Ari Garber

Post‐liver transplantation sarcopenia in cirrhosis: A prospective evaluation

Pre‐transplant sarcopenia (reduced skeletal muscle mass) predicts poor outcome in cirrhosis. In contrast, whether muscle mass increases post‐orthotopic liver transplantation (OLT) is not known and was studied prospectively.

Impact of Single- vs. Split-Dose Low-Volume Bowel Preparations on Bowel Movement Kinetics, Patient Inconvenience, and Polyp Detection: A Prospective Trial.

OBJECTIVES:There are little data on bowel movement (BM) kinetics induced by bowel preparation. Whether single-dose (SID) or split-dose (SPD) regimens differ in terms of patient convenience is unclear. We compared BM kinetics, sleep and travel disruptions, and polyp detection rates in patients undergoing colonoscopy assigned to SID vs. SPDs.METHODS:Patients were randomly assigned to 2-L SID or SPD (SPD1 and SPD2) bowel preparations. Surveys were completed querying the onset, duration, cessation, and intensity of BMs, along with sleep and travel disruption en route to the endoscopy center. Colon cleansing quality and polyp histology were recorded.RESULTS:A total of 341 patients were enrolled, 51% in SPD and 49% in SID. Over half of patients had their first BM within 60 min of starting the preparation. After dosing, 92% of SID and 66% of SPD1 patients achieved clear effluent (P<0.001), whereas it was reported in 97% of SPD2 patients (P=0.028 vs. SID). Total duration (P=0.041) and intensity (P<0.001) of BMs were greater in SID. More patients in SID woke up for BMs (65.9 vs. 48.8%, P<0.003). No differences in the need to stop driving en route to colonoscopy were noted. Bowel prep quality was better in SPD (P<0.001). Although no difference in the adenoma detection rate was noted, the sessile-serrated polyp detection rate was greater in SPD than in SID (9.9 vs. 2.4%, P=0.004).CONCLUSIONS:Our data demonstrate that SPD bowel preparation results in decreased intensity and duration of BMs, less patient inconvenience, improved bowel preparation, and increased sessile-serrated polyp detection rates.

Donor IFNL4 Genotype Is Associated with Early Post-Transplant Fibrosis in Recipients with Hepatitis C

Background and Aims Early post-transplant hepatic fibrosis is associated with poor outcomes and may be influenced by donor/recipient genetic factors. The rs368234815 IFNL4 polymorphism is related to the previously described IL28B polymorphism, which predicts etiology-independent hepatic fibrosis. The aim of this study was to identify the impact of donor and/or recipient IFNL4 genotype on early fibrosis among patients transplanted for hepatitis C (HCV). Methods Clinical data were collected for 302 consecutive patients transplanted for HCV. 116 patients who had available liver biopsies and donor/recipient DNA were included. 28% of these patients with stage 2 fibrosis or greater were compared to patients without significant post-transplant fibrosis with respect to clinical features as well as donor/recipient IFNL4 genotype. Results The IFNL4 TT/TT genotype was found in 26.0% of recipients and 38.6% of donors. Patients who developed early post-transplant fibrosis had a 3.45 adjusted odds of having donor IFNL4 TT/TT genotype (p = 0.012). Donor IFNL4 TT/TT genotype also predicted decreased overall survival compared to non-TT/TT genotypes (p = 0.016). Conclusions Donor IFNL4 TT/TT genotype, a favorable predictor of spontaneous HCV clearance pre-transplant, is associated with increased early post-transplant fibrosis and decreased survival.

Novel Therapeutic Strategies in the Management of Non-Variceal Upper Gastrointestinal Bleeding

Non-variceal upper gastrointestinal bleeding, the most common etiology of which is peptic ulcer disease, remains a persistent challenge despite a reduction in both its incidence and mortality. Both pharmacologic and endoscopic techniques have been developed to achieve hemostasis, with varying degrees of success. Among the pharmacologic therapies, proton pump inhibitors remain the mainstay of treatment, as they reduce the risk of rebleeding and requirement for recurrent endoscopic evaluation. Tranexamic acid, a derivative of the amino acid lysine, is an antifibrinolytic agent whose role requires further investigation before application. Endoscopically delivered pharmacotherapy, including Hemospray (Cook Medical), EndoClot (EndoClot Plus Inc.), and Ankaferd Blood Stopper (Ankaferd Health Products), in addition to standard epinephrine, show promise in this regard, although their mechanisms of action require further investigation. Non-pharmacologic endoscopic techniques use one of the following two methods to achieve hemostasis: ablation or mechanical tamponade, which may involve using endoscopic clips, cautery, argon plasma coagulation, over-the-scope clipping devices, radiofrequency ablation, and cryotherapy. This review aimed to highlight these novel and fundamental hemostatic strategies and the research supporting their efficacy.

