Systematic review and meta-analysis: Transient elastography compared to liver biopsy for staging of liver fibrosis in primary biliary cholangitis.

INTRODUCTION AND OBJECTIVES: Primary biliary cholangitis (PBC) is an autoimmune liver disease, with 60% of patients being asymptomatic at diagnosis and 30% progressing rapidly into liver fibrosis. Liver biopsy is standard for staging fibrosis, but performance of non-invasive methods such as transient elastography (TE) have not been evaluated. We conducted a meta-analysis of articles up to May 2022 to evaluate the performance of TE compared with liver biopsy in adult patients with PBC. MATERIALS AND METHODS: Two reviewers performed the search and assessed which articles were included. The quality of each study was evaluated according to QUADAS-2 and NOS. Meta-analysis of sensitivity and specificity was conducted with a bivariate random-effects model. The protocol was registered in PROSPERO, ID CRD42020199915. RESULTS: Four studies involving 377 patients were included. Only stages F3 and F4 were computed in the meta-analysis. TE had a pooled sensitivity of 68% and specificity of 92% for stage F3 and a pooled sensitivity of 90% and specificity of 94% for stage F4. The AUROC curves were 0.91 (95% Confidence Interval (CI) 0.88-0.93) and 0.97 (95% CI 0.96-0.98) for stages F3 and F4, respectively. The mean cut-off points of TE for stage F3 were 9.28 kPa (95% CI 4.98-13.57) and for stage F4 were 15.2 kPa (95% CI 7.02-23.37). CONCLUSIONS: TE performance compared with liver biopsy in adult patients with PBC was excellent for staging liver fibrosis and was able to rule out cirrhosis in clinical practice.

COVID-19: Current Status in Gastrointestinal, Hepatic, and Pancreatic Diseases-A Concise Review.

The gastrointestinal tract plays an important role in the pathogenesis of COVID-19. The angiotensin-converting enzyme 2 receptor and the transmembrane protease serine 2 receptor bind and activate SARS-CoV-2 and are present in high concentrations throughout the gastrointestinal tract. Most patients present with gastrointestinal symptoms and/or abnormal liver function tests, both of which have been associated with adverse outcomes. The mechanisms of liver damage are currently under investigation, but the damage is usually transient and nonsevere. Liver transplantation is the only definitive treatment for acute liver failure and end-stage liver disease, and unfortunately, because of the need for ventilators during the COVID-19 pandemic, most liver transplant programs have been suspended. Patients with gastrointestinal autoimmune diseases require close follow-up and may need modification in immunosuppression. Acute pancreatitis is a rare manifestation of COVID-19, but it must be considered in patients with abdominal pain. The gastrointestinal tract, including the liver and the pancreas, has an intimate relationship with COVID-19 that is currently under active investigation.

Localized genitourinary tract Aspergillus infection in an immunocompetent patient: Bladder and epidydimal aspergillosis.

Invasive bladder Aspergillosis has only been reported in six publications so far. A 74-year-old male, presented to the emergency department with fever, abdominal pain, and right testicular enlargement. Abdominal computed tomography concluded a bladder tumor and testicular ultrasound reported right epididymitis. Cystoscopy showed a bladder fungal mass, which was extracted with cystotomy. Pathological findings reported Aspergillus species. The patient was successfully treated with 4-week oral Isovuconazole. The first bladder Aspergillosis was published in 1978. The most recent case was published in 2020. Aspergillosis infection is extremely rare disease, treatment with Isavuconazole is efficient.

Liver and spleen elastography as predictor of portal hypertension and esophageal varices.

Liver stiffness is related to the degree of hepatic fibrosis which ultimately causes portal hypertension and gastroesophageal varices. Variceal bleeding is a worrisome and potentially fatal complication of cirrhosis, primary prophylaxis has demonstrated a reduction in decompensation and mortality. Portal hypertension and esophageal varices needing treatment could be predicted through noninvasive methods, including elastography, that evaluates the mechanical properties of liver or spleen tissue in concordance to the propagation of mechanical waves. The accurate prediction of the risk of gastroesophageal varices could spare unnecessary endoscopies in patients with low probability of finding varices needing treatment. In the current review, we discuss the elastography modalities available and the current evidence for its implementation in daily clinical practice.

