BACKGROUND AND AIMS:The coexistence of liver steatosis in patients with chronic viral hepatitis B (CHB) is growing relevant as the global epidemic of obesity and type 2 diabetes mellitus (T2DM). The aim of this study was to identify the metabolic risk factors linked to steatotic liver disease (SLD) in Romanian patients with CHB. METHODS:In this prospective study, we evaluated 320,000 individuals in the LIVE(RO)2 nationwide screening program in Romania from 2021 to 2023. The majority of the patients had undergone transient elastography using controlled attenuation parameter (CAP) to diagnose liver steatosis, and they belonged to vulnerable categories. Exclusion criteria included heavy alcohol consumption, any other liver disease unrelated to CHB, and the lack of CAP evaluation. RESULTS:5,321 individuals (1.67%) were found with CHB in the screening program. In the final analysis we included 1,970 patients, with a mean age of 55.87±13.84 years; 57.9% of them were males, with a mean body mass index (BMI) level of 27.26 kg/m², and 61.9% of the patients were vulnerable. The prevalence of SLD was 42.2% in the group of vulnerable individuals, compared with non-vulnerable participants, who had a prevalence of SLD of 26.4%. Moreover, patients with vulnerable conditions have a higher prevalence of T2DM (11.5%), hypertension (41.3%), and raised BMI levels ≥25 kg/m² (71.3%). In our study, vulnerable subjects had a higher prevalence of hepatitis B virus e antigen (HBeAg) positivity of 3%, and it was found to be a protective risk factor for hepatic steatosis development (aOR=0.397). Also, these patients had a higher prevalence of severe liver fibrosis (≥ F3) of 17.1%, compared with those non-vulnerable, with a prevalence of 9.7% of severe liver fibrosis. More than that, we find that the presence of HBeAg-positive increases the risk of severe liver fibrosis progression 6 times higher. CONCLUSIONS:In our study we found a prevalence of hepatic steatosis of 42.2% in the cohort of vulnerable untreated patients with CHB, and the prevalence of severe fibrosis was 17.1%. Presence of HBeAg-positive was found to be a protective risk factor for hepatic steatosis but accelerates the development of severe fibrosis along with T2DM, which is more common in the vulnerable CHB cohort.

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is the primary treatment option for choledocholithiasis. However, this procedure carries an inherent non-negligible risk of complications, requiring precise indications and careful patient selection. Endoscopic ultrasonography (EUS) can verify the presence of bile duct stones prior to ERCP. The current ESGE recommendations permit ERCP in high-risk patients without confirmation; however, several individuals undergo ERCP without evident advantage, indicating a necessity for enhanced stratification. Objectives: We aim to evaluate the rate of EUS-validated choledocholithiasis in patients with suspected common bile duct (CBD) stones and to determine the predictors of residual stones. A secondary objective was to create and internally validate a streamlined scoring system to enhance risk assessment in ESGE high-risk patients. Methods: We conducted a retrospective analysis of patients who had endoscopic ultrasound for suspected choledocholithiasis from January 2023 to December 2024 at a tertiary center. Multivariate logistic regression determined independent predictors of retained calculi. A simplified score was derived from model coefficients and internally validated. Results: Among 438 examined patients, 186 were included and 87 had choledocholithiasis confirmed via EUS. ERCP was conducted in 81 patients and postponed for 6 patients due to contraindications. According to the ESGE criteria, 10 patients (5.4%) were classified as low risk, 92 (49.5%) as intermediate risk, and 84 (45.2%) as high risk for choledocholithiasis. For high-risk individuals, EUS identified stones in 45 (53.5%), while 39 (46.4%) experienced spontaneous clearance. Acute pancreatitis (aOR 0.075), cholangitis (aOR 6.939), and EUS CBD diameter (aOR 1.220 per mm) were independent predictors of stones. The resultant three-component score (-2 to +4 points) demonstrated effective discrimination (AUROC 0.788). A criterion of ≥2 resulted in 85.7% sensitivity and 59.0% specificity. Conclusions: Almost fifty percent of ESGE high-risk patients were not found to have CBD stones during EUS. Integrating EUS data with a straightforward predictive score may enhance risk classification and avert superfluous ERCP procedures.

