Naltrexone tripled abstinence in compensated alcohol-associated cirrhosis

The edition in brief

The most consequential finding today addresses a treatment gap that has persisted because of a fear rather than because of evidence. NAL-CI 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. Mean MELD was about 12.6. Point-prevalence abstinence at 12 weeks was 64% with naltrexone versus 22% with placebo (odds ratio 10.86, 95% CI 1.89 to 62.2, p<0.001). Lapses at three months fell from 54% to 28%. No patient developed hepatic decompensation attributable to the study drug and no transaminase rose above five times the upper limit of normal. A multicentre Korean trial randomised 813 patients at moderate-to-high risk of post-ERCP pancreatitis, in centres where rectal NSAIDs are unavailable, to acetate-buffered crystalloid or lactated Ringer's under a symptom-guided 4-hour hydration protocol. Pancreatitis occurred in 11.5% versus 12.4% (relative risk 0.93, 95% CI 0.64 to 1.35) — no difference, so lactated Ringer's stands. In 346 patients with chronic portal vein thrombosis without cirrhosis, spleen stiffness of 40 kPa or below ruled out high-risk varices with 96 to 97% negative predictive value and would spare about 42% of screening endoscopies. The American Society for Gastrointestinal Endoscopy has published a GRADE-based guideline on endoscopy in acute lower gastrointestinal bleeding, and a joint Rome Foundation and IOIBD consensus has standardised the definition and management of IBD with IBS-like symptoms.