Long-Term Management of Esophageal Varices by Endoscopic Sclerotherapy (EST): A Review of 12 Years' Experience

A total of 566 patients with variceal bleeding caused by cirrhosis of the liver, noncirrhotic portal fibrosis (NCPF) and extrahepatic portal venous obstruction (EHO) were treated by repeated endoscopic injection sclerotherapy. This decreased rebleeding was evidenced by a reduction in mean bleeding risk factor and transfusion requirement. Both the factors were significantly (P < 0.001) decreased in all three groups of patients. Rebleeding occurred before eradication in 27.7% of patients with cirrhosis, 24.3% of those with NCPF, and 11% of those with EHO. Significantly more patients with cirrhosis and NCPF bled in comparison to EHO. Irrespective of the etiology, fewer patients of Child's A class bled than those of Child's B and C classes (P < 0.001). The median bleeding-free period was longer in patients with EHO than in those with cirrhosis (P < 0.05). This period was also significantly longer in Child's A class than in Child's B and the latter had a longer median bleeding-free period than Child's C class (P < 0.01). Variceal eradication was achieved in 80% of patients with cirrhosis, 87% of patients with NCPF, and 90% of patients with EHO. The success of variceal eradication was higher in EHO patients in contrast with patients with cirrhosis of the liver. Similarly, eradication was better in Child's A class patients than in Child's B and C class patients. Recurrence of varices and complications were not influenced by the Child's status or etiology of portal hypertension. The probability of survival at 10 years was higher in patients with EHO (88%) and NCPF (80%) than in patients with cirrhosis (50%). Similarly, patients with Child's A (88%) status survived longer than those with Child's B (42%) status, and patients with Child's B status had a longer survival than Child's C status patients (0%). Thus, endoscopic variceal sclerotherapy appears to be a useful procedure for the long-term management of patients after an esophageal variceal bleeding irrespective of the etiology of portal hypertension

Is increased hepatitis C virus case-finding combined with current or 8-week to 12-week direct-acting antiviral therapy cost-effective in UK prisons? A prevention benefit analysis

UNLABELLED: Prisoners have a high prevalence of hepatitis C virus (HCV), but case-finding may not have been cost-effective because treatment often exceeded average prison stay combined with a lack of continuity of care. We assessed the cost-effectiveness of increased HCV case-finding and treatment in UK prisons using short-course therapies. A dynamic HCV transmission model assesses the cost-effectiveness of doubling HCV case-finding (achieved through introducing opt-out HCV testing in UK pilot prisons) and increasing treatment in UK prisons compared to status quo voluntary risk-based testing (6% prison entrants/year), using currently recommended therapies (8-24 weeks) or interferon (IFN)-free direct-acting antivirals (DAAs; 8-12 weeks, 95% sustained virological response, £3300/week). Costs (British pounds, £) and health utilities (quality-adjusted life years) were used to calculate mean incremental cost-effectiveness ratios (ICERs). We assumed 56% referral and 2.5%/25% of referred people who inject drugs (PWID)/ex-PWID treated within 2 months of diagnosis in prison. PWID and ex-PWID or non-PWID are in prison an average 4 and 8 months, respectively. Doubling prison testing rates with existing treatments produces a mean ICER of £19,850/quality-adjusted life years gained compared to current testing/treatment and is 45% likely to be cost-effective under a £20,000 willingness-to-pay threshold. Switching to 8-week to 12-week IFN-free DAAs in prisons could increase cost-effectiveness (ICER £15,090/quality-adjusted life years gained). Excluding prevention benefit decreases cost-effectiveness. If >10% referred PWID are treated in prison (2.5% base case), either treatment could be highly cost-effective (ICER<£13,000). HCV case-finding and IFN-free DAAs could be highly cost-effective if DAA cost is 10% lower or with 8 weeks' duration. CONCLUSIONS: Increased HCV testing in UK prisons (such as through opt-out testing) is borderline cost-effective compared to status quo voluntary risk-based testing under a £20,000 willingness to pay with current treatments but likely to be cost-effective if short-course IFN-free DAAs are used and could be highly cost-effective if PWID treatment rates were increased. (Hepatology 2016;63:1796-1808)

Provision and standards of care for treatment and follow-up of patients with Autoimmune Hepatitis (AIH)

Background Autoimmune hepatitis (AIH) is a substantial UK health burden, but there is variation in care, facilities and in opinion regarding management. We conducted an audit of service provision and care of patients with AIH in 28 UK hospitals. Methods Centres provided information about staffing, infrastructure and patient management (measured against predefined guideline-based standards) via a web-based data collection tool. Results Hospitals (14 university hospitals (UHs), 14 district general hospitals (DGHs)) had median (range) of 8 (3-23) gastroenterologists; including 3 (0-10) hepatologists. Eight hospitals (29%, all DGHs) had no hepatologist. In individual hospital departments, there were 50% (18-100) of all consultants managing AIH: in DGH's 92% (20-100) vs 46% (17-100) in UHs. Specialist nurses managed AIH in only 18%. Seventeen (61%) hospitals had a histopathologist with a liver interest, these were more likely to find rosettes than those without (172/795 vs 50/368; p<0.001). Of 999 steroid-treated patients with ≥12 months follow-up, 25% received steroids for <12 months. After 1 year of treatment, 82% of patients achieved normal serum alanine aminotransaminase (ALT); this was higher in UHs than DGHs. Three-monthly liver blood tests were inadequately recorded in 26%. Of potentially eligible patients with liver decompensation, transplantation was apparently not considered in 5% (n=7). The same standards were attained in different types of hospital. Conclusion Management of AIH in UK hospitals is often shared between most gastroenterologists. Blood test monitoring and treatment duration are not always in line with recommendations. Some eligible patients with decompensation are not discussed with transplant teams. Care might be improved by expanding specialist input and management by fewer designated consultants

International genome-wide meta-analysis identifies new primary biliary cirrhosis risk loci and targetable pathogenic pathways.

Primary biliary cirrhosis (PBC) is a classical autoimmune liver disease for which effective immunomodulatory therapy is lacking. Here we perform meta-analyses of discovery data sets from genome-wide association studies of European subjects (n=2,764 cases and 10,475 controls) followed by validation genotyping in an independent cohort (n=3,716 cases and 4,261 controls). We discover and validate six previously unknown risk loci for PBC (Pcombined<5 × 10(-8)) and used pathway analysis to identify JAK-STAT/IL12/IL27 signalling and cytokine-cytokine pathways, for which relevant therapies exist