Anitha Yadav

Performance of the patency capsule compared with nonenteroclysis radiologic examinations in patients with known or suspected intestinal strictures

BACKGROUND The patency capsule (PC) is used before capsule endoscopy (CE) in patients with known or suspected small-bowel (SB) strictures or obstruction (SBO) to avoid CE retention. False-positive PC examination results can occur in patients with delayed transit without obstruction, precluding the use of CE. Radiological tests are another option to evaluate the presence of SBO before CE. OBJECTIVES Comparison of the PC and radiological examinations to detect clinically significant SB strictures. MAIN OUTCOME MEASUREMENTS Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the PC, and radiological tests for detecting significant strictures. RESULTS Forty-two patients underwent a PC study and radiological examinations. Both of the examinations showed similar sensitivity (57% vs 71%; P = 1.00) and specificity (86% vs 97%; P = .22). The receiver-operating characteristic curves evaluating combined sensitivity and specificity were also similar in both the PC and radiological examinations (0.71 vs 0.84, respectively; P = .46). Pooling results from both the PC and radiological tests had the highest sensitivity and NPV (100%, 100%). False-positive results occurred in 5 PC examinations and 1 radiological examination. The PC examination had 3 false-negative results (9%), whereas radiological tests had 2 (6%). LIMITATIONS Retrospective study. CONCLUSIONS The NPV for the PC and radiological tests were not significantly different, suggesting that if findings on either test are negative before CE, the patient will most likely pass the capsule without incident. Radiological tests can be used to minimize PC study false-positive results by confirming or excluding the presence of a significant stricture suspected by the PC and to localize the PC if passage is delayed.

Relationship between sarcopenia, six-minute walk distance and health-related quality of life in liver transplant candidates.

Sarcopenia, or loss of skeletal muscle mass, is associated with increased mortality and morbidity in liver transplant (LT) candidates. Six‐minute walk distance (6MWD) and health‐related quality of life (HRQOL) as assessed by short form 36 scores (SF‐36) also impact clinical outcomes in these patients. This study explored the relationship between the sarcopenia, 6MWD, and HRQOL in LT candidates. Sarcopenia was evaluated based on skeletal muscle mass index (SMI) quantified from abdominal computed tomography. Patients were followed until death, removal from the wait list or the end of the study period. Two hundred and thirteen patients listed for LT were included. The mean SMI, 6MWD and mean gait speed were 54.3 ± 9.7, 370.5 m and 1 m/s, respectively. Sarcopenia was noted in 22.2% of LT candidates. There was no correlation between sarcopenia, 6MWD, and SF‐36 scores. The 6MWD, but not sarcopenia, was an independent predictor of mortality (hazard ratio = 2.1 [0.9–4.7]). In summary, sarcopenia did not emerge as a significant predictor of waitlist mortality and also failed to correlate with either functional capacity or HRQOL in LT candidates. In patients with ESLD awaiting LT, 6MWD appears to be a more useful prognostic indicator than the presence of sarcopenia.

New Onset Diabetes Mellitus in Living Donor versus Deceased Donor Liver Transplant Recipients: Analysis of the UNOS/OPTN Database

New onset diabetes after transplantation (NODAT) occurs less frequently in living donor liver transplant (LDLT) recipients than in deceased donor liver transplant (DDLT) recipients. The aim of this study was to compare the incidence and predictive factors for NODAT in LDLT versus DDLT recipients. The Organ Procurement and Transplant Network/United Network for Organ Sharing database was reviewed from 2004 to 2010, and 902 LDLT and 19,582 DDLT nondiabetic recipients were included. The overall incidence of NODAT was 12.2% at 1 year after liver transplantation. At 1, 3, and 5 years after transplant, the incidence of NODAT in LDLT recipients was 7.4, 2.1, and 2.6%, respectively, compared to 12.5, 3.4, and 1.9%, respectively, in DDLT recipients. LDLT recipients have a lower risk of NODAT compared to DDLT recipients (hazard ratio = 0.63 (0.52–0.75), P < 0.001). Predictors for NODAT in LDLT recipients were hepatitis C (HCV) and treated acute cellular rejection (ACR). Risk factors in DDLT recipients were recipient male gender, recipient age, body mass index, donor age, donor diabetes, HCV, and treated ACR. LDLT recipients have a lower incidence and fewer risk factors for NODAT compared to DDLT recipients. Early identification of risk factors will assist timely clinical interventions to prevent NODAT complications.

Osteoporosis in chronic liver disease.

