Brain reserve is an important concept to understand the variability of damage associated with brain-related diseases and includes the adaptation of cognitive processes to preserve brain function. A good cognitive reserve might delay the onset of clinical manifestations of neurodegenerative diseases as well as hepatic encephalopathy, improving the quality of life in patients with chronic liver diseases. By stimulating activities and maintaining overall health, individuals may be able to enhance their brain's resilience to age-related changes and pathology. This review aims to collect all the data available on the role of brain reserve in hepatic encephalopathy development, and the potential effect of a good brain reserve in slowing down hepatic encephalopathy progression and frequency.

Gastrointestinal fistulas can be a complication of severe acute pancreatitis, and their incidence is low and sporadically reported in the literature. The most frequently reported site is in the colon, followed by duodenal fistulas. Psoas abscess is a rare condition. Iliopsoas abscesses are classified as primary or secondary. Secondary abscesses develop by spreading infection from contiguous anatomical structures, such as the gastrointestinal tract. We present the case of a recurrent left psoas abscess secondary to a duodenal fistula as a late complication of necrotizing pancreatitis resolved by endoscopic treatment.

Introduction and aims: Posttransplantation diabetes mellitus (PTDM) is a serious long-term complication that has a negative impact on graft and patient survival. The purpose of the present study was to describe the incidence of PTDM in a Mexican cohort and evaluate its association with a previous family history of diabetes (FHD). Methods: A retrospective single -center cohort study was conducted on patients undergoing liver transplantation. The primary outcome was time from liver transplantation to PTDM. The diagnosis of PTDM was established using the ADA criteria. A mediation analysis that used adjusted Cox regression models and considered pretransplant prediabetes a mediator was performed, to determine the total effect and direct effect of FHD on PTDM. Results: A total of 152 patients were included, with a median follow-up time of 41 months; 19.2% (n = 29) had pretransplant diabetes. During the follow-up time, 15% of patients developed PTDM (n = 23), with an incidence rate of 4.71 cases/100 person -years. PTDM was significantly higher in patients with FHD, compared with those with no FHD (8.72 cases/100 person -years vs 2.04 cases/100 person -years, respectively; P = .001). The adjusted hazard ratio of PTDM for FHD was 4.14 (95% CI 1.60-10.7), P = .005) and 3.48 (95% CI 1.35-9.01, P = .010), when further controlled for pretransplant prediabetes. Conclusion: The occurrence of PTDM was similar to that reported in most international studies. As with type 2 diabetes, family history plays an important role in the development of PTDM, even after accounting for pretransplant prediabetes. Patients with FHD should undergo a stricter metabolic program. (c) 2023 Asociaci & oacute;n Mexicana de Gastroenterolog & iacute;a. Published by Masson Doyma M & eacute;xico S.A.

Protein-losing enteropathy is a gastrointestinal complication of Graft versus host disease. The clinical presentation can be similar to that of multiple pathologies and represents a diagnostic challenge for clinicians. We report a 23-year-old man with a history of acute lymphoid leukemia that required allogeneic hematopoietic stem cell transplantation that came to evaluation due to anasarca. We report a 23-year-old man with a history of acute lymphoid leukemia who required allogeneic hematopoietic stem cell transplantation and came to evaluation due to anasarca.

Endoscopic retrograde cholangiopancreatography (ERCP) is a common procedure, but it poses challenges in patients with surgically altered gastrointestinal anatomy (SAGA). Alternative techniques like single-balloon enteroscopy (SBE), double-balloon enteroscopy (DBE), or push enteroscopy (PE) have been used, albeit with potential complications. Limited Latin American data exists on ERCP complications in SAGA patients. Our goal is to describe complications of ERCP in SAGA at a national referral institution. Retrospective, single-center cohort study. All SAGA ERCP procedures performed at the Gastrointestinal Endoscopy Department of the National Institute of Medical Sciences and Nutrition Salvador Zubirán from January 2008 to May 2023 were included. Extracted data from records included procedure specifics, endoscope type, success, and complications. Complications were evaluated during procedure and 28-day post-procedure and classified using the AGREE system. A total of 266 procedures in 174 patients were included, 74

