We hypothesized that sorafenib plus transarterial chemoembolization (TACE) would confer survival benefits over sorafenib alone for advanced hepatocellular carcinoma (aHCC). We investigated this while using the population-based All-Cancer Dataset to assemble a cohort (n = 3674; median age, 60; 83% men) of patients receiving sorafenib for aHCC (Child-Pugh A) with macro-vascular invasion or nodal/distant metastases. The patients were classified into the sorafenib-TACE group (n = 426) or the propensity score-matched sorafenib-alone group (n = 1686). All of the participants were followed up until death or the end of the study. Time-dependent Cox model and the Mantel–Byar test were used for survival analysis. During the median follow-ups of 221 and 133 days for the sorafenib-TACE and sorafenib-alone groups, 164 (39%) and 916 (54%) deaths occurred, respectively; the corresponding median overall survivals (OS) were 381 and 204 days, respectively (hazard ratio, HR: 0.74; 95% confidence interval, CI, 0.63–0.88; p = 0.021). The one-year and six-month OS were 53.5% and 80.3% in the sorafenib-TACE group and 32.4% and 54.4% in the sorafenib-alone group, respectively. The major complications were comparable between the two groups. The addition of TACE to sorafenib improves survival, with a 26% reduction in mortality. These findings provide strong real-world evidence that supports this combination strategy for eligible Child-Pugh A aHCC patients.

Background/purpose: An increased prevalence of non-alcoholic fatty liver disease (NAFLD) is observed in patients with inflammatory bowel disease (IBD) in Western countries. Both intestinal inflammation and metabolic factors contribute to the pathogenesis of IBD-associated NAFLD. The burden of NAFLD is not clear in the Asian population. This study aimed to evaluate the prevalence of NAFLD and liver fibrosis in a cohort of Taiwanese patients with IBD. Methods: From January to December 2019, patients with IBD who underwent ultrasound examination were enrolled. Hepatic steatosis and fibrosis were measured with liver stiffness measurement (LSM) and controlled attenuation parameter (CAP) using FibroScan. Patients with a history of excessive alcohol or recent steroid use were excluded. Univariate and multivariate analysis were performed. Results: A total of 81 consecutive patients were enrolled and included in the analysis (45 with ulcerative colitis, 36 with Crohn’s disease). The median age was 42 years old. The patients were classified in terms of body mass index as normal weight (54.3%), underweight (11.1%), overweight (28.4%), and obese (6.2%). The mean CAP increased to 162.22 dB/m in the underweight group, 210.86 dB/m in the normal weight group, 260.7 dB/m in the overweight group, and 274.0 dB/m in the obese group. NAFLD was observed in 29.6% of the patients, 1.2% of which had significant fibrosis. Increased body mass index (odds ratio [OR] 1.33, 95% confidence interval [CI] 1.1–1.62) and older age at IBD diagnosis (OR: 1.05, 95% CI 1–1.11) was found to be associated with the presence of NAFLD. Conclusion: In this study, the prevalence of NAFLD was lower (29.6%) in IBD patients than in the Western population. Higher BMI and older age were associated with NAFLD in our study.

In recent years, ultrasound attenuation imaging (ATI) has emerged as a new method to detect liver steatosis. However, thus far, no studies have confirmed the clinical utility of this technology. Using a retrospective database analysis of 28 patients with chronic liver disease who underwent ultrasound liver biopsy and ATI, we compared the presence and degree of steatosis measured by ATI with the results obtained through liver biopsy. The area under the receiver operating characteristic curve (AUROC) of the ATI for differentiating between normal and hepatic steatosis was 0.97 (95% confidence interval: 0.83–1.00). The AUROC of the ATI was 0.99 (95% confidence interval: 0.86–1.00) in grade ≥2 liver steatosis and 0.97 (95% confidence interval: 0.82–1.00) in grade 3. ATI showed good consistency and accuracy for the steatosis grading of liver biopsy. Therefore, ATI represents a novel diagnostic measurement to support the diagnosis of liver steatosis in non-invasive clinical practice.

The management of peptic ulcer bleeding is clinically challenging. For decades, the Forrest classification has been used for risk stratification for nonvariceal ulcer bleeding. The perception and interpretation of the Forrest classification vary among different endoscopists. The relationship between the bleeder and ulcer images and the different stages of the Forrest classification has not been studied yet. Endoscopic still images of 276 patients with peptic ulcer bleeding for the past 3 years were retrieved and reviewed. The intra-rater agreement and inter-rater agreement were compared. The obtained endoscopic images were manually drawn to delineate the extent of the ulcer and bleeding area. The areas of the region of interest were compared between the different stages of the Forrest classification. A total of 276 images were first classified by two experienced tutor endoscopists. The images were reviewed by six other endoscopists. A good intra-rater correlation was observed (0.92–0.98). A good inter-rater correlation was observed among the different levels of experience (0.639–0.859). The correlation was higher among tutor and junior endoscopists than among experienced endoscopists. Low-risk Forrest IIC and III lesions show distinct patterns compared to high-risk Forrest I, IIA, or IIB lesions. We found good agreement of the Forrest classification among different endoscopists in a single institution. This is the first study to quantitively analyze the obtained and explain the distinct patterns of bleeding ulcers from endoscopy images.

In this article, we report a case study of a 54-year old man who presented with massive gastrointestinal bleeding. Esophagogastroduodenoscopy and colonoscopy had been performed in another hospital, but the location of the bleeding could not be identified, and the patient was transferred to our hospital. An initial abdominal computed tomography scan showed only a large blood clot in the small bowel and colon, with duodenojejunal diverticulosis. Emergent angiography was performed due to persistent active bleeding. Active bleeding from the jejunum was found, and the patient received a double balloon enteroscopy, which disclosed active bleeding in one of the jejunal diverticula. Two hemoclips were applied to treat the Dieulafoy's lesion within the diverticulum. The patient had no bleeding during the month following treatment. Bleeding of the jejunal diverticulum is a rare clinical condition, and only a few cases have been reported in the literature with successful endoscopic treatment. A short review of the current methods of diagnosis and treatment of this rare disorder is provided.

Shun-Wen Hsiao, Hsu-Heng Yen, and Yang-Yuan Chen. Gut and Liver 2022;16:840-8. https://doi.org/10.5009/gnl210479