Mechanisms and Management of Acute Pancreatitis

Acute pancreatitis represents a disorder characterized by acute necroinflammatory changes of the pancreas and is histologically characterized by acinar cell destruction. Diagnosed clinically with the Revised Atlanta Criteria, and with alcohol and cholelithiasis/choledocholithiasis as the two most prominent antecedents, acute pancreatitis ranks first amongst gastrointestinal diagnoses requiring admission and 21st amongst all diagnoses requiring hospitalization with estimated costs approximating 2.6 billion dollars annually. Complications arising from acute pancreatitis follow a progression from pancreatic/peripancreatic fluid collections to pseudocysts and from pancreatic/peripancreatic necrosis to walled-off necrosis that typically occur over the course of a 4-week interval. Treatment relies heavily on fluid resuscitation and nutrition with advanced endoscopic techniques and cholecystectomy utilized in the setting of gallstone pancreatitis. When necessity dictates a drainage procedure (persistent abdominal pain, gastric or duodenal outlet obstruction, biliary obstruction, and infection), an endoscopic ultrasound with advanced endoscopic techniques and technology rather than surgical intervention is increasingly being utilized to manage symptomatic pseudocysts and walled-off pancreatic necrosis by performing a cystogastrostomy.

Risk factors for Barrett's esophagus

Barretts esophagus (BE) is a well‐recognized precursor of esophageal adenocarcinoma (EAC) and is defined as ≥1 cm segment of salmon‐colored mucosa extending above the gastroesophageal junction into the tubular esophagus with biopsy confirmation of metaplastic replacement of the normal squamous epithelium by intestinal‐type columnar epithelium. The incidence of both BE and EAC has been increasing over the past few decades. As a result, preventing the development of BE by identifying and understanding its modifiable and non‐modifiable risk factors may help reduce the incidence of EAC. Over the recent past, a tremendous amount of progress has been made towards improving our knowledge of risk factors and pathogenesis of BE. This article reviews the evidence for the various risk factors for developing BE.

Gallstones: Watch and wait, or intervene?

Gallstones are common in the United States, affecting an estimated 1 in 7 adults. Fortunately, they are asymptomatic in up to 80% of cases, and current guidelines do not recommend cholecystectomy unless they cause symptoms. Laparoscopic cholecystectomy is the standard treatment for symptomatic gallstones, acute cholecystitis, and gallstone pancreatitis. Consider laparoscopic cholecystectomy for symptomatic cholelithiasis, expectant management for asymptomatic cases.

Resident-Led Handoffs Training for Interns: Online Versus Live Instruction with Subsequent Skills Assessment

AAIM is the largest academically focused specialty organization representing departments of internal medicine at medical schools and teaching hospitals in the United States and Canada. As a consortium of five organizations, AAIM represents department chairs and chiefs; clerkship, residency, and fellowship program directors; division chiefs; and academic and business administrators as well as other faculty and staff in departments of internal medicine and their divisions.

Extraosseous Calcification of the Esophagus: Clinicopathologic Correlates of Esophageal Mucosal Calcinosis

Esophageal mucosal calcinosis (EMC) is a rare cause of dysphagia with high morbidity. We present a patient who experienced melena and 3 months of solid and liquid dysphagia along with bilateral lower extremity pain, erythema, and edema later determined to be calcific uremic arteriolopathy (CUA), or calciphylaxis. An esophagogastroduodenoscopy revealed nodularity and linear ulcerations in the upper third of the esophagus. Histology showed active inflammation and ulceration with small foci of subepithelial and intraepithelial calcification consistent with EMC. There is no known treatment for this disorder. Sodium thiosulfate, typically used to treat CUA, did not improve her dysphagia.