Prevalence of Steatotic Liver Disease in U.S. And Risk of Complications

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M Kalligeros et al. Clin Gastroenterol Hepatol 2024; 22: 1330-1332. Prevalence of Steatotic Liver Disease (MASLD, MetALD, and ALD) in the United States: NHANES 2017-2020

9698 participants in NHANES during the 2017-2020 cycle completed a transient elastography examination. After excluding patients less than 18 years, these were the key findings:

  • 37.87% had steatotic liver disease
  • 32.45% had MASLD
  • 2.56% had MetALD
  • 1.17% and ALD

Limitations: database study, lack of liver biopsy, reliance on self-reports of alcohol consumption

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M-H Lee et al. Clin Gastroenterol Hepatol 2024; 22: 1275-1285. Open Access! Chronic Viral Hepatitis B and C Outweigh MASLD in the Associated Risk of Cirrhosis and HCC

Methods: 336,866 adults aged ≥30 years were prospectively enrolled in a health screening program between 1997–2013

Key findings:

  • 122,669 (36.4%) had MASLD. Over a mean follow-up of 15 years, 5562 new cases of cirrhosis and 2273 new cases of HCC were diagnosed.
  • Hazard ratios for HCC were 8.86 for MASLD with HBV or HCV, compared with non-SLD without HBV or HCV
  • Hazard ratios for HCC were 8.81 for HBV or HCV with non-SLD (SLD), and 1.52 for MASLD without HBV or HCV

My take: MASLD significantly increased cirrhosis and HCC risks; however the risk of HBV or HCV was much greater. The high prevalence rates of MASLD guarantees a huge need for liver disease management for the foreseeable future.

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Descanso Gardens (Los Angeles)

Ulcerative Colitis Therapy for Castaways? And PYRAMID Safety Data

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S Kedia et al. Clin Gastroenterol Hepatol 2024; 22: 1295-1306. Open Access! Coconut Water Induces Clinical Remission in Mild to Moderate Ulcerative Colitis: Double-blind Placebo-controlled Trial

Background: “Coconut water (CW) possesses anti-inflammatory properties, can potentially manipulate the microbiome, is a rich source of dietary potassium,” and may be an effective treatment for mild to moderate ulcerative colitis (UC).

Methods: Along with standard medical therapy, four hundred mL of CW (200 mL 2/day) or placebo fluid was administered for 8 weeks to adults (CW, n = 49; placebo, n = 46) with mild to moderate UC

Key findings:

  • Clinical response (57.1% vs 28.3%; odds ratio [OR], 3.4), remission (53.1% vs 28.3%; OR, 2.9), and proportion of patients with fecal calprotectin (FCP) <150 μg/g (30.6% vs 6.5%; OR, 6.3) all significantly favored CW group
  • There was not a significant difference in endoscopic outcomes

The authors indicate CW may be a useful adjunct for mild to moderate colitis but should be avoided in those patients taking medications that affect potassium and those with chronic kidney disease.

My take: This would be a good study to repeat to confirm whether CW is helpful for colitis. Certainly too much CW (a high FODMAP beverage) can contribute to a laxative effect and elevated potassium in some people. If a person with colitis is stranded on an island, CW may help until a rescue arrives.

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D Ahuja et al. Clin Gastroenterol Hepatol 2024; 22: 1286-1294. Impact of Treatment Response on Risk of Serious Infections in Patients With Crohn’s Disease: Secondary Analysis of the PYRAMID Registry

In this prospective observational real-world treatment registry…

Key findings:

  • Of 1515 adalimumab-treated patients, 763 (50.4%) were classified as responders at 6 months
  • Compared with nonresponders, responders were less likely to have moderate to severe symptoms (55.6% vs 33%), or require steroids (45.5% vs 17.3%) or opiates (6.6% vs 1.3%) at baseline
  • During follow-up evaluation, using stabilized inverse probability of treatment weighting, responders were 34% less likely to experience serious infections compared with nonresponders (hazard ratio, 0.66)

The study results are similar to a registry-based rheumatoid arthritis study by Strangfeld et al (Ann Rheu m Dis 2011; 70: 1914-1920), which showed effective treatment was associated with less steroid use and a decline int risk of serious infections.

My take: This study indicates that lack of control of CD increases the risk for complications and infections. So, while patients are concerned about medication adverse effects, the complications of foregoing treatment or ineffective treatment are usually more concerning.

