Systematic review of the role of calprotectin in cirrhosis.

BACKGROUND: Calprotectin is a calcium-binding-S100-protein synthetized mainly in neutrophils which has been demonstrated to be an accurate biomarker of the presence of these cells. Gut barrier dysfunction in patients with advanced chronic liver disease (ACLD), in addition to the lack of noninvasive tools for diagnosis and prognosis of cirrhosis decompensations, has raised interest in this biomarker. AIMS: Our aim is to summarize the current evidence regarding the role of calprotectin in terms of its diagnostic and prognostic utility in ACLD. METHODS: We performed a systematic search (PROSPERO registration no. CRD42023389069) of original articles published without any restrictions on the publication date until January 2023 providing information about calprotectin for the prognosis or diagnosis of ACLD and its decompensations in adult patients. RESULTS: A total 227 articles were identified, and 26 observational studies finally met the inclusion criteria. In 14 studies, calprotectin was measured in ascitic fluid, all of which reported higher calprotectin values in spontaneous bacterial peritonitis, while cut-off points for its diagnosis were proposed in nine studies. Three studies reported higher faecal calprotectin levels in patients with hepatic encephalopathy and portal hypertension. Four studies evaluated faecal calprotectin and one plasma calprotectin as biomarkers for gut barrier integrity and bacterial translocation. CONCLUSIONS: Calprotectin is emerging as a promising biomarker in ACLD, particularly for the management of bacterial infections and alcohol-related liver disease. Further research with better study designs should help to determine the feasibility of calprotectin measurement in routine clinical practice.

Response Variability to Drug Testing in Two Models of Chemically Induced Colitis.

The lack of knowledge regarding the pathogenesis of IBD is a challenge for the development of more effective and safer therapies. Although in vivo preclinical approaches are critical for drug testing, none of the existing models accurately reproduce human IBD. Factors that influence the intra-individual response to drugs have barely been described. With this in mind, our aim was to compare the anti-inflammatory efficacy of a new molecule (MTADV) to that of corticosteroids in TNBS and DSS-induced colitis mice of both sexes in order to clarify further the response mechanism involved and the variability between sexes. The drugs were administered preventively and therapeutically, and real-time bioluminescence was performed for the in vivo time-course colitis monitoring. Morphometric data were also collected, and colonic cytokines and acute plasma phase proteins were analyzed by qRT-PCR and ELISA, respectively-bioluminescence images correlated with inflammatory markers. In the TNBS model, dexamethasone worked better in females, while MTADV improved inflammation in males. In DSS-colitis, both therapies worked similarly. Based on the molecular profiles, interaction networks were constructed to pinpoint the drivers of therapeutic response that were highly dependent on the sex. In conclusion, our results suggest the importance of considering sex in IBD preclinical drug screening.

Corrigendum: Development and Characterization of a New Endoscopic Drug-Eluting Platform With Proven Efficacy in Acute and Chronic Experimental Colitis.

[This corrects the article DOI: 10.3389/fmed.2020.00415.].

Endoscopic Shielding With Platelet-rich Plasma After Resection Of Large Colorectal Lesions.

BACKGROUND: Platelet-rich plasma (PRP) has demonstrated efficacy as submucosal injection before endoscopic mucosal resection or local injection after endoscopic submucosal dissection of nonpedunculated colorectal lesions. METHODS: The EndoPRP study was a prospective single-center study to analyze the efficacy of PRP shield after endoscopic mucosal resection of large nonpedunculated colorectal lesio with impossible clip closure, assessed by the incidence of delayed bleeding (DB) and delayed perforation, and percentage of mucosal restoration after 4 weeks (mucosal healing rate). RESULTS: Shielding technique with PRP was performed in 4 patients, aged 52 to 80, with 4 lesions at rectum (mean size 53.7±20.6 mm, range 35 to 80 mm). DB occurred in 1 lesion (25% of all lesions), no required blood transfusion or endoscopic treatment. No postoperative delayed perforation occurred. Mucosal healing rate was of 78.6% after 4 weeks. CONCLUSIONS: PRP shield failed in prevent DB, probably due to migration and failure in the adherence in large wounds. Future comparative studies are needed to confirm these data.

Development and Characterization of a New Endoscopic Drug-Eluting Platform With Proven Efficacy in Acute and Chronic Experimental Colitis.

