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Features on contrast-enhanced computed tomography for predicting recurrent esophageal variceal bleeding in patients with hepatocellular carcinoma | BMC Gastroenterology

by Dr. Michael Lee – Health Editor
written by Dr. Michael Lee – Health Editor

CT Scans Show Promise in Predicting, Managing Bleeding Risk in Liver disease Patients – New Research

New findings suggest that CT scans can effectively identify patients at high risk of recurrent esophageal variceal (EV) bleeding, a life-threatening complication of cirrhosis-not-to-be-ignored/” title=”5 early signs of … not to be ignored”>liver disease, perhaps allowing for proactive intervention. A retrospective study analyzing data from a single institution demonstrated a correlation between the size of submucosal esophageal varices visible on CT scans and the likelihood of re-bleeding. Researchers propose utilizing CT scans – particularly with contrast – to identify high-risk patients who might benefit from procedures like partial splenic artery embolization.

The study, published recently, focused on patients with cirrhosis and hepatocellular carcinoma (HCC) who underwent endoscopic intervention for EV bleeding. analysis of prior CT scans revealed that larger submucosal varices were considerably associated with recurrent bleeding events. This suggests CT imaging could serve as a valuable tool alongside endoscopy, offering a faster and more readily available assessment, especially during off-hours.

“CT surveillance could provide several pieces of facts, including the risk of the next EV bleeding, besides assessing treatment response of HCC,” the authors state. They point to the speed and accessibility of CT scans as advantages over endoscopy, despite acknowledging endoscopy remains the gold standard for both diagnosis and treatment.

Though, the researchers also highlighted several limitations. The study’s retrospective design and single-institution focus necessitate further validation through larger, multi-center prospective trials. The lack of routine post-endoscopic contrast-enhanced CT scans limited their ability to fully assess residual varices and re-bleeding risk. Furthermore, the study only included patients who were candidates for and received endoscopic treatment, potentially underestimating the overall incidence of recurrent bleeding. The complex, multifactorial nature of EV bleeding – influenced by factors like HCC burden, portal pressure, and overall health – also wasn’t fully explored.

Despite these limitations, the study underscores the potential for radiologists and clinicians to recognize large submucosal EVs on CT scans as a warning sign, prompting consideration of more aggressive treatment strategies to improve patient outcomes.future research should focus on a more comprehensive understanding of portosystemic shunts and the interplay of various factors contributing to EV bleeding in cirrhotic patients with HCC.

Sources:

Koconis KG, Singh H, Soares G.Partial Splenic embolization in the treatment of patients with portal hypertension: a review of the english Language literature. J Vasc Interv radiol. 2007;18:463-81. Martino A, Amitrano L, Guardascione M, Di Serafino M, Bennato R, Martino R, de Leone A, Orsini L, Romano L, Lombardi G. The role of computed tomography for the prediction of esophageal variceal bleeding: current status and future perspectives. World J Gastrointest Endosc. 2023;15(12):681-9.
* Elhendawy M, Elkalla F. Computed tomography for prediction of esophageal variceal bleeding. World J Gastrointest Endosc. 2024;16(3):175-7.

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Health

Delayed Brain Bleeds in Head Trauma Rare With Anticoagulants

by Dr. Michael Lee – Health Editor
written by Dr. Michael Lee – Health Editor

Mild Head Trauma: Study Reveals Risks of Delayed Brain Bleeds

A recent study reveals that some individuals with mild traumatic brain injuries, who initially show no bleeding on a CT scan, might experience delayed intracranial hemorrhage if they take blood thinners. This finding underscores the importance of monitoring these patients closely.

Study Findings

Researchers examined 596 patients with mild traumatic brain injuries. These patients were also receiving anticoagulant therapy and initially presented with a negative CT scan. The median age of the participants was 83 years old; 46.5% were men. Atrial fibrillation was the most prevalent reason for anticoagulant use, and 74.5% of patients were on direct oral anticoagulants.

The primary goal was to determine the incidence of delayed intracranial hemorrhage (ICH). Secondary outcomes included the need for neurosurgical interventions and 30-day mortality. After 24 hours, all patients underwent a second CT scan. This follow-up was crucial in identifying delayed bleeds.

