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Endometriosis affects approximately 11% of women; the disease can be categorized as pelvic endometriosis and extrapelvic endometriosis, based on anatomic presentation. It is estimated that about 12% of extrapelvic disease involves the diaphragm or thoracic cavity.

While diaphragmatic endometriosis often is asymptomatic, patients who are symptomatic can experience progressive and incapacitating pain. A significant number of patients with diaphragmatic endometriosis can go undiagnosed for long periods of time because of a traditional focus on the lower pelvic region. Some cases are misdiagnosed as other conditions involving the gastrointestinal tract or of cardiothoracic origin, because of the propensity of diaphragmatic disease to occur posteriorly and hide behind the liver. The variable appearance of endometriotic lesions and the lack of reliable diagnostic or imaging tests also can contribute to delayed diagnosis.

Pathophysiology

In addition to retrograde menstruation, there are two other common theories regarding the pathophysiology of thoracic endometriosis. First, high prostaglandin F2-alpha at ovulation may result in vasospasm and ischemia of the lungs (resulting, in turn, in alveolar rupture and subsequent pneumothorax). Second, the loss of a mucus plug during menses may result in communication between the environment and peritoneal cavity.

Courtesy Dr. Ceana Nezhat

A multidisciplinary approach

Since the introduction of video laparoscopy and ease of evaluation of the upper abdomen, more extrapelvic endometriosis – including disease in the upper abdomen and diaphragm – is being diagnosed. The thoracic and visceral diaphragm are the most commonly described sites of thoracic endometriosis, and disease is often right sided, with parenchymal involvement less commonly reported.

Courtesy Dr. Ceana Nezhat

Watch a video from Dr. Ceana Nezhat demonstrating a step wise vaporization and excision of diaphragmatic endometriosis utilizing different techniques.
(Courtesy Dr. Ceana Nezhat)

Plasma jet energy and ultrasonic energy are good alternatives when a CO₂ laser is not available and are preferable to the use of cold scissors because of subsequent bleeding, which requires bipolar hemostasis.

Monopolar electrocautery is not as good a choice for treating diaphragmatic endometriosis because of higher depth of penetration, which may cause tissue necrosis and subsequent delayed diaphragmatic fenestrations. It also may cause unpredictable diaphragmatic muscular contractions and electrical conduction transmitted to the heart, inducing arrhythmia.

For patients treated via combined VALS and VATS procedures, endometriotic lesions involving the entire thickness of the diaphragm should be completely resected, and the defect can be repaired with either sutures or staples.

In all cases, special anesthesia considerations must be made given the inability to completely ventilate the lung. In our practice, we use a double-lumen endotracheal tube for single lung ventilation, if needed. A bronchial blocker is used to isolate the lung when the double-lumen endotracheal tube cannot be inserted.

It is important to note that we do not recommend VATS with VALS in all suspicious cases. We reserve VATS only for patients with catamenial pneumothorax, catamenial hemothorax, hemoptysis, and pulmonary nodules, defined as Thoracic Endometriosis Syndrome. We usually start with medical management first, then proceed to VALS, and finally, VATS, with the intention to treat if the patient fails nonsurgical treatments. It is better to avoid VATS, if possible, because it is associated with longer recovery and more pain; it should be done if all else fails.

If the patient has completed childbearing or passed reproductive age, bilateral salpingectomy, or hysterectomy with or without bilateral salpingo-oophorectomy, may be considered as the first step prior to more aggressive excisional procedures. This is especially true for widespread lesions, as branches of the phrenic nerve are difficult to see and injury could result in paralysis of the diaphragm. It’s important to appreciate that if estrogen stimulation to the diaphragmatic lesions is to cease for the long term, hormonal suppression or surgical treatment including bilateral oophorectomy should be utilized.

My colleagues and I have reported on our experience with a multidisciplinary approach in the treatment of diaphragmatic endometriosis in 25 patients. All had both pelvic and thoracic symptoms, and the majority had endometrial implants on both the thoracic and visceral sides of the diaphragm.

There were two postoperative complications: a diaphragmatic hernia and a vaginal cuff hematoma. Over a follow-up period of 3-18 months, all 25 patients had significant improvement or resolution of their chest complaints, and most remained asymptomatic for more than 6 months (JSLS. 2014 Jul-Sep;18[3]. pii: e2014.00312. doi: 10.4293/JSLS.2014.00312).

Dr. Ceana Nezhat is the fellowship director of Nezhat Medical Center, the medical director of training and education at Northside Hospital, and an adjunct clinical professor of gynecology and obstetrics at Emory University, all in Atlanta. He is president of SRS (Society of Reproductive Surgeons) and past president of AAGL (American Association of Gynecologic Laparoscopists). Dr. Nezhat is a consultant for Novuson Surgical, Karl Storz Endoscopy, Lumenis, and AbbVie; a medical advisor for Plasma Surgical, and a member of the scientific advisory board for SurgiQuest.

Suggested readings

1. Nezhat C, Nezhat F, Nezhat C. Nezhat’s Operative Gynecologic Laparoscopy with Hysteroscopy. Fourth Edition. Cambridge University Press. 2013.

2. Am J Med. 1996 Feb;100(2):164-70.

3. Fertil Steril. 1998 Jun;69(6):1048-55.

4. Clin Obstet Gynecol. 1999 Sep;42(3):699-711.

5. JSLS. 2012 Jan-Mar; 16(1):140-2.

Endometriosis affects approximately 11% of women; the disease can be categorized as pelvic endometriosis and extrapelvic endometriosis, based on anatomic presentation. It is estimated that about 12% of extrapelvic disease involves the diaphragm or thoracic cavity.

While diaphragmatic endometriosis often is asymptomatic, patients who are symptomatic can experience progressive and incapacitating pain. A significant number of patients with diaphragmatic endometriosis can go undiagnosed for long periods of time because of a traditional focus on the lower pelvic region. Some cases are misdiagnosed as other conditions involving the gastrointestinal tract or of cardiothoracic origin, because of the propensity of diaphragmatic disease to occur posteriorly and hide behind the liver. The variable appearance of endometriotic lesions and the lack of reliable diagnostic or imaging tests also can contribute to delayed diagnosis.

Pathophysiology

In addition to retrograde menstruation, there are two other common theories regarding the pathophysiology of thoracic endometriosis. First, high prostaglandin F2-alpha at ovulation may result in vasospasm and ischemia of the lungs (resulting, in turn, in alveolar rupture and subsequent pneumothorax). Second, the loss of a mucus plug during menses may result in communication between the environment and peritoneal cavity.

Courtesy Dr. Ceana Nezhat

A multidisciplinary approach

Since the introduction of video laparoscopy and ease of evaluation of the upper abdomen, more extrapelvic endometriosis – including disease in the upper abdomen and diaphragm – is being diagnosed. The thoracic and visceral diaphragm are the most commonly described sites of thoracic endometriosis, and disease is often right sided, with parenchymal involvement less commonly reported.