Conflict of interest: No Introduction and Objectives: Non-invasive methods for screening metabolic dysfunction-associated steatotic liver disease (MASLD) are gaining attention. A recent advancement in non-invasive screening is the MAFLD-S score, a tool that exclusively uses clinical data to predict the risk of MASLD.The aim is to evaluate the performance of the MAFLD-S score to identify individuals with MASLD in a cohort of apparently healthy individuals. Patients / Materials and Methods: A cross-sectional study was conducted including adults with unknown MASLD. A transient elastography was performed and hepatic steatosis was defined by a controlled attenuation parameter (CAP) > 248 dB/m. The MASLD criteria were assessed, and the MAFLD-S score, Fatty Liver Index (FLI) and Hepatic Steatosis Index (HSI) were calculated in each member of the cohort. The classification accuracy of these scores was evaluated through their areas under the receiver-operating characteristic (AUROC) curves and their calibration to predict the risk of MASLD was assessed graphically. Results and Discussion: A total of 521 participants were included, being 61% women, and the mean age was 41 years. The frequency of MASLD in the study population was 44.1%. The area under the ROC curve for MAFLD-S was 0.823 (95% CI, 0.788-0.858), for FLI was 0.841 (95% CI, 0.807-0.875) and for HSI was 0.822 (95% CI, 0.787-0.858). The calculated sensitivity for MAFLD-S score using the recommended threshold was 61% (95% CI 0.55-0.68) and specificity of 81% (95% CI 0.77-0.86), for FLI sensitivity was 62% (95% CI 0.56-0.68) and specificity was 82% (95% CI 0.78-0.87) and for HSI sensitivity was 85% (95% CI 0.80-.89) and specificity was 61% (95% CI 0.56-0.67). Conclusions: The MAFLD-S score, a tool that only uses clinical variables, confirmed to be a very good tool for screening MASLD in apparently healthy individuals in Mexico.

Molecular and cellular characterization of tumors is essential due to the complex and heterogeneous nature of cancer. In recent decades, many bioinformatic tools and experimental techniques have been developed to achieve personalized characterization of tumors. However, sample handling continues to be a major challenge as limitations such as prior treatments before sample acquisition, the amount of tissue obtained, transportation, or the inability to process fresh samples pose a hurdle for experimental strategies that require viable cell suspensions. Here, we present an optimized protocol that allows the recovery of highly viable cell suspensions from breast cancer primary tumor biopsies. Using these cell suspensions we have successfully characterized genome architecture through Hi-C. Also, we have evaluated single-cell gene expression and the tumor cellular microenvironment through single-cell RNAseq. Both technologies are key in the detailed and personalized molecular characterization of tumor samples. The protocol described here is a cost-effective alternative to obtain viable cell suspensions from biopsies simply and efficiently.

La diabetes mellitus posterior a trasplante (DMPT) es una complicación grave de largo plazo que tiene un impacto negativo sobre el injerto y la sobrevida del paciente. El objetivo del presente estudio fue describir la incidencia de la DMPT en una cohorte mexicana y evaluar su asociación con el antecedente familiar de diabetes (AFD). Se realizó un estudio de cohorte retrospectivo unicéntrico de pacientes sometidos a trasplante hepático. El desenlace primario fue el tiempo entre el trasplante hepático y el desarrollo de DMPT. El diagnóstico de DMPT fue establecido utilizando los criterios de la ADA. Se realizó un análisis de mediación que utilizó modelos de regresión de Cox ajustados y se manejó la prediabetes pretrasplante como mediador, para determinar el efecto total y el efecto directo del AFD sobre la DMPT. Se incluyó a un total de 152 pacientes, con una mediana de seguimiento de 41 meses; 19.2% (n = 29) presentaron diabetes pretrasplante. Durante el tiempo de seguimiento, 15% de los pacientes desarrollaron DMPT (n = 23), con una tasa de incidencia de 4.71 casos/100 personas-año. La DMPT fue significativamente más elevada en pacientes con AFD en comparación con aquellos sin AFD (8.72 casos/100 personas-año vs. 2.04 casos/100 personas-año, respectivamente; p = 0.001). El cociente de riesgo ajustado para el desarrollo de DMPT en los pacientes con AFD fue 4.14 (IC 95% 1.60-10.7; p = 0.005) y 3.49 (IC 95% 1.35-9.01; p = 0.010), cuando se controló por prediabetes pretrasplante. La incidencia de DMPT fue similar a la reportada en la mayoría de los estudios internacionales. Al igual que con la diabetes tipo 2, el AFD desempeña un papel importante en el desarrollo de la DMPT, incluso después de considerar la prediabetes pretrasplante. Los pacientes con AFD deben someterse a un programa metabólico más estricto. Posttransplantation diabetes mellitus (PTDM) is a serious long-term complication that has a negative impact on graft and patient survival. The purpose of the present study was to describe the incidence of PTDM in a Mexican cohort and evaluate its association with a previous family history of diabetes (FHD). A retrospective single-center cohort study was conducted on patients undergoing liver transplantation. The primary outcome was time from liver transplantation to PTDM. The diagnosis of PTDM was established using the ADA criteria. A mediation analysis that used adjusted Cox regression models and considered pretransplant prediabetes a mediator was performed, to determine the total effect and direct effect of FHD on PTDM. A total of 152 patients were included, with a median follow-up time of 41 months; 19.2% (n = 29) had pretransplant diabetes. During the follow-up time, 15% of patients developed PTDM (n = 23), with an incidence rate of 4.71 cases/100 person-years. PTDM was significantly higher in patients with FHD, compared with those with no FHD (8.72 cases/100 person-years vs 2.04 cases/100 person-years, respectively; P = .001). The adjusted hazard ratio of PTDM for FHD was 4.14 (95% CI 1.60-10.7), P = .005) and 3.48 (95% CI 1.35-9.01, P = .010), when further controlled for pretransplant prediabetes. The occurrence of PTDM was similar to that reported in most international studies. As with type 2 diabetes, family history plays an important role in the development of PTDM, even after accounting for pretransplant prediabetes. Patients with FHD should undergo a stricter metabolic program.