Background: Over the last two decades, therapy for benign esophageal strictures has shifted from empirical dilatations and surgery to evidence-based and complex endoscopic and surgical procedures, aiming to achieve long-term esophageal patency. Aim: The purpose of our study is to provide descriptive evidence regarding the appropriate tailored medical, endoscopic, and surgical management of benign esophageal strictures. Methods: This retrospective study includes patients with benign esophageal strictures; the data collected encompass the complete patient profiles, detailed etiologic and anatomic workups of the strictures, comprehensive imaging, as well as management and follow-up details. Technical and clinical success rates, adverse events, stricture patency, and the need for additional therapy have been evaluated. Results: Most of the strictures (80.2%) were complex, requiring advanced techniques for management. The primary treatment involved endoscopic dilation, performed with Savary-Gillard bougie dilators in 76.7% of cases and pneumatic balloon dilators in 23.3% of cases. Clinical success was achieved in 95.3% of patients, with a significant improvement in the Ogilvie dysphagia score. Patients with caustic strictures required repeated dilations over the years, compared to shorter intervals for peptic strictures. Adverse events were minimal (e.g., perforation 2.3% and bleeding 4.7%) and managed predominantly endoscopically. Refractory strictures (16.3%) required advanced interventions, including fully covered self-expandable metallic stents (fc-SEMS) and corticosteroid injections. Conclusions: Both our data and the current literature support the use of tailored endoscopic strategies as the first-choice options for managing benign esophageal strictures. Our results strongly suggest against one-size-fits-all therapeutic alternatives.

Background: The transition from the term non-alcoholic fatty liver disease (NAFLD) to steatotic liver disease (SLD), an umbrella term for several related conditions, offers benefits, particularly in identifying cardiometabolic risk factors more effectively. However, the impact of alcohol consumption on liver disease progression remains significant, leading to the recognition of a new entity: MetALD (metabolic dysfunction-associated steatotic liver disease with moderate alcohol intake). Aim: This study aimed to compare characteristics associated with liver disease progression in diabetic patients diagnosed with metabolic dysfunction-associated steatotic liver disease (MASLD) versus those with MetALD. Materials and Methods: In this prospective study, 286 diabetic patients were followed for 12 months. All patients underwent transient elastography (TE) and ultrasound to assess hepatic steatosis. Participants were classified into MASLD and MetALD groups. The performance of fibrosis-4 index (FIB-4), and NAFLD fibrosis score (NFS) were also evaluated. Results: MASLD was diagnosed in 58.2% (167 patients), of whom 4.9% (7 patients) had TE values suggestive for liver cirrhosis. Among those with MetALD, 17.6% (21 patients) had TE values compatible with advanced fibrosis. MASLD subjects presented a slight decrease in liver fibrosis values from 6.58 ± 2.27 kPa to 6.03 ± 1.57 kPa in the 12 months. On the contrary, MetALD subjects had an increase of liver stiffness measurements (LSM) values from 11.83 ± 6.27 kPa to 12.24 ± 8.66 kPa. Conclusions: in diabetic patients, the coexistence of moderate alcohol intake and cardiometabolic risk factors (MetALD) is associated with more advanced liver fibrosis and impaired long-term glycemic control, compared to MASLD alone.

BACKGROUND AND AIMS:Viral hepatitis C remains one of the leading causes of virus-related morbidity and mortality worldwide, being the main etiological cause of cirrhosis and hepatocarcinoma which transforms it into a global health problem. It investigated the prevalence and risk factors for hepatitis C virus (HCV) infection in Romania. METHODS:This prospective study was conducted between 2021 and 2023 by an extensive national Romanian screening program LIVE(RO)2 of 320,000 participants, most of whom being a part of deemed vulnerable populations. All participants agreed to an informed written consent and potential risk factors for HCV transmission were investigated by questionnaire. RESULTS:Out of the 320,000 screened individuals, 3,859 were infected with HCV meaning 1.21% prevalence (95%CI: 1.17-1.24). HCV-infected individuals were meanly aged at 65.8 ± 12.93 years, significantly higher as compared to non-infected participants (54.03 ± 16.41 years, p<0.0001). The main risk factors associated with HCV chronic infection included male gender, being aged between 30-49 or 60-69 years old, low level of education, being unvaccinated, unemployed, not married, with personal history of blood or blood products transfusion, hemodialysis, surgical interventions, tattooing, being in contact with family members with hepatitis, with hospitalizations, imprisoned, and performing unprotected sexual contacts or with partners diagnosed with sexually transmitted infectious diseases. CONCLUSIONS:The prevalence of HCV infection in Romania is 1.21%. Additional to providing supplemental healthcare support to vulnerable populations, the current study contributes in Romania's national HCV elimination objectives.