Delayed ICH developed in 2% of the patients, with subarachnoid hemorrhage and subdural hematoma being the most prevalent findings, occurring in five patients each. None of the individuals with delayed ICH needed neurosurgical intervention or died within a month.

“The low incidence of delayed ICH suggests that patients with minor traumatic brain injury and normal initial CT imaging may be safely discharged without extended hospital observation, provided they have no additional risk factors,”

— The Authors

Patients with delayed ICH were more likely to have experienced high-energy trauma. Additionally, there was a trend, though not statistically significant, toward a higher frequency of delayed ICH in those taking vitamin K antagonists compared to those on direct oral anticoagulants. According to the Centers for Disease Control and Prevention, around 2.8 million traumatic brain injury-related emergency department visits occurred in 2021 in the United States alone. (CDC 2021)

Important Considerations

During hospitalization, 66% of patients with delayed ICH experienced complications, including infections and delirium. The study, led by Jacopo Davide Giamello, was published in Injury on June 11, 2025.

The research had limitations, being a retrospective study from a single center, which could introduce bias. Information about long-term outcomes and medication adherence was not available. However, the data provides important insights into managing patients with mild head injuries who are on blood thinners.

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Health

Early, Aggressive BP Lowering Tied to Better ICH Outcomes

by Dr. Michael Lee – Health Editor
written by Dr. Michael Lee – Health Editor

Aggressive Blood Pressure Control Improves Stroke Outcomes

Early Intervention is Key for Better Recovery and Reduced Risks

New research reveals that swiftly lowering blood pressure after an intracerebral hemorrhage (ICH) can significantly improve patient outcomes, potentially saving lives. Prompt treatment, especially within the first few hours, leads to better neurological function, fewer adverse events, and reduced mortality rates for those suffering from this type of stroke.

Early Treatment Yields Stronger Results

A pooled analysis of four Intensive BP Reduction in Acute Cerebral Hemorrhage Trials (INTERACT1-4) has confirmed the benefits of early, intensive blood pressure management for individuals experiencing ICH. The most positive results were found when the intervention was administered within three hours of the onset of ICH symptoms. Current guidelines suggest a systolic BP target of less than 180 mm Hg within one hour of symptom onset, whereas the intensive treatment approach aims for less than 140 mm Hg within the same timeframe.

The studies involved over 10,000 adults with acute ICH. Participants were randomly assigned to receive either intensive or guideline-recommended BP-lowering treatment within an hour of symptom onset. The primary outcome measure was functional recovery, determined using the modified Rankin scale. The intensive treatment group showed significantly lower mean systolic BP rates at one hour compared to the guideline group, 149.6 mm Hg versus 158.8 mm Hg, respectively.

“The data presented make a compelling case for ultra-early intensive blood pressure reduction as a potentially useful intervention to improve outcomes in people with acute ICH.”

—David J. Werring, PhD, Department of Translational Neuroscience and Stroke, University College London Queen Square Institute of Neurology, London

Those receiving intensive treatment also experienced reduced odds of neurological deterioration within seven days, along with fewer serious adverse events and deaths. According to the American Stroke Association, stroke is a leading cause of death in the United States, with nearly 800,000 strokes occurring annually (American Stroke Association).

Timing and Impact on Hematoma Growth

Investigators also assessed the impact of treatment timing and its effect on hematoma volume. Results from a CT substudy of almost 3000 participants revealed no significant effect on either relative or absolute hematoma growth in the initial 24 hours between intensive and guideline treatment approaches. However, when intensive BP lowering began within three hours of symptom onset, functional recovery improved, and hematoma growth was reduced in almost a quarter of patients.

Expert Insights

In an accompanying editorial, David J. Werring noted the importance of considering the specific pathophysiology of ICH, where hematoma expansion plays a major role in the first few hours. He suggested that intensive BP lowering could be a useful intervention to improve outcomes for individuals with acute ICH, emphasizing the need for further research.

The analysis was funded by a multitude of organizations worldwide, and the investigators disclosed various financial relationships. Despite the limitations of the study, the results underscore the critical importance of early intervention in managing ICH. More research is warranted, but the current findings strongly support the idea that, as Werring concluded, “time is brain” for those with ICH.