Background and Aims: Mucosal lesions refractory to biological treatments represent unmet needs in patients with inflammatory bowel disease (IBD) that require new treatment modalities. We developed and characterized a new endoscopic drug-eluting hydrogel (CoverGel) with proven efficacy in acute and chronic experimental colitis (EC) in rats. Methods: CoverGel was developed based on appropriate rheological, drug release, gelation, structural, and degradation property capacities to allow endoscopic application. Experimental colitis (EC) was induced by TNBS application in rats. In acute EC 40, rats were randomized in five groups (eight each): Sham, Control, CoverGel, CoverGel + Infliximab (IFX) and CoverGel + Vedolizumab (VDZ). In chronic EC, 12 rats were randomized in two groups (six each): IFX s.c. and CoverGel + IFX. Endoscopic, histological, and blood test were performed during follow-up to evaluate clinical success. Antibodies to IFX (ATIs) were evaluated in chronic EC animal study. Results: CoverGel is a biocompatible and bioadhesive reverse thermosensitive gelation hydrogel with a macroporous structure and drug release capacity. In acute EC animals treated with CoverGel + IFX or CoverGel + VDZ showed significantly clinical success (weight recovery, mucosal restoration, and bacterial translocation) as compared with controls and animals without a bioactive drug. In a chronic EC animal study, clinical efficacy was comparable in both groups. Levels of ATIs were significantly lower in animals treated with CoverGel + IFX vs. IFX s.c. (0.90 ± 0.06 µg/mL-c vs. 1.97 ± 0.66 µg/mL-c, p = 0.0025). Conclusions: CoverGel is an endoscopic vehicle to locally deliver biological drugs with proven efficacy in acute and chronic EC in rats and induce less immunogenicity reaction.

Comparative study of electrical and rheological properties of different solutions used in endoscopic mucosal resection.

BACKGROUND AND AIM: The study of electrical and rheological properties of solutions to carry out endoscopic resection procedures could determinate the best candidate. An ex vivo study with porcine stomachs was conducted to analyze electrical resistivity (R) and rheological properties (temperature, viscosity, height and lasting of the cushion) of different substances used in these techniques. METHODS: Tested solutions were: 0.9% saline (S), platelet-rich plasma (PRP), Gliceol (GC), hyaluronic acid 2% (HA), Pluronic-F127 20% (PL), saline with 10% glucose (GS), Gelaspan (GP), Covergel-BiBio (TB) and PRP with TB (PRP+TB). Measurements of electrical and rheological properties were done at 0, 15, 30, 45 and 60 min after submucosal injection. RESULTS: Solutions showed a wide variability of transepithelial R after submucosal injection. Substances able to maintain the highest R 60 min postinjection were TB (7 × 104 Ω), HA (7 × 104 Ω) and PL (7 × 104 Ω). Protective solutions against deep thermal injury (Tª lower than 60°C) were PL (47.6°C), TB (55°C) and HA (56.63°C). Shortest time to carry out resections were observed with GC (17.66″), PRP (20.3″) and GS (23.45″). Solutions with less cushion decrease (<25%) after 60 min were TB (11.74%), PL (18.63%) and PRP (22.12%). CONCLUSIONS: Covergel-BiBio, PL and HA were the best solutions with long-term protective effects (transepithelial R, lower thermal injury and less cushion decrease). Solutions with quicker resection time were GC, PRP and GS.

Submucosal injection of platelet-rich plasma in endoscopic resection of large sessile lesions.

AIM: To prospectively evaluate the efficacy of submucosal injection of platelet-rich plasma (PRP) on endoscopic resection of large sessile lesions. METHODS: Eleven patients were submitted to endoscopic mucosal resection (EMR) with prior injection of PRP, obtained at the time of endoscopy. Patients were followed during 1 mo. The incidence of adverse events (delayed bleeding or perforation) and the percentage of mucosal healing (MHR) after 4 wk were registered. RESULTS: EMR was performed in 11 lesions (46.4 mm ± 4 mm, range 40-70 mm). Delayed bleeding or perforation was not observed in any patient. Mean ulcerated area at baseline was 22.7 cm2 ± 11.7 cm2 whereas at week 4 were 2.9 cm2 ± 1.5 cm2. Patients treated with PRP showed a very high MHR after 4 wk (87.5%). CONCLUSION: PRP is an easy-to-obtain solution with proven and favourable biological activities that could be used in advanced endoscopic resection.

