Hepatocellular carcinoma surveillance in patients with liver cirrhosis: Are we following the guidelines?

Introduction The British Society of Gastroenterology (BSG) recommends, if HCC surveillance is offered, 6 monthly ultrasound- scan with serum AFP.1 We aim to evaluate our screening practice in liver cirrhosis patients and compare it with the BSG guidelines. Methodology Retrospectively, all patients with liver disease who admitted to gastroenterology ward between January 2020 and Jun 2020 at Royal Lancaster Infirmary were assessed. Stages of liver cirrhosis were taken into consideration with the presence of decompensated liver disease signs and the underlying cause of liver cirrhosis.2 Data collected from Electronic- Patients Record included any blood test, ultrasound, and endoscopy report. We analysed the data by using One-Way ANOVA on SPSS. Results Total number of hepatology admissions during the study period was 183 patients with 65% (n=119) known to have liver cirrhosis. 74% were male (n=137) of total admissions and only forty-six female patients. Among individuals with liver cirrhosis, twenty-seven patients had Child-Pugh (A) liver cirrhosis with Fifty and forty-two had Child-Pugh (B) and (C) respectively. Admission with decompensated Alcoholic liver Cirrhosis was higher in male patients 69% (n=47) compare to female patients of only 30% (n=21) (p= 0.001). None of the patients had autoimmune or metabolic liver disease as main cause of cirrhosis (p= 0.0001). Oesophageal varices were diagnosed in thirty-one patients (26%) predominantly males (n=22). HCC surveillance with Ultrasound occurred in 85% (n=102) whereas only 73 patients (61.3%) had AFP checked. The ANOVA results suggest the HCC surveillance differs significantly between different stages of liver cirrhosis (Child-Pugh A, B and C) (F3,359 = 6.11, p= 0.003). Male patients had more robust HCC surveillance (M=37.61, SD=23.46, n=13) in comparison to Female patients with liver cirrhosis (M=13.38, SD = 8.60, n = 13). This was statistically significant, t (24) = 2.06, (p= 0.0009). Conclusion More than two third of Hepatology admissions have liver cirrhosis, however, the study period was during the first COVID-19 wave, yet the adherence to the BSG in HCC surveillance guidelines was achieved in 85% and 61.3% with USS and AFP respectively. Significant improvement is required;hence, we recommend adding checklist and proforma to the patients' record as this may improve our practice.

Acute on chronic liver failure (ACLF) during COVID-19;single UK based hospital experience

Introduction In patients with known liver disease, acute decompensation in association with organ failure due to acute liver insult is known as Acute on Chronic Liver Failure (ACLF).1 We aim to identify and assess the presence of ACLF during the first COVID-19 wave and the main insulting agent. Methodology We retrospectively assessed all patients who had been admitted to our hospital with liver pathology between January 2020 to Jun 2020. Blood tests, radiological imagines, histological results, and endoscopy reports were electronically retrieved. Patients were divided using Child-Pugh liver cirrhosis scoring, MELD and UKELD.2 Fisher's test, Chi-square and SPSS used in data analysis. Results Total number of liver admissions 194 during the study period of 2020. 145 were males (74.74%) and 25.2% were females (n=49) with 156 patients above fifty years (80.41%) (p= 0.0028). Thirty-three of them had variceal bleeding (n=17) and sixty-two had normal gastroscopy (31.9%) whereases ninety-nine did not have gastroscopy (OR=1.61;95%CI =1.9;2.852, p= 0.0024). During the study period, 36.08% of the studied individuals had Child- Pugh score of (A and B) (n=70 each) with only fifty-four who had Child-Pugh (C) liver cirrhosis (n=54), p= 0.008. Acute on Chronic Liver Failure (ACLF) was identified in eight patients (4.12%), while ninety-one had decompensated liver disease (46.9%) and (51.4%) had compensated liver cirrhosis (OR=1.05;95%CI=0.51;3.05, p= 0.015). Although 96.9% had Alcoholic hepatitis (n=188) as the cause of ACLF, 3.1% had other causes (p= 0.0019). Interestingly, 7.7% had (MELD score higher than 40) (n=15) and 12.8% had UKELD score of more than 49 (n=25) (OR=2.90;95% CI=3.99, p=.005). Conclusion Few numbers of patients had ACLF during the first COVID-19 wave however majority of them had alcohol hepatitis as main trigger. We recommend a robust community education programme to help reducing this phenomenon especially during the stressful times.

