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Determining the stage of fibrosis is an essential element of chronic hepatitis C (HCV) management. This study aims to evaluate aminotransferase to platelet ratio (APRI) score in comparison with Vibration-Controlled Transient Elastography (VCTE) for assessing the severity of liver disease in HCV-infected patients. Material and methods: We retrospectively enrolled 293 HCV-infected patients with different stages of fibrosis who achieved sustained virological response (SVR) after direct-acting antivirals (DAAs) therapy, which have been evaluated by VCTE from 1st September 2020 to 30th July 2021. Results: Two hundred and ninety-three patients (72.7% females, mean age of 61.75 ± 10.87 years, and mean BMI of 27.85 ± 4.63 kg/m2) were evaluated. As estimated by VCTE, 44 (15%) of patients were without liver fibrosis (F0), 80 (27.3%) with F1 (mild), 39 (13.3%) with F2 (significant), 43 (14.7%) with F3 (advanced) liver fibrosis, and 87 (29.7%) with F4 (cirrhosis), with a mean value of liver stiffness measurements (LSM) of 10.17 ± 7.42 kPa. The APRI score has a positive correlation with the LSM score (p=0.047), predicting severe liver disease adequately. The optimal receiver operator curve (ROC) for predicting advanced fibrosis was > 1.15 (area under the curve [AUC] 0.79, 95% CI 0.71-0.83; p < 0.001) with a sensitivity (Ss) of 82.5%, specificity (Sp) 28%, a positive predictive value (PPV) of 72%, and negative predictive value (NPV) of 81%. Conclusions: APRI score can predict well the advanced liver fibrosis and cirrhosis and can be a useful non-invasive biochemical marker for resource-limited management of HCV-infected patients.

Several studies suggested a regression of liver fibrosis (LF) over time after successful therapy in HCV infected patients. The aim of this study was to assess the changes of fibrosis occurring after successful direct acting antiviral (DAA) treatment using transient elastography (TE) and FIB-4 score in patients with HCV genotype 1 b compensated cirrhosis. Material and methods: LF were evaluated by TE and FIB-4 at baseline, sustained virological response (SVR) and 12 months after end of treatment (EOT). LF regression was defined as an improvement of ≥ 30% in Fibroscan® score at follow-up compared to baseline. Results: There were 98 patients with HCV-related compensated liver cirrhosis who achieved SVR after DAAs, most female (65.3%), aged 60.64 ± 9.56 years. Overall, LF had a significant improvement with a median (IQR) regression of 4.5 (1.8-7.8) from baseline to SVR and 5.1 (2.5-8.65) from baseline to 12 months after EOT (p

After great concerns were raised regarding a high incidence of hepatocellular carcinoma (HCC) after direct acting antivirals (DAAs) therapy in cirrhotic HCV patients, an avalanche of studies that debated this issue emerged, whose results highlighted also a more aggressive HCC pattern after DAAs. We aimed to assess the pattern and imaging features of HCC in patients with HCV-related liver cirrhosis after DAAs. Material and methods: This is a single-center case-controlled retrospective study in which we included consecutive patients with HCC and HCV-related liver cirrhosis admitted in our clinic between January 1st, 2016 and May 1st, 2018. Results: Sixty-nine patients with HCV-related cirrhosis and HCC were divided into 2 groups depending on the DAAs-treated or untreated status: group I included 15 patients that were previously treated with DAAs and group II included 54 naive patients. Regarding the distribution of HCC, there were no significant differences between the two groups (73.3% of group I patients and 55.5% of group II had unicentric lesion, p=0.215). The tumor size was significantly higher in group II compared to group I, with 66.6% of patients in group I and only 29.6% of patients in group II that have a tumor size less than 3 cm (p=0.009). Supportive treatment without ablation was more frequent in group II (33.3%) than in group I (6.6%) (p=0.047). Conclusions: Our study found no evidence of a more aggressive behavior of HCC after DAAs treatment compared to naive patients. Furthermore, the pattern of HCC after DAAs did not affect the access to curative treatment.