Courtesy Dr. Ceana Nezhat

Watch a video from Dr. Ceana Nezhat demonstrating a step wise vaporization and excision of diaphragmatic endometriosis utilizing different techniques.
(Courtesy Dr. Ceana Nezhat)

Plasma jet energy and ultrasonic energy are good alternatives when a CO₂ laser is not available and are preferable to the use of cold scissors because of subsequent bleeding, which requires bipolar hemostasis.

Monopolar electrocautery is not as good a choice for treating diaphragmatic endometriosis because of higher depth of penetration, which may cause tissue necrosis and subsequent delayed diaphragmatic fenestrations. It also may cause unpredictable diaphragmatic muscular contractions and electrical conduction transmitted to the heart, inducing arrhythmia.

For patients treated via combined VALS and VATS procedures, endometriotic lesions involving the entire thickness of the diaphragm should be completely resected, and the defect can be repaired with either sutures or staples.

In all cases, special anesthesia considerations must be made given the inability to completely ventilate the lung. In our practice, we use a double-lumen endotracheal tube for single lung ventilation, if needed. A bronchial blocker is used to isolate the lung when the double-lumen endotracheal tube cannot be inserted.

It is important to note that we do not recommend VATS with VALS in all suspicious cases. We reserve VATS only for patients with catamenial pneumothorax, catamenial hemothorax, hemoptysis, and pulmonary nodules, defined as Thoracic Endometriosis Syndrome. We usually start with medical management first, then proceed to VALS, and finally, VATS, with the intention to treat if the patient fails nonsurgical treatments. It is better to avoid VATS, if possible, because it is associated with longer recovery and more pain; it should be done if all else fails.

If the patient has completed childbearing or passed reproductive age, bilateral salpingectomy, or hysterectomy with or without bilateral salpingo-oophorectomy, may be considered as the first step prior to more aggressive excisional procedures. This is especially true for widespread lesions, as branches of the phrenic nerve are difficult to see and injury could result in paralysis of the diaphragm. It’s important to appreciate that if estrogen stimulation to the diaphragmatic lesions is to cease for the long term, hormonal suppression or surgical treatment including bilateral oophorectomy should be utilized.

My colleagues and I have reported on our experience with a multidisciplinary approach in the treatment of diaphragmatic endometriosis in 25 patients. All had both pelvic and thoracic symptoms, and the majority had endometrial implants on both the thoracic and visceral sides of the diaphragm.

There were two postoperative complications: a diaphragmatic hernia and a vaginal cuff hematoma. Over a follow-up period of 3-18 months, all 25 patients had significant improvement or resolution of their chest complaints, and most remained asymptomatic for more than 6 months (JSLS. 2014 Jul-Sep;18[3]. pii: e2014.00312. doi: 10.4293/JSLS.2014.00312).

Dr. Ceana Nezhat is the fellowship director of Nezhat Medical Center, the medical director of training and education at Northside Hospital, and an adjunct clinical professor of gynecology and obstetrics at Emory University, all in Atlanta. He is president of SRS (Society of Reproductive Surgeons) and past president of AAGL (American Association of Gynecologic Laparoscopists). Dr. Nezhat is a consultant for Novuson Surgical, Karl Storz Endoscopy, Lumenis, and AbbVie; a medical advisor for Plasma Surgical, and a member of the scientific advisory board for SurgiQuest.

Suggested readings

1. Nezhat C, Nezhat F, Nezhat C. Nezhat’s Operative Gynecologic Laparoscopy with Hysteroscopy. Fourth Edition. Cambridge University Press. 2013.

2. Am J Med. 1996 Feb;100(2):164-70.

3. Fertil Steril. 1998 Jun;69(6):1048-55.

4. Clin Obstet Gynecol. 1999 Sep;42(3):699-711.

5. JSLS. 2012 Jan-Mar; 16(1):140-2.

Endometriosis affects approximately 11% of women; the disease can be categorized as pelvic endometriosis and extrapelvic endometriosis, based on anatomic presentation. It is estimated that about 12% of extrapelvic disease involves the diaphragm or thoracic cavity.

While diaphragmatic endometriosis often is asymptomatic, patients who are symptomatic can experience progressive and incapacitating pain. A significant number of patients with diaphragmatic endometriosis can go undiagnosed for long periods of time because of a traditional focus on the lower pelvic region. Some cases are misdiagnosed as other conditions involving the gastrointestinal tract or of cardiothoracic origin, because of the propensity of diaphragmatic disease to occur posteriorly and hide behind the liver. The variable appearance of endometriotic lesions and the lack of reliable diagnostic or imaging tests also can contribute to delayed diagnosis.

Pathophysiology

In addition to retrograde menstruation, there are two other common theories regarding the pathophysiology of thoracic endometriosis. First, high prostaglandin F2-alpha at ovulation may result in vasospasm and ischemia of the lungs (resulting, in turn, in alveolar rupture and subsequent pneumothorax). Second, the loss of a mucus plug during menses may result in communication between the environment and peritoneal cavity.

Courtesy Dr. Ceana Nezhat

A multidisciplinary approach

Since the introduction of video laparoscopy and ease of evaluation of the upper abdomen, more extrapelvic endometriosis – including disease in the upper abdomen and diaphragm – is being diagnosed. The thoracic and visceral diaphragm are the most commonly described sites of thoracic endometriosis, and disease is often right sided, with parenchymal involvement less commonly reported.

Courtesy Dr. Ceana Nezhat

Watch a video from Dr. Ceana Nezhat demonstrating a step wise vaporization and excision of diaphragmatic endometriosis utilizing different techniques.
(Courtesy Dr. Ceana Nezhat)

Plasma jet energy and ultrasonic energy are good alternatives when a CO₂ laser is not available and are preferable to the use of cold scissors because of subsequent bleeding, which requires bipolar hemostasis.

Monopolar electrocautery is not as good a choice for treating diaphragmatic endometriosis because of higher depth of penetration, which may cause tissue necrosis and subsequent delayed diaphragmatic fenestrations. It also may cause unpredictable diaphragmatic muscular contractions and electrical conduction transmitted to the heart, inducing arrhythmia.

For patients treated via combined VALS and VATS procedures, endometriotic lesions involving the entire thickness of the diaphragm should be completely resected, and the defect can be repaired with either sutures or staples.

In all cases, special anesthesia considerations must be made given the inability to completely ventilate the lung. In our practice, we use a double-lumen endotracheal tube for single lung ventilation, if needed. A bronchial blocker is used to isolate the lung when the double-lumen endotracheal tube cannot be inserted.

It is important to note that we do not recommend VATS with VALS in all suspicious cases. We reserve VATS only for patients with catamenial pneumothorax, catamenial hemothorax, hemoptysis, and pulmonary nodules, defined as Thoracic Endometriosis Syndrome. We usually start with medical management first, then proceed to VALS, and finally, VATS, with the intention to treat if the patient fails nonsurgical treatments. It is better to avoid VATS, if possible, because it is associated with longer recovery and more pain; it should be done if all else fails.