The use of immunosuppressive medications for solid organ transplantation is associated with cardiovascular, metabolic, and oncologic complications. On the other hand, the development of graft rejection is associated with increased mortality and graft dysfunction. Liver transplant recipients can withdraw from immunosuppression without developing graft injury while preserving an adequate antimicrobial response - a characteristic known as immunotolerance. Immunotolerance can be spontaneously or pharmacologically achieved. Contrary to the classic dogma, clinical studies have elucidated low rates of true spontaneous immunotolerance (no serologic or histological markers of immune injury) among liver transplant recipients. However, clinical, serologic, and tissue biomarkers can aid in selecting patients in whom immunosuppression can be safely withdrawn. For those who failed an immunosuppression withdrawal trial or are at high risk of rejection, pharmacological interventions for immunotolerance induction are under development. In this review, we provide an overview of the mechanisms of immunotolerance, the clinical studies investigating predictors and biomarkers of spontaneous immunotolerance, as well as the potential pharmacological interventions for inducing it.

Acute-on chronic liver failure (ACLF) has been an intensively debated topic mainly due to the lack of a unified definition and diagnostic criteria. The growing number of publications describing the mechanisms of ACLF development, the progression of the disease, outcomes and treatment has contributed to a better understanding of the disease, however, it has also sparked the debate about this condition. As an attempt to provide medical professionals with a more uniform definition that could be applied to our population, the first Mexican consensus was performed by a panel of experts in the area of hepatology in Mexico. We used the most relevant and impactful publications along with the clinical and research experience of the consensus participants. The consensus was led by 4 coordinators who provided the most relevant bibliography by doing an exhaustive search on the topic. The entire bibliography was made available to the members of the consensus for consultation at any time during the process and six working groups were formed to develop the following sections: 1.- Generalities, definitions, and criteria, 2.- Pathophysiology of cirrhosis, 3.- Genetics in ACLF, 4.- Clinical manifestations, 5.- Liver transplantation in ACLF, 6.- Other treatments.

Portal hypertension may have major consequences on the pulmonary vasculature due to the complex pathophysiological interactions between the liver and lungs. Portopulmonary hypertension (PoPH), a subset of group 1 pulmonary hypertension (PH), is a serious pulmonary vascular disease secondary to portal hypertension, and is the fourth most common subtype of pulmonary arterial hypertension. It is most commonly observed in cirrhotic patients; however, patients with noncirrhotic portal hypertension can also develop it. On suspicion of PoPH, the initial evaluation is by a transthoracic echocardiogram in which, if elevated pulmonary pressures are shown, patients should undergo right heart catheterization to confirm the diagnosis. The prognosis is extremely poor in untreated patients; therefore, management includes pulmonary arterial hypertension therapies with the aim of improving pulmonary hemodynamics and moving patients to orthotopic liver transplantation (OLT). In this article, we review in detail the epidemiology, pathophysiology, process for diagnosis, and most current treatments including OLT and prognosis in patients with PoPH. In addition, we present a diagnostic algorithm that includes the current criteria to properly select patients with PoPH who are candidates for OLT.