Nonalcoholic fatty liver disease (NAFLD) has emerged as the most frequent cause of liver disease worldwide, comprising a plethora of conditions, ranging from steatosis to end-stage liver disease. Cardiovascular disease (CVD) has been associated with NAFLD and CVD-related events represent the main cause of death in patients with NAFLD, surpassing liver-related mortality. This association is not surprising as NAFLD has been considered a part of the metabolic syndrome and has been related to numerous CVD risk factors, namely, insulin resistance, abdominal obesity, dyslipidemia, hyperuricemia, chronic kidney disease, and type 2 diabetes. Moreover, both NAFLD and CVD present similar pathophysiological mechanisms, such as increased visceral adiposity, altered lipid metabolism, increased oxidative stress, and systemic inflammation that could explain their association. Whether NAFLD increases the risk for CVD or these diagnostic entities represent distinct manifestations of the metabolic syndrome has not yet been clarified. This review focuses on the relation between NAFLD and the spectrum of CVD, considering the pathophysiological mechanisms, risk factors, current evidence, and future directions.

Worldwide, the leading cause of chronic liver disease is represented by nonalcoholic fatty liver disease (NAFLD) which has now become a global epidemic of the 21st century, affecting 1 in 4 adults, and which appears to be associated with the steadily increasing rates of metabolic syndrome and its components (obesity, type 2 diabetes mellitus (T2DM), and dyslipidemia). NAFLD has been reported to be associated with extrahepatic manifestations such as cardiovascular disease, T2DM, chronic kidney disease, extrahepatic malignancies (e.g., colorectal cancer), endocrine diseases (e.g., hypothyroidism, polycystic ovarian syndrome, psoriasis, and osteoporosis), obstructive sleep apnea, and iron overload. The prevalence of NAFLD is very high, affecting 25–30% of the world population and encloses two steps: (1) nonalcoholic fatty liver (NAFL), which includes steatosis only, and (2) nonalcoholic steatohepatitis (NASH) defined by the presence of steatosis and inflammation with hepatocyte ballooning, with or without fibrosis which can progress to liver fibrosis, hepatocellular carcinoma, and liver transplantation. Current data define a more complex relationship between NAFLD and T2DM than was previously believed, underlining a bidirectional and mutual association between the two entities. This review aims to summarize the current literature regarding the incidence of T2DM among patients with NAFLD and also the prevalence of NAFLD in T2DM patients, highlighting the recent key studies. Clinicians should screen, diagnose, and treat T2DM in patients with NAFLD in order to avoid short- and long-term complications.

Early identification of acute pancreatitis etiology is essential for choosing the best therapeutic management. The main causes are cholelithiasis and alcohol consumption. Tumors that obstruct the main pancreatic duct are uncommon causes of acute pancreatitis. Duodenal neuroendocrine tumors are rare entities and may be exceptional causes of acute pancreatitis. A 57-year-old male, with associated severe cardiovascular pathology, was admitted with clinical and biological picture of acute pancreatitis. Biliary and alcoholic causes were excluded. Abdominal contrast-enhanced computed tomography scan identified circumferential wall thickening of the second segment of the duodenum with peri-ampullary and papillary nodular non-homogenous contrast enhancement aspect. Upper gastrointestinal endoscopy described irregular hypertrophic duodenal mucosal folds and biopsies were performed. The histopathological diagnosis after immunohistochemistry tests was duodenal large-cell neuroendocrine carcinoma. The patient was referred to the oncology clinic and palliative treatment was initiated. The evolution was marked by additional complications due to the tumor evolution – upper gastrointestinal bleeding and obstructive jaundice, conservatory treated and, respectively, by interventional radiology technique. This case illustrates that, although often obvious, etiological diagnosis approach of acute pancreatitis can be sometimes challenging. Tumor cause is infrequent and requires thorough work-up, as the treatment is different. Although extremely rare and sometimes with mild clinical presentation, duodenal neuroendocrine carcinomas may have dramatic onset and evolution, involving extensive therapeutic resources.

