EASL Clinical Practice Guidelines on non-invasive tests for evaluation of liver disease severity and prognosis – 2021 update

The concept of 'cirrhosis' is evolving and it is now clear that compensated and decompensated cirrhosis are completely different in terms of prognosis. Furthermore, the term 'advanced chronic liver disease (ACLD)' better reflects the continuum of histological changes occurring in the liver, which continue to progress even after cirrhosis has developed, and might regress after removing the etiological factor causing the liver disease. In compensated ACLD, portal hypertension marks the progression to a stage with higher risk of clinical complication and requires an appropriate evaluation and treatment. Invasive tests to diagnose cirrhosis (liver biopsy) and portal hypertension (hepatic venous pressure gradient measurement and endoscopy) remain of crucial importance in several difficult clinical scenarios, but their need can be reduced by using different non-invasive tests in standard cases. Among non-invasive tests, the accepted use, major limitations and major benefits of serum markers of fibrosis, elastography and imaging methods are summarized in the present review.

Diagnosis of cirrhosis and portal hypertension: imaging, non-invasive markers of fibrosis and liver biopsy.

Emerging non-invasive approaches for diagnosis and monitoring of portal hypertension.

Portal Hypertension: Pathogenesis and Diagnosis.

Liver cirrhosis is the fourth cause of death in adults in Western countries, with complications of portal hypertension being responsible for most casualties. In order to reduce mortality, development of accurate diagnostic methods for early diagnosis, effective etiologic treatment, improved pharmacological therapy for portal hypertension, and effective therapies for end-stage liver failure are required. Early detection of cirrhosis and portal hypertension is now possible using simple non-invasive methods, leading to the advancement of individualized risk stratification in clinical practice. Despite previous assumptions, cirrhosis can regress if its etiologic cause is effectively removed. Nevertheless, while this is now possible for cirrhosis caused by chronic hepatitis C, the incidence of cirrhosis due to non-alcoholic steatohepatitis has increased dramatically and effective therapies are not yet available. New drugs acting on the dynamic component of hepatic vascular resistance are being studied and will likely improve the future management of portal hypertension. Cirrhosis is now seen as a dynamic disease able to progress and regress between the compensated and decompensated stages. This opinion article aims to provide the author’s personal view of the current major advances and challenges in this field.

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Advances and challenges in cirrhosis and portal hypertension

Non-invasive assessment of portal hypertension using quantitative magnetic resonance imaging

Creation of a gastrogastric conduit by use of a lumen-apposing metal stent in a patient who had extensive small-bowel surgery secondary to a Peterson hernia.

To the editor, An aorto-enteric fistula (AEF) is an abnormal communication between the aorta and the gastrointestinal (GI) tract. It can be classified into primary AEF (PAEF) and secondary AEF (SAEF). PAEFs commonly arise from an abdominal aortic aneurysm or inflammatory/infected aorta process (aortitis/sepsis) with an incidence of 0.04–0.07% [1]. SAEFs are an uncommon complication of aortic abdominal reconstruction with an incidence of 0.6–4%. SAEFs can be subcategorised into two types: Type 1, a ‘true’ AEF, which develops between the proximal aortic suture line and GI tract, and Type 2, a para-prosthetic enteric pseudo-fistula with no real communication (i.e. bleeding from an eroded bowel wall) [2]. AEFs typically present with a primary trivial herald bleed that is sometimes followed by a life-threatening gastrointestinal haemorrhage [3]. We present here a rare case of PAEF, diagnosed on CT angiography (CTA) and successfully treated with endovascular aortic repair. We review benefits and drawbacks of CTA relative to endoscopy and explore the concept of CTA as an important investigation for active GI bleeding. A 16-year-old boy, with metastatic testicular carcinoma on a chemotherapy regimen with good therapeutic response, presented to our tertiary vascular centre very unwell with epigastric pain, two episodes of haematemesis and melaena. Prior to endoscopy, an urgent tri-phasic CT mesenteric angiogram was performed. This revealed a subtle distal aortic ‘beaking’ into the small bowel (loop of proximal jejunum) encased by a chronic para-aortic necrotic soft tissue mass (Fig. 1A, B). Urgent digital subtraction angiography (DSA) confirmed a PAEF (Fig. 2). The patient underwent endovascular aorto-uniiliac stent graft which relined the infra-renal aorta and proximal half of right common iliac artery (CIA) and excluded the left CIA. This required embolisation of the proximal left common iliac artery (CIA) followed by a distal crossover femoral–femoral bypass surgery (Fig. 3). The patient made good recovery and continues treatment with good chemotherapy response since the procedure (almost 2 years so far). In fact, the success of performed procedure managed to break into the local news as a full story to describe this specific treatment and increase public awareness of natural history and complications of metastatic testicular cancer [4]. The potentially life-saving step in this case was the decision to refer the patient for a CTA before performing endoscopy. In retrospect, had the endoscopist proceeded to scope, the outcome could have been catastrophic. Manipulation of the foregut during endoscopy may have Electronic supplementary material The online version of this article (https://doi.org/10.1007/s00270-018-1914-3) contains supplementary material, which is available to authorized users.

Paediatric Interventional Management of Primary Aorto-Enteric Fistula (PAEF).

A 43-year-old man had a peritoneovenous shunt inserted for the treatment of chylous ascites secondary to myelofibrosis. Despite being on anticoagulation for superior mesenteric vein thrombosis, he developed shunt dysfunction within two weeks of insertion. Superior venacavography showed multiple filling defects in the right axillary vein, no filling of the right brachiocephalic and right subclavian vein, and thrombotic occlusion of the internal jugular veins bilaterally. The shunt was removed 11 days after insertion, and there was extensive thrombosis of the venous end of the shunt and the compressible pump chamber. Shunt thrombosis is known to occur but remains a rare complication, with 87% of such obstructions being due to a thrombus at the tip of the venous end of the shunt. Extensive thrombosis of the shunt (as in the present case) is very rare.

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Simon Travis

Papers

Non-invasive assessment of portal hypertension using quantitative magnetic resonance imaging

Creation of a gastrogastric conduit by use of a lumen-apposing metal stent in a patient who had extensive small-bowel surgery secondary to a Peterson hernia.

Paediatric Interventional Management of Primary Aorto-Enteric Fistula (PAEF).

Spontaneous central venous thrombosis and shunt occlusion following peritoneovenous shunt placement for intractable ascites.