Liver cirrhosis is the primary contributor to global mortality associated with chronic liver diseases (CLD). Certain liver infections, including viral hepatitis B (VHB) and C (VHC), alcohol-related liver disease (ALD), and metabolic dysfunction-associated steatotic liver disease (MASLD) are significant contributors to the development of liver cirrhosis. This study aimed to evaluate the prevalence of liver steatosis and fibrosis in individuals with vulnerable conditions. Subjects residing in a rural Romanian county or having lower educational attainment were selected for this study. Following the acquisition of informed consent, a demographic, clinical, and physiological characterization was conducted for each participant. The AUDIT-C questionnaire was obtained from every participant. Transient Elastography (TE) measured liver fibrosis, while blood tests screened for the presence of hepatitis viruses B and C. Among the 571 screened vulnerable subjects, 52.7% were males, and 17.3% were identified as heavy drinkers. Metabolic syndrome was identified in 37.3% of patients and 70% of subjects exhibited a body mass index of ≥ 25 kg/m2. Furthermore, 8.5% of participants tested positive for HBs antigen, while 6.1% had HCV antibodies. Additionally, 35.7% of the participants in our study had MASLD, and 7.1% had metabolic dysfunction and alcohol-related liver disease (MetALD) according to the AUDIT-C questionnaire. On TE exams, we found that 9.9% of the participants had advanced fibrosis, 16.1% had cirrhosis, and 24.5% had severe steatosis. Hence, the prevalence of advanced fibrosis and cirrhosis is elevated in asymptomatic healthy individuals from vulnerable conditions in Northeastern Romania, particularly among those with various risk factors. Most of the subjects were identified with MetALD and ALD demonstrating the efficacy of the new nomenclature in identifying the etiology of liver fibrosis.

Metabolic dysfunction-associated steatotic liver disease (MASLD) challenges traditional paradigms by manifesting in lean individuals. The link between MASLD and inflammatory bowel disease (IBD) underscores the importance of the gut–liver axis in disease progression and chronic inflammation. This study evaluates MASLD prevalence, clinical characteristics, and diagnostic predictors in lean individuals with and without IBD. This prospective study included 387 lean patients. Hepatic steatosis and fibrosis were assessed using vibration-controlled transient elastography (VCTE). Anthropometric, clinical and biological data were compared. The subgroup analyses focused on MASLD patients with and without IBD. MASLD was present in 34.1% of lean individuals and 46.3% of those who were lean with IBD. MASLD patients had increased visceral adiposity (CUN-BAE: 31.21 ± 5.42 vs. 24.57 ± 6.49, p < 0.001) and metabolic dysfunction, including dyslipidemia and elevated fasting glucose. IBD-MASLD patients exhibited greater hepatic steatosis and systemic inflammation. CUN-BAE outperformed FLI and HSI in predicting liver steatosis, especially in IBD patients (AUC = 0.806). Lean MASLD, particularly in IBD patients, highlights the need for tailored diagnostic and management strategies. The gut–liver axis plays a key role in disease progression, and the CUN-BAE index demonstrates superior accuracy for identifying liver steatosis.

Metabolic dysfunction-associated steatotic liver disease (MASLD) is increasingly recognized in patients with inflammatory bowel disease (IBD), but accurate, disease-specific predictive tools are lacking. This study aimed to identify key risk factors and develop tailored prediction models for MASLD in IBD patients. Material and methods: In a retrospective-prospective cohort of 157 IBD patients (Ulcerative colitis: 51.6%; Crohn's disease: 48.4%), we performed serial clinical, laboratory, and imaging evaluations across four clinical visits. Hepatic steatosis was assessed using transient elastography with controlled attenuation parameter (CAP >273 dB/m). Logistic regression identified independent risk factors for MASLD, leading to the development of an additive clinical score and a logistic regression-based score. Their diagnostic performances were compared with established indices (Hepatic steatosis index (HSI), Fatty liver index (FLI)). Results: MASLD was diagnosed in 37 patients (23.5%). Independent predictors included smoking (OR 3.55), dyslipidemia (OR 2.82), hypertension (OR 2.77), prolonged IBD duration, higher BMI, male sex, frequent disease flares, and corticosteroid exposure. The additive score (cut-off ≥3) showed good sensitivity (36.1%) but high specificity (94%). The logistic score (cut-off ≥3.5) achieved moderate specificity (45.3%) with excellent sensitivity (86.1%). Both models outperformed HSI (AUC 0.671) and FLI (AUC 0.701). CAP remained the most accurate tool (AUC 0.957). Conclusion: MASLD is highly prevalent in IBD patients, driven by both metabolic and disease-specific factors. The proposed clinical scores provide simple, accessible tools for early risk stratification, potentially guiding personalized surveillance in settings lacking advanced imaging technologies.

