Background and aims: There are several short-term prognostic scores for alcoholic hepatitis (AH) that combine demographical and biochemical parameters. The extent of liver fibrosis may also be relevant to the prognosis of AH with potential added value. We evaluated collagen proportionate area (CPA) as a predictor of short and long-term mortality in AH. Methods: We retrospectively included patients with biopsy-verified AH. Clinical, laboratory and outcome data were collected. CPA and five AH scores were calculated: Maddrey's DF, MELD, GAHS, ABIC, and the Lille Model. Predictors of short and long-term all-cause mortality were assessed using Cox regression analysis. Results: We included 140 patients with AH. In total, 67 (48%) patients died after a median follow-up of 66 (IQR 102) months, with 17 (12%) dying within the first 90-days. CPA was not a predictor of 90-days mortality and had no additional value to the prognostic AH scores on short-term mortality. However, CPA predicted long-term mortality independently of prognostic AH scores. Importantly, CPA and abstinence from alcohol were independent predictors of long-term mortality in patients alive 90 days after the biopsy. Conclusion: CPA predicts long-term mortality in patients with AH independently of abstinence from alcohol but has no prognostic value on short-term mortality.

SummaryBackgroundNo prognostic tools are established for alcohol‐related liver disease (ALD). Collagen proportionate area (CPA) measurement is a technique that quantifies fibrous tissue in liver biopsies using digital image analysis.AimTo assess the predictive value of CPA on hepatic decompensation and liver‐related mortality in ALDMethodsIn a multicentre cohort study, we included 386 patients with biopsy‐verified ALD and with long‐term follow‐up. In the development cohort of 276 patients, we assessed the predictors of hepatic decompensation and liver‐related death in standard and competing risk multivariable Cox regression analyses. The results were validated in an independent prospective cohort of 110 patients, where CPA was also correlated with liver stiffness measurement (LSM).ResultsIn the development cohort, 231 (84%) patients had early/compensated ALD (non‐cirrhotic or compensated cirrhosis) and 45 (16%) had decompensated cirrhosis. In the validation cohort, all patients had early/compensated ALD. Independent predictors of liver‐related mortality were higher CPA values (HR = 1.04, 95% CI 1.02‐1.04) and advanced fibrosis (HR = 2.80, 95% CI 1.29‐6.05) with similar results in standard and competing risk multivariable Cox regression analysis. In early/compensated ALD, CPA was the only independent predictor of hepatic decompensation and liver‐related death (HR = 1.08, 95% CI 1.06‐1.11). In the prospective cohort, we validated that CPA independently predicts hepatic decompensation in early/compensated ALD. The predictive power of CPA and LSM was equally strong.ConclusionsCPA predicts liver‐related mortality in ALD and hepatic decompensation and/or liver‐related death in early/compensated ALD. Traditional histological assessment may benefit from the addition of CPA to the evaluation of ALD.

Herpes esophagitis (HE) is a rare condition in immunocompetent adolescents. However, it commonly occurs as a primary infection in younger individuals. Herein, we report a 16-year-old female patient who had a history of fever for 5 days, odynophagia, and orolabial herpes infection for 7 days. Clusters of painful vesicles on an erythematous base on the lips, gingiva, and palate were observed on physical examination. Further, esophagogastroduodenoscopy revealed diffuse linear ulcerations in the distal esophagus. The patient then received the following treatment: intravenous (I.V.) acyclovir 5 mg/kg three times a day, I.V. omeprazole 40 mg two times a day, and acyclovir 5% cream four times a day. After 8 days of admission, the patient was discharged. A follow-up esophagogastroduodenoscopy was performed 7 weeks after discharge, and the results revealed that the esophageal mucosa had a normal appearance. The effect of antiviral treatment against HE remains unknown in these patients. Nevertheless, it is believed to accelerate the healing process in individuals with esophageal mucosal barrier damage. To the best of our knowledge, this case of a female adolescent with an intact immune system is the sixth case of herpes simplex esophagitis to be reported in the literature.

Question: A 62-year-old woman with recurrent intrahepatic cholangiocarcinoma 17 months after segment-oriented liver resection presented to the emergency department after 3 episodes of hematemesis over 4 hours. Symptoms appeared 1 month after radiofrequency tumor ablation. Physical examination revealed a soft, nondistended abdomen with a wellhealed surgical scar in the right upper quadrant and normoactive bowel sounds. There was no tenderness on palpation. Laboratory findings were notable, showing hematocrit and hemoglobin levels of 29.5% and 9.9 g/dL, respectively. Chest and plain abdominal radiography images (Figure A and B) were unremarkable. Esophagogastroduodenoscopy was performed immediately (Figure C), followed by abdominal computed tomography (Figures D and E).What could be the cause of hematemesis in this patient? What is the appropriate treatment?

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