Abimbola Adike

International Normalized Ratio Does Not Predict Gastrointestinal Bleeding After Endoscopic Retrograde Cholangiopancreatography in Patients With Cirrhosis

Background Cirrhosis is often accompanied by an elevated international normalized ratio (INR) due to a decrease in pro-coagulant factors. An elevated INR in cirrhosis is often interpreted as an increased risk of bleeding. There are a paucity of data in the literature on the use of INR to predict risk of gastrointestinal bleeding (GIB) following endoscopic retrograde cholangiopancreatography (ERCP) in patients with cirrhosis. The aims of the study were to determine if there is a correlation between INR and GIB following ERCP in patients with cirrhosis, and to determine if there is a difference in frequency of post-ERCP complications in patients with and without cirrhosis. Methods A retrospective review of all ERCP procedures was performed at a tertiary care institution between 2012 and 2015. We identified ERCPs performed in patients with cirrhosis and compared them to a randomly selected group without liver cirrhosis. Univariate analysis was performed using Chi-square and ANOVA tests. A multivariable logistic regression model using generalized estimating equations was used to examine the association between INR and GIB. Results There were a total of 1,610 ERCPs performed from 2012 to 2015 with 129 performed in 56 patients with cirrhosis compared with 392 ERCPs performed in 310 patients without cirrhosis. There was no difference in the frequency of GIB following ERCP in both groups (P = 0.117). However, there was a difference in overall complications between both groups (P = 0.007), but no difference observed amongst Child-Turcotte-Pugh classes (P = NS). In a multivariable analysis, sphincterotomy during ERCP (odds ratio (OR) = 3.22; 95% confidence interval (CI): 1.05 - 9.94; P = 0.042) and cirrhosis (OR = 3.58; 95% CI: 1.22 - 10.47; P = 0.02) were significant for predicting GIB. Anti-coagulation (OR = 2.90; 95% CI: 0.82 - 10.23; P = 0.097) and INR were not significant in the multivariable model (OR = 2.09; 95% CI: 0.85 - 5.12; P = 0.10). Conclusion There was a statistical difference in overall complications between patients with and without cirrhosis but no difference was observed amongst Child-Turcotte-Pugh classes. Overall, INR was not a significant factor in predicting risk of bleeding in patients after ERCP.

Small Intestinal Bacterial Overgrowth: Nutritional Implications, Diagnosis, and Management

Small intestinal bacterial overgrowth (SIBO), characterized by the presence of excessive bacteria in the small intestine, is typically described as a malabsorptive syndrome occurring in the context of gut stasis syndromes. SIBO is now considered to be a disorder associated with diverse clinical conditions without classic risk factors for SIBO and a cause of several nonspecific gastrointestinal and nongastrointestinal symptoms. Because there is currently no gold standard for diagnosing SIBO, its prevalence and role in the pathogenesis of other diseases remain uncertain; as does optimal treatment of patients with relapsing symptoms.

Hydroxycut-related Vanishing Bile Duct Syndrome.

Figure 1. (A) Marked portal expansion with edema and a mixed inflammatory cell infiltrate including lymphocytes, plasma cells, and eosinophils. The bile ducts show marked inflammation with both lymphocytes and neutrophils (H&E; original magnification, 100). (B) Centrilobular region with ballooning of hepatocytes and cholestasis (H&E; original magnification, 200). 3 1072 361 223 4.3 2.6 0.99 4 704 351 177 1.5 0.94 12 345 121 66 0.3 0.99 24 237 69 40 0.3 28 253 80 47 0.3 0.90 36 197 59 36 0.3

An Unusual Suspect: Lymphoepithelial Cyst of the Pancreas

Lymphoepithelial cysts (LECs) of the pancreas are benign, rare pancreatic cysts that are found predominantly in men. These cysts can present as a diagnostic conundrum given their rarity and difficulty of distinguishing these cysts from those with malignant potential. We present an incidental case of a LEC in a middle-aged man.

Pseudocirrhosis: A Case Series and Literature Review

Pseudocirrhosis describes morphological changes of the liver that closely mimic cirrhosis, without the typical histopathological changes seen in cirrhosis. It most commonly occurs in patients with metastatic breast cancer, although it has been reported in other malignancies as well. Like in cirrhosis, portal hypertension is often seen in patients with pseudocirrhosis. Pseudocirrhosis is a rare but important complication of metastatic cancer. In this case series and literature review, we describe 6 patients with hormone-receptor-positive metastatic breast cancer. We report the significant morbidity associated with pseudocirrhosis in the course of treatment in patients with metastatic breast cancer.