Medical Billing Trap: Hospital Pricing for Urgent Care Visits and Outpatient Departments

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Danielle Ofri. NY Times (June 17, 2024): Even Doctors Like Me Are Falling Into This Medical Bill Trap

An excerpt:

I reflected on how urgent-care centers filled a perfect niche between the overkill of an emergency room and the near impossibility of snagging an immediate orthopedic appointment….Two weeks later a bill arrived: The radiology charge from NorthShore University HealthSystem for the ankle and wrist X-rays was $1,168, a price that seemed way out of range for something that usually costs around $100 for each X-ray. When I examined the bill more closely, I saw that the radiology portion came not from the urgent care center but from a hospital, so we were billed for hospital-based X-rays. When I inquired about the bill, I was told that the center was hospital-affiliated and as such, is allowed to charge hospital prices…

It turns out that I’d stumbled into a lucrative corner of the health care market called hospital outpatient departments, or HOPDs. They do some of the same outpatient care — colonoscopies, X-rays, medication injections — just as doctors’ offices and clinics do. But because they are considered part of a hospital, they get to charge hospital-level prices for these outpatient procedures, even though the patients aren’t as sick as inpatients. Since these facilities don’t necessarily look like hospitals, patients can be easily deceived and end up with hefty financial surprises…

As of 2022, federal law protects patients from surprise bills if they are unknowingly treated by out-of-network doctors. But there is no federal protection for patients who are unknowingly treated in higher-priced hospital affiliates that look like normal doctors’ offices or urgent care clinics...

HOPDs turn out to be an attractive business plan for hospitals that are aggressively acquiring doctors’ practices. ​​When these acquisitions occur, prices often rise as patients are now seen in “hospital facilities.”

It’s time for Congress to protect patients from both unfair pricing schemes and health care deception. MedPAC, the nonpartisan Medicare Payment Advisory Commission, recently recommended to Congress a basic set of site-neutral policies. It would apply site-neutral payments to a handful of low-risk procedures — some imaging, medication injections, simple office procedures — and this would apply to all HOPDs.

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How to Sort Out Chronic Laryngeal Symptoms and Reflux

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Two recent articles provide some insight into the muddy waters of laryngeal symptoms and reflux which is a much bigger challenge in the adult population than in the pediatric age group.

AJ Krause et al. Clin Gastroenterol Hepatol 2024; 22: 1200-1209. Open Access! Validated Clinical Score to Predict Gastroesophageal Reflux in Patients With Chronic Laryngeal Symptoms: COuGH RefluX

AJ Krause et al. Am J Gastroenterol 2024; 119: 627-634. Diagnostic Yield of Ambulatory Reflux Monitoring Systems for Evaluation of Chronic Laryngeal Symptoms. Thanks to Dr. Benjamin Gold for this reference.

In the first study, there were a total of 856 adults, 304 in the training cohort and 552 in the validation cohort. Key finding: In the validation phase, the COuGH RefluX score had an area under the curve of 0.67 (95% CI, 0.62–0.71), with 79% sensitivity and 81% specificity for proven GERD. Graphical abstract from the first study:

In the second study, the authors retrospectively examined 813 adults with chronic laryngeal symptoms over a 5 year period comparing . The diagnostic yield for prolonged wireless pH testing (n=296) was compared to 24-hour pH-impedance monitoring (n=532) off anti-secretory agents. Key finding: the prolonged wireless pH testing had a yield of 50% compared to 27% for the 24-hr pH-impedance testing.

My take: In the 1st study, the scoring system of cough, obesity, globus sensation, hiatal hernia, regurgitation, and male sex provides a good idea about the likelihood of reflux. In the 2nd study, the authors conclude that prolonged wireless pH testing may be preferrable due to higher diagnostic yield. However, the more proper conclusion is that we still don’t know the best way to determine when reflux causes chronic laryngeal symptoms or even the best way to measure reflux.

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Evaluation of Hematochezia in Infants with Congenital Heart Disease

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S Pradham et al. J Pediatr 2024; 269: 113992. Management of Hematochezia in Infants with Congenital Heart Disease Admitted to the Acute Care Cardiology Unit: A Multicenter Retrospective Pilot Study

Methods: This was a multicenter retrospective review of patient characteristics and evaluation of all hematochezia events in patients (n=121 patients with 180 events) with CHD <6 months admitted to acute care cardiology unit at 3 high-volume tertiary care centers from February 2019 to January 2021. In total, 61% of affected patients had single-ventricle physiology (38% hypoplastic left heart syndrome). Most patients (81%) were full-term.

Key findings:

  • 77% of hematochezia events were benign, and 23% were due to necrotizing enterocolitis (NEC). There were no surgical interventions for NEC or deaths from NEC. 
  • Those with NEC were significantly younger (34 vs 56 days, P < .01) and smaller (3.7 vs 4 kg, P < .01). Single-ventricle physiology was significantly associated with NEC.
  • Bloodwork (CBC, WBC, CRP, Blood Culture) did not aid diagnosis

My take: If concerned about NEC which is increased in those with congenital heart disease, obtain an AXR. Overall, the outcomes of NEC in this cohort were good –all resolved with medical management.

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Huntingdon Lake (Sandy Springs, Atlanta)

Crohn’s Disease: Risankizumab Real-World Data

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A Zinger et al. Clin Gastroenterol Hepatol 2024; 22: 1336-1338. Risankizumab Effectiveness and Safety in Crohn’s Disease: Real-world Data From a Large Tertiary Center

In a group of 80 patients with Crohn’s disease with evidence of active disease, the authors examined the effectiveness of risankizumab with prospectively-collected data. Patients received 600 mg intravenously at 0, 4, and 8 weeks. Only 6 patients (8%) were unexposed to prior advanced therapy; 44 patients (55%) had prior ustekinumab (UST) therapy.