Osteoporosis is a common skeletal complication seen in patients with chronic liver disease. Osteoporosis is usually asymptomatic and, if untreated, can result in fractures and impaired quality of life. For this review, we performed a systematic search of the PubMed database, and all recent peer-reviewed articles regarding the prevalence, pathophysiology, diagnosis, and management of osteoporosis in chronic liver disease were included. The prevalence of osteoporosis varies between 11% and 58% in patients with chronic liver disease and in transplant recipients. The etiology of osteoporosis is multifactorial and only partially understood. Various factors linked to the pathogenesis of bone loss are vitamin D, calcium, insulin growth factor-1, receptor activation of nuclear factor-κB ligand (RANKL), bilirubin, fibronectin, leptin, proinflammatory cytokines, and genetic polymorphisms. Management of osteoporosis involves early diagnosis, identifying and minimizing risk factors, general supportive care, nutrition therapy, and pharmacotherapy. Osteoporosis is diagnosed based on the bone mineral density (BMD) assessment using dual-energy X-ray absorptiometry scan. Measurement of BMD should be considered in all patients with advanced liver disease and in transplant recipients. Vitamin D and calcium supplementation is recommended for all patients with osteoporosis. Specific agents used for treatment of osteoporosis include bisphosphonates, calcitonin, hormonal therapy, and raloxifene. Bisphosphonates have become the mainstay of therapy for osteoporosis prevention and treatment. Prolonged suppression of bone remodeling resulting in atypical fractures has emerged as a significant complication with long-term use of bisphosphonates. Newer treatment agents and better fracture prevention strategies are necessary to prevent and treat osteoporosis.

Diaphragm disease of the small bowel: a retrospective review of CT findings.

OBJECTIVE The purpose of this article is to report the CT findings of pathologically proven diaphragm disease in the small bowel. MATERIALS AND METHODS A retrospective review identified 12 patients with pathologically proven small-bowel diaphragm disease who underwent CT within 6 months of surgical resection. Two radiologists, who were unblinded to pathologic and clinical findings, evaluated CT examinations for imaging findings of disease extent, appearance, and location. Clinical history and postoperative follow-up were also performed. RESULTS The most common presenting symptoms were abdominal pain (7/12 [58%]) and anemia (5/12 [42%]). Long-term use of nonsteroidal antiinflammatory drugs was documented in 58% (7/12) of patients. The most common location of small-bowel diaphragms was the ileum (8/12 [67%]). The CT findings were abnormal in 92% (11/12) of patients. The most common CT findings were small-bowel strictures (11/12 [92%]) and focal (median length, 1 cm) bowel wall thickening (8/12 [67%]). Other less common CT findings included mucosal hyperenhancement (6/12 [50%]), small-bowel dilatation (5/12 [42%]), and video capsule retention (6/9 [67%]). Postoperative follow-up in 11 patients found recurrent symptoms in four patients. CONCLUSION Small-bowel diaphragm disease should be considered in patients with a history of long-term use of nonsteroidal antiinflammatory drugs, chronic abdominal pain, and anemia who present with CT findings of short, symmetric ileal strictures and focal bowel wall thickening.

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.

Cholestasis Related to Systemic Disorders

A wide variety of systemic conditions can indirectly affect the liver and cause cholestasis, including infectious, hormonal, cardiac, genetic, infiltrative, and rheumatologic disorders. Hepatobiliary injury from systemic disease can occur at any anatomic level ranging from the small biliary canaliculi to large intrahepatic bile ducts, and cause a spectrum of manifestations from asymptomatic liver function test abnormalities to acute liver failure. The objective of this chapter is to review an array of systemic disorders affecting the liver and to discuss the pathophysiology, clinical presentation, diagnosis, and treatment options.

W1064 Double Balloon Enteroscopy (DBE): the Largest United States Single Center Experience

G A A b st ra ct s 76% and 79%, specificity was 36% and 33%, positive predictive value (PPV) was 16% and 18% and negative predictive value was 97% and 97%, respectively. ROC area using the short axis was significantly larger than that of the long axis (0.80 vs. 0.77, p=0.0027), suggesting that the short axis is better than the long axis for predicting metastatic status. Conclusions: LN size in rectal cancer reflects metastatic status. The short axis of LNs was a better indicator than the long axis to predict metastatic status. However, the PPV was quite low even when the criterion for nodal metastasis is set at ≥3 mm for the short axis. Table 1 the rate of metastatic disease by nodal size