If the patient has completed childbearing or passed reproductive age, bilateral salpingectomy, or hysterectomy with or without bilateral salpingo-oophorectomy, may be considered as the first step prior to more aggressive excisional procedures. This is especially true for widespread lesions, as branches of the phrenic nerve are difficult to see and injury could result in paralysis of the diaphragm. It’s important to appreciate that if estrogen stimulation to the diaphragmatic lesions is to cease for the long term, hormonal suppression or surgical treatment including bilateral oophorectomy should be utilized.

My colleagues and I have reported on our experience with a multidisciplinary approach in the treatment of diaphragmatic endometriosis in 25 patients. All had both pelvic and thoracic symptoms, and the majority had endometrial implants on both the thoracic and visceral sides of the diaphragm.

There were two postoperative complications: a diaphragmatic hernia and a vaginal cuff hematoma. Over a follow-up period of 3-18 months, all 25 patients had significant improvement or resolution of their chest complaints, and most remained asymptomatic for more than 6 months (JSLS. 2014 Jul-Sep;18[3]. pii: e2014.00312. doi: 10.4293/JSLS.2014.00312).

Dr. Ceana Nezhat is the fellowship director of Nezhat Medical Center, the medical director of training and education at Northside Hospital, and an adjunct clinical professor of gynecology and obstetrics at Emory University, all in Atlanta. He is president of SRS (Society of Reproductive Surgeons) and past president of AAGL (American Association of Gynecologic Laparoscopists). Dr. Nezhat is a consultant for Novuson Surgical, Karl Storz Endoscopy, Lumenis, and AbbVie; a medical advisor for Plasma Surgical, and a member of the scientific advisory board for SurgiQuest.

Suggested readings

1. Nezhat C, Nezhat F, Nezhat C. Nezhat’s Operative Gynecologic Laparoscopy with Hysteroscopy. Fourth Edition. Cambridge University Press. 2013.

2. Am J Med. 1996 Feb;100(2):164-70.

3. Fertil Steril. 1998 Jun;69(6):1048-55.

4. Clin Obstet Gynecol. 1999 Sep;42(3):699-711.

5. JSLS. 2012 Jan-Mar; 16(1):140-2.

Alcohol consumption produced no apparent cardiovascular benefits among individuals with nonalcoholic fatty liver disease, according to a study of 570 white and black adults from the Coronary Artery Risk Development in Young Adults (CARDIA) longitudinal cohort.

After researchers controlled for multiple demographic and clinical confounders, alcohol use was not associated with cardiovascular risk factors such as diabetes, hypertension, or hyperlipidemia, nor with homeostatic model assessment of insulin resistance, C-reactive protein level, total cholesterol, systolic or diastolic blood pressure, coronary artery calcification, E/A ratio, or global longitudinal strain among individuals with nonalcoholic fatty liver disease (NAFLD), reported Lisa B. VanWagner, MD, of Northwestern University, Chicago, and her associates. “[A] recommendation of cardiovascular disease risk benefit of alcohol use in persons with NAFLD cannot be made based on the current findings,” they wrote. They advocated for prospective, long-term studies to better understand how various types and doses of alcohol affect hard cardiovascular endpoints in patients with NAFLD. Their study was published in Gastroenterology.

CARDIA enrolled 5,115 black and white adults aged 18-30 years from four cities in the United States, and followed them long term. Participants were asked about alcohol consumption at study entry and again at 15, 20, and 25 years of follow-up. At year 25, participants underwent computed tomography (CT) examinations of the thorax and abdomen and tissue Doppler echocardiography with myocardial strain measured by speckle tracking (Gastroenterology. 2017 Aug 9. doi: 10.1053/j.gastro.2017.08.012).

Fuse/Thinkstock

The 570 participants with NAFLD averaged 50 years of age, 54% were black, 46% were female, and 58% consumed at least one alcoholic drink per week, said the researchers. Compared with nondrinkers, drinkers had attained significantly higher education levels, were significantly more likely to be white and male, and had a significantly lower average body mass index (34.4 kg/m² vs. 37.3 kg/m²) and C-reactive protein level (4.2 vs. 6.1 mg per L), and a significantly lower prevalence of diabetes (23% vs. 37%), impaired glucose tolerance (42% vs. 49%), obesity (75% vs. 83%) and metabolic syndrome (55% vs. 66%) (P less than .05 for all comparisons). Drinkers and nondrinkers resembled each other in terms of lipid profiles, use of lipid-lowering medications, liver attenuation scores, and systolic and diastolic blood pressures, although significantly more nondrinkers used antihypertensive medications (46% vs.35%; P = .005).

Drinkers had a higher prevalence of coronary artery calcification, defined as Agatston score above 0 (42% vs. 34%), and the difference approached statistical significance (P = .05). However, after they adjusted for multiple potential confounders, the researchers found no link between alcohol consumption and risk factors for cardiovascular disease or between alcohol consumption and measures of subclinical cardiovascular disease. This finding persisted in sensitivity analyses that examined alcohol dose, binge drinking, history of cardiovascular events, and former heavy alcohol use.

SOURCE: AMERICAN GASTROENTEROLOGICAL ASSOCIATION

Taken together, the findings “challenge the belief that alcohol use may reduce cardiovascular disease risk in persons with nonalcoholic fatty liver disease,” the investigators concluded. Clinical heart failure was too rare to reliably assess, but “we failed to observe an association between alcohol use and multiple markers of subclinical changes in cardiac structure and function that may be precursors of incident heart failure in NAFLD,” they wrote. More longitudinal studies would be needed to clarify how moderate alcohol use in NAFLD affects coronary artery calcification or changes in myocardial structure and function, they cautioned.

The National Institutes of Health supported the work. The investigators reported having no relevant conflicts of interest.

Alcohol consumption produced no apparent cardiovascular benefits among individuals with nonalcoholic fatty liver disease, according to a study of 570 white and black adults from the Coronary Artery Risk Development in Young Adults (CARDIA) longitudinal cohort.

After researchers controlled for multiple demographic and clinical confounders, alcohol use was not associated with cardiovascular risk factors such as diabetes, hypertension, or hyperlipidemia, nor with homeostatic model assessment of insulin resistance, C-reactive protein level, total cholesterol, systolic or diastolic blood pressure, coronary artery calcification, E/A ratio, or global longitudinal strain among individuals with nonalcoholic fatty liver disease (NAFLD), reported Lisa B. VanWagner, MD, of Northwestern University, Chicago, and her associates. “[A] recommendation of cardiovascular disease risk benefit of alcohol use in persons with NAFLD cannot be made based on the current findings,” they wrote. They advocated for prospective, long-term studies to better understand how various types and doses of alcohol affect hard cardiovascular endpoints in patients with NAFLD. Their study was published in Gastroenterology.

