NAFLD is one of the most important causes of liver disease worldwide and will probably emerge as the leading cause of end-stage liver disease in the coming decades, with the disease affecting both adults and children. The epidemiology and demographic characteristics of NAFLD vary worldwide, usually parallel to the prevalence of obesity, but a substantial proportion of patients are lean. The large number of patients with NAFLD with potential for progressive liver disease creates challenges for screening, as the diagnosis of NASH necessitates invasive liver biopsy. Furthermore, individuals with NAFLD have a high frequency of metabolic comorbidities and could place a growing strain on health-care systems from their need for management. While awaiting the development effective therapies, this disease warrants the attention of primary care physicians, specialists and health policy makers.

/pdf/global-burden-of-nafld-and-nash-trends-predictions-risk-2rbbbzfuoo.pdf

Global burden of NAFLD and NASH: trends, predictions, risk factors and prevention

http://www.swscn.org.uk/wp/wp-content/uploads/2014/11/IPMN_International-consensus-guidelines-20121.pdf

International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas

https://www.journal-of-hepatology.eu/article/S0168-8278(18)32388-2/pdf

Burden of liver diseases in the world

Worldwide, some 240 million people have chronic hepatitis B virus (HBV), with the highest rates of infection in Africa and Asia. Our understanding of the natural history of HBV infection and the potential for therapy of the resultant disease is continuously improving. New data have become available since the previous APASL guidelines for management of HBV infection were published in 2012. The objective of this manuscript is to update the recommendations for the optimal management of chronic HBV infection. The 2015 guidelines were developed by a panel of Asian experts chosen by the APASL. The clinical practice guidelines are based on evidence from existing publications or, if evidence was unavailable, on the experts' personal experience and opinion after deliberations. Manuscripts and abstracts of important meetings published through January 2015 have been evaluated. This guideline covers the full spectrum of care of patients infected with hepatitis B, including new terminology, natural history, screening, vaccination, counseling, diagnosis, assessment of the stage of liver disease, the indications, timing, choice and duration of single or combination of antiviral drugs, screening for HCC, management in special situations like childhood, pregnancy, coinfections, renal impairment and pre- and post-liver transplant, and policy guidelines. However, areas of uncertainty still exist, and clinicians, patients, and public health authorities must therefore continue to make choices on the basis of the evolving evidence. The final clinical practice guidelines and recommendations are presented here, along with the relevant background information.

/pdf/asian-pacific-clinical-practice-guidelines-on-the-management-za5qxgu5i6.pdf

Asian-Pacific clinical practice guidelines on the management of hepatitis B: a 2015 update.

Relationship between stress, eating behavior, and obesity.

Stress, defined as an acute threat to homeostasis, evokes an adaptive or allostatic response and can have both a short- and long-term influence on the function of the gastrointestinal tract. The enteric nervous system is connected bidirectionally to the brain by parasympathetic and sympathetic pathways forming the brain-gut axis. The neural network of the brain, which generates the stress response, is called the central stress circuitry and includes the paraventricular nucleus of the hypothalamus, amygdala and periaqueductal gray. It receives input from the somatic and visceral afferent pathways and also from the visceral motor cortex including the medial prefrontal, anterior cingulate and insular cortex. The output of this central stress circuit is called the emotional motor system and includes automatic efferents, the hypothalamus-pituitary-adrenal axis and pain modulatory systems. Severe or long-term stress can induce long-term alteration in the stress response (plasticity). Corticotropin releasing factor (CRF) is a key mediator of the central stress response. Two CRF receptor subtypes, R1 and R2, have been described. They mediate increased colonic motor activity and slowed gastric emptying, respectively, in response to stress. Specific CRF receptor antagonists injected into the 0 block these visceral manifestations of stress. Circulating glucocorticoids exert an inhibitory effect on the stress response by receptors located in the medial prefrontal cortex and hippocampus. Many other neurotransmitters and neuroimmunomodulators are being evaluated. Stress increases the intestinal permeability to large antigenic molecules. It can lead to mast cell activation, degranulation and colonic mucin depletion. A reversal of small bowel water and electrolyte absorption occurs in response to stress and is mediated cholinergically. Stress also leads to increased susceptibility to colonic inflammation, which can be adaptively transferred among rats by sensitized CD4(+) lymphocytes. The association between stress and various gastrointestinal diseases, including functional bowel disorders, inflammatory bowel disease, peptic ulcer disease and gastroesophageal reflux disease, is being actively investigated. Attention to the close relation between the brain and gut has opened many therapeutic avenues for the future.

https://sibotesting.com/wp-content/uploads/2015/11/Stress-and-the-Gastrointestinal-Tract-2015-Review.pdf

Stress and the gastrointestinal tract.