HEPACONTROL. A program that reduces early readmissions, mortality at 60 days, and healthcare costs in decompensated cirrhosis.

BACKGROUND & AIMS: Decompensated cirrhosis patients have an elevated incidence of early readmission, mortality and economic burden. The aims of HEPACONTROL were to reduce early readmission and to evaluate its impact on mortality and emergency department visits. PATIENTS AND METHODS: Quasi-experimental study with control group which compared two cohorts of patients discharged after being admitted for cirrhosis-related complications. A prospective cohort (n=80), who followed the HEPACONTROL program, which began with a follow-up examination seven days after discharge at the Hepatology Unit Day Hospital and a retrospective cohort of patients (n=112), who had been given a standard follow-up. Outcome variables that were compared between both groups were early readmission rates, the number of emergency department visits post-discharge, financial costs and mortality. RESULTS: The rate of early readmission was lower in the group with HEPACONTROL (11.3% vs 29.5%; P=.003). Also, the mean number of visits to the emergency department post-discharge (1.10±1.64 vs 1.71±2.36; P=.035), mortality at 60days (3.8% vs 14.3%; P=.016), and the cost of early readmission were all lower compared with the group with standard follow-up (P=.029). CONCLUSIONS: HEPACONTROL decreases the incidence of early readmission the rate of emergency department visits and mortality at 60days in patients with decompensated cirrhosis, and it is cost-effective.

Endoscopic shielding technique, a new method in therapeutic endoscopy.

Prevention of late complications after large endoscopic resection is inefficient with current methods. Endoscopic shielding, as a simple and safe technique, has been proposed to improve the incidence of these events. Different methods, sheets or hydrogels, have showed proven efficacy in the prevention of late bleeding and perforation, as well as the improvement of tissue repair, in experimental models and in clinical practice.

Early hospital readmission in decompensated cirrhosis: Incidence, impact on mortality, and predictive factors.

BACKGROUND & AIMS: The early hospital readmission of patients with decompensated cirrhosis is a current problem. A study is presented on the incidence, the impact on mortality, and the predictive factors of early hospital readmission. PATIENTS AND METHODS: On the study included 112 cirrhotic patients, discharged after some decompensation between January 2013 and May 2014. Multivariate analyses were performed to identify predictors of early readmission and mortality. RESULTS: The early readmission rate was 29.5%. The predictive factors were male gender (OR: 2.81; 95% CI: 1.07-7.35), Model for End-Stage Liver Disease-sodium score ≥15 (OR: 3.79; 95% CI 1.48-9.64), and Charlson index ≥7 (OR: 4.34, 95% CI 1.65-11.4). This model enabled patients to be classified into low or high risk of early readmissions (13.6% vs. 52.2%). The mortality rate was significantly higher among patients with early readmission (73% vs. 35%) (p<.0001). After adjusting for the Model for End-Stage Liver Disease-sodium score, Charlson index, dependence in activities of daily living, educational status, and number of medications on discharge, the early readmission was independently associated with mortality. CONCLUSIONS: Early hospital readmission is common, and is independently associated with mortality. Male gender, MELD-Na ≥15, and Charlson index ≥7 are predictors of early readmission. These results could be used to develop future strategies to reduce early readmission.

Endoscopic shielding technique with a newly developed hydrogel to prevent thermal injury in two experimental models.