CARDIA enrolled 5,115 black and white adults aged 18-30 years from four cities in the United States, and followed them long term. Participants were asked about alcohol consumption at study entry and again at 15, 20, and 25 years of follow-up. At year 25, participants underwent computed tomography (CT) examinations of the thorax and abdomen and tissue Doppler echocardiography with myocardial strain measured by speckle tracking (Gastroenterology. 2017 Aug 9. doi: 10.1053/j.gastro.2017.08.012).

Fuse/Thinkstock

The 570 participants with NAFLD averaged 50 years of age, 54% were black, 46% were female, and 58% consumed at least one alcoholic drink per week, said the researchers. Compared with nondrinkers, drinkers had attained significantly higher education levels, were significantly more likely to be white and male, and had a significantly lower average body mass index (34.4 kg/m² vs. 37.3 kg/m²) and C-reactive protein level (4.2 vs. 6.1 mg per L), and a significantly lower prevalence of diabetes (23% vs. 37%), impaired glucose tolerance (42% vs. 49%), obesity (75% vs. 83%) and metabolic syndrome (55% vs. 66%) (P less than .05 for all comparisons). Drinkers and nondrinkers resembled each other in terms of lipid profiles, use of lipid-lowering medications, liver attenuation scores, and systolic and diastolic blood pressures, although significantly more nondrinkers used antihypertensive medications (46% vs.35%; P = .005).

Drinkers had a higher prevalence of coronary artery calcification, defined as Agatston score above 0 (42% vs. 34%), and the difference approached statistical significance (P = .05). However, after they adjusted for multiple potential confounders, the researchers found no link between alcohol consumption and risk factors for cardiovascular disease or between alcohol consumption and measures of subclinical cardiovascular disease. This finding persisted in sensitivity analyses that examined alcohol dose, binge drinking, history of cardiovascular events, and former heavy alcohol use.

SOURCE: AMERICAN GASTROENTEROLOGICAL ASSOCIATION

Taken together, the findings “challenge the belief that alcohol use may reduce cardiovascular disease risk in persons with nonalcoholic fatty liver disease,” the investigators concluded. Clinical heart failure was too rare to reliably assess, but “we failed to observe an association between alcohol use and multiple markers of subclinical changes in cardiac structure and function that may be precursors of incident heart failure in NAFLD,” they wrote. More longitudinal studies would be needed to clarify how moderate alcohol use in NAFLD affects coronary artery calcification or changes in myocardial structure and function, they cautioned.

The National Institutes of Health supported the work. The investigators reported having no relevant conflicts of interest.

Alcohol consumption produced no apparent cardiovascular benefits among individuals with nonalcoholic fatty liver disease, according to a study of 570 white and black adults from the Coronary Artery Risk Development in Young Adults (CARDIA) longitudinal cohort.

After researchers controlled for multiple demographic and clinical confounders, alcohol use was not associated with cardiovascular risk factors such as diabetes, hypertension, or hyperlipidemia, nor with homeostatic model assessment of insulin resistance, C-reactive protein level, total cholesterol, systolic or diastolic blood pressure, coronary artery calcification, E/A ratio, or global longitudinal strain among individuals with nonalcoholic fatty liver disease (NAFLD), reported Lisa B. VanWagner, MD, of Northwestern University, Chicago, and her associates. “[A] recommendation of cardiovascular disease risk benefit of alcohol use in persons with NAFLD cannot be made based on the current findings,” they wrote. They advocated for prospective, long-term studies to better understand how various types and doses of alcohol affect hard cardiovascular endpoints in patients with NAFLD. Their study was published in Gastroenterology.

CARDIA enrolled 5,115 black and white adults aged 18-30 years from four cities in the United States, and followed them long term. Participants were asked about alcohol consumption at study entry and again at 15, 20, and 25 years of follow-up. At year 25, participants underwent computed tomography (CT) examinations of the thorax and abdomen and tissue Doppler echocardiography with myocardial strain measured by speckle tracking (Gastroenterology. 2017 Aug 9. doi: 10.1053/j.gastro.2017.08.012).

Fuse/Thinkstock

The 570 participants with NAFLD averaged 50 years of age, 54% were black, 46% were female, and 58% consumed at least one alcoholic drink per week, said the researchers. Compared with nondrinkers, drinkers had attained significantly higher education levels, were significantly more likely to be white and male, and had a significantly lower average body mass index (34.4 kg/m² vs. 37.3 kg/m²) and C-reactive protein level (4.2 vs. 6.1 mg per L), and a significantly lower prevalence of diabetes (23% vs. 37%), impaired glucose tolerance (42% vs. 49%), obesity (75% vs. 83%) and metabolic syndrome (55% vs. 66%) (P less than .05 for all comparisons). Drinkers and nondrinkers resembled each other in terms of lipid profiles, use of lipid-lowering medications, liver attenuation scores, and systolic and diastolic blood pressures, although significantly more nondrinkers used antihypertensive medications (46% vs.35%; P = .005).

Drinkers had a higher prevalence of coronary artery calcification, defined as Agatston score above 0 (42% vs. 34%), and the difference approached statistical significance (P = .05). However, after they adjusted for multiple potential confounders, the researchers found no link between alcohol consumption and risk factors for cardiovascular disease or between alcohol consumption and measures of subclinical cardiovascular disease. This finding persisted in sensitivity analyses that examined alcohol dose, binge drinking, history of cardiovascular events, and former heavy alcohol use.

SOURCE: AMERICAN GASTROENTEROLOGICAL ASSOCIATION

Taken together, the findings “challenge the belief that alcohol use may reduce cardiovascular disease risk in persons with nonalcoholic fatty liver disease,” the investigators concluded. Clinical heart failure was too rare to reliably assess, but “we failed to observe an association between alcohol use and multiple markers of subclinical changes in cardiac structure and function that may be precursors of incident heart failure in NAFLD,” they wrote. More longitudinal studies would be needed to clarify how moderate alcohol use in NAFLD affects coronary artery calcification or changes in myocardial structure and function, they cautioned.

The National Institutes of Health supported the work. The investigators reported having no relevant conflicts of interest.

WASHINGTON – Flu vaccination rates remain below the 70% Healthy People 2020 goal for most of the U.S. population, but data show that a recommendation from a clinician can encourage individuals to get vaccinated and to vaccinate their children, according to a panel of experts who spoke at a press briefing sponsored by the National Foundation for Infectious Diseases.

“Annual vaccination is our first line of defense against the flu,” William Schaffner, MD, of Vanderbilt University, Nashville, Tenn., said at the briefing. The unpredictable nature of the flu makes annual vaccination even more important – and the earlier, the better, said Dr. Schaffner. “If you have seen one flu season, you have seen ... one flu season.”

In a video interview at the briefing, experts emphasized the safety and effectiveness of the flu vaccine for a range of populations, including children, pregnant women, and older adults. And they offered tips to convince patients of the importance of vaccination, as well as the need to make sure health care staff are protected.

