Douglas Grunwald

Noninvasive markers in the assessment and management of autoimmune liver diseases.

Historically, liver biopsy has been used to determine the etiology of liver disease, the degree of inflammation, the stage of liver fibrosis, and the response to treatments. In the last decade, the advent of noninvasive tests has improved the diagnosis and management of autoimmune liver diseases. For example, serum markers can identify hepatic inflammation, whereas ultrasound and MRI can diagnose liver fibrosis. Physicians now have a much larger repertoire of diagnostic tests to assess the liver parenchyma compared with liver biopsy alone. In some rare cases, noninvasive tests may provide an alternative to liver biopsy. In general, however, these noninvasive tests complement liver biopsy and provide quick, accurate, and reliable adjunctive data.

The Effect of Right Colon Retroflexion on Adenoma Detection: A Systematic Review and Meta-analysis.

Background: Although colonoscopy with polypectomy can prevent up to 80% of colorectal cancers, a significant adenoma miss rate still exists, particularly in the right colon. Previous studies addressing right colon retroflexion have revealed discordant evidence regarding the benefit of this maneuver on adenoma detection with concomitant concerns about safety and rates of maneuver success. In this meta-analysis, we sought to determine the effect of right colon retroflexion on improving adenoma detection compared with conventional colonoscopy without retroflexion, as well as determine the rates of retroflexion maneuver success and adverse events. Methods: Multiple databases including MEDLINE, Embase, and Web of Science were searched for studies on right colon retroflexion and its impact on adenoma detection compared with conventional colonoscopy. Pooled analyses of adenoma detection and retroflexion success were based on mixed-effects and random-effects models with heterogeneity analyses. Results: Eight studies met the inclusion criteria (N=3660). The primary analysis comparing colonoscopy with right-sided retroflexion versus conventional colonoscopy to determine the per-adenoma miss rate in the right colon was 16.9% (95% confidence interval, 12.5%-22.5%). The overall rate of successful retroflexion was 91.9% (95% confidence interval, 86%-95%) and rate of adverse events was 0.03%. Conclusions: Colonoscopy with right-sided retroflexion significantly increases the detection of adenomas in the right colon compared with conventional colonoscopy with a high rate of maneuver success and small risk of adverse events. Thus, reexamination of the right colon in retroflexed view should be strongly considered in future standard of care colonoscopy guidelines for quality improvement in colon cancer prevention.

Comparison of Vascular Plugs and Pushable Coils for Variceal Embolization After TIPS.

OBJECTIVE Transjugular intrahepatic portosystemic shunt (TIPS) with variceal embolization is routinely performed to treat variceal bleeding. Embolization using vascular plugs is reported, but outcomes are not known. Outcomes and material costs of embolization using vascular plugs and coils are compared. MATERIALS AND METHODS A single centers medical records of TIPS procedures (May 2003-December 2014) with variceal embolization were reviewed. Twenty patients with vascular plug embolization (age [± SD], 50 ± 10 years; seven men and 13 women; median Model for End-Stage Liver Disease [MELD], 20; interquartile range [IQR], 14-23) were compared with an age-, sex-, and MELD-matched cohort who underwent coil embolization (age, 50 ± 9 years; seven men and 13 women; median MELD, 17; IQR, 15-19; p = 0.52). Procedure details, primary outcome (rebleeding), secondary outcome (mortality), and costs were compared. RESULTS Vascular plug use was associated with a lower fluoroscopy time (49.05 minutes [IQR, 36-62] vs 68 minutes [IQR, 49-76]; p = 0.006) and total procedure time (255 minutes [IQR, 205-290] for vascular plugs vs 275 minutes [IQR, 230-330]; p = 0.05). Total volume of contrast agent used was similar (180 mL [IQR, 155-234] for vascular plugs vs 210 mL [IQR, 185-261]; p = 0.14). In patients with at least a 30-day follow-up, rebleeding rates (2/17 [12%] for vascular plugs vs 4/15 [27%]; p = 0.40) and mortality (2/17 [12%] for vascular plugs vs 4/15 [27%]; p = 0.66) were similar. Per procedure, vascular plugs cost significantly more than coils (

Hemodynamic Variation and Intravenous Fluids Administered During ERCP and the Association With Post-ERCP Pancreatitis.

1292 ±

A Standardized Assessment of Functional Disability Predicts 1-year Mortality in Patients Undergoing Transjugular Intrahepatic Portosystemic Shunt for Refractory Ascites.