Association of liver steatosis and fibrosis with clinical outcomes in patients with SARS-CoV-2 infection (COVID-19).

INTRODUCTION AND OBJECTIVES: Liver function tests (LFT) abnormalities are reported in up to 50% of COVID-19 patients, and metabolic comorbidities are associated with poorer outcomes. The aim of the study was to determine the prevalence of liver steatosis and fibrosis in patients with COVID-19 and their association with clinical outcomes. MATERIAL AND METHODS: Retrospective study in hospitalized COVID-19 patients was conducted. The risk for liver steatosis was estimated by HSI > 36, and risk for advanced liver fibrosis with APRI > 1.0, NAFLD FS > 0.675 and/or FIB-4 > 3.25. Clinical outcomes were admission to Intensive Care Unit (ICU) and mortality. RESULTS: Of 155 patients, 71.6% were male (n = 111), and 28.4% (n = 44) were obese. Abnormal LFT were present in 96.8% (n = 150), prevalence of steatosis was 42.6% (n = 66) and of significative liver fibrosis was 44.5% (n = 69). Liver fibrosis by FIB-4 was associated with risk of ICU admission (OR 1.74 [95%CI 1.74-2.68; p = 0.023]) and mortality (OR 6.45 [95%CI 2.01-20.83, p = 0.002]); no independent associations were found. CONCLUSIONS: The prevalence of steatosis and significant liver fibrosis was high in COVID-19 patients but was not associated with clinical outcomes.

Increased incidence of and microbiologic changes in pyogenic liver abscesses in the Mexican population.

BACKGROUND: Pyogenic liver abscess (PLA) is a rare disease with an estimated incidence that varies widely across the globe, being as high as 115.4/100000 habitants in Taiwan and as low as 1.1-1.2/100000 habitants in Europe and Canada. Even though there are multiple microorganisms capable of producing an abscess in the liver, including Entamoeba histolytica, fungi, and viruses, most abscesses are derived from bacterial infections. The epidemiology of PLA in Mexico is currently unknown. AIM: To describe the clinical, demographic and microbiologic characteristics of PLA in Mexico. METHODS: This is a retrospective study carried out in two centers, and included patients seen between 2006 and 2018 with the diagnosis of pyogenic abscess. We collected demographic, clinical, and microbiological information, treatment, complications, and outcomes. A logistic regression analysis was used to determine the association between different variables and mortality rates. RESULTS: A total of 345 patients were included in this study. 233 (67.5%) had confirmed PLA, 133 (30%) patients had no positive culture and negative serology and 9 (2.5%) had mixed abscesses. The mean age was 50 years (ranging from 16-97 years) and 63% were female. 65% of the patients had positive cultures for Extended Spectrum Beta-Lactamases (ESBL)-Escherichia coli and Klebsiella pneumoniae. Cefotaxime was administered in 60% of cases. The most common sources of infection were ascending cholangitis and cholecystitis in 34 (10%) and 31 (9%), respectively. The median length of hospital stay was 14 d. 165 patients underwent percutaneous catheter drainage. The inpatient mortality rate was 63%. Immunocompromised state [OR 3.9, 95%CI: 1.42-10.46], ESBL- Escherichia coli [OR 6.7, 95%CI: 2.7-16.2] and Klebsiella pneumoniae [OR 4-8, 95%CI: 1.6-14.4] predicted inpatient mortality by multivariate analysis. CONCLUSION: The prevalence of PLA is increasing in Mexico and has a very high mortality rate. ESBL-Escherichia coli and Klebsiella pneumoniae are the most common microorganisms causing PLA and are independent predictors of inpatient mortality.

Negative pressure therapy in combination with mesh-mediated fascial traction in the treatment of infected pancreatic necrosis. A new therapeutic option.