Briefing participants included former Department of Health and Human Services Secretary Thomas A. Price, MD; Patricia A. Stinchfield, RN, MS, CPNP, CIC of Children’s Hospitals and Clinics of Minnesota, St. Paul; Kathleen M. Neuzil, MD, of the University of Maryland; and Daniel B. Jernigan, MD, of the Centers for Disease Control and Prevention.

The clinicians interviewed had no financial conflicts to disclose.

WASHINGTON – Flu vaccination rates remain below the 70% Healthy People 2020 goal for most of the U.S. population, but data show that a recommendation from a clinician can encourage individuals to get vaccinated and to vaccinate their children, according to a panel of experts who spoke at a press briefing sponsored by the National Foundation for Infectious Diseases.

“Annual vaccination is our first line of defense against the flu,” William Schaffner, MD, of Vanderbilt University, Nashville, Tenn., said at the briefing. The unpredictable nature of the flu makes annual vaccination even more important – and the earlier, the better, said Dr. Schaffner. “If you have seen one flu season, you have seen ... one flu season.”

In a video interview at the briefing, experts emphasized the safety and effectiveness of the flu vaccine for a range of populations, including children, pregnant women, and older adults. And they offered tips to convince patients of the importance of vaccination, as well as the need to make sure health care staff are protected.

Briefing participants included former Department of Health and Human Services Secretary Thomas A. Price, MD; Patricia A. Stinchfield, RN, MS, CPNP, CIC of Children’s Hospitals and Clinics of Minnesota, St. Paul; Kathleen M. Neuzil, MD, of the University of Maryland; and Daniel B. Jernigan, MD, of the Centers for Disease Control and Prevention.

The clinicians interviewed had no financial conflicts to disclose.

WASHINGTON – Flu vaccination rates remain below the 70% Healthy People 2020 goal for most of the U.S. population, but data show that a recommendation from a clinician can encourage individuals to get vaccinated and to vaccinate their children, according to a panel of experts who spoke at a press briefing sponsored by the National Foundation for Infectious Diseases.

“Annual vaccination is our first line of defense against the flu,” William Schaffner, MD, of Vanderbilt University, Nashville, Tenn., said at the briefing. The unpredictable nature of the flu makes annual vaccination even more important – and the earlier, the better, said Dr. Schaffner. “If you have seen one flu season, you have seen ... one flu season.”

In a video interview at the briefing, experts emphasized the safety and effectiveness of the flu vaccine for a range of populations, including children, pregnant women, and older adults. And they offered tips to convince patients of the importance of vaccination, as well as the need to make sure health care staff are protected.

Briefing participants included former Department of Health and Human Services Secretary Thomas A. Price, MD; Patricia A. Stinchfield, RN, MS, CPNP, CIC of Children’s Hospitals and Clinics of Minnesota, St. Paul; Kathleen M. Neuzil, MD, of the University of Maryland; and Daniel B. Jernigan, MD, of the Centers for Disease Control and Prevention.

The clinicians interviewed had no financial conflicts to disclose.

Arthroscopic identification and evaluation of the meniscomeniscal ligament.

Arthroscopic identification and evaluation of the meniscomeniscal ligament.

Arthroscopic identification and evaluation of the meniscomeniscal ligament.

SAN FRANCISCO – The American Academy of Pediatrics recently released new hypertension guidelines for children and adolescents.

Some of the advice is similar to the group’s last effort in 2004, but there are a few key changes that clinicians need to know, according to lead author Joseph Flynn, MD, professor of pediatrics and chief of nephrology at Seattle Children’s Hospital. He explained what they are, and the reasons behind them, in an interview at the joint hypertension scientific sessions sponsored by the American Heart Association and the American Society of Hypertension (Pediatrics. 2017 Aug 21. doi: 10.1542/peds.2017-1904).

The prevalence of pediatric hypertension, he said, now rivals asthma.

[email protected]

SAN FRANCISCO – The American Academy of Pediatrics recently released new hypertension guidelines for children and adolescents.

Some of the advice is similar to the group’s last effort in 2004, but there are a few key changes that clinicians need to know, according to lead author Joseph Flynn, MD, professor of pediatrics and chief of nephrology at Seattle Children’s Hospital. He explained what they are, and the reasons behind them, in an interview at the joint hypertension scientific sessions sponsored by the American Heart Association and the American Society of Hypertension (Pediatrics. 2017 Aug 21. doi: 10.1542/peds.2017-1904).

The prevalence of pediatric hypertension, he said, now rivals asthma.

[email protected]

SAN FRANCISCO – The American Academy of Pediatrics recently released new hypertension guidelines for children and adolescents.

Some of the advice is similar to the group’s last effort in 2004, but there are a few key changes that clinicians need to know, according to lead author Joseph Flynn, MD, professor of pediatrics and chief of nephrology at Seattle Children’s Hospital. He explained what they are, and the reasons behind them, in an interview at the joint hypertension scientific sessions sponsored by the American Heart Association and the American Society of Hypertension (Pediatrics. 2017 Aug 21. doi: 10.1542/peds.2017-1904).

The prevalence of pediatric hypertension, he said, now rivals asthma.

[email protected]

SILVER SPRING, MD. – The emotional challenges facing alopecia areata patients are as tough, or tougher, than the physical challenges, according to many patients participating in a public meeting on alopecia areata patient-focused drug development.

A panel of patients shared their experiences of living with alopecia areata, including Elizabeth DeCarlo of Wilmington, Delaware. In a video interview at the meeting, held at FDA headquarters on Sept. 11, Ms. DeCarlo elaborated on what she would like clinicians to understand about alopecia patients that might surprise them, and what matters to her as a patient.

“I would tell them to be more compassionate,” Ms. DeCarlo said. “It’s very emotional.” She also emphasized the value of giving alopecia patients information about local support groups, as well as national organizations such as the National Alopecia Areata Foundation.

Ms. DeCarlo had no financial conflicts to disclose.

SILVER SPRING, MD. – The emotional challenges facing alopecia areata patients are as tough, or tougher, than the physical challenges, according to many patients participating in a public meeting on alopecia areata patient-focused drug development.

A panel of patients shared their experiences of living with alopecia areata, including Elizabeth DeCarlo of Wilmington, Delaware. In a video interview at the meeting, held at FDA headquarters on Sept. 11, Ms. DeCarlo elaborated on what she would like clinicians to understand about alopecia patients that might surprise them, and what matters to her as a patient.

“I would tell them to be more compassionate,” Ms. DeCarlo said. “It’s very emotional.” She also emphasized the value of giving alopecia patients information about local support groups, as well as national organizations such as the National Alopecia Areata Foundation.

Ms. DeCarlo had no financial conflicts to disclose.

SILVER SPRING, MD. – The emotional challenges facing alopecia areata patients are as tough, or tougher, than the physical challenges, according to many patients participating in a public meeting on alopecia areata patient-focused drug development.