Key findings:

  • Clinical remission was 78% in patients without prior ustekinumab therapy and 64% in those with prior ustekinumab therapy
  • Steroid-free clinical remission was 75% and 52%, respectively in patients without and with prior ustekinumab therapy. Overall, 63% of patients achieved a steroid-free clinical remission

My take: This study shows that risankizumab, a selective IL23 inhibitor, has good effectiveness, even in patients previously treated with a IL12/23 inhibitor. It highlights our need to better understand the reasons why a more selective agent is able to work after patients failed to respond to UST treatment.

Unrelated article: KA Chien et al. JPGN 2024; 79: 10-17. (Kudos to the authors including my partner Dr. Ben Gold). This article detailed the median work RVUs target for practices and composition of healthcare team to provider ratios: Nursing 0.80, MA 0.29, dietician 0.29, social worker 0.14, and psychologist 0.13. The article reviews salary structure/incentives and wellness initiatives as well.

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Positioning Radiology Tests for GI Bleeding

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N Sengupta et al. Am J Gastroenterol 2024; 119: 438-449. Open Access! The Role of Imaging for Gastrointestinal Bleeding: Consensus Recommendations From the American College of Gastroenterology and Society of Abdominal Radiology. Thanks to Dr. Benjamin Gold for this reference.

This article was jointly published: Radiology 2024; 310(3):e232298

This article focuses on GI bleeding in adults; it has a lot of useful information about the advantages, disadvantages, techniques and performance date of numerous radiology tests which can help sort out GI bleeding.

CTE identification of a Dieulafoy’s lesion (from Figure 4)
CTE here shows a slowly bleeding angioectasia (arrow), most conspicuous on the delayed phase.

Some of the recommendations for Overt Lower GI Bleeding:

CT Angiography:

Catheter Angiography:

99mTc-RBC Scan

For Suspected Small Bowel Bleeding:

CT Enterography (uses oral contrast). Technique: CTE should be performed using multiphase technique in patients older than 40 years of age where vascular lesions are a common cause for bleeding.

Meckel’s Scan “A Meckel scan can be considered to identify the cause of unexplained intermittent GI bleeding in children and adolescents after negative endoscopic evaluation, including capsule endoscopy if available, and cross-sectional evaluation of the small bowel.”

Radiology compared to capsule endoscopy and balloon-assisted endoscopy The authors discuss the advantages and limitations of radiologic testing versus capsule endoscopy and balloon-assisted endoscopy for small bowel bleeding is provided in Appendix S5

My take: This article provides a good update/review on useful radiologic imaging for GI bleeding. For pediatric GI bleeding, the etiologies are much different and many patients should be evaluated with a Meckel’s scan prior to panendoscopy (depending on the clinical presentation).

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Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

Relooking at 6-Year Data of Maralixibat for Alagille Syndrome

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BE Hansen et al. Hepatology 2024; 79: 1279-1292. Open Access! Event-free survival of maralixibat-treated patients with Alagille syndrome compared to a real-world cohort from GALA

This study compared “6-year outcomes from maralixibat trials with an aligned and harmonized natural history cohort from the Global ALagille Alliance (GALA) study.”

Based on a quick review, some the data appears to overlap a recent report in the same journal: RJ Sokol et al. Hepatology 2023; 78: 1698-1710. Open Access! Predictors of 6-year event-free survival in Alagille syndrome patients treated with maralixibat, an ileal bile acid transporter inhibitor (See blog post: Six Year Data for IBAT Inhibitor Treatment for Alagille Syndrome).

In the current study, “event-free survival, defined as the time to first event of manifestations of portal hypertension (variceal bleeding, ascites requiring therapy), surgical biliary diversion, liver transplant, or death, was analyzed by Cox proportional hazards methods.”

Key findings:

  • Event-free survival in the maralixibat cohort (n=84) was significantly better than the GALA cohort (n=469) (HR, 0.305)
  • Transplant-free survival showed similar results (aHR, 0.33)

In their discussion, the authors note that much of the improvement in event-free survival is due to improvement in pruritus which is a main indication for liver transplantation. They speculate that improvement in event-free survival is also related to more broad-based clinical improvement (observed in ICONIC study), perhaps due to reduction in retained hepatic bile acids.

One of the limitations, reliance on a historical control, is discussed. “Historical control comparison is useful when there are ethical concerns regarding the recruitment of patients for long-term control arms requiring several years of study in life-threatening or debilitating diseases.”

My take: In this real-world comparison, Maralixibat, clearly was associated with improved outcomes. How much of this was due to relief of intractable pruritus and how much of this may be due to other biologic factors remains uncertain.

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