Background and aims: Increases in both the prevalence and severity of metabolic dysfunction-associated steatotic liver disease (MASLD) and obesity are closely related. Type 2 diabetes (T2DM) has been associated with metabolic dysfunction-associated steatohepatitis (MASH)-related cirrhosis and hepatocellular carcinoma. Semaglutide is a glucagon-like peptide-1 (GLP-1) receptor agonist approved for the treatment of T2DM and has an important role in weight loss. Also, it may represent a new therapeutic option for the treatment of MASH in obese diabetic patients. The main outcomes were changes from baseline in liver steatosis and fibrosis at week 24. Material and methods: A total of one hundred eighty-seven patients with T2DM were eligible for this prospective study; ninety-five subjects were treated with oral semaglutide, and ninety-two patients were treated with dapagliflozin as an add-on to metformin. All the subjects were evaluated using Vibration Controlled Transient Elastography (VCTE) from June to December 2022. Results: From our cohort, 54% of the patients were females, with a mean age of 59.92 ± 11.89 years and a mean body mass index (BMI) of 29.53 ± 5.33 kg/m2. Following a six-month medication period, we observed a substantial reduction in anthropometric measurements, including the BMI, waist circumference (WC), and waist-to-hip ratio (WtHr), in both groups. Regarding HbA1c, a notable decrease was observed in the semaglutide group (p < 0.001) when compared to the dapagliflozin group (p = 0.011). In addition, the liver stiffness measurement (LSM) according to VCTE improved significantly in the semaglutide group participants from 8.07 ± 2.90 kPa at baseline to 6.51 ± 3.09 kPa after medication (p < 0.001). Conclusion: The superior metabolic effects of semaglutide, correlated to dapagliflozin, may contribute to a more efficient decrease in hepatic stress and injury, leading to a substantial enhancement of liver function in T2DM patients. Further investigations conducted over an ideal timeframe are necessary to confirm the evidence presented in this study.

Background and Objectives: Sustained virologic responses (SVRs) lead to a decrease in portal hypertension, the regression of fibrosis, and the improvement in the hepatic synthesis of procoagulant and anticoagulant factors. We aimed to assess the influence of SVR on coagulation parameters in cirrhotic patients with HCV treated with DAAs. Methods: We performed a prospective study in the Institute of Gastroenterology and Hepatology Iasi, Romania, between January 2022 and February 2024. We included patients diagnosed with compensated and decompensated HCV-related liver cirrhosis, treated with direct antivirals (PrOD ± RBV or SOF/LED ± RBV) for 12/24 weeks. Blood samples for biochemical, immunological, and coagulation tests were collected at the baseline, end of treatment (EOT), and once sustained virological response had been achieved over a period of 12/24 weeks (SVR12/24). Results: We analyzed a group of 52 patients with HCV-related liver cirrhosis, predominantly female (68.0%), and the degree of severity of cirrhosis placed the patients mainly in Child–Pugh classes B (40%) and C (36%). All patients achieved SVRs. The MELD score decreased at EOT (13.48 ± 4.273; p = 0.001) and SVR (9.88 ± 2.774; p = 0.000), compared to the baseline (14.92 ± 4.707). The FibroScan values decreased at SVR (17.596 ± 3.7276; p = 0.000) compared to the baseline (26.068 ± 7.0954). For all common coagulation parameters (platelets, INR, PT, fibrinogen, aPTT), there was a trend towards improvement during treatment, including changes which were statistically significant for the majority of patients. Factor II was low at the baseline (75.40 ± 7.506) but increased at EOT (87.40 ± 9.587) and, later, at SVR (99.12 ± 11.695; p = 0.000). The FVIII values increased at the baseline (175.52 ± 16.414) and decreased at EOT (151.48 ± 13.703) and SVR (143.40 ± 13.937). The FvW values decreased during treatment (146.84 ± 9.428, at baseline; 141.32 ± 9.690, p = 0.000, at EOT; and 126.68 ± 17.960, at SVR). In regard to the anticoagulant factors (PC, PS, ATIII), a significant improvement was brought on by SVR. Advanced stages of liver disease showed the most diminished FII activity, while at the baseline and in Child–Pugh C patients we recorded the highest values of FVIII and FvW. Conclusions: Our study proved that the “reset” of coagulopathy might be due to the improvement in liver function due to viral eradication secondary to AAD therapy.

Aims Climate change and its impact on the environment are matters of high concern. Thus, we aimed to assess the real-life perception of the European recommendations for environmental sustainability in endoscopy in a tertiary-care center in Romania.