A panel of patients shared their experiences of living with alopecia areata, including Elizabeth DeCarlo of Wilmington, Delaware. In a video interview at the meeting, held at FDA headquarters on Sept. 11, Ms. DeCarlo elaborated on what she would like clinicians to understand about alopecia patients that might surprise them, and what matters to her as a patient.

“I would tell them to be more compassionate,” Ms. DeCarlo said. “It’s very emotional.” She also emphasized the value of giving alopecia patients information about local support groups, as well as national organizations such as the National Alopecia Areata Foundation.

Ms. DeCarlo had no financial conflicts to disclose.

A large prospective study of middle-aged and older women found no convincing evidence that using proton pump inhibitors increased their risk of dementia, investigators reported.

However, using H₂ receptor antagonists for at least 9 years was associated with a slight decrease in scores of learning and working memory (mean decrease, –0.2; 95% confidence interval, –0.3 to –0.08; P less than .001), Paul Lochhead, MBChB, PhD, and his associates wrote in the October issue of Gastroenterology (doi: 10.1053/j.gastro.2017.06.061). “Since our primary hypothesis related to PPI [proton pump inhibitor] use, our findings for [H₂ receptor antagonists] should be interpreted with caution,” they said.
 

Source: American Gastroenterological Association

In a recent German study of a medical claims database, use of PPIs was associated with a 44% increase in the likelihood of incident dementia (JAMA Neurol. 2016;73:410-6). “The existence of a causal mechanism linking PPI use to dementia is suggested by observations from cellular and animal models of Alzheimer’s disease, where PPI exposure appears to influence amyloid-beta metabolism,” Dr. Lochhead and his associates wrote. “However, other preclinical data on PPIs and Alzheimer’s disease are conflicting.” Noting that cognitive function predicts dementia later in life, they analyzed prospective data on medications and other potential risk factors from 13,864 participants in the Nurses’ Health Study II who had completed Cogstate, a computerized, self-administered neuropsychological battery.

Study participants averaged 61 years old when they underwent cognitive testing, ranging in age from 50 to 70 years. Users of PPIs tended to be older, had more comorbidities, were less physically active, had higher body mass indexes, had less education, and ate a lower-quality diet than women who did not use PPIs. After adjusting for such confounders, using PPIs for 9-14 years was associated with a modest decrease in scores for psychomotor speed and attention (mean score difference, compared with never users, –0.06; 95% CI, –0.11 to 0.00; P = .03). “For comparison, in multivariable models, a 1-year increase in age was associated with mean score decreases of 0.03 for psychomotor speed and attention, 0.02 for learning and working memory, and 0.03 for overall cognition,” the researchers wrote.
 

Next, they examined links between use of H₂ receptor antagonists and cognitive scores among 10,778 study participants who had used PPIs for 2 years or less. Use of H₂ receptor antagonists for 9-14 years predicted poorer scores on learning, working memory, and overall cognition, even after controlling for potential confounders (P less than or equal to .002). “The magnitudes of mean score differences were larger than those observed in the analysis of PPI use, particularly for learning and working memory,” the researchers noted. Additionally, PPI use did not predict lower cognitive scores among individuals who had never used H₂ receptor antagonists.

On the other hand, using PPIs for 9-14 years was associated with the equivalent of about 2 years of age-related cognitive decline, and controlling for exposure to H₂ receptor antagonists weakened even this modest effect, the investigators said. Users and nonusers of PPIs tend to differ on many measures, and analyses of claims data, such as the German study above, are less able to account for these potential confounders, they noted. “Nonjudicious PPI prescribing is especially frequent among the elderly and those with cognitive impairment,” they added. “Therefore, elderly individuals who have frequent contact with health providers are at increased risk of both PPI prescription and dementia diagnosis. This bias may not be completely mitigated by adjustment for comorbidities or polypharmacy.”

The findings regarding H₂ receptor antagonists reflect those of three smaller cohort studies, and these medications are known to cause central nervous system effects in the elderly, including delirium, the researchers said. Ranitidine and cimetidine have anticholinergic effects that also could “pose a risk for adverse cognitive effects with long-term use.”

Dr. Lochhead reported having no conflicts. Two coinvestigators disclosed ties to Bayer Healthcare, Pfizer, Aralez Pharmaceuticals, AbbVie, Samsung Bioepis, and Takeda.

A large prospective study of middle-aged and older women found no convincing evidence that using proton pump inhibitors increased their risk of dementia, investigators reported.

However, using H₂ receptor antagonists for at least 9 years was associated with a slight decrease in scores of learning and working memory (mean decrease, –0.2; 95% confidence interval, –0.3 to –0.08; P less than .001), Paul Lochhead, MBChB, PhD, and his associates wrote in the October issue of Gastroenterology (doi: 10.1053/j.gastro.2017.06.061). “Since our primary hypothesis related to PPI [proton pump inhibitor] use, our findings for [H₂ receptor antagonists] should be interpreted with caution,” they said.
 

Source: American Gastroenterological Association

In a recent German study of a medical claims database, use of PPIs was associated with a 44% increase in the likelihood of incident dementia (JAMA Neurol. 2016;73:410-6). “The existence of a causal mechanism linking PPI use to dementia is suggested by observations from cellular and animal models of Alzheimer’s disease, where PPI exposure appears to influence amyloid-beta metabolism,” Dr. Lochhead and his associates wrote. “However, other preclinical data on PPIs and Alzheimer’s disease are conflicting.” Noting that cognitive function predicts dementia later in life, they analyzed prospective data on medications and other potential risk factors from 13,864 participants in the Nurses’ Health Study II who had completed Cogstate, a computerized, self-administered neuropsychological battery.

Study participants averaged 61 years old when they underwent cognitive testing, ranging in age from 50 to 70 years. Users of PPIs tended to be older, had more comorbidities, were less physically active, had higher body mass indexes, had less education, and ate a lower-quality diet than women who did not use PPIs. After adjusting for such confounders, using PPIs for 9-14 years was associated with a modest decrease in scores for psychomotor speed and attention (mean score difference, compared with never users, –0.06; 95% CI, –0.11 to 0.00; P = .03). “For comparison, in multivariable models, a 1-year increase in age was associated with mean score decreases of 0.03 for psychomotor speed and attention, 0.02 for learning and working memory, and 0.03 for overall cognition,” the researchers wrote.
 

Next, they examined links between use of H₂ receptor antagonists and cognitive scores among 10,778 study participants who had used PPIs for 2 years or less. Use of H₂ receptor antagonists for 9-14 years predicted poorer scores on learning, working memory, and overall cognition, even after controlling for potential confounders (P less than or equal to .002). “The magnitudes of mean score differences were larger than those observed in the analysis of PPI use, particularly for learning and working memory,” the researchers noted. Additionally, PPI use did not predict lower cognitive scores among individuals who had never used H₂ receptor antagonists.