BACKGROUND AND AIM: A newly developed hydrogel, applied through the endoscope as an endoscopic shielding technique (EndoSTech), is aimed to prevent deep thermal injury and to accelerate the healing process of colonic induced ulcers after therapeutic endoscopy. METHODS: Lesions were performed in rats (n = 24) and pigs (n = 8). Rats were randomized to receive EndoSTech (eight rats each) with: saline (control), hyaluronic acid and product. In pigs, three ulcer sites were produced in each pig: endoscopic mucosal resection (EMR)-ulcer with prior saline injection (A; EMR-saline), EMR-saline plus EndoSTech with product (B; EMR-saline-P), and EMR with prior injection of product plus EndoSTech-P (C; EMR-P-P). At the end of the 14-day study, the same lesions were performed again in healthy mucosa to assess acute injury. Animals were sacrificed after 7 (rats) and 14 (pigs) days. Ulcers were macroscopically and histopathologically evaluated. Thermal injury (necrosis) was assessed with a 1-4 scale. RESULTS: In rats, treatment with product improved mucosal healing comparing with saline and hyaluronic acid (70% vs 30.3% and 47.2%; P = 0.003), avoiding mortality (0% vs 50% and 25%; P = 0.038), and perforation (0% vs 100% and 33.3%; P = 0.02); respectively. In pigs, submucosal injection of product induced a marked trend towards a less deep thermal injury (C = 2.25-0.46 vs A and B = 2.75-0.46; P = 0.127). Mucosal healing rate was higher with product (B = 90.2-3.9%, C = 91.3-5.5% vs A = 73.1-12.6%; P = 0.002). CONCLUSIONS: This new hydrogel demonstrates strong healing properties in preclinical models. In addition, submucosal injection of this product is able to avoid high thermal load of the gastrointestinal wall.

Efficacy of platelet-rich plasma as a shielding technique after endoscopic mucosal resection in rat and porcine models.

BACKGROUND AND STUDY AIMS: The aims were to assess the efficacy of endoscopic application of Platelet-rich plasma (PRP) to prevent delayed perforation and to induce mucosal healing after endoscopic resections. PATIENTS AND METHODS: Colonic induced lesions were performed in rats (n = 16) and pigs (n = 4). Animals were randomized to receive onto the lesions saline (control) or PRP. Animals underwent endoscopic follow-up. Thermal injury was assessed with a 1 - 4 scale: (1) mucosal necrosis; (2) submucosal necrosis; (3) muscularis propria necrosis; and (4) serosal necrosis RESULTS: Saline treatment showed 50 % of mortality in rats (P = 0.02). Mean ulcerated area after 48 hours and 7 days was significantly smaller with PRP than with saline (0.27 ±â€Š0.02 cm(2) and 0.08 ±â€Š0.01 cm(2) vs. 0.56 ±â€Š0.1 cm(2) and 0.40 ±â€Š0.06 cm(2); P < 0.001). The incidence of thermal injury was significantly lower with PRP (1.25 ±â€Š0.46) than in controls (2.25 ±â€Š0.50); P = 0.006. The porcine model showed a trend toward higher mucosal restoration in animals treated with PRP than with saline at weeks 1 and 2 (Median area in cm(2): 0.55 and 0.40 vs. 1.32 and 0.79) CONCLUSIONS: Application of PRP to colonic mucosal lesions showed strong healing properties in rat and porcine models.

New method for isolation of rat lamina propria macrophages in colonic tissue.

Studies on intestinal cells in the lamina propria are important for understanding the cellular and immune responses in the gut. There is a lack of specific isolating procedures of macrophage cells in rats. Two different procedures of macrophage isolation of the lamina propria in rats are compared: a standard mice protocol for lymphocyte isolation (A) adapted to rat samples and a new protocol developed specifically for rats (B). Significant differences are observed when analyzing the effect of the isolation method on the cell number, viability and phenotype. This has important implications when further functional studies are required.

Microperforation of the colon: animal model in rats to reproduce mucosal thermal damage.

BACKGROUND: The aim of the present study was to develop a rat model of colonic microperforation secondary to thermal injury for future studies to assess new treatments. METHODS: Twenty-four male Sprague-Dawley rats were used in this study. Hot biopsy forceps were used for all treatments. All lesions were created in proximal left colon using the soft coagulation setting. The power setting tested was 40 W, and the durations of monopolar soft coagulation application evaluated were 2, 3, and 4 s. RESULTS: In the acute phase, 48 h after thermal injury, durations of cautery of 2 and 3 s resulted in transmural necrosis, whereas with 4 s microperforation was obtained. In the late phase, 7 d after the damage, only duration of cautery of 4 s showed deep cautery effects, with signs of peritonitis. CONCLUSIONS: We determined optimal power settings and duration of therapy in a rat model for producing electrocautery that involves transmural necrosis with microperforation.

Colonoscopy in rats: An endoscopic, histological and tomographic study.

