Edward W. Holt

Long-term clinical outcomes after endoscopic minor papilla therapy in symptomatic patients with pancreas divisum.

Objectives: To assess the long-term outcomes of endoscopic minor papilla therapy in a spectrum of symptomatic patients with pancreas divisum. Methods: Patients with pancreas divisum coded in a prospective database as having had minor papilla endotherapy (July 1997-May 2003, n = 145) were grouped into 3 categories: (1) acute recurrent pancreatitis, (2) chronic pancreatitis, and (3) chronic/recurrent epigastric pain. Telephone follow-up was conducted (78% of patients), including quesions regarding interval co-interventions and narcotic use. Primary success was defined as clinical improvement (better or cured on a Likert scale), without needing narcotics, after 1 therapeutic endoscopic retrograde cholangiopancreatography. Fisher exact and Mann-Whitney U tests and multivariate logistic regression were used to identify predictors of success. Results: Primary success rates in acute recurrent pancreatitis, chronic pancreatitis, and chronic/recurrent epigastric pain were achieved in 53.2%, 18.2%, and 41.4%, respectively; and secondary success rates (≤2 additional endoscopic retrograde cholangiopancreatographies), 71.0%, 45.5%, and 55.2%, respectively (median follow-up, 43.0 months; range, 14-116 months). Younger age (median age, 46.5 years [no success] vs 58.0 years [success]; P < 0.0001) and chronic pancreatitis (odds ratio, 0.10; 95% confidence interval, 0.03-0.39; P = 0.001) independently predicted a lower chance of success. Conclusions: Significant long-term improvement can be achieved with endoscopic therapy in selected patients with pancreas divisum, although many require multiple procedures. Older patients, without chronic pancreatitis, were most likely to respond.

Concurrent Obesity, Diabetes, and Steatosis Increase Risk of Advanced Fibrosis Among HCV Patients: A Systematic Review.

BackgroundRising rates of obesity, diabetes mellitus (DM), and nonalcoholic fatty liver disease among patients with chronic hepatitis C virus infection (HCV) may contribute to more rapid disease progression.AimTo evaluate the impact of concurrent obesity, DM, and steatosis on disease progression among HCV patients.MethodsA systematic review using structured keyword search of MEDLINE and EMBASE from January 1, 2001, to July 1, 2014, was performed to identify original articles evaluating the association of obesity, DM, and steatosis with advanced fibrosis (AF) among adults with chronic HCV. Studies involving HCV patients coinfected with human immunodeficiency virus, hepatitis B virus, hepatocellular carcinoma, or other chronic liver diseases were excluded. Quality assessment utilized Newcastle–Ottawa Scale.ResultsTwenty cohort studies met inclusion criteria for analyses. Obesity was associated with increased risk of AF in seven studies with effect size ranging from OR 1.08 to 7.69. However, four studies did not demonstrate a significant association between obesity and AