmHg and introduced the “unclassified PulH” phenotype. We evaluated whether the hemodynamic phenotype and severity of asymptomatic PulH influenced long-term survival. Methods. We retrospectively analyzed consecutive patients undergoing routine hepatic and right-heart catheterization between 2016 and 2023. PulH phenotypes were pre-capillary (mPAP >20 mmHg, PCWP ≤15 mmHg, PVR ≥2 WU), post-capillary (mPAP > 20mmHg, PCWP >15 mmHg), and unclassified (mPAP >20 mmHg, PCWP ≤15 mmHg, PVR <2 WU). Mild PulH was defined by mPAP 21–24 mmHg and conclamant by mPAP ≥25 mmHg. We excluded patients on beta-blockers, diuretics, and other drugs affecting cardio-pulmonary function. Five-year transplant-free survival (5y-TFS) and 5-year not liver-related mortality (5y-NLRM; censoring at first decompensation, HCC diagnosis, or first ACLF episode leading to death/transplantation) were assessed. Results. Among 1632 screened patients, 325 (20%) met no exclusion criteria; 198 (61%) presented with PulH. Unclassified PulH was most frequent (30%), followed by post-capillary (17%) and pre-capillary (14%). Liver function was preserved (MELD 10.4±3.8, Child-Pugh 5.7±1.2), and clinically significant portal hypertension was evident in 83%, without major differences between patients with or without PulH. During a mean follow-up of 4.9±2.7 years, 110 patients decompensated (34%), 89 developed HCC (27%), 115 died (35%), and 49 underwent transplantation (15%). Five-year TFS differed significantly across PulH phenotypes (67% no-PulH, 61% unclassified, 53% pre/post-capillary; p=0.01). Corresponding 5y-NLRM rates were 94%, 86% and 74% (p<0.001). Both TSF and NLRM pairwise comparison showed significant differences between no-PulH and either unclassified or pre/post-capillary PulH. TFS (67%, 60%, and 50% in no-PulH, mild, and conclamant PulH, respectively; p=0.006) and NLRM (94%, 82%, and 76%, respectively; p<0.001) both declined with increasing PulH severity. Pairwise contrasts showed significant differences between no-PulH and either mild or conclamant PulH in both frameworks. In multivariable analysis for NLRM, similar to TFS, PulH severity independently predicted mortality: mild PulH (HR 3.68, p=0.007) and conclamant PulH (HR 5.45, p<0.001), together with age (HR 1.07, p<0.001), CP score (HR 1.28, p<0.001), and hemoglobin (HR 0.82, p=0.011). Replacing severity with PulH phenotypes, unclassified PulH (HR 3.39, p=0.013) and pre/post-capillary PulH (HR 4.87, p<0.001) emerged as independent risk factors. Conclusions. In compensated cirrhosis, both PulH phenotype and severity have an independent impact on long-term survival.