Background and Objectives: Spontaneous bacterial peritonitis (SBP) is a life-threatening complication of liver cirrhosis. Antibiotic prophylaxis is effective but can lead to an increased incidence of Clostridioides difficile infection (CDI). The aim of this study was to evaluate the incidence of CDI and the risk factors in cirrhotic patients with a previous episode of SBP receiving norfloxacin as secondary prophylaxis. Materials and Methods: We performed a prospective, cohort study including patients with liver cirrhosis and SBP, successfully treated over a 2-year period in a tertiary university hospital. All the patients received secondary prophylaxis for SBP with norfloxacin 400 mg/day. Results: There were 122 patients with liver cirrhosis and SBP included (mean age 57.5 ± 10.8 years, 65.5% males). Alcoholic cirrhosis was the major etiology accounting for 63.1% of cases. The mean MELD score was 19.7 ± 6.1. Twenty-three (18.8%) of all patients developed CDI during follow-up, corresponding to an incidence of 24.8 cases per 10,000 person-years. The multivariate Cox regression analysis demonstrated that alcoholic LC etiology (HR 1.40, 95% CI 1.104–2.441, p = 0.029) and Child-Pugh C class (HR 2.50, 95% CI 1.257–3.850, p = 0.034) were independent risk factors for CDI development during norfloxacin secondary prophylaxis. The development of CDI did not influence the mortality rates in cirrhotic patients with SBP receiving norfloxacin. Conclusions: Cirrhotic patients with SBP and Child-Pugh C class and alcoholic liver cirrhosis had a higher risk of developing Clostridioides difficile infection during norfloxacin secondary prophylaxis. In patients with alcoholic Child-Pugh C class liver cirrhosis, alternative prophylaxis should be evaluated as SBP secondary prophylaxis.

Background: Considering the excellent safety profile and the high efficacy rates, great benefits were expected with the availability of the new direct-acting antivirals (DAAs) in treating hepatitis C virus (HCV) infection. Following the publication of two articles in 2016 on the high incidence rates of hepatocelullar carcinoma (HCC) following DAAs, several papers revealed contradictory results, thereby casting shadows on the role of DAAs in hepatocarcinogenesis. Objectives: The present study aimed to assess the incidence and risk factors of HCC in patients with HCV genotype 1b infection and compensated cirrhosis with the sustained virological response (SVR) following DAAs. Methods: This multicentric prospective study encompassed 479 patients with HCV genotype 1b compensated cirrhosis treated with paritaprevir/ritonavir/ombitasvir and dasabuvir (PrOD) +/- ribavirin (RBV) for 12 weeks in two tertiary centers in Northeastern Romania. The patients were prospectively followed up in the Institute of Gastroenterology Iasi, Romania, from November 2015 to December 2020. Results: During the follow-up period (mean 60.11 ± 3.87 months), 23 patients (4.8%) developed HCC. The 1-, 3-, and 5-year cumulative incidence rates of HCC were 1.1, 1.9, and 2.6%, respectively. At the time of the diagnosis, 15 patients (65%) had a single tumor, 12 patients (52.2%) were within the Milan criteria, and nine persons (39%) had Barcelona liver cancer stage 0-A. In this regard, the mean AFP level was 35.3 ± 93.1 ng/mL. A multivariate analysis, age above 65 years, and a cutoff point of AFP ≥ 10 ng/mL at the end of treatment were independent factors associated with HCC. A majority of the patients (n = 11, 47.8%) received curative treatment by surgical resection. In this study, histopathological examination identified a moderately differentiated tumor (G2) in 5 patients, five patients had a poorly differentiated tumor (G3), and only one patient had a well-differentiated tumor (G1). Conclusions: Our study revealed no evidence of the high incidence rate of HCC after the long-term follow-up of patients with HCV-related liver cirrhosis and SVR following DAA treatment. However, the cumulative 5-year risk remained above the cutoff point, and this makes the HCC screening cost-effective. The HCC occurrence appears to be associated with aging and a moderately increased AFP level at EOT (≥ 10 ng/mL).

