Background:To determine the superiority of the combination of endoscopic retrograde cholangiopancreatography (ERCP) and digital single-operator cholangioscopy (DSOC) in the same sitting over the individual modality alone in patients with indeterminate biliary strictures.Materials and Methods:A randomized study enrolled 60 adult patients with biliary strictures who were randomized into two groups: ERCP + DSOC and ERCP/DSOC. Histopathologic or cytologic assessment was performed in terms of benign, indeterminate, or malignant nature of the strictures. Procedural adverse events were documented. Accuracy in terms of sensitivity (Sn), specificity (Sp), and predictive value [positive (PPV) and negative (NPV)] were noted.Results:As per final diagnosis, in ERCP/DSOC group, there were 12 (40%) benign cases and 18 (60%) malignant cases, and in group ERCP + DSOC, there were 8 (26.67%) benign cases and 22 (73.33%) malignant cases. ERCP/DSOC labeled 16 (53.33%) patients as benign, 8 (26.67%) as malignant, and 6 (20%) as indeterminate, while ERCP + DSOC labeled 8 (26.67%) as benign, 17 (56.67%) as malignant, and 5 (16.67%) as indeterminate. The Sn, Sp, PPV, and NPV of ERCP/DSOC were 44.4%, 75%, 100%, and 56.25%, and for ERCP + DSOC was 77.27%, 62.50%, 100%, and 62.5%, respectively (P = 0.033). Side effects were statistically similar in both the groups (P > 0.05).Conclusion:To conclude, the combination of ERCP with DSOC is safe and effective with higher diagnostic sensitivity (77.27%) in comparison to standard ERCP or DSOC alone (44.4%) for the diagnosis of biliary strictures.

INTRODUCTION:The prevalence of metabolic dysfunction-associated fatty liver disease (MAFLD) and its complication, MAFLD-related acute-on-chronic liver failure (MAFLD-ACLF), is rising. Yet, factors determining patient outcomes in MAFLD-ACLF remain understudied. METHODS:Patients with MAFLD-ACLF were recruited from the Asian Pacific Association for the Study of the Liver-ACLF Research Consortium (AARC registry). The diagnosis of MAFLD-ACLF was made when the treating unit had identified the etiology of chronic liver disease as MAFLD (or previous nomenclature such as non-alcoholic fatty liver disease, non-alcoholic steatohepatitis, or non-alcoholic steatohepatitis-cirrhosis). Patients with coexisting other etiologies of chronic liver disease (such as alcohol, hepatitis B virus, hepatitis C virus, etc.) were excluded. Data were randomly split into derivation (n = 258) and validation (n = 111) cohorts at a 70:30 ratio. The primary outcome was 90-day mortality. Only the baseline clinical, laboratory features and severity scores were considered. RESULTS:The derivation group had 258 patients; 60% were male, with a mean age of 53. Diabetes was noted in 27% and hypertension in 29%. The dominant precipitants included viral hepatitis (hepatitis A virus and hepatitis E virus, 32%), drug-induced injury (drug-induced liver injury, 29%), and sepsis (23%). Model for End-Stage Liver Disease-Sodium (MELD-Na) and AARC scores on admission averaged 32 ± 6 and 10.4 ± 1.9. At 90 days, 51% survived. Nonviral precipitant, diabetes, bilirubin, international normalized ratio, and encephalopathy were independent factors influencing mortality. Adding diabetes and precipitant to MELD-Na and AARC scores, the novel MAFLD-MELD-Na score (+12 for diabetes, +12 for nonviral precipitant), and MAFLD-AARC score (+5 for each) were formed. These outperformed the standard scores in both cohorts. DISCUSSION:Almost half of patients with MAFLD-ACLF die within 90 days. Diabetes and nonviral precipitants such as drug-induced liver injury and sepsis lead to adverse outcomes. The new MAFLD-MELD-Na and MAFLD-AARC scores provide reliable 90-day mortality predictions for patients with MAFLD-ACLF.