BACKGROUND & AIMS:Portal hypertension is a major challenge in patients with cirrhosis requiring surgery. This study aimed to evaluate the efficacy of under-dilated neoadjuvant transjugular intrahepatic portosystemic shunt (U.N-TIPS) in enabling elective extrahepatic oncologic surgery in patients with cirrhosis and clinically significant portal hypertension (CSPH). METHODS:This retrospective multicenter analysis included 34 patients who underwent U.N-TIPS (diameter 5-7 mm) between June 2018 and April 2023. The primary outcome was the ability of U.N-TIPS to enable surgical interventions otherwise contraindicated. Secondary outcomes were perioperative complications, overt hepatic encephalopathy (OHE), heart failure, and survival rates at 6 months and 1 year post-TIPS. RESULTS:At baseline, 53% of patients had decompensated cirrhosis. The most common malignancies were colorectal (32%) and gastric (15%). Final diameters were 5/6/7 mm in 9/17/8 patients, respectively. Mean porto-caval pressure gradient (PCPG) significantly decreased from 21 ± 4.5 to 11 ± 3.2 mmHg (p < 0.001), with all patients achieving PCPG < 16 mmHg. Thirty-two patients (94%) underwent planned surgery, with a median TIPS-to-surgery interval of 42 days (IQR 45). Postoperative complications occurred in 38% of patients-mostly infections-and were independently associated with pre-surgery MELD score and haemoglobin. Post-TIPS OHE occurred in 22%, with no persistent cases; symptomatic heart failure developed in 6%. Six-month and one-year survival rates were 85% and 76%, respectively, without significant difference between pre-TIPS compensated and decompensated patients (p = 0.21). CONCLUSIONS:U.N-TIPS represents an applicable strategy for enabling curative oncologic surgery in selected patients with cirrhosis and CSPH. Under-dilation reduces shunt-related complications while preserving hemodynamic efficacy, expanding TIPS applicability. IMPACT AND IMPLICATIONS:U.N-TIPS addresses the critical barrier of portal hypertension in oncologic patients with cirrhosis, offering access to surgical treatments considered unfeasible while maintaining an adequate safety profile. These findings are particularly significant for hepatologists, oncologists, interventional radiologists, and surgeons managing the increasingly common clinical scenario of cirrhosis with concurrent extrahepatic malignancies. In clinical practice, our results support the implementation of multidisciplinary tumour boards that incorporate portal pressure assessment and TIPS indication in pre-surgical planning. However, large, controlled studies are needed to compare outcomes between compensated patients with CSPH who undergo U.N-TIPS versus those who do not receive this intervention.

Background & Aims: Overt hepatic encephalopathy (OHE) continues to be the primary complication following transjugular intrahepatic portosystemic shunt (TIPS) placement. It significantly impairs patients' health-related quality of life, particularly in its recurrent and persistent forms, and may outweigh the benefits of the procedure. This study aimed to develop and internally validate a prognostic score incorporating quantified electroencephalography (qEEG) to predict the risk of post-TIPS recurrent OHE at 3 and 6 months. Methods: We prospectively enrolled 161 consecutive patients with cirrhosis undergoing elective TIPS for refractory or recurrent ascites or secondary prophylaxis of variceal bleeding. All patients underwent qEEG assessment using validated spectral analysis criteria prior to TIPS placement. A multivariable Cox regression model was constructed to estimate the risk of recurrent OHE. Model performance was evaluated using time-dependent ROC curves, calibration plots, decision curve analysis, and internal validation via bootstrap resampling (B = 1,500). Results: Independent predictors of recurrent OHE included age, serum albumin, prior OHE history, and qEEG alterations, which were incorporated into the novel qEEG-TIPS score. The time-dependent AUCs were 0.76 (95% CI 0.70-0.82) and 0.80 (95% CI 0.76-0.85) at 3 and 6 months, respectively. The score identified high-risk patients with a significantly greater incidence of recurrent OHE at 6 months (48% vs. 8% in low-risk patients, p <0.001). Internal validation yielded an optimism-corrected C-index of 0.74 (95% CI 0.69-0.84), indicating mild overfitting but good predictive stability. Decision curve analysis supported the clinical utility of the model. Conclusions: The qEEG-TIPS score demonstrated good discrimination and calibration in predicting short-term risk of recurrent OHE after TIPS. This tool may assist in risk stratification and guide personalized management both before and after TIPS. Impact and implications: Recurrent overt hepatic encephalopathy (OHE) is the primary complication of transjugular intrahepatic portosystemic shunt (TIPS) in patients with cirrhosis, markedly reducing quality of life, increasing healthcare burden, and complicating clinical decision-making. This study introduces and internally validates the qEEG-TIPS score, a novel, non-invasive tool integrating quantified electroencephalography with clinical variables to predict the short-term risk of recurrent OHE after elective TIPS. These findings hold particular relevance for patients, hepatologists, and transplant teams as they enable more personalized risk assessment prior to TIPS and may guide decisions on prophylaxis, patient selection, and post-procedural monitoring. If externally validated, the qEEG-TIPS score could enhance clinical pathways by identifying high-risk patients for targeted interventions, supporting more cost-effective and patient-centered TIPS management strategies.