Primary sclerosing cholangitis in children versus adults: lessons for the clinic

ABSTRACT Introduction: Primary sclerosing cholangitis (PSC) is a rare cholestatic disorder that presents with multifocal biliary strictures. PSC has a variable course but often leads to progressive liver disease, and most patients will eventually require liver transplantation. PSC has a strong association with inflammatory bowel disease and autoimmune liver disease. Areas covered: The objective of this article is to compare and contrast the clinical features and natural history of PSC in children to adults. We performed a PubMed search of the English literature using keywords ‘primary sclerosing cholangitis’, ‘PSC’, ‘children’, and ‘pediatric.’ Expert commentary: While certain features of PSC are similar in the pediatric and adult population, there are unique features of pediatric PSC. More longitudinal studies are needed to better understand the natural history of pediatric PSC. It is conceivable that treatment for PSC that will alter the course of disease may become available in the future.

An incidental windsock diverticulum

Windsock diverticulum is a rare anomalous finding of a true intraluminal duodenal diverticulum. While complications of bowel obstruction, bleeding, and pancreatitis may occur, most patients are asymptomatic. Surgical or endoscopic management may be pursued when complications develop.

Metastatic renal cell carcinoma presenting with melena

Renal cell carcinoma is a highly malignant neoplasm. Metastasis to the pancreas and gastrointestinal tract is rare. In this case report, we show images of metastatic renal cell carcinoma to the upper gastrointestinal tract in a patient who presented with melena.

Is the level of cleanliness using segmental boston bowel preparation scale associated with a higher adenoma detection rate

Background The impact of Boston bowel preparation scale (BBPS) scores on the adenoma detection rate (ADR) in each segment has not been adequately addressed. The aim of this study was to determine the association between segmental or overall ADR and serrated polyp detection rate (SDR) with segmental and total BBPS scores. Methods All outpatient screening colonoscopies with documented BBPS scores were retrospectively reviewed at a tertiary institution from January to December 2013. Chi-square tests and logistic regression were used to analyze the detection rates of adenomas and serrated polyps with bowel prep scores. Odds ratios were calculated using logistic regression that controlled for withdrawal time, age, body mass index, diabetes status and sex. Results We analyzed 1991 colonoscopies. The overall ADR was 37.5% (95% confidence interval [CI], 35.3-39.6). There was a significant difference in the overall ADR, and in SDR across all bowel category groups, with total BBPS scores of 8 and 9 having lower detection rates than scores of 5, 6 and 7. As the quality of bowel preparation increased, there was a statistical decrease in the ADR (odds ratio [OR] 0.79 [CI 0.66-0.94], P=0.04) of the right colon, while in the left colon, there was a statistical decrease in SDR (OR 0.78, [CI 0.65-0.92] P=0.019). Conclusion Segmental ADR and SDR both decreased as prep scores increased, decreasing notably in patients with excellent prep scores of 8 and 9. A possible explanation for this unexpected discrepancy may be related to longer and better visualization of the mucosa when cleansing and suctioning is necessary.

A Magnetic Hitchhiker

A 54-year-old woman with a history of bicycle-related blunt abdominal trauma three years previously presented for the treatment of choledocholithiasis. Abdominal computed tomography incidentally revealed a right renal artery pseudoaneurysm with calcifications, and magnetic resonance cholangiopancreatography showed a stricture of the bile duct with stones (a). She underwent endoscopic cholangiopancreatography with removal of the stones, and the stricture was located at the same level as the calcifications of the pseudoaneurysm (b). Intraductal ultrasonography and transpapillary forceps biopsies were performed, and no signs of malignancy were found. As consistent with the previously injured area, we made a diagnosis of bile duct stricture and renal artery pseudoaneurysm caused by bicycle-related trauma. Reexamination by ultrasound confirmed the stricture’s location at the upper border of the pancreas (c), which is a favorite site of traumatic bile duct stricture. The stricture had not changed as of 27-month follow-up. (Informed consent was obtained from the patient to publish these images.)