Chaitanya Allamneni

Orthotopic liver transplantation changes the course of gastric antral vascular ectasia: a case series from a transplant center

Background and aim Gastric antral vascular ectasia (GAVE) is an important cause of upper gastrointestinal bleeding and anemia in patients with cirrhosis. The aim of our study was to evaluate the effect of orthotopic liver transplantation (OLT) on GAVE and associated anemia. Patients and methods We performed a chart review and identified all cirrhotic patients with GAVE who underwent OLT at the University Of Alabama at Birmingham between 2005 and 2013. Population’s demographics, etiology of cirrhosis, comorbidities, presentation and treatment modalities of GAVE, endoscopic and histopathologic reports, hemoglobin values before and after transplant, and immunosuppressive regimens were collected. Results Twelve patients were identified, mean age 52.4±4.4 years; seven were men (58.3%); 11 (91.7%) were White; and 6 of 12 patients had biopsy-proven GAVE. The most common etiology of cirrhosis in the cohort was chronic hepatitis C and obesity was the most common chronic condition in 50 and 83.3%, respectively. Anemia resolution was observed in 9/12 (75%) patients who underwent OLT with an increase in hemoglobin from 8.1±2.4 (5.7–13.1) before transplant to 12.0±1.4 (10–15) after transplant (P<0.0001). Esophagogastroduodenoscopy after transplant was performed in all 12 (100%) patients. The mean time between transplant and post-OLT esophagogastroduodenoscopy was 13.8±18.28 (2–57) months; complete resolution of GAVE was observed in 10 (83.3%) patients, with resolving GAVE in one (8.3%) patient. Conclusion GAVE is an important cause of anemia and upper gastrointestinal bleeding in patients with liver cirrhosis. Our findings show that liver transplantation can resolve GAVE and related anemia.

Over-the-scope clip to close bleeding pancreaticoduodenal fistula

re 1. A, CT of the abdomen/pelvis with severe acute pancreatitis, with several peripancreatic gas-containing fluid collections, and periduodenal fluid ctions with air within the collection, suggesting fistula. Decreased pancreatic parenchymal enhancement suggesting pancreatic necrosis; also seen are iple calcifications within the pancreatic head consistent with chronic pancreatitis. B, C, Initial EGD with no bleeding source identified in the esophstomach, or duodenum. B, Normal second part of the duodenum on EGD, with Dobhoff tube visualized. C, Colonoscopic view was also unremarkwith only small internal hemorrhoids visualized. D, E, Repeated EGD after hematochezia revealed a blood clot (D), thought to be overlying the r papilla, at the duodenal sweep. E, Placement of 2 endoclips proximal to the bleeding lesion for further endoscopic versus interventional radiology s. F, EUS view showing no evidence of pancreatic divisum with an anatomically normal pancreatic duct. G, Major and minor papilla visualized on ated endoscopy. The blood clot thought to be overlying the minor papilla was in fact visualized at a separate location. H, Deployment of over-thee “bear claw” clip to close bleeding fistula.

Bleeding at Roux-en-Y jejunojejunal anastomosis after orthotopic liver transplantation

A 14-year-old girl with a medical history of primary sclerosing cholangitis/autoimmune hepatitis overlap syndrome diagnosed at age 2, complicated by decompensated cirrhosis, underwent orthotopic liver transplantation (OLT). During OLT she underwent a standard Roux-en-Y hepaticojejunostomy in which the Roux limb was created by dividing the jejunum downstream from the ligament of Treitz. Twenty-four hours after OLT, she experienced hematochezia and acute anemia, raising concern for a luminal bleed as an adverse event of hepaticojejunostomy formation. She was subsequently referred for double-balloon enteroscopy (Video 1, available online at www.VideoGIE.org). On anterior double-balloon enteroscopy, blood was visualized in the stomach, duodenum, and entire visualized jejunum. The jejunojejunal anastomosis was patent, with healthy-appearing mucosa, and an intact staple line with

Socioeconomic Status and Race are both Independently associated with Increased Hospitalization Rate among Crohn’s Disease Patients

Racial disparities are observed clinically in Crohn’s Disease (CD) with research suggesting African Americans (AA) have worse outcomes than Caucasian Americans (CA). The aim of this study is to assess whether socioeconomic status (SES) rather than race is the major predictor of worse outcomes. We designed a retrospective cohort study of 944 CD patients seen at our center. Patients’ billing zip codes were collected and average income and percent of population living above or below poverty level (PL) for each zip code calculated. Patients were separated by quartiles using average state income level and federal PL. Demographics and hospitalization rates were collected. Poison regression models estimated incidence rate ratios (IRR) for CD-related hospitalizations. Incidence rate (IR) of hospitalization per 100-person years for the lowest income group was 118 (CI 91.4–152.3), highest income group was 29 (CI 21.7–38.9), Above PL was 26.9 (25.9–28.9), Below PL was 35.9 (33.1–38.9), CA was 25.3 (23.7–27), and AA was 51.4 (46.8–56.3). IRR for a CD-related hospitalization for lowest income group was 2.01 (CI 1.34–3.01), for Below PL was 1.26 (CI 1.12–1.42), and for AAs was 1.88 (CI 1.66–2.12). SES and race are both associated with hospitalization among CD patients and need further investigation.