Introduction: About 20% of the biliary strictures remains indeterminate after extensive investigations. ERCP with brush cytology is the standard technique for the evaluation of indeterminate biliary strictures. But ERCP-guided brush cytology has a low sensitivity of 15-60%. DSOC allows high resolution direct visualization of the bile duct and biopsy sampling under direct vision. Studies have shown that sensitivity of DSOC ranges from 66% to 72% for diagnosing malignant nature in indeterminate cases. The present study was conducted to compare the efficacy of ERCP versus DSOC for accurate diagnosis of indeterminate biliary strictures. Methods: We conducted a randomized study over the period of one year (December 2021 to December 2022) in a tertiary care hospital of Bihar, India, wherein 60 consecutive patients of indeterminate biliary strictures were enrolled and divided randomly into 2 groups. Institutional Ethical Committee clearance and patient consent was obtained. ERCP Group (n = 35): ERCP visual impression and ERCP-guided brushing DSOC Group (n = 25): DSOC impression with DSOC-guided biopsy sampling. Histopathologic or cytologic assessment was performed in terms of benign, indeterminate or malignant nature of the strictures. Procedural adverse events were documented. Sensitivity, Specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy (DA) were calculated. Results: Final pathological diagnosis was 18 malignant and 17 benign in the first group and 15 malignant and 10 benign in the second group. ERCP diagnosed 5 malignant and 4 benign cases as indeterminate while DSOC diagnosed 3 benign cases as indeterminate. The sensitivity of DSOC biopsy (70.18%) was significantly higher than ERCP brush cytology (24.12%) (P < 0.02). The differentiating visual findings during DSOC were tortuous dilated vessel (22.5 %) , Infiltrative stricture (16.5%) , polypoid mass (12.2%), nodular elevated lesion (9.6%) , irregular papillary lesion (11%). The sensitivity of visualisation was significantly better in DSOC (90.1%) over ERCP (60.7%) (P < 0.03). Side-effects were statistically similar in both the groups. Conclusion: DSOC is safe and effective with higher diagnostic sensitivity (70.18%) in comparison to ERCP (24.12%) in the diagnosis of indeterminate biliary strictures (P < 0.02). The sensitivity of DSOC visual interpretation during (90.1 %) was also better than ERCP(60.7%). The overall diagnostic accuracy is also superior with DSOC (70%) over ERCP (50%) (P < 0.05).

Hepatitis E virus (HEV) is an important cause of repeated waterborne outbreaks of acute hepatitis. Recently, several extrahepatic manifestations (EHMs) have been described in patients with HEV infection. Of these, neurological disorders are the most common EHM associated with HEV. The involvement of both the peripheral nervous system and central nervous system can occur together or in isolation. Patients can present with normal liver function tests, which can often be misleading for physicians. There is a paucity of data on HEV-related neurological manifestations; and these data are mostly described as case reports and case series. In this review, we analyzed data of 163 reported cases of HEV-related neurological disorders. The mechanisms of pathogenesis, clinico-demographic profile, and outcomes of the HEV-related neurological disorders are described in this article. Nerve root and plexus disorder were found to be the most commonly reported disease, followed by meningoencephalitis.

Background There is variability in the fecal calprotectin (FCP) cut-off level for the prediction of inflammatory bowel disease (IBD) activity and differentiation from irritable bowel disease (IBS). We aimed to assess the status of the optimal FCP cut-off value for the evaluation of IBD. Methods We reviewed the existing literature regarding the optimal FCP cut-off level in patients with IBD for the prediction of disease activity, remission, relapse and differentiation from IBS patients. Results The study reveals the large quantitative differences in FCP cut-off levels in different study populations (from 50 to918 microgram/gram) (table 1). FCP cut-off value for the initial diagnosis of IBD or active disease status ranged from 50 to800 microgram/gram. A cut-off level of 50–250 microgram/gram differentiated patients of IBD from IBS. Cut-off level of FCP for the prediction of remission ranged from 250 to 918 microgram/gram. Cut-off value for the prediction of relapse ranged from 50 to200 microgram/gram. Variability in the cut-off level is due to the use of different test kits and different study populations. Gastrointestinal infections and chronic subclinical intestinal inflammation, may explain the higher cut-off FCP levels in underdeveloped populations. Studies have demonstrated high levels of FCP in patients with intestinal tuberculosis and chronic giardia infection. Conclusions There is a wide variation in FCP cut-off levels in the initial diagnosis of IBD as well as in follow-up post-treatment. The FCP cut-off levels vary from country to country. The FCP test requires validation of the available test kits and finding of appropriate cut-off levels for different study populations.

Continuous infusion of terlipressin causes more stable reduction in portal venous pressure than intermittent infusion. The aim of the study was to compare the efficacy of continuous infusion vs. intermittent boluses of terlipressin to control acute variceal bleeding (AVB) in patients with portal hypertension.