Surveillance and screening of hepatocellular carcinoma in cirrhotic patients, can we do better?

Background and Aim: The British Society of Gastroenterology (BSG) recommends, if HCC surveillance is offered, 6 monthly ultrasound-scan with serum AFP. We aim to evaluate our screening practice in liver cirrhosis patients and compare it with the BSG guidelines. Methods: Retrospectively, all patients with liver cirrhosis at different stages who were admitted to gastroenterology ward between January 2020 and June 2020 at Royal Lancaster Infirmary were assessed. Data were analysed using one-way ANOVA on SPSS. Results: Total number of hepatology admissions during the study period was 183 patients with 65% (n = 119) known to have liver cirrhosis. 74% were male (n = 137) of total admissions and only 46 female patients. Among individuals with liver cirrhosis, 27 patients had Child-Pugh (A) liver cirrhosis with 50 and 42 had Child-Pugh (B) and (C) respectively. Admission with decompensated alcoholic liver cirrhosis was higher in male patients 69% (n = 47) compare to female patients of only 30% (n = 21) (p = 0.001). None of the patients had autoimmune or metabolic liver disease as main cause of cirrhosis (p = 0.0001). Oesophageal varices were diagnosed in 31 patients (26%) predominantly males (n = 22). HCC surveillance with ultrasound occurred in 85% (n = 102) whereas only 73 patients (61.3%) had AFP checked. The ANOVA results suggest the HCC surveillance differs significantly between different stages of liver cirrhosis (Child-Pugh A, B and C) (F3,359 = 6.11, p = 0.003). Male patients had more robust HCC surveillance (M = 37.61, SD = 23.46, n = 13) in comparison to female patients with liver cirrhosis (M = 13.38, SD = 8.60, n = 13). This was statistically significant, t(24) = 2.06, (p = 0.0009). Conclusion: Two third of hepatology admissions have liver cirrhosis;however, the study period was during the first COVID-19 wave, HCC surveillance guidelines was achieved in 85% and 61.3% with USS and AFP, respectively. We recommend adding HCC checklist and proforma to the patients' record.

Timing of endoscopic retrograde cholangiopancreatography (ERCP) in patients with acute gallstone pancreatitis during the first wave of COVID-19 pandemic, are we following the guidelines!

Aims: Introduction Gallstone is well known, among other aetiologies, cause of Acute pancreatitis . It is crucial to makeearly diagnosis as different treatment approached is recommended which includes early ERCP and cholecystectomy . In aproven or suspected gallstone pancreatitis, patients should undergo a therapeutic ERCP within 72 hours as per BSGguidleines . Methods We retrospectively studied all ERCP procedures done during the first wave of Covid-19 between Jan-Jun 2020.Data were retrieved using electronic patient records as well as endoscopic reporting applications. Results 113 ERCP had been performed in our hospital during the first wave of Covid-19. Among them, they was only 8patients who had ERCP for Acute Gallstone Pancreatitis. 5 patients only had ERCP during the 72 hours of the onset of painoccurred in 60 % (n = 3). 2 patients did not have their ERCP within the recommended time and one patient received medicaltreatment. Conclusions 60 % adherence is not adequate. We recommend development of local stander of procedure, pathway, orenhancement of early referral to Endoscopy unit. We recommend that all referral to ERCP will need to be reviewed withmore urgency. Feedback to the acute medical team and emergency department to make more urgent referral tohepatobiliary team when gallstone pancreatitis is suspected.