Background and aim: In acute liver failure (ALF), the brain is exposed to high levels of ammonia. Human studies defining the clinical significance of ammonia in ALF are lacking. This prospective study evaluated the relationship of arterial ammonia levels at admission to complications and survival among patients with ALF. Methods: Eighty consecutive ALF patients admitted from March 2001 to December 2003 were followed up until death or complete recovery. All had arterial ammonia estimation at admission (enzymatic method). Logistic regression analysis was performed to identify independent predictors of mortality. Results: Forty two (52.5%) patients died. Non-survivors had significantly higher median ammonia levels than survivors (174.7 v 105.0 μmol/l; p 7.40). Levels of partial pressure of ammonia were equally correlated with outcome. Conclusion: Arterial ammonia at presentation is predictive of outcome and can be used for risk stratification. Ammonia lowering therapies in patients with ALF should be evaluated.

https://gut.bmj.com/content/gutjnl/55/1/98.full.pdf

Predictive value of arterial ammonia for complications and outcome in acute liver failure.

https://www.giejournal.org/article/S0016-5107(09)02834-X/pdf

Diagnostic utility of EUS-guided FNA in patients with gastric submucosal tumors

https://aasldpubs.onlinelibrary.wiley.com/doi/epdf/10.1002/hep.22493

A 20-year single-center experience with acute liver failure during pregnancy: is the prognosis really worse?

The aim of this study was to evaluate the feasibility and safety of endoscopic ultrasonography (EUS)-guided trucut biopsy (TCB) for diagnosis of autoimmune pancreatitis (AIP). Fourteen patients with suspected AIP based on imaging studies underwent both EUS-guided fine-needle aspiration (FNA) and EUS-TCB for diagnosis of AIP and exclusion of pancreatic cancer (PC). According to the revised Japanese clinical diagnostic criteria, AIP was diagnosed in eight while the remaining six patients had pancreatitis of other etiologies. Pathologically, AIP was defined as lymphoplasmacytic sclerosing pancreatitis (LPSP), and sub-divided into two types: definite LPSP (d-LPSP) showing fulspectrum of LPSP and probable LPSP (p-LPSP) without obliterative phlebitis or abundant (>10 cells/hpf) IgG4-positive plasmacytes infiltration. PC was excluded in all patients. EUS-FNA resulted in three of eight patients with AIP were reported as p-LPSP, one was reported as normal, and 4 were inconclusive. One of six with non-autoimmune pancreatitis was diagnosed as p-LPSP on EUS-FNA, one as idiopathic chronic pancreatitis (ICP) and four were inconclusive. By using EUS-TCB, all AIP patients were diagnosed as LPSP (4 d-LPSP and 4 p-LPSP). Of the six patients with non-autoimmune pancreatitis, three were diagnosed as LPSP (1 d-LPSP and 2 p-LPSP) and three showed ICP on TCB. No complications were identified in any patient with either EUS-FNA or TCB. EUS-TCB is a safe and accurate procedure for obtaining a histological diagnosis in patients with suspected AIP. EUS-TCB can serve as a rescue technique in cases of AIP lacking typical findings.

Vikram Bhatia

Papers

Stress and the gastrointestinal tract.

Predictive value of arterial ammonia for complications and outcome in acute liver failure.

Diagnostic utility of EUS-guided FNA in patients with gastric submucosal tumors

A 20-year single-center experience with acute liver failure during pregnancy: is the prognosis really worse?

Histological diagnosis of autoimmune pancreatitis using EUS-guided trucut biopsy: A comparison study with EUS-FNA