AIM: To describe colon anatomy with colonoscopy and computed tomography (CT) to develop a rat model for future studies of therapeutic colonoscopy. METHODS: Eighteen male Sprague-Dawley rats, on average 400-420 g, underwent total colonoscopy, CT and histological examination. Colonoscopy was performed after bowel preparation with a baby upper gastrointestinal endoscopy with an outer diameter of 6.7 mm. CT obtained a 3D image of total colon after a rectal enema with radiological contrast. Macroscopic and microscopic examinations were examined with a conventional technique (hematoxylin and eosin). Colonic wall thickness, length and diameter measurements were taken from the anus, 3, 7, 14 and 20 cm from the anal margin. RESULTS: The median colonoscope depth was 24 cm (range 20-28 cm). Endoscopic and tomographic study of colon morphology showed an easy access with tubular morphology in the entire left colon (proximal left colon and rectum). Transverse colon was unapparent on colonoscopy. Right colon, proximal to the splenic flexure, was the largest part of the colon and assumed saccular morphology with tangential trabecula. Radiological measurements of the colonic length and diameter substantiate a subdivision of the right colon into two parts, the cecum and distal right colon. In addition, histological measurement of the colonic wall thickness confirmed a progressive decrease from rectum to cecum. The muscular layer was thinner in the proximal left colon. CONCLUSION: The combination of colonoscopy, tomography and histology leads to a better characterization of the entire colon. These data are important for deciding when to perform endoscopic resections or when to induce perforations to apply endoscopic treatments.

Role of scavenger receptors in the pathophysiology of chronic liver diseases.

Scavenger receptors comprise a large family of structurally diverse proteins that are involved in many homeostatic functions. They recognize a wide range of ligands, from pathogen-associated molecular patterns (PAMPs) to endogenous, as well as modified host-derived molecules (DAMPs). The liver deals with blood micro-organisms and DAMPs released from injured organs, thus performing vital metabolic and clearance functions that require the uptake of nutrients and toxins. Many liver cell types, including hepatocytes and Kupffer cells, express scavenger receptors that play key roles in hepatitis C virus entry, lipid uptake, and macrophage activation, among others. Chronic liver disease causes high morbidity and mortality worldwide. Hepatitis virus infection, alcohol abuse, and non-alcoholic fatty liver are the main etiologies associated with this disease. In this context, continuous inflammation as a result of liver damage leads to hepatic fibrosis, which frequently brings about cirrhosis and ultimately hepatocellular carcinoma. In this review, we will summarize the role of scavenger receptors in the pathophysiology of chronic liver diseases. We will also emphasize their potential as biomarkers of advanced liver disease, including cirrhosis and cancer.

Determination of the ideal preparation for colonoscopy in a rat model.

BACKGROUND: Quality bowel preparation is essential to examine the entire colon adequately. No trials comparing different purgative regimens are available in animal models. The aim was to compare 5 methods for bowel cleansing to develop a rat model to study therapeutic colonoscopy. METHODS: Twenty-five rats were assigned to one of 5 regimens: (1) high-volume polyethylene glycol electrolyte solution (HV-PEG-ES, 40 mL); (2) low-volume PEG-ES (LV-PEG-ES, 20 mL); (3) high-volume PEG-ES+ascorbic acid (HV-PEG-ES+AA, 20 mL); (4) LV-PEG-ES+AA, 10 mL; (5) rectal enema with saline solution (RE-SS). Bowel preparation quality was rated by total colonoscopy. RESULTS: RE-SS is the best regime for left colon cleansing, whereas HV-PEG-ES and HV-PEG-ES+AA solutions resulted in significantly better cleansing in the whole colon. HV-PEG-ES+AA regimen needed less volume, and administration was easier. CONCLUSIONS: A total of 20 mL of PEG-ES+AA before colonoscopy is the best regimen to explore the whole colon, whereas to explore the left colon RE-SS is adequate.

Rifaximin, but not growth factor 1, reduces brain edema in cirrhotic rats.

