Sickle cell disease (SCD) is a common hemoglobinopathy which can affect multiple organ systems in the body. Within the digestive tract, the hepatobiliary system is most commonly affected in SCD. The manifestations range from benign hyperbilirubinemia to overt liver failure, with the spectrum of acute clinical presentations often referred to as “sickle cell hepatopathy”. This is an umbrella term referring to liver dysfunction and hyperbilirubinemia due to intrahepatic sickling process during SCD crisis leading to ischemia, sequestration and cholestasis. In this review, we detail the pathophysiology, clinical presentation and biochemical features of various acute and chronic hepatobiliary manifestations of SCD and present and evaluate existing evidence with regards to management of this disease process. We also discuss recent advances and controversies such as the role of liver transplantation in sickle cell hepatopathy and highlight important questions in this field which would require further research. Our aim with this review is to help increase the understanding, aid in early diagnosis and improve management of this important disease process.

Hepatitis E viral infection has traditionally been considered an acute, self-limited, water borne disease similar to hepatitis A, endemic to developing countries. However, over the past decade, zoonotic transmission and progression to chronicity in human patients has been identified, resulting in persistently elevated transaminase levels, progressive liver injury and cirrhosis. In addition to liver injury, neurological, renal and rheumatological manifestations have also been reported. Chronic hepatitis E occurs mainly in immunosuppressed individuals such as transplant recipients, human immunodeficiency virus patients with low CD4 counts and in patients with hematological malignancies receiving chemotherapy. Diagnosis is established by persistent elevation of hepatitis E virus RNA in the stool or serum. This population often requires treatment with antiviral agents, particularly ribavirin, as spontaneous clearance with reduction in immunosuppression occurs only in about a third of the patients. The purpose of this review, is to further discuss the clinical presentation, and recent advances in diagnosis, treatment and prophylaxis of chronic hepatitis E.

Non-variceal gastrointestinal bleeding (GIB) is a significant cause of mortality and morbidity worldwide which is encountered in the ambulatory and hospital settings. Hemorrhage form the gastrointestinal (GI) tract is categorized as upper GIB, small bowel bleeding (also formerly referred to as obscure GIB) or lower GIB. Although the etiologies of GIB are variable, a strong, consistent risk factor is use of non-steroidal anti-inflammatory drugs. Advances in the endoscopic diagnosis and treatment of GIB have led to improved outcomes. We present an updated review of the current practices regarding the diagnosis and management of non-variceal GIB, and possible future directions.

Esophageal variceal bleeding remains the leading cause of acute mortality in patients with cirrhosis. Platelet count to spleen diameter (PC/SD) ratio less than 909 is one of several parameters proposed for the noninvasive prediction of esophageal varices. The aim of this study is to systematically review the evidence on the diagnostic accuracy of the 909 ratio. We identified relevant studies from a MEDLINE search and performed a meta-analysis to estimate the pooled sensitivity, specificity, and positive and negative likelihood ratios (LRs) using Meta-Disc software. Eight studies met the inclusion criteria and included a total of 1275 patients. Meta-analysis yielded a pooled sensitivity of 89% [95% confidence interval (CI) 87-92%; I2 statistic 92.9%] and a pooled specificity of 74% (95% CI 70-78%; I2 statistic 94.5%). The pooled positive LR was 3.5 (95% CI 1.92-6.25; I2 statistic 94.0%) and the pooled negative LR was 0.12 (95% CI 0.05-0.32; I2 statistic 90.8%). The quality of the evidence as assessed by the GRADE methodology was low. In its present form, the test characteristics of PC/SD ratio of 909 may not be adequate to completely replace esophagogastroduodenoscopy as a noninvasive screening tool for esophageal varices, given the low grade of evidence. However, it may be potentially useful as part of a prediction rule incorporating other clinical characteristics or varying PC/SD cutoffs. When compared with other noninvasive predictor tools, the PC/SD ratio is elegant, simple, and inexpensive. With some minor modifications, it may become a helpful tool to limit the number of endoscopies in primary prophylaxis to be performed in patients with portal hypertension.