(1) Background: The World Health Organization adopted a strategy for the Global Health Sector on Viral Hepatitis in 2016, with the main objective of eliminating hepatitis C virus (HCV) by 2030. In this work, we aimed to evaluate the prevalence of HCV infection and risk factors in a Romanian village using population-based screening as part of the global C virus eradication program. (2) Methods: We conducted a prospective study from March 2019 to February 2020, based on a strategy as part of a project designed to educate, screen, treat and eliminate HCV infection in all adults in a village located in Northeastern Romania. (3) Results: In total, 3507 subjects were invited to be screened by rapid diagnostic orientation tests (RDOT). Overall, 2945 (84%) subjects were tested, out of whom 78 (2.64%) were found to have positive HCV antibodies and were scheduled for further evaluation in a tertiary center of gastroenterology/hepatology in order to be linked to care. In total, 66 (85%) subjects presented for evaluation and 55 (83%) had detectable HCV RNA. Of these, 54 (98%) completed antiviral treatment and 53 (99%) obtained a sustained virological response. (4) Conclusions: The elimination of hepatitis C worldwide has a higher chance of success if micro-elimination strategies based on mass screening are adopted.

Vibration-Controlled Transient Elastography (VCTE) with Controlled Attenuation Parameter (CAP) is a widely used non-invasive technique for concomitant assessment of liver steatosis and fibrosis in patients with nonalcoholic fatty liver disease (NAFLD). We aimed to evaluate the level both of hepatic steatosis and fibrosis as well as the associated risk factors in patients referred to our unit with clinically suspected NAFLD or diagnosed by abdominal ultrasonography. Two hundred four patients were prospectively included in this study and assessed by VCTE with CAP. The final analysis included 181 patients with reliable liver stiffness measurements (LSMs) (53% female, mean age 57.62 ± 11.8 years and BMI 29.48 ± 4.85 kg/m2). According to the cut-off values for steatosis grading, there were 10 (5.5%) patients without steatosis (S0), 30 (16.6%) with mild (S1), 45 (24.9%) moderate (S2), and 96 (53%) severe (S3) steatosis. Based on LSM, there were 73 (40.3%) patients without fibrosis (F0), 42 (23.2%) with mild (F1), 32 (17.7%) significant (F2), 19 (10.5%) advanced (F3) fibrosis, and 15 (8.3%) with cirrhosis (F4). In addition, we found an association between several metabolic components and hepatic steatosis and fibrosis. Thus, in the multivariate analysis, higher BMI, fasting plasma glucose, triglycerides, low-density lipoprotein cholesterol, and serum uric were associated with increased CAP. Furthermore, higher serum uric acid and alpha-fetoprotein together with lower platelets count and albumin levels were associated with increased LSM. The assessment of steatosis and fibrosis using VCTE and CAP should be performed in all patients with suspected or previously diagnosed NAFLD in units with available facilities.

