Allon Kahn

Universal fungal prophylaxis and risk of coccidioidomycosis in liver transplant recipients living in an endemic area.

Recipients of liver transplantation (LT) are at increased risk for symptomatic coccidioidomycosis, primarily because of chronic immunosuppression and impaired cellular immunity. Unfortunately, no consensus exists regarding optimal posttransplant prophylaxis. In a prior study at our institution, we observed both de novo and recurrent coccidioidomycosis despite targeted antifungal prophylaxis. In response, in February 2011, we instituted a universal prophylaxis program consisting of fluconazole (200 mg daily) for the first posttransplant year. In the current study, we retrospectively reviewed the medical records of all patients who underwent LT between the initiation of universal prophylaxis and July 11, 2013. Patients receiving a second transplant or dual‐organ transplant and those who died or did not have follow‐up in the 12‐month post‐LT period were excluded. Data from the universal prophylaxis cohort were compared with previously published data from the targeted prophylaxis era. Of the 160 patients undergoing LT during the study period, 143 met criteria for data analysis. When compared with the 349 patients in the targeted prophylaxis cohort, patients in the universal prophylaxis group were older and had higher rates of pre‐LT coccidioidomycosis, asymptomatic coccidioidal seropositivity, posttransplant diabetes mellitus, and renal insufficiency. Fluconazole‐related toxicity occurred in 13 of the universal prophylaxis patients, 7 of whom were required to discontinue use of the medication. Coccidioidomycosis developed in 10 of the 391 patients (2.6%) in the targeted prophylaxis cohort and in none of the patients in the universal prophylaxis group (P = 0.04). These data strongly support the use of a 1‐year antifungal prophylaxis regimen for LT recipients in endemic regions. Liver Transpl 21:353–361, 2015.

Duodenal Aspirates for Small Intestine Bacterial Overgrowth: Yield, PPIs, and Outcomes after Treatment at a Tertiary Academic Medical Center

Duodenal aspirates are not commonly collected, but they can be easily used in detection of small intestinal bacterial overgrowth (SIBO). Proton pump inhibitor (PPI) use has been proposed to contribute to the development of SIBO. We aimed to determine the yield of SIBO-positive cultures detected in duodenal aspirates, the relationship between SIBO and PPI use, and the clinical outcomes of patients identified by this method. In a retrospective study, we analyzed electronic medical records from 1263 consecutive patients undergoing upper endoscopy at a tertiary medical center. Aspirates were collected thought out the third and fourth portions of the duodenum, and cultures were considered to be positive for SIBO if they produced more than 100,000 cfu/mL. Culture analysis of duodenal aspirates identified SIBO in one-third of patients. A significantly higher percentage of patients with SIBO use PPIs than patients without SIBO, indicating a possible association. Similar proportions of patients with SIBO improved whether or not they received antibiotic treatment, calling into question the use of this expensive therapy for this disorder.

Factitious Disorder in Crohn's Disease: Recurrent Pancytopenia Caused by Surreptitious Ingestion of 6-Mercaptopurine

Factitious disorder is a rare psychiatric illness characterized by the willful and deceptive induction of illness for the purpose of assuming the sick role. It presents a substantial diagnostic challenge, as patients often go to great lengths to conceal their deception. Accordingly, its presence in the full spectrum of gastrointestinal diseases is likely underappreciated. While factitious gastrointestinal bleeding, abdominal pain and diarrhea are relatively common, factitious non-gastrointestinal symptoms in the setting of gastrointestinal illness have been infrequently reported. We present the case of a patient with Crohns disease with recurrent pancytopenia attributed to the surreptitious ingestion of 6-mercaptopurine. In patients with possible access to immunomodulatory drugs, a high suspicion for and early identification of factitious disorder may improve patient outcomes and avoid invasive and costly diagnostic evaluations.

