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BACKGROUND: Depression and hepatic encephalopathy are common in patients with advanced liver disease. Although these are distinct entities, they share several clinical features. In this analysis, we evaluated whether having a history of depression was associated with developing hepatic encephalopathy in patients with advanced liver disease. METHODS: We performed a retrospective cohort study of patients with cirrhosis referred for liver transplant. Patients were categorized into 1 of 2 groups: "history of depression" or "no history of depression." Multivariable logistic regression was used to evaluate history of depression as a potential independent predictor of hepatic encephalopathy. RESULTS: A total of 447 patients were included, of which 158 (35%) had a history of depression and 233 (52%) had experienced hepatic encephalopathy. Hepatic encephalopathy was more common in patients with a history of depression (63% vs 46%, P < .01). On multivariate analyses, depression history was independently associated with hepatic encephalopathy (aOR 2.3, 95% CI 1.4-3.6), along with alcohol associated cirrhosis (aOR 2.0, 95% CI 1.3-3.2), history of ascites (aOR 3.5, 95% CI 2.1-5.9) and presence of a trans-jugular intra-hepatic shunt (aOR 9.2, 95% CI 2.6-32.6). The relationship between history of depression and hepatic encephalopathy remained significant in a subgroup of patients with alcohol associated liver disease (P = .04). Among those with a history of depression, SNRI prescription was more common in the hepatic encephalopathy group (14% vs 3%), and SNRI prescription was as an independent predictor of hepatic encephalopathy in the multivariable model (OR 4.8, 95% CI 1.0-24.6) CONCLUSIONS: Patients with a history of depression were significantly more likely to experience hepatic encephalopathy. Patients with cirrhosis who have a history of depression should be closely monitored for the development of hepatic encephalopathy. Further research is needed to understand the nuances of this relationship and whether the use of certain psychiatric medications may modify the relationship between depression and hepatic encephalopathy.

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BACKGROUND: Indications to refer patients with cirrhosis for liver transplant evaluation (LTE) include hepatic decompensation or a model for end stage liver disease (MELD-Na) score ≥ 15. Few studies have evaluated how delaying referral beyond these criteria affects patient outcomes. AIM: To evaluate clinical characteristics of patients undergoing inpatient LTE and to assess the effects of delayed LTE on patient outcomes (death, transplantation). METHODS: This is a single center retrospective cohort study assessing all patients undergoing inpatient LTE (n = 159) at a large quaternary care and liver transplant center between 10/23/2017-7/31/2021. Delayed referral was defined as having prior indication (decompensation, MELD-Na ≥ 15) for LTE without referral. Early referral was defined as referrals made within 3 mo of having an indication based on practice guidelines. Logistic regression and Cox Hazard Regression were used to evaluate the relationship between delayed referral and patient outcomes. RESULTS: Many patients who require expedited inpatient LTE had delayed referrals. Misconceptions regarding transplant candidacy were a leading cause of delayed referral. Ultimately, delayed referrals negatively affected overall patient outcome and an independent predictor of both death and not receiving a transplant. Delayed referral was associated with a 2.5 hazard risk of death. CONCLUSION: Beyond initial access to an liver transplant (LT) center, delaying LTE increases risk of death and reduces risk of LT in patients with chronic liver disease. There is substantial opportunity to increase the percentage of patients undergoing LTE when first clinically indicated. It is crucial for providers to remain informed about the latest guidelines on liver transplant candidacy and the transplant referral process.

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Video 1EUS-guided rendezvous technique for pancreas divisum.

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BACKGROUND Gastric heterotopia is a benign entity found throughout the gastrointestinal tract but is rarely identified in the rectum. Since 1939, only 94 cases have ever been identified, and it can present as a mass formation with symptomatology that mimics colorectal malignancy. In some instances, malignancy has been shown to arise within rectal gastric heterotopia. Here, we present 3 cases from the past 20-year period of rectal gastric heterotopia at a single tertiary institution. CASE REPORT A 25-year-old man (case 1), a 58-year-old woman (case 2), and a 33-year-old man (case 3) were found to have polypoid mass-like lesions greater than 1.0 cm within the rectum. Following biopsy, pathology showed gastric oxyntic mucosa flanked by colorectal mucosa, thus indicating gastric heterotopia. Presenting symptoms from all patients consisted of unspecified anal pain, hematochezia, or a combination of both. All patients were treated with endoscopic mucosal resection (EMR), which provided relief of symptoms and confirmed no evidence of invasive malignancy. CONCLUSIONS Rectal gastric heterotopia can mimic malignancy and in very rare instances can harbor high-grade dysplasia as well as invasive carcinoma. EMR seems to be a definitive treatment that offers relief to patient symptomatology and reassurance that any dysplasia is identified and removed.

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Hepatocellular carcinoma (HCC) is the fifth most common cancer and the second leading cause of cancer-related death worldwide. Hepatitis B virus (HBV) infection is among the main risk factors for HCC. The risk of HCC is not eliminated completely after viral suppression, due to HBV DNA integrated into human chromosomes. Cirrhosis, HBV viral DNA levels, age, male gender, the immune response of the host against HBV, and a combination of obesity and diabetes are among the main risk factors for HCC. Active viral replication and long-standing active disease with inflammation are associated with a higher risk of HCC. Treatment of HBV with nucleos(t)ide analogues (NAs) decreased HCC risk by effectively decreasing viral load and inflammation. Similar risk factors have been reported in hepatitis B patients after seroclearance. Studies have reported decreased risk of HCC after seroclearance, but there were also conflicting results from a few studies indicating no difference in risk of developing HCC. The difference in HCC rates could be because of other factors such as coinfection, occult HBV infection, family history, HBV genotype, and other comorbidities. Due to the persistent risk of HCC after seroclearance, HCC surveillance is critical for early detection, especially in high-risk patients. However, long-term studies might be needed to further validate the results.

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Video 1Video presentation of a single session EUS-guided cholecystoduodenostomy and gastrojejunostomy.

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BACKGROUND AND AIMS: Increasingly, gastroenterologists are being asked to assist in the closure of defects. Although there are several available tools that can be used for defect closure, there remains a need for devices that are easy to use, effective, and durable. The aim of this case series is to demonstrate the use of a novel helical tack system in the closure of upper GI defects. METHODS: Two cases of challenging upper GI defects were identified. One case involved a perforated duodenal ulcer, and the other involved a nonhealing marginal ulcer. In both cases, the helical tack system was used for defect closure. RESULTS: In both cases, defect closure was achieved using the helical tack system; however, 2 series of tacks were required in each case. There were no adverse events. Neither patient has required additional surgical or endoscopic interventions. CONCLUSIONS: The helical tack system is a new device that may be useful for the closure of challenging upper GI defects. Additional comparative studies are needed to better understand the advantages and disadvantages of this system relative to other closure tools.

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OBJECTIVES: Laparoscopic cholecystectomy (LC) following acute gallstone cholangitis reduces the recurrence of biliary symptoms; however, the timing of LC has not been determined yet. The aim of our study was to evaluate the impact of performing LC during admission on the 30-day readmission rate. METHODS: We conducted a retrospective cohort study of acute gallstone cholangitis patients who underwent endoscopic clearance (EC) of the bile duct through endoscopic retrograde cholangiopancreatography between April 2013 and May 2018. Patients were classified into two groups: EC only group and EC followed by LC during admission (EC + LC) group. The primary outcome was the 30-day readmission rate. RESULTS: A total of 95 patients with acute cholangitis were included in the analysis. Of these patients, 35 patients (36.8%) underwent LC during admission. The 30-day readmission rate was significantly lower in the EC + LC group compared to the EC group (2.9% vs. 26.7%, P 0.003). In a multivariate regression analysis, patients who underwent LC during admission had 90% lower odds of readmission within 30 days compared to patients who did not (OR 0.1, 95% CI (0.01-0.9), P 0.04). CONCLUSIONS: Performing laparoscopic cholecystectomy during admission for acute gallstone cholangitis patients following endoscopic clearance of the bile duct significantly reduced the 30-day readmission rate without affecting the length of stay.

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INTRODUCTION: Liver cancer-secreted serine protease inhibitor Kazal (LC-SPIK) is a protein that is specifically elevated in cases of hepatocellular carcinoma (HCC). We assessed the performance of LC-SPIK in detecting HCC, including its early stages, in patients with cirrhosis, hepatitis B virus (HBV), and hepatitis C virus (HCV). METHODS: We enrolled 488 patients, including 164 HCC patients (81 early HCC) and 324 controls in a blinded, prospective, case-control study. Serum LC-SPIK levels were determined by an enzyme-linked immunosorbent assay-based assay. The performance of serum LC-SPIK and α-fetoprotein (AFP), including area under the curve (AUC), sensitivity, and specificity, are compared. The performance of LC-SPIK was evaluated in an independent validation cohort with 102 patients. RESULTS: In distinguishing all HCC patients from those with cirrhosis and chronic HBV/HCV, LC-SPIK had an AUC of 0.87, with 80% sensitivity and 90% specificity using a cutoff of 21.5 ng/mL. This is significantly higher than AFP, which had an AUC of 0.70 and 52% sensitivity and 86% specificity using a standard cutoff value of 20.0 ng/mL. For early-stage HCC (Barcelona Clinic Liver Cancer stage 0 and A), LC-SPIK had an AUC of 0.85, with 72% sensitivity and 90% specificity, compared with AFP, which had an AUC of 0.61, with 42% sensitivity and 86% specificity. In addition, LC-SPIK accurately detected the presence of HCC in more than 70% of HCC patients with false-negative AFP results. DISCUSSION: The study provided strong evidence that LC-SPIK detects HCC, including early-stage HCC, with high sensitivity and specificity, and might be useful for surveillance in cirrhotic and chronic HBV/HCV patients, who are at an elevated risk of developing HCC.

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