Background: The outbreak of the coronavirus disease 2019 (COVID-19) has led to significant changes in endoscopy units worldwide, with potential impact on patients&rsquo, welfare as well as on endoscopy training. We aimed to assess the real-life impact of COVID-19 on the endoscopy unit in a tertiary care center from Romania. Methods: A 6.5-month period during the COVID-19 pandemic was compared to a similar period from 2019. Results: A 6.2-fold decrease of endoscopic procedures was noted. Colonoscopies were reduced from 916 to 42, p &lt, 0.001, flexible sigmoidoscopies from 189 to 14, p = 0.009, upper gastrointestinal (GI) endoscopies from 2269 to 401, p = 0.006, and ERCP from 234 to 125, p &lt, 0.001. The percentage of emergency procedures increased (38.8% vs. 26.2%, p &lt, 0.001), as well as the rate of endoscopies performed for upper GI bleeding (42.5% vs. 24.4%, respectively, p &lt, 0.001). The detection of cancers was considerably reduced (57 compared to 249, p = 0.001). There were fewer complications and higher success rates (7.6% vs. 19.2%, p &lt, 0.001, and 94.2% vs. 90.7%, respectively). Fellows participation was also reduced from 90% to 40.9% (p &lt, 0.001). Conclusions: The COVID-19 pandemic has significantly altered the workflow of the endoscopy unit, lowering the number of procedures performed and potentially compromising the early detection of cancers.

Nonalcoholic fatty liver disease (NAFLD) has a rising prevalence worldwide. Its potential for evolution towards liver cirrhosis and hepatocellular carcinoma, as well as associations with extrahepatic manifestations, represents a double burden for patients and physicians alike. Recently, there has been increasing evidence of the association between NAFLD and a number of endocrinopathies, such as hypothyroidism, polycystic ovarian syndrome (PCOS), hypopituitarism, growth hormone deficiency (GHD), hypogonadism, and hypercortisolism. Definite correlations are supported by clear evidence so far, but further studies are needed in order to completely clarify the pathogenic mechanisms and, especially, to identify therapeutic implications. In this review, we present the main relationships between NAFLD and endocrinopathies, emphasizing the reciprocal causality, evolutive interconnections, and current clinical scenarios of presentations of which the clinicians should be aware.

Direct acting antivirals (DAAs) have revolutionized the treatment of hepatitis C virus (HCV) infection, achieving high rates (≥ 95%) of sustained virological response, with a good safety profile and high compliance rates. Consequently, it had been expected that viral clearance will reduce morbidity and mortality rates, as well as the risk of hepatocellular carcinoma (HCC). However, since 2016, concerns have been raised over an unexpected high rate of HCC occurrence and recurrence after DAA therapy, which led to an avalanche of studies with contradictory results. We aimed to review the most recent and relevant articles regarding the risk of HCC after DAA treatment and identify the associated risk factors.

Background Nonalcoholic steatohepatitis (NASH) is a subtype of non-alcoholic fatty liver disease (NAFLD) with a potentially progressive course to liver fibrosis, cirrhosis with its complications, or even hepatocellular carcinoma. NAFLD is a rapidly growing chronic liver disease, with a global prevalence of about 25%, with a significant increase in the last 2 decades, changing the landscape of hepatology. This study aimed to undertake a bibliometric global analysis of research literature focusing on NASH. Methods We searched the Scopus database to identify all articles pertaining to "non-alcoholic steatohepatitis" or "NASH" - the 2 keywords used to search in the title or abstract within the time period 1980 to 2018. The collected data included document type, author, journal, publication year, citation reports, country, and were analyzed using Microsoft Excel and Microsoft Word. Results A total number of 6632 articles published in 1355 journals were retrieved. English was the predominant language of publication, USA being the most productive with 1937 articles published (29.2% of the total number of publications), followed by Japan with 909, representing 13.7% of publications. Hepatology, Journal of Hepatology and World Journal of Gastroenterology were the most active journals. Research articles were the most common type of publications (4524; 68.22%), followed by review articles (1359; 20.49%). The total number of citations received by all publications was 274,041, with an average of 41.32 per article (range: 0-4384). The average number of authors per article has increased in the last 2 decades, whereas the trend of single- (or few) authored publications has decreased. Conclusion This study indicates that NASH is a significant topic in the hepatology research, as proved by the huge number of publications, recording an exponential growth in the last 2 decades. The USA stands out as by far the most productive country.