AIM: To compare rifaximin and insulin-like growth factor (IGF)-1 treatment of hyperammonemia and brain edema in cirrhotic rats with portal occlusion. METHODS: Rats with CCl4-induced cirrhosis with ascites plus portal vein occlusion and controls were randomized into six groups: Cirrhosis; Cirrhosis + IGF-1; Cirrhosis + rifaximin; Controls; Controls + IGF-1; and Controls + rifaximin. An oral glutamine-challenge test was performed, and plasma and cerebral ammonia, glucose, bilirubin, transaminases, endotoxemia, brain water content and ileocecal cultures were measured and liver histology was assessed. RESULTS: Rifaximin treatment significantly reduced bacterial overgrowth and endotoxemia compared with cirrhosis groups, and improved some liver function parameters (bilirubin, alanine aminotransferase and aspartate aminotransferase). These effects were associated with a significant reduction in cerebral water content. Blood and cerebral ammonia levels, and area-under-the-curve values for oral glutamine-challenge tests were similar in rifaximin-treated cirrhotic rats and control group animals. By contrast, IGF-1 administration failed to improve most alterations observed in cirrhosis. CONCLUSION: By reducing gut bacterial overgrowth, only rifaximin was capable of normalizing plasma and brain ammonia and thereby abolishing low-grade brain edema, alterations associated with hepatic encephalopathy.

Rat CCl(4)-induced cirrhosis plus total portal vein ligation: a new model for the study of hyperammonaemia and brain oedema.

INTRODUCTION: Animal models used to study hyperammonaemic disorders related to chronic liver disease are unsatisfactory. These animals only develop hyperammonaemia and brain oedema when fed with diets supplemented with amonium acetate. AIM: To develop a novel experimental model of hyperammonaemia and brain oedema in CCl(4)-induced cirrhosis in rats. METHODS: Four groups were studied: rats with sham intervention (S), rats with total portal vein ligation (TPVL), cirrhotic rats (LC), and cirrhotic rats with TPVL (LC+TPVL). When ascites was diagnosed, oral glutamine challenge (OGC) test was performed. Blood, liver, lungs and brain samples were collected to quantify liver function parameters, plasmatic and cerebral ammonia, endotoxaemia, liver and brain histology, brain oedema and portosystemic shunting degree. RESULTS: LC+TPVL rats showed a significant increase in portosystemic shunting when compared with LC group and a significant derangement in liver function when compared with TPVL group. These alterations resulted in a significant increase in plasmatic and brain ammonia concentrations and a higher plasmatic endotoxaemia as compared with others. Similarly, the area under OGC curve was significantly increased in LC+TPVL group as compared with the others, and correlates with portal shunting. Low-grade brain oedema was only observed in LC+TPVL group. All cirrhotic groups showed liver regeneration nodules and type-II Alzheimer astrocytes CONCLUSION: LC+TPVL reproduce the main alterations - portosystemic shunting, plasmatic and cerebral hyperammonaemia and low-grade brain oedema - observed in cirrhotic patients with hepatic encephalopathy.

Serum concentrations of insulin-like growth factor-I (igf-I) as a marker of liver fibrosis in patients with chronic hepatitis C.

Liver biopsy was until recently the only way of evaluating liver fibrosis. Noninvasive tests for hepatic fibrosis, without potential risks, are desired by clinicians as well as patients. Insulin-like growth factor-I (IGF-I) synthesis is disturbed in liver fibrosis and reflects the severity of the clinical stage. We assessed serum IGF-I levels in patients with chronic hepatitis C (CHC) to correlate with liver fibrosis and antiviral therapy. Forty patients with CHC and persistently abnormal alanine aminotransferase values were enrolled and treated with peginterferon alpha-2a 180 microg per week plus ribavirin for 24 (n=20) or 48 (n=20) weeks. All patients underwent liver biopsy before treatment (METAVIR fibrosis stage F0, n=13; F1-F2, n=14; F3, n=7; F4, n=6). Serum IGF-I was measured at baseline, at the end of treatment period, and 24 weeks after finishing treatment. Mean IGF-I values were significantly lower in patients with advanced fibrosis (F4, 65.9+/-17.9 ng/mL) than in the others (F0, 145.2+/-47.1; F1-F2, 150.3+/-89.6; and F3, 121.4+/-35.2 ng/mL; P < .05). Serum IGF-I levels increased during combined therapy, being this increment markedly higher in patients with sustained virologic response. In conclusion, IGF-I synthesis is disturbed in CHC and reflects the severity of the liver fibrosis. Combined therapy improves serum IGF-I levels. IGF-I could represent a good, noninvasive marker of liver fibrosis.