Although high mortality is associated with liver cirrhosis, patients usually have a good quality of life in the compensated phase, and the disease may progress undiagnosed for many years. Vibration-controlled transient elastography with controlled attenuation parameter is a useful noninvasive tool used to estimate both the severity of fibrosis and steatosis. Hence, we aimed to establish the prevalence of significant liver fibrosis diagnosed by vibration-controlled transient elastography in an apparently healthy population. Between December 2021 and March 2022, we conducted a prospective screening of liver fibrosis in apparently healthy participants from different counties of Northeastern Romania. All subjects’ medical history was recorded through a comprehensive questionnaire and underwent a liver stiffness measurement. Participants with abnormal liver stiffness measurement values were further evaluated by laboratory tests to identify the etiology of chronic liver disease. A total of 127 apparently healthy subjects were enrolled, mainly females (59.8%), with a mean age of 56±11 years. Overall, 12.6% of participants were found to have significant to advanced fibrosis, and 5.4% had liver cirrhosis. Among 184 participants with clinically significant fibrosis (≥8.0 kPa), 26.1% had a history of heavy alcohol intake, 22.3% tested positive for hepatitis B and C infection, and 2.1% with other etiologies. The remaining 49.5% participants with clinically significant fibrosis were diagnosed with NAFLD, with a mean controlled attenuation parameter value of 282±34 dB/m. The high prevalence of significant liver fibrosis in the general population of Romania is alarming and should raise awareness among clinicians and public health systems. Vibration-controlled transient elastography has demonstrated its usefulness as a screening tool to identify advanced liver fibrosis in general population and should be used in liver disease prevention strategies.

Introduction: Alcohol consumption (AC) represents a widespread cause of liver diseases affecting 10–20% of the population. The study aimed to evaluate the relationship between advanced liver fibrosis (ALF) measured by transient elastography (TE), laboratory parameters, and the amount of AC depending on non-modifiable risk factors such as age and gender. Methods: We examined 689 patients with an average age of 49.32 ± 14.31 years, 72.9% males, without liver pathology, who admitted a moderate/high consumption (female ≤ 7 versus > 7 drinks/week; male ≤ 14 versus > 14 drinks/week) for at least five years. The fibrosis level was adjusted according to transaminase levels. Predictive factors were established using univariate regression analysis. Results: ALF (≥F3) was detected in 19.30% of subjects, predominantly males (14.1%) and patients over 55 years (12.5%). Excessive consumption of distilled spirits is associated with ALF in females (OR = 4.5), males (OR = 6.43) and patients over 55 years (OR = 3.73). A particularity highlighted in both genders, regardless of the age group, was the negative correlation between the decrease in the number of platelets, the albumin concentration, and the appearance of AFL. Conclusions: Screening using TE represents an approach for early detection of ALF in asymptomatic populations and the development of a risk stratification scheme.

Hepatitis C virus (HCV) chronic infection has an important tumorigenic propensity and represents a major cause of hepatocellular carcinoma (HCC). Although the therapy of chronic HCV infection has been revolutionized with the introduction of direct acting antivirals (DAAs) resulting in sustained virological response (SVR) in up to 98% of patients, viral clearance does not totally alleviate the risk of liver-related complications, including HCC. The aim of our study was to assess the performance of predictive scores for HCC occurrence in patients with chronic HCV infection who obtained SVR with DAAs. Material and methods: We conducted a prospective study in which we included 992 patients diagnosed with chronic HCV infection and treated with DAAs, between 1st November 2015 and 31st December 2020. HCC risk scoring systems were applied to each patient enrolled in the study before starting DAA treatment. HCC was diagnosed by imaging methods such as computed tomography and magnetic resonance imaging. Results: Of the 992 patients included in the study, 59 (5.9%) were diagnosed with HCC during the follow-up period, mostly women (55.9%) with a mean age of 60-69 years. The mean time to HCC onset was 19.53 +/- 11.553 months, with a median of 17 months, with a cumulative incidence at 1, 3, and 5 years of 1.1%, 2.1%, and 2.9%, respectively. The General Evaluation Score (GES), aMAP and ADRESS score had statistically significant higher values in patients with HCC than in those without HCC. GES demonstrated a good discriminating power with an AUC coefficient of 0.804 at a cut-off value of 6.25 which has good sensitivity and specificity (0.746 and 0.799, respectively). Conclusions: GES score has a very good predictive power for the risk of HCC after obtaining SVR and could be recommended in clinical practice. Future development and validation of other individualized predictive scores score is needed for a correct and cost-efficient selection of patients with high risk of HCC.