On the other hand, using PPIs for 9-14 years was associated with the equivalent of about 2 years of age-related cognitive decline, and controlling for exposure to H₂ receptor antagonists weakened even this modest effect, the investigators said. Users and nonusers of PPIs tend to differ on many measures, and analyses of claims data, such as the German study above, are less able to account for these potential confounders, they noted. “Nonjudicious PPI prescribing is especially frequent among the elderly and those with cognitive impairment,” they added. “Therefore, elderly individuals who have frequent contact with health providers are at increased risk of both PPI prescription and dementia diagnosis. This bias may not be completely mitigated by adjustment for comorbidities or polypharmacy.”

The findings regarding H₂ receptor antagonists reflect those of three smaller cohort studies, and these medications are known to cause central nervous system effects in the elderly, including delirium, the researchers said. Ranitidine and cimetidine have anticholinergic effects that also could “pose a risk for adverse cognitive effects with long-term use.”

Dr. Lochhead reported having no conflicts. Two coinvestigators disclosed ties to Bayer Healthcare, Pfizer, Aralez Pharmaceuticals, AbbVie, Samsung Bioepis, and Takeda.

A large prospective study of middle-aged and older women found no convincing evidence that using proton pump inhibitors increased their risk of dementia, investigators reported.

However, using H₂ receptor antagonists for at least 9 years was associated with a slight decrease in scores of learning and working memory (mean decrease, –0.2; 95% confidence interval, –0.3 to –0.08; P less than .001), Paul Lochhead, MBChB, PhD, and his associates wrote in the October issue of Gastroenterology (doi: 10.1053/j.gastro.2017.06.061). “Since our primary hypothesis related to PPI [proton pump inhibitor] use, our findings for [H₂ receptor antagonists] should be interpreted with caution,” they said.
 

Source: American Gastroenterological Association

In a recent German study of a medical claims database, use of PPIs was associated with a 44% increase in the likelihood of incident dementia (JAMA Neurol. 2016;73:410-6). “The existence of a causal mechanism linking PPI use to dementia is suggested by observations from cellular and animal models of Alzheimer’s disease, where PPI exposure appears to influence amyloid-beta metabolism,” Dr. Lochhead and his associates wrote. “However, other preclinical data on PPIs and Alzheimer’s disease are conflicting.” Noting that cognitive function predicts dementia later in life, they analyzed prospective data on medications and other potential risk factors from 13,864 participants in the Nurses’ Health Study II who had completed Cogstate, a computerized, self-administered neuropsychological battery.

Study participants averaged 61 years old when they underwent cognitive testing, ranging in age from 50 to 70 years. Users of PPIs tended to be older, had more comorbidities, were less physically active, had higher body mass indexes, had less education, and ate a lower-quality diet than women who did not use PPIs. After adjusting for such confounders, using PPIs for 9-14 years was associated with a modest decrease in scores for psychomotor speed and attention (mean score difference, compared with never users, –0.06; 95% CI, –0.11 to 0.00; P = .03). “For comparison, in multivariable models, a 1-year increase in age was associated with mean score decreases of 0.03 for psychomotor speed and attention, 0.02 for learning and working memory, and 0.03 for overall cognition,” the researchers wrote.
 

Next, they examined links between use of H₂ receptor antagonists and cognitive scores among 10,778 study participants who had used PPIs for 2 years or less. Use of H₂ receptor antagonists for 9-14 years predicted poorer scores on learning, working memory, and overall cognition, even after controlling for potential confounders (P less than or equal to .002). “The magnitudes of mean score differences were larger than those observed in the analysis of PPI use, particularly for learning and working memory,” the researchers noted. Additionally, PPI use did not predict lower cognitive scores among individuals who had never used H₂ receptor antagonists.

On the other hand, using PPIs for 9-14 years was associated with the equivalent of about 2 years of age-related cognitive decline, and controlling for exposure to H₂ receptor antagonists weakened even this modest effect, the investigators said. Users and nonusers of PPIs tend to differ on many measures, and analyses of claims data, such as the German study above, are less able to account for these potential confounders, they noted. “Nonjudicious PPI prescribing is especially frequent among the elderly and those with cognitive impairment,” they added. “Therefore, elderly individuals who have frequent contact with health providers are at increased risk of both PPI prescription and dementia diagnosis. This bias may not be completely mitigated by adjustment for comorbidities or polypharmacy.”

The findings regarding H₂ receptor antagonists reflect those of three smaller cohort studies, and these medications are known to cause central nervous system effects in the elderly, including delirium, the researchers said. Ranitidine and cimetidine have anticholinergic effects that also could “pose a risk for adverse cognitive effects with long-term use.”

Dr. Lochhead reported having no conflicts. Two coinvestigators disclosed ties to Bayer Healthcare, Pfizer, Aralez Pharmaceuticals, AbbVie, Samsung Bioepis, and Takeda.

For patients with compensated cirrhosis, statin therapy was associated with about a 46% decrease in the risk of hepatic decompensation and mortality and with a 27% drop in the risk of portal hypertension and variceal bleeding, according to moderate-quality evidence from a systematic review and meta-analysis of 13 studies.

Low-quality data also suggested that statins might help protect against the progression of noncirrhotic chronic liver disease, said Rebecca G. Kim of the University of California at San Diego and her associates. “Large, pragmatic randomized controlled trials in patients with compensated cirrhosis are required to confirm these observations,” they wrote in the October issue of Clinical Gastroenterology and Hepatology (doi: 10.1016/j.cgh.2017.04.039).

Prior studies have reported mixed findings on how statin therapy affects chronic liver disease. For their review, Ms. Kim and her associates searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, Cochrane Database and Systematic Reviews, Scopus, Web of Science, and PubMed for randomized controlled trials or cohort studies published through March 25, 2017. They identified 10 cohort studies and three randomized controlled trials of adults with fibrosis without cirrhosis, compensated cirrhosis, or decompensated cirrhosis that evaluated statin exposure and reported associations between exposure and outcomes related to cirrhosis. They excluded case-control studies, cross-sectional studies, and studies that focused only on the relationship between statin use and the risk of hepatocellular carcinoma.

The resulting data set included 121,058 patients with chronic liver diseases, of whom 85% had chronic hepatitis C virus infection. A total of 46% of patients were exposed to statins, which appeared to reduce their risk of hepatic decompensation, variceal bleeding, and mortality. Among 87 such patients in five studies, statin use was associated with a 46% decrease in the risk of hepatic decompensation and death, with risk ratios of 0.54 (95% confidence intervals, 0.46-0.62 and 0.47-0.61, respectively). Statin use also was associated with a 27% lower risk of variceal bleeding or progression of portal hypertension, based on an analysis of 110 events in 236 patients from three trials (RR, 0.73; 95% CI, 0.59-0.91). Finally, statin use also was associated with a 58% lower risk of fibrosis progression or cirrhosis in patients with noncirrhotic chronic liver disease, but the 95% CIs for the risk estimate did not reach statistical significance (0.16-1.11).

