The edition · Gastroenterology & Hepatology
Naltrexone tripled abstinence in compensated alcohol-related cirrhosis
An Indian trial finds naltrexone safe and effective in compensated alcohol-associated cirrhosis, spleen stiffness can spare four in ten screening endoscopies in portal vein thrombosis, and acetate buffering adds nothing to lactated Ringer's for post-ERCP pancreatitis.
The edition in brief
The NAL-CI trial randomised 100 patients with compensated alcohol-associated cirrhosis and DSM-5 alcohol use disorder to naltrexone 50 mg daily or placebo for 12 weeks, with standardised psychosocial support in both arms. Point-prevalence abstinence at 12 weeks was 64% versus 22% (odds ratio 10.86, 95% CI 1.89 to 62.2), lapses fell from 54% to 28%, and craving scores dropped significantly. No patient decompensated on study drug and no transaminase rose above five times the upper limit of normal. Mean age was 43 and mean MELD about 12.6. A VALDIG study of 346 patients with chronic portal vein thrombosis without cirrhosis found spleen stiffness of 40 kPa or below on transient elastography ruled out high-risk varices with 96 to 97% negative predictive value, sparing 41 to 43% of screening endoscopies while missing 3 to 5% of high-risk varices. A Korean trial in 813 patients randomised acetate-buffered crystalloid against lactated Ringer's for post-ERCP pancreatitis prophylaxis under a symptom-guided 4-hour hydration protocol, at hospitals without rectal NSAIDs. Rates were 11.5% and 12.4% (relative risk 0.93, 95% CI 0.64 to 1.35) — no difference. Notably, 68.3% of patients were pain-free at 4 hours and needed no further fluid, with 7.4% pancreatitis and no severe cases. The ASGE has published a GRADE-based guideline on endoscopy in acute lower gastrointestinal bleeding, covering colonoscopy versus CT angiography, timing, bowel preparation, and band ligation versus clipping for diverticular bleeding. Today's pearl: alcohol use disorder in cirrhosis is a treatable disease, and referral is not a plan.
NAL-CI: naltrexone works in compensated alcohol-related cirrhosis, and it was safe
Offer naltrexone 50 mg daily alongside psychosocial support to patients with compensated alcohol-associated cirrhosis who are still drinking — it tripled 12-week abstinence with no hepatic safety signal.
Spleen stiffness spares four in ten screening endoscopies in portal vein thrombosis
Use spleen stiffness at or below 40 kPa to defer screening endoscopy in chronic portal vein thrombosis without cirrhosis — it spares about 40% of procedures with a 96% negative predictive value.
For post-ERCP pancreatitis, the fluid does not matter — and four hours may be enough
Stay with lactated Ringer's for post-ERCP hydration, and use pain at four hours to decide who needs the second four hours — two-thirds of patients did not.
In alcohol-related liver disease, 'advised to stop drinking' is not a treatment plan
Manage alcohol use disorder in liver clinic as an active diagnosis — formal screening, withdrawal risk assessment, pharmacotherapy and a named support provider with a review date.
ASGE issues a GRADE-based guideline on endoscopy in acute lower GI bleeding
New ASGE guidance settles the recurring arguments in lower GI bleeding — first modality, urgency, preparation and diverticular haemostasis technique — so check it against your unit's out-of-hours pathway.
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