BACKGROUND: Acute pancreatitis represents one of the most frequent digestive pathologies worldwide, which can be complicated as an infected necrotizing acute pancreatitis, that may require treatment with necrosectomy and open abdomen with the risk that this leads to the appearance of intestinal fistula and giant incisional hernias difficult to manage. CLINICAL CASE: A 35-year-old woman underwent laparoscopic cholecystectomy for acute cholecystitis, which was re-admitted due to jaundice and abdominal pain 3 days after her hospital discharge. Diagnostic laparoscopy is performed, where a 3200 cc biliperitoneum secondary to a cystic duct stump leak is located and drained. Likewise, an endoscopic retrograde cholangiopancreatography (ERCP) is performed, with extraction of an impacted bile gallstone in the distal common bile duct. It presents as a complication of the procedure an acute post-ERCP pancreatitis with infected pancreatic necrosis. Open pancreatic necrosectomy was performed with a negative pressure therapy and mesh-mediated fascial traction, achieving resolution of the infectious condition with definitive closure of the abdominal cavity without incisional hernia or postoperative intestinal fistula. CONCLUSION: Patients with complicated acute pancreatitis with infected pancreatic necrosis represent a challenge in their treatment due to the serious nature of the condition and the morbidity associated with it. A therapeutic option is presented with the combined use of negative pressure therapy (ABThera™) and mesh-mediated fascial traction. With this report we propose a potential line of research to determine its role in the treatment of these patients, as well as their possible advantages and complications.

ANTECEDENTES: La pancreatitis aguda representa una de las enfermedades digestivas más frecuentes en todo el mundo, la cual puede complicarse como una pancreatitis aguda necrotizante infectada, que puede necesitar tratamiento con necrosectomía y abdomen abierto, con el riesgo que esto conlleva de aparición de fistula intestinal y hernias incisionales gigantes de difícil tratamiento. CASO CLÍNICO: Mujer de 35 años, intervenida de colecistectomía laparoscópica por colecistitis aguda, que es reingresada por ictericia y dolor abdominal 3 días después de su egreso hospitalario. Se realiza laparoscopia diagnóstica, en la que se encuentra y drena un biliperitoneo de 3200 cc secundario a una fuga de muñón del conducto cístico. Así mismo, se practica una colangiopancreatografía retrógrada endoscópica (CPRE), con extracción de un lito biliar impactado en el colédoco distal. Presenta como complicación del procedimiento pancreatitis aguda tras la CPRE con necrosis pancreática infectada. Se realiza necrosectomía pancreática abierta con sistema de presión negativa y tracción fascial mediante malla, logrando la resolución del cuadro infeccioso con cierre definitivo de la cavidad abdominal sin presentar hernia incisional ni fistula intestinal posoperatoria. CONCLUSIÓN: Los pacientes con pancreatitis aguda complicada con necrosis pancreática infectada representan un reto en su tratamiento por la naturaleza grave del padecimiento y la morbilidad asociada. Se presenta una opción terapéutica con el uso combinado de presión negativa (ABThera™) y tracción fascial mediante malla. Con el presente reporte se propone una potencial línea de investigación para determinar su papel en el tratamiento de estos pacientes, así como sus posibles ventajas y complicaciones.

Primary Cutaneous Mucormycosis Caused by Rhizopus oryzae: A Case Report and Review of Literature.

Mucormycosis is an invasive infection caused by opportunistic fungi. Rhizopus, Lichtheimia, Mucor and Rhizomucor are the most common isolated genera. Primary cutaneous mucormycosis is usually related to traumatic injuries, but immunocompromised cases are associated with underlying conditions such as diabetes mellitus and malignancies. The treatment of choice is surgical debridement and liposomal amphotericin B. We present a 40-year-old male with fever and a painful necrotic lesion on the middle back and history of poorly controlled diabetes mellitus. Rhizopus oryzae was isolated and identified using an internal transcribed spacer regions ITS1 and ITS2. An initial good response to treatment was observed; however, 7 days later a diabetic ketoacidosis due to poor adherence to treatment caused a lethal outcome.