Background: Classification of portal hypertension (PH) is crucial to define prognosis and management strategies. When different/unclear etiologies coexist, non-invasive tests (NITs) and hepatic venous pressure gradient (HVPG) may be inconclusive. Measuring HVPG together with PortoHepatic (PHPG) and PortoCaval (PCPG), a technique we nominated hybrid Transjugular–Percutaneous PortoHepatic Pressure Gradient (hTP-PHPG), represents the only available approach to define both the anatomical site(s) and magnitude of PH. Aim: To assess the safety and diagnostic utility of hTP-PHPG.Methods: We retrospectively analyzed all patients undergoing hTP-PHPG between 2022–2025 at our Hemodynamic Lab. Under local anesthesia, light sedation and combined fluoroscopic and ultrasound guidance hepatic venography, HVPG, PHPG, PCPG (and right heart catheterization) were performed. Pressures were recorded using a multichannel polygraph, with continuous waveform acquisition. Reassessment of liver and spleen stiffness was also performed in all patients while transjugular/percutaneous liver biopsy was performed when indicated.Results: Forty-five patients underwent hTP-PHPG (mean age 57±11 years, 38% male). All had chronic liver disease and signs of PH not fully explained by the underlying liver etiology, thereby suspected for concomitant non-sinusoidal PH, such as portosinusoidal vascular disorder. The procedure was well tolerated and successful in all patients, with 4% of minor complications and no serious adverse events. Mean HVPG, PHPG and PCPG were 7±6, 14±9 and 15±9 mmHg, respectively. Intrahepatic vein-to-vein shunts were present in 24%. Combined pressure gradients analysis showed pure presinusoidal clinically significant PH (CSPH) in 24% (HVPG <10mmHg, PHPG10mmHg), sinusoidal CSPH in 11% (HVPG and PHPG both 1mmHg, without significant differences), mixed sinusoidal–presinusoidal CSPH in 22% (HVPG 1mmg, PHPG 1mmg eceeding HVPG by >2mmHg), non-CSPH in 16% (PHPG exceeding HVPG by >2mmHg in only one patient), and no PH in 27% (HVPG and PHPG <5mmHg). Significant hepato-cava pressure gradient (>2mmHg) was present in 9% of cases indicating the presence of an additional post-sinusoidal component. Although this component increased PH, it did not determine any shift towards CSPH. Among NITs, the Baveno VII combined criteria yielded the best performance. However, it showed a 25% error rate in CSPH ruling-out, 12% in ruling-in, and 9% persistence in the grey-zone (16% misclassification). Surprisingly, defining CSPH solely by presence of esophageal varices would have yielded 13% false positives (HVPG/PCPG/PHPG <10mmHg).Conclusions: hTP-PHPG is a safe and resolutive method for assessing the anatomical site(s) and magnitude of PH in patients with clinically evident or suspected PH of undefined-mixed-etiology. Presence of varices without CSPH further highlights the rational for the implementation of hTP-PHPG in referral centers for the diagnosis of PH.

Background & Aim: Transjugular intrahepatic portosystemic shunt (TIPS) is an established therapeutic option for portal hypertension-related complications, including refractory ascites and variceal bleeding. Despite significant technical and clinical improvements, post-TIPS overt hepatic encephalopathy (OHE) remains the most frequent complication, particularly in its recurrent form, which profoundly impairs health-related quality of life and may challenge the overall benefit of TIPS. While several factors have been associated with increased OHE risk, current predictive tools lack accuracy and clinical utility. Quantified electroencephalography (qEEG) allows objective assessment of neurophysiological alterations in cirrhosis and may provide additional prognostic information. This study aimed to develop and internally validate a model integrating qEEG data with clinical variables to predict the risk of recurrent OHE after elective TIPS.Methods: In this prospective cohort study, 161 consecutive patients with cirrhosis undergoing elective TIPS for refractory ascites or secondary prophylaxis of variceal bleeding were enrolled between 2015-2024. Before TIPS, all patients underwent qEEG assessment by validated spectral analysis criteria. The primary endpoint was recurrent OHE, defined as at least two episodes within six months after TIPS. A Cox proportional hazards model was built using baseline variables by backward selection. Model discrimination was assessed by time-dependent receiver operating characteristic (ROC) analysis, and calibration was evaluated using calibration plots, intercept and slope estimation. Internal validation was performed through 1,500 bootstrap resamples to obtain optimism-corrected performance metrics.Results: During follow-up, 35 patients (22%) developed recurrent OHE. Independent predictors were age, albumin, history of OHE, and altered qEEG pattern. The model demonstrated good discrimination, with AUCs of 0.803 (95% CI 0.756-0.850) at 6 months. Internal validation yielded optimism-corrected C-index of 0.739 (95% CI 0.691-0.842) and calibration slope of 0.915 (95% CI 0.685-1.154), indicating consistent discrimination and adequate calibration with only modest overfitting. The model identified a high-risk subgroup with a 6-month risk of recurrent OHE of 48% (95% CI 32-61), compared with 8% (95% CI 3-13) among low-risk patients (p <0.001).Conclusions: A predictive model incorporating qEEG features with standard clinical variables accurately estimated the risk of recurrent OHE after TIPS. The model showed good discrimination, satisfactory calibration, and promising clinical utility. Pre-TIPS qEEG assessment may help identify patients at increased risk of recurrent OHE, supporting tailored prophylactic strategies, optimized patient counseling, and more individualized post-TIPS follow-up. External validation is warranted to confirm its generalizability and facilitate its integration into routine clinical practice.

BACKGROUND:Clinically significant portal hypertension (CSPH) drives decompensation and mortality in advanced chronic liver disease (ACLD). Although non-selective β-blockers (NSBB) reduce risk, accurate identification of patients with CSPH requires invasive hepatic venous pressure gradient (HVPG) measurement. The non-invasive Baveno-VII CSPH criteria based on liver stiffness measurement (LSM) and platelet count (PLT)-yield 40-50% indeterminate ("gray-zone") results and vary across etiologies and elastography techniques. Spleen stiffness measurement (SSM) has been proposed to improve the accuracy of the Baveno-VII CSPH criteria. We developed and validated a machine-learning (ML) model integrating pan-elastographic LSM and SSM results with clinical variables to improve CSPH rule-out and rule-in accuracy while minimizing indeterminate cases. METHODS:We analyzed 1,435 compensated ACLD patients with paired HVPG, LSM, SSM, and clinical parameters. LSM and SSM were obtained by vibration-controlled transient elastography (VCTE), two-dimensional shear-wave elastography (2D-SWE), or point-SWE (p-SWE). Models were trained (n=943) and internally validated (n=150) using harmonized LSM/SSM from different technologies and clinical variables (PLT, Child-Pugh, age, gender, etiology). Cut-offs were selected for 100% negative predictive value (NPV) to rule-out and 100% positive predictive value (PPV) to rule-in CSPH. External validation was conducted in 342 patients across seven centers, comparing ML performance against Baveno VII, Baveno-SSM single- and dual-cut-off criteria, and, in the VCTE subgroup, ANTICIPATE and NICER scores. RESULTS:A Random Forest-based model based achieved the highest performance (external validation: AUC=0.91, Brier Score=0.13), with cut-offs≤0.45 (rule-out) and ≥0.60 (rule-in) yielding NPV=0.90 (95%C.I.0.84-0.94) and PPV=0.96 (95%C.I.0.92-0.98). The ML gray-zone was 12.3%, versus 47.9% (Baveno VII;p<0.001), 38.6% (Baveno-SSM-dual;p<0.001), and 19.6% (Baveno-SSM-single;p<0.05). In the VCTE external-validation subgroup (n=275), ELM achieved comparable rule-in performance to ANTICIPATE and NICER, while reducing the gray zone to 12.0% versus 41.1% and 41.8%, respectively. CONCLUSIONS:The ELM Score outperformed current Baveno criteria and markedly reduced gray zones across elastography modalities, supporting broader, safer, and non-invasive identification of ACLD patients with HVPG-defined CSPH who may be candidates for NSBB therapy.

SOS/VOD is a life-threatening complication of hematopoietic stem cell transplantation, especially in children, with incidences reaching up to 15-20%. Despite efforts, SOS/VOD remains unpredictable with significant morbidity and mortality. High-risk criteria are clearly defined, and the pediatric EBMT diagnostic criteria have improved sensitivity, reducing treatment delays and enhancing outcomes. A meta-analysis combining retrospective and prospective studies found a risk ratio of 0.30 for SOS/VOD with defibrotide (DF) prophylaxis. Additionally, two prospective trials were conducted: the pediatric prevention trial (NCT00272948) and the Harmony Trial (NCT02851407), involving adults and children, with primary outcomes of incidence and SOS/VOD-free survival, respectively. The trials produced conflicting results regarding the effectiveness of prophylactic DF. Despite significant limitations of the Harmony trial, a direct healthcare professional communication (DHPC) from the European Medicines Agency (EMA) advised against prophylactic DF. This recommendation has serious consequences for children, especially infants, who are among the most vulnerable groups receiving HSCT. Therefore, a panel of experts issued guidelines for children at high risk for SOS/VOD, in which DF prophylaxis is considered justified. These guidelines include a weighted scoring system based on all relevant high-risk criteria to predict SOS/VOD, supporting decisions regarding the use of prophylactic DF in children.

Irritable bowel syndrome (IBS) is a common gastrointestinal disorder characterized by recurrent abdominal pain and altered bowel habits that significantly impair patients’ quality of life. Dietary triggers of IBS symptoms are common, and consequently, diet-based treatments are often prescribed. We conducted a review of current evidence on dietary interventions for IBS, focusing specifically on the evaluation of the scientific rationale and effectiveness of the most commonly adopted diets. Clinical trials and guideline recommendations were analyzed to assess each diet’s efficacy in symptom relief and patient adherence. Traditional dietary advice, although not a structured diet, but rather a set of lifestyle and dietary recommendations, is commonly recommended as first-line therapy and provides a solid base for symptom improvement in almost half of patients with IBS. Conversely, the low-FODMAP diet is a strict dietary pattern characterized first by the exclusion and then by the gradual and personalized reintroduction of several foods. Several clinical trials have demonstrated the efficacy of a low-FODMAP diet in reducing global IBS symptoms, and due to the established evidence, it is now incorporated into many clinical guidelines as a second- or even first-line approach for patients with IBS. Limited data supports the starch- and sucrose-reduced diet as an option for symptom relief, with evidence stemming from the relatively recent finding of hypomorphic variants of the sucrose-isomaltase gene in a subset of patients with IBS. Nonetheless, its application in clinical practice is still very limited. Data on gluten-free diet is more controversial as although it may benefit a subset of patients with IBS, strong evidence is still lacking for identifying the best candidates for a restrictive diet with a high burden in terms of economical, psychological and social costs. Beyond exclusion diets, a few studies on the Mediterranean diet suggest it may be a potential option with benefits that go beyond IBS symptom relief. Overall, dietary modification can significantly alleviate IBS symptoms. Tailoring recommendations to individual patient triggers may further enhance outcomes.

Hepatic Veno-occlusive disease/sinusoidal obstruction syndrome (VOD/SOS) is a severe complication following hematopoietic stem cell transplantation (HSCT), traditionally diagnosed based on clinical criteria. This study aimed to evaluate the diagnostic performance of liver stiffness measurement (LSM) as a non-invasive tool for non invasive diagnosis of VOD/SOS. A multicentre clinical trial was conducted in Italy from April 2018 to December 2021, screening 1089 patients across 25 centers. VOD/SOS diagnosis followed established clinical guidelines, and patients underwent comprehensive clinical, laboratory, and imaging evaluations up to +100 days post-HSCT or until VOD/SOS diagnosis. LSM was measured pre-HSCT and on specific post-transplant days (ClinicalTrials.gov: NCT03426358). The study enrolled 774 adults and 167 children. The +100-day incidence of VOD/SOS HSCT was 5.53 and 5.26 in the overall and allo-HSCT population, higher in children (14.3