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EULAR/ERS Guideline: Managing CTD-ILD – New Recommendations

by Dr. Michael Lee – Health Editor
written by Dr. Michael Lee – Health Editor

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New Guidelines Call for Increased Interstitial Lung Disease Screening in Autoimmune Patients

Table of Contents

BARCELONA, Spain – In a move set to reshape clinical practice, the European Alliance of Associations for Rheumatology (EULAR) and the European Respiratory Society (ERS) have jointly released new guidelines advocating for systematic screening of interstitial lung disease (ILD) in all patients diagnosed with systemic sclerosis (SSc) and mixed connective tissue disease (MCTD). The declaration was made at the EULAR 2025 Annual Meeting.

These complete, disease-specific recommendations aim to standardize the screening, diagnosis, and management of ILD across various connective tissue diseases (CTDs), including SSc, MCTD, rheumatoid arthritis (RA), idiopathic inflammatory myopathies (IIM), and Sjögren’s disease (SjD).The guidelines mark a notable step forward, representing the first collaborative effort between rheumatologists and pulmonologists in Europe to address ILD in this patient population.

Screening Recommendations for Interstitial Lung Disease

the cornerstone of the new guidelines is the strong recommendation for systematic ILD screening using high-resolution computed tomography (HRCT) in all SSc and MCTD patients, irrespective of pre-existing risk factors. This recommendation extends to patients with IIM, excluding those with inclusion body myositis. For individuals with RA,SjD,and other CTDs,the guidelines advise an initial assessment for disease-specific risk factors,followed by HRCT screening for those with identified risks.

Did You Know? The American Thoracic Society estimates that ILD affects approximately 15% of patients with rheumatoid arthritis[[1].

While previous recommendations supported screening in SSc, the inclusion of RA patients with risk factors marks a significant expansion. According to Dr. Bernhard Hellmich, this broadened scope is expected to identify more patients who could benefit from early therapeutic intervention, potentially leading to improved long-term outcomes.

Notably, the guidelines do not specify a screening frequency due to limited evidence. Dr. Anna-Maria Hoffmann-Vold suggests mirroring the diagnostic approach and reassessing for new ILD progression risk factors. The guidelines explicitly advise against substituting HRCT with pulmonary function tests or lung ultrasound for initial screening. However, forced vital capacity and diffusing capacity of the lungs for carbon monoxide can be incorporated in the presence of symptoms or CT abnormalities.

Monitoring ILD Progression After Diagnosis

The guidelines provide specific timeframes for monitoring ILD progression post-diagnosis, tailored to individual diseases and stratified by ILD progression risk. Clinicians are advised to assess risk based on prior lung function tests, HRCT results, the 6-minute walking test, and risk factors such as disease-specific circulating markers, disease activity, and HRCT patterns.

Based on these assessments, patients are categorized as high or low risk. Monitoring frequency varies accordingly. for high-risk patients with any CTD, lung function tests are recommended every 3-6 months during the initial years, followed by every 6-12 months thereafter. Lower-risk patients should undergo lung function tests every 6-12 months initially, and then annually.

Treatment Strategies for Interstitial Lung Disease

the new guidelines offer detailed treatment recommendations, outlining available options for each disease and providing guidance on selecting the most appropriate medication for individual patients. The guidelines strongly recommend tocilizumab for SSc-ILD patients with early diffuse SSc and signs of inflammation. For IIM-ILD patients, immunosuppressive treatment, including glucocorticoids, calcineurin inhibitors, rituximab, mycophenolate, or azathioprine, is recommended.

Other treatment recommendations are conditional, reflecting limited patient populations and a scarcity of randomized controlled trials. Individual treatment algorithms are provided for SSc-ILD, RA-ILD, and IIM-ILD.

Dr. Hellmich believes that these comprehensive guidelines will facilitate earlier treatment initiation, potentially improving patient prognosis. He noted that the inclusion of certain therapies in the EULAR guidelines may encourage their use in clinical practice,even if they are currently considered off-label.

Pro Tip: Staying informed about the latest research and guidelines is crucial for providing optimal care to patients with connective tissue diseases and interstitial lung disease.

The full guidelines are slated for publication next month in the Annals of the Rheumatic Diseases and European Respiratory Journal.

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