Comparative Effectiveness of Vedolizumab vs. Infliximab Induction Therapy in Ulcerative Colitis: Experience of a Real-World Cohort at a Tertiary Inflammatory Bowel Disease Center

Background Vedolizumab (VDZ), an adhesion molecule inhibitor and infliximab (IFX), a tumor necrosis factor (TNF) blocker, are both approved as first-line induction agents in moderately to severely active ulcerative colitis (UC). However, there are no head-to-head studies comparing the relative effectiveness of the two agents. Here we provide a real-world comparison of these two agents. Methods We conducted an ambidirectional cohort study of adult UC patients seen at our tertiary inflammatory bowel disease (IBD) center from 2012 to 2017. Each patient had moderately to severely active UC via partial Mayo score and was induced with IFX or VDZ. They were followed until assessment of clinical response. Poisson regression was used to calculate clinical response rates and rate ratios. Results Of 59 patients who met inclusion criteria, 27 and 32 patients were induced with IFX and VDZ, respectively. Totally, 18/27 (66.7%) patients induced with IFX vs. 24/32 (78.1%) patients induced with VDZ were clinical responders. Response rates per 100 person-weeks (PW) were similar for VDZ (5.21) and IFX (5.38). The effectiveness in terms of induction of clinical response (incidence rate ratio, IRR) was not statistically significant for VDZ vs. IFX (IRR 0.97, 95% confidence interval (CI) 0.53 - 1.77). Among TNF blocker naive patients, IRR was also not statistically significant between VDZ (6.74/100 PW) and IFX (6.48/100 PW) (IRR 1.04, 95% CI 0.47 - 2.29). Among TNF blocker experienced patients, there was a higher response rate for VDZ (4.52) vs. IFX (2.29) per 100 PW, but the IRR did not reveal statistical significance (IRR 1.97, 95% CI 0.45 - 8.63) due to small sample size of TNF blocker experienced patients who received IFX. Five patients developed severe infection or adverse reaction during IFX induction requiring exclusion, whereas no VDZ patients were excluded for this reason. Conclusions Our study revealed a higher proportion of patients who responded to VDZ vs. IFX; however when accounting for period between induction and assessment of clinical response, rates of clinical response were similar. A key difference between the two groups was the higher response rate in the VDZ group among TNF blocker experienced patients; however, a larger cohort is needed to further elaborate on this difference. VDZ held its own against IFX and this study strengthens its standing as a first-line agent among TNF blocker naive as well as TNF blocker experienced UC patients.

Length of Barrett’s segment predicts failure of eradication in radiofrequency ablation for Barrett’s esophagus: a retrospective cohort study

BackgroundWe aim to investigate factors that may contribute to failure of eradication of dysplastic Barrett’s Esophagus among patients undergoing radiofrequency ablation treatment.MethodsA retrospective review of patients undergoing radiofrequency ablation for treatment of Barrett’s Esophagus was performed. Data analyzed included patient demographics, medical history, length of Barrett’s Esophagus, number of radiofrequency ablation sessions, and histopathology. Subsets of patients achieving complete eradication were compared with those not achieving complete eradication.ResultsA total of 107 patients underwent radiofrequency ablation for Barrett’s Esophagus, the majority white, overweight, and male. Before treatment, 63 patients had low-grade dysplasia, and 44 patients had high-grade dysplasia or carcinoma. Complete eradication was achieved in a majority of patients (57% for metaplasia, and 76.6% for dysplasia). Failure of eradication occurred in 15.7% of patients. The median number of radiofrequency ablation treatments in patients achieving complete eradication was 3 sessions, compared to 4 sessions for failure of eradication (pu2009=u20090.06). Barrett’s esophagus length of more than 5xa0cm was predictive of failure of eradication (pu2009<u20090.001).ConclusionsRadiofrequency ablation for dysplastic Barrett’s Esophagus is a proven and effective treatment modality, associated with a high rate of complete eradication. Our rates of eradication from a center starting an ablation program are comparable to previously published studies. Length of Barrett’s segment >u20095xa0cm was found to be predictive of failure of eradication in patients undergoing radiofrequency ablation.

Flexible endoscopic management of Zenker’s diverticulum

re 1. A, Barium esophagram revealing ZD and a prominent CP. B, Landmark triad of ZD to the left, a prominent cricopharyngeus (CP bar) in the le, and the esophagus with nasogastric tube to the right. C, Needle-knife used to initially incise through prominent cricopharyngeus.D,Muscle fibers icopharyngeus visible after incision with the needle-knife. E, Ceramic ball insulated tip knife, which allows more controlled cutting, in use. rough-the-scope clips applied at base of diverticulum after cricopharyngeal incision to close any potential defects. G, Barium esophagram after omy revealing a small residual ZD. Intubation was also notably easier after myotomy. ZD, Zenker’s diverticulum; CP, cricopharyngeal muscle.