Introduction and Objectives Acute variceal hemorrhage (AVH) is a serious complication of portal hypertension and is associated with high mortality and high cost. Limited information exists regarding AVH management in Latin America (LATAM). This study aimed to gather data on AVH management and resource availability across LATAM. The goal was to bridge the knowledge gap, enhance medical attention, and optimize specialized care for patients with AVH in the region. Materials and Methods A survey was conducted using Microsoft Forms with recruitment via social media invitations and collaboration with local medical associations. It gathered data on demographics, clinical practices, and specialized resource availability. The LATAM countries were classified based on economic development (World Bank's classification system). Variables are described using percentages or medians and interquartile ranges and compared among socioeconomic regions using a chi-square test or analysis of variance as appropriate. Results In total, 798 respondents from 20 LATAM countries completed the survey. The median age was 39 years, with 80% attending specialists, 14% residents, and 6% fellows. Countries were represented by 6% high-income, 72% upper-middle income, and 21% lower- middle income populations. Gastroenterology (62%) was the predominant specialty, followed by internal medicine (23%), gastrointestinal endoscopy (18%), and hepatology (18%). Tertiary care centers accounted for 45% of the participants primary activities, followed by second-level care (30%) and private practice (21%). As for the existence of endoscopy suites, there were no differences between surveyed countries but their availability 24/7 remains higher in high income countries. The availability of vasoactive drugs correlated with economic development. The detailed findings are presented in Table 1. Conclusions In LATAM, the absence of standardized protocols, limited resources, and expertise pose challenges in AVH management. Enhancing access to specialized care and implementing standardized protocols is crucial to improve patient outcomes in the region.

Background and Aims:Metabolic-associated fatty liver disease (MAFLD) is a leading cause of chronic liver disease. Nowadays, the prevalence of MAFLD in Mexico is unknown with no screening point-of-care tools. We aimed to estimate the prevalence of MAFLD in Mexico and to develop a score for MAFLD screening. Methods:We conducted a cross-sectional study in 5 Mexican states, including adult subjects evaluated in checkup campaigns. Subjects underwent a liver ultrasound to look for hepatic steatosis. Based on the most clinically relevant variables associated with MAFLD, we developed the MAFLD-screening score (MAFLD-S). Discrimination and calibration of the score were evaluated using the area under the ROC curve and observed vs predicted plots, respectively. Results:We included 3357 participants (60% female, mean age 47 ± 12 years). Fifty-two percent had hepatic steatosis, and 47% met MAFLD criteria. Subjects with MAFLD were older (48 ± 11 vs 45 ± 13 years, P < .001), were more frequently males (43% vs 36%, P < .001), and had a higher body mass index (31.6 + 4.9 vs 25.6 + 3.8 kg/m2, P < .001) than subjects without MAFLD. The MAFLD-S includes age, body mass index, gender, diabetes, hypertension, and dyslipidemia and has an area under the curve of 0.852, 95% CI = 0.828-0.877, with a sensitivity of 78.8% and a specificity of 82.8% for the optimal cutoff. Using data from the National Health and Nutrition Survey 2018-2019, we predicted a MAFLD national prevalence of 49.6%. Conclusion:Nearly half of the Mexican population has MAFLD, representing a present and future challenge. With external validation, the MAFLD-S could be a valuable and practical screening tool.