Deglutition Syncope: A Case Report and Review of the Literature

Deglutition syncope (DS) is a rare, neurally-mediated syncopal syndrome arising from an aberrant vagotonic reflex during swallow-associated esophageal dilation. Its association with gastroesophageal disorders often prompts gastroenterology consultation. An 89-year-old man with recent dysphagia and otalgia was admitted after a syncopal episode occurred while eating. Esophageal imaging and endoscopy demonstrated no causative abnormalities. Maxillofacial imaging revealed chronic sinusitis and mastoiditis. Telemetry monitoring demonstrated high-grade atrioventricular block and pause associated with swallowing. His symptoms and swallow-associated arrhythmia resolved after dual chamber pacemaker implantation. DS is highly treatable once identified and multidisciplinary coordination is helpful in optimizing outcomes and avoiding superfluous testing.

Ibrutinib-induced acute liver failure

Waldenstrom’s macroglobulinemia (WM) is a lymphoplasmacytic lymphoma characterized by monocloncal IgM gammopathy and bone marrow infiltration [1]. First-line treatment has traditionally consisted o...

IgG4-Seronegative Autoimmune Pancreatitis and Sclerosing Cholangitis.

IgG4-related disease is a relatively novel clinical entity whose gastrointestinal manifestations include type 1 autoimmune pancreatitis (AIP) and IgG4-associated sclerosing cholangitis. The presence of elevated serum IgG4 is suggestive but not essential for the diagnosis of type 1 AIP and is a pervasive feature of the proposed diagnostic criteria. The differential diagnosis of type 1 AIP includes malignant conditions, emphasizing the importance of a deliberate, comprehensive evaluation. Management of patients with a suggestive clinical presentation, but without serum IgG4 elevation, is difficult. Here we present three cases of IgG4-seronegative AIP and sclerosing cholangitis that responded to empiric steroid therapy and discuss approach considerations. These cases demonstrate the value of meticulous application of existing diagnostic algorithms to achieve a clinical diagnosis and avoid surgical intervention.

Use of volumetric laser endomicroscopy for determining candidates for endoscopic therapy in superficial esophageal squamous cell carcinoma

Background Accurate staging of superficial esophageal squamous cell cancer (ESCC) for endoscopic therapy is challenging. Optical coherence tomography (OCT) has been shown to be superior to high-resolution endoscopic ultrasound (EUS). Volumetric Laser Endomicroscopy (VLE), a second-generation OCT, has recently become commercially available. Objective To assess if VLE can determine which patients with superficial ESSC can undergo endoscopic therapy. Methods This is a multi-center retrospective study. Patients were included if (a) they had visible ESCC, (b) they underwent VLE and EUS for staging, and c) if superficial disease was suspected then endoscopic resection had to be performed to have accurate histology to compare the VLE scan to. VLE scans were then compared to the gold standard: histology for superficial disease and EUS for disease T1b and greater. Results Seventeen patients were included with the following disease: squamous intraepithelial neoplasia (4 patients), T1a disease (6 patients), T1b (2 patients), T2 disease (2 patients) and T3 disease (3 patients). VLE was able to distinguish superficial disease, defined as disease limited up to the lamina propria, from non-superficial disease in all cases. Conclusions VLE may be able to determine which ESCC patients are candidates for endoscopic therapy. Prospective studies are needed to confirm this.

Volumetric laser endomicroscopy interpretation and feature analysis in dysplastic Barrett's esophagus: Barrett's Esophagus Endomicroscopy

Volumetric laser endomicroscopy (VLE) is used to identify Barretts esophagus (BE) dysplasia. Selection of a dysplastic region of interest (ROI) can be challenging due to feature variability across a large amount of data. The degree of agreement among VLE users in selecting a ROI has not been studied.

Gastric lap-band infection due to Mycobacterium abscessus presenting as new-onset ascites in a cirrhotic patient

Abstract Nontuberculous mycobacteria are ubiquitous environmental organisms that are infrequently implicated as pathogens. Peritoneal infection with nontuberculous mycobacteria is rare and published reports are most commonly associated with peritoneal dialysis. This study describes a case of a 41-year-old woman with cirrhosis who had Mycobacterium abscessus peritonitis and an abdominal abscess resulting from infection of a remotely placed gastric band (Lap-Band; Apollo Endosurgery, Inc).