Source: American Gastroenterological Association

Most studies lacked data on dose and duration of statin exposure, the researchers said. However, four cohort studies reported dose-dependent effects that were most pronounced after more than a year of treatment. “Similarly, several different types of statins were studied, and observed effects were assumed to be class-specific effects,” the reviewers wrote. “However, it is possible that lipophilic and lipophobic statins may have differential efficacy in decreasing fibrosis progression.”

Together, these findings support prior studies suggesting that statin therapy is safe and can potentially reduce the risk of hepatocellular carcinoma in this patient population, they concluded. Statins “may potentially improve patient-relevant outcomes in patients with chronic liver diseases and improve survival without significant additional costs.”

The reviewers acknowledged the American Gastroenterological Association Foundation, a T. Franklin Williams Scholarship Award, the National Institutes of Health, and the National Library of Medicine. They reported having no relevant conflicts of interest.

This story was updated on 9/13/2017.

For patients with compensated cirrhosis, statin therapy was associated with about a 46% decrease in the risk of hepatic decompensation and mortality and with a 27% drop in the risk of portal hypertension and variceal bleeding, according to moderate-quality evidence from a systematic review and meta-analysis of 13 studies.

Low-quality data also suggested that statins might help protect against the progression of noncirrhotic chronic liver disease, said Rebecca G. Kim of the University of California at San Diego and her associates. “Large, pragmatic randomized controlled trials in patients with compensated cirrhosis are required to confirm these observations,” they wrote in the October issue of Clinical Gastroenterology and Hepatology (doi: 10.1016/j.cgh.2017.04.039).

Prior studies have reported mixed findings on how statin therapy affects chronic liver disease. For their review, Ms. Kim and her associates searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, Cochrane Database and Systematic Reviews, Scopus, Web of Science, and PubMed for randomized controlled trials or cohort studies published through March 25, 2017. They identified 10 cohort studies and three randomized controlled trials of adults with fibrosis without cirrhosis, compensated cirrhosis, or decompensated cirrhosis that evaluated statin exposure and reported associations between exposure and outcomes related to cirrhosis. They excluded case-control studies, cross-sectional studies, and studies that focused only on the relationship between statin use and the risk of hepatocellular carcinoma.

The resulting data set included 121,058 patients with chronic liver diseases, of whom 85% had chronic hepatitis C virus infection. A total of 46% of patients were exposed to statins, which appeared to reduce their risk of hepatic decompensation, variceal bleeding, and mortality. Among 87 such patients in five studies, statin use was associated with a 46% decrease in the risk of hepatic decompensation and death, with risk ratios of 0.54 (95% confidence intervals, 0.46-0.62 and 0.47-0.61, respectively). Statin use also was associated with a 27% lower risk of variceal bleeding or progression of portal hypertension, based on an analysis of 110 events in 236 patients from three trials (RR, 0.73; 95% CI, 0.59-0.91). Finally, statin use also was associated with a 58% lower risk of fibrosis progression or cirrhosis in patients with noncirrhotic chronic liver disease, but the 95% CIs for the risk estimate did not reach statistical significance (0.16-1.11).

Source: American Gastroenterological Association

Most studies lacked data on dose and duration of statin exposure, the researchers said. However, four cohort studies reported dose-dependent effects that were most pronounced after more than a year of treatment. “Similarly, several different types of statins were studied, and observed effects were assumed to be class-specific effects,” the reviewers wrote. “However, it is possible that lipophilic and lipophobic statins may have differential efficacy in decreasing fibrosis progression.”

Together, these findings support prior studies suggesting that statin therapy is safe and can potentially reduce the risk of hepatocellular carcinoma in this patient population, they concluded. Statins “may potentially improve patient-relevant outcomes in patients with chronic liver diseases and improve survival without significant additional costs.”

The reviewers acknowledged the American Gastroenterological Association Foundation, a T. Franklin Williams Scholarship Award, the National Institutes of Health, and the National Library of Medicine. They reported having no relevant conflicts of interest.

This story was updated on 9/13/2017.

For patients with compensated cirrhosis, statin therapy was associated with about a 46% decrease in the risk of hepatic decompensation and mortality and with a 27% drop in the risk of portal hypertension and variceal bleeding, according to moderate-quality evidence from a systematic review and meta-analysis of 13 studies.

Low-quality data also suggested that statins might help protect against the progression of noncirrhotic chronic liver disease, said Rebecca G. Kim of the University of California at San Diego and her associates. “Large, pragmatic randomized controlled trials in patients with compensated cirrhosis are required to confirm these observations,” they wrote in the October issue of Clinical Gastroenterology and Hepatology (doi: 10.1016/j.cgh.2017.04.039).

Prior studies have reported mixed findings on how statin therapy affects chronic liver disease. For their review, Ms. Kim and her associates searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, Cochrane Database and Systematic Reviews, Scopus, Web of Science, and PubMed for randomized controlled trials or cohort studies published through March 25, 2017. They identified 10 cohort studies and three randomized controlled trials of adults with fibrosis without cirrhosis, compensated cirrhosis, or decompensated cirrhosis that evaluated statin exposure and reported associations between exposure and outcomes related to cirrhosis. They excluded case-control studies, cross-sectional studies, and studies that focused only on the relationship between statin use and the risk of hepatocellular carcinoma.

The resulting data set included 121,058 patients with chronic liver diseases, of whom 85% had chronic hepatitis C virus infection. A total of 46% of patients were exposed to statins, which appeared to reduce their risk of hepatic decompensation, variceal bleeding, and mortality. Among 87 such patients in five studies, statin use was associated with a 46% decrease in the risk of hepatic decompensation and death, with risk ratios of 0.54 (95% confidence intervals, 0.46-0.62 and 0.47-0.61, respectively). Statin use also was associated with a 27% lower risk of variceal bleeding or progression of portal hypertension, based on an analysis of 110 events in 236 patients from three trials (RR, 0.73; 95% CI, 0.59-0.91). Finally, statin use also was associated with a 58% lower risk of fibrosis progression or cirrhosis in patients with noncirrhotic chronic liver disease, but the 95% CIs for the risk estimate did not reach statistical significance (0.16-1.11).

Source: American Gastroenterological Association

Most studies lacked data on dose and duration of statin exposure, the researchers said. However, four cohort studies reported dose-dependent effects that were most pronounced after more than a year of treatment. “Similarly, several different types of statins were studied, and observed effects were assumed to be class-specific effects,” the reviewers wrote. “However, it is possible that lipophilic and lipophobic statins may have differential efficacy in decreasing fibrosis progression.”

Together, these findings support prior studies suggesting that statin therapy is safe and can potentially reduce the risk of hepatocellular carcinoma in this patient population, they concluded. Statins “may potentially improve patient-relevant outcomes in patients with chronic liver diseases and improve survival without significant additional costs.”

The reviewers acknowledged the American Gastroenterological Association Foundation, a T. Franklin Williams Scholarship Award, the National Institutes of Health, and the National Library of Medicine. They reported having no relevant conflicts of interest.

This story was updated on 9/13/2017.