Background: Liver transplant (LT) recipients with diabetes mellitus (DM) are at an increased risk of facing adverse post-transplant outcomes such as non-alcoholic steatohepatitis (NASH) and cardiovascular events.GLP-1 receptor agonists (GLP-1RA) and SGLT-2 inhibitors (SGLT-2i) are novel anti-diabetic agent classes that have demonstrated significant cardioprotective benefits in addition to weight loss and glycemic control in patients with type 2 DM.While emerging evidence suggests a similar metabolic effect in solid-organ transplant (SOT) recipients, limited data exists surrounding the efficacy and safety of these agents in the LT population.Aim: To investigate the efficacy and safety profile of GLP-1RA and SGLT-2i in LT recipients with type 2 DM.Methods: A single-center retrospective analysis of prospectively collected data from a LT recipient database was conducted (1990 -2021).Patients above the age of 18 were included if they had pre-existing diabetes or new-onset diabetes following LT and if they were taking a novel anti-diabetic medication such as a GLP-1RA (liraglutide, semaglutide), SGLT-2i (canagliflozin, dapagliflozin, empagliflozin), or both for at least 3 months.Metabolic and clinical parameters including changes in hemoglobin A1c (HbA1c), blood glucose, liver enzymes, weight, body mass index (BMI), and renal function were collected at 3-, 6-, 12-, 18-, and 24-months following initiation of one of the novel antidiabetic medications.Adverse effects including serum immunosuppressant levels and incidence of graft failure were also recorded.Results: 32 LT recipients were started on a GLP-1RA, 78 were started on an SGLT-2i, and 12 had been initiated on both agents.There were no significant differences in baseline characteristics of age, sex, co-morbidities, time since transplant, HbA1c, or creatinine prior to initiation of these medications.LT recipients who were started on dual anti-diabetic agents at baseline had a higher BMI (p=0.011) and higher levels of liver enzymes (AST, p=0.004;ALT, p<0.001) compared to patients who were started on a single agent.Combined treatment with both GLP-1RA and SGLT-2i resulted in significant decreases in AST (p=0.008) and ALT (p=0.002) at 6 months when compared to the novel anti-diabetic agent monotherapy groups (Table 1).Hb1Ac, glomerular filtration rate (GFR), and tacrolimus levels remained statistically similar at 3-, 6-, 12-, 18-, and 24-months between all three groups.No significant increase in adverse outcomes were found amongst all three groups (Table 2).Conclusion: GLP-1RA and SGLT-2i are safe to use in LT recipients.Combination therapy may be more effective than single-agent treatment for targeting NASH in LT recipients with DM.Further studies are required to evaluate the long-term safety and efficacy of these agents in this population.

Background Cirrhosis is a public health threat associated with high mortality. Alcoholic Liver Disease (ALD) is the leading cause in Latin America and Metabolic Associated Fatty Liver Disease (MAFLD) in western countries. In Mexico, ALD and chronic Hepatitis C Virus infection (HCV) were the most frequent aetiologies during the past decades. We aimed to describe the trends in the aetiologies of cirrhosis in a middle-income country. Methods We performed a retrospective cohort study including patients diagnosed with cirrhosis between 2000 and 2019 from six different tertiary care hospitals in central Mexico. We collected information regarding cirrhosis etiology, year of diagnosis, hepatocellular carcinoma development, liver transplantation, and death. We illustrated the change in the tendencies of cirrhosis aetiologies by displaying the proportional incidence of each etiology over time stratified by age and gender, and we compared these proportions over time using chi square tests. Findings Overall, 4,584 patients were included. In 2019, MAFLD was the most frequent cirrhosis etiology (30%), followed by ALD (24%) and HCV (23%). During the study period, MAFLD became the leading etiology, ALD remained second, and HCV passed from first to fourth. When analysed by gender, ALD was the leading etiology for men and MAFLD for women. The annual incidence of HCC was 3.84 cases/100 persons-year, the median survival after diagnosis was 12.1 years, and seven percent underwent LT. Interpretation Increased alcohol consumption and the obesity epidemic have caused a transition in the aetiologies of cirrhosis in Mexico. Public health policies must be tailored accordingly to mitigate the burden of alcohol and metabolic conditions in developing countries. Copyright (C) 2021 The Author(s). Published by Elsevier Ltd.

Sinusoidal Obstruction Syndrome (SOS) refers to an obliterative inflammation of terminal hepatic veins characterized by hepatomegaly, right upper quadrant pain, jaundice, and ascites, most often occurring in patients after hematopoietic stem cell transplantation (HSCT), although many other etiologies have been described. The diagnosis is suspected based on clinical features, risk factors and confirmed by liver biopsy. Many treatments have been described, mostly studied in SOS after HSCT. Little is known about the treatment of SOS in liver transplant (LT) recipients. Herein we describe an adult male patient with liver cirrhosis secondary to SOS which recurred two years after LT and was treated with systemic anticoagulation and double immunosuppressive scheme with calcineurin inhibitors and mycophenolate mofetil. Our case highlights the possible immunological background in patients presenting with SOS after LT.