676 vs

An Analysis of Factors Predicting Successful Transition From Pancreatology Abstracts to Full Publications

228 ±

The location of obstruction predicts stent occlusion in malignant gastric outlet obstruction

292, p < 0.0001). CONCLUSION The use of vascular plugs or coils has similar outcomes for variceal embolization after TIPS. The advantages of vascular plug use (i.e., reduced fluoroscopy or procedure time) may be offset by increased material cost, a trade-off that merits further study given current cost concerns in health care.

A National Survey of the Prevalence and Impact of Cytomegalovirus Infection Among Hospitalized Patients With Ulcerative Colitis.

Objectives We sought to determine whether hypotension and the amount of intravenous (IV) fluids administered during endoscopic retrograde cholangiopancreatography (ERCP) were associated with post-ERCP pancreatitis. Methods We identified patients who developed post-ERCP pancreatitis between 2009 and 2013. Using a case-control design, we extracted baseline and intra-ERCP vital signs and the amount of IV fluids given. We used regression to analyze the association between these factors and the risk of post-ERCP pancreatitis. Results We found no association between intraprocedure hypotension (P = 0.17), bradycardia (P = 0.20), hypoxemia (P = 1.0), dehydration (P = 0.80), and post-ERCP pancreatitis. An increase in mean arterial pressure (MAP) more than 20 units from baseline (odds ratio [OR], 1.8; P = 0.03), increasing amount of IV fluids administered during ERCP (OR, 1.5; P = 0.03), female sex (OR, 2.6; P = 0.001), and younger age (OR, 1.02; P = 0.01) were associated with post-ERCP pancreatitis. In multivariate regression, female sex maintained statistical significance (P = 0.01); MAP more than 20 units from baseline (P = 0.1) and increased IV fluids (P = 0.09) showed an insignificant trend. Conclusions Hypotension during ERCP was not associated with post-ERCP pancreatitis. An increase in MAP more than 20 units from baseline and an increase in the amount of IV fluids administered during ERCP may increase the risk of post-ERCP pancreatitis.

Pseudomembranous Collagenous Colitis: A Case of Not-so-Microscopic Colitis

Goals: To determine the association between functional disability and mortality after transjugular intrahepatic portosystemic shunt (TIPS). Background: TIPS is a common therapeutic procedure for cirrhotic patients with refractory ascites. The conventional metric for periprocedure risk stratification is the model for end-stage liver disease (MELD), which uses biochemical parameters to predict post-TIPS mortality. It does not account for functional disability. Study: This is a retrospective cohort study of 83 patients admitted at an academic liver transplant center with cirrhosis and refractory ascites for the purpose of TIPS placement. We assessed the association of patients’ reported activities of daily living (ADL) on a scale of 1 to 21 before TIPS with a primary outcome of 1-year mortality. Multivariable regression to adjust for MELD and Child class was performed. Results: A higher ADL score or functional independence, was associated with decreased 1-year mortality when modeled as both a continuous variable [odds ratio (OR), 0.80; 95% confidence interval (CI), 0.66-0.97; P=0.02) and a dichotomous variable (ADL 21 vs. <21; OR, 0.21; 95% CI, 0.05-0.70; P=0.01). After adjusting for MELD and Child class, functional independence was associated with decreased 1-year transplant-free mortality (OR, 0.22; 95% CI, 0.05-0.77; P=0.02). An ADL score consistent with dependence (<21) was significantly associated with a 3.40-day (95% CI, 1.76-5.04) longer hospital stay, adjusting for MELD and Child class (P<0.0001). Conclusions: Functional disability is a predictor of post-TIPS mortality and length of stay after controlling for MELD.

Endoscopic Image After Subselective Embolization of a Bleeding Colonic Diverticulum.

Objectives Historically, less than half of peer-reviewed abstracts are published. We set out to determine how many pancreas-related abstracts are published within 5 years of presentation at gastroenterology conferences and to determine a model that predicts successful transition from abstract to journal publication. Methods We collected data on study design from all pancreas-related abstracts at the 2010 Digestive Disease Week (DDW), American College of Gastroenterology, and American Pancreatic Association conferences. We then determined whether an abstract was published by October 2015 using a standardized search algorithm. Results Of 412 abstracts, 39.8% were published. Studies that were of basic science or translational design (P = 0.02, 0.01, respectively); had more listed authors (P = 0.05); employed randomized, prospective, and multicenter methodology (P = 0.02); and were accepted to DDW (P = 0.02) were more likely to be published. After regression, basic/translational studies (P = 0.002, 0.02, respectively) and DDW-accepted abstracts (P = 0.004) continued to predict successful publication. Conclusions It is not clear why only 40% of the pancreas abstracts from 2010 were published 5 years later. Some abstracts may go unpublished because of methodological flaws that escape detection during abstract peer review. Therefore, physicians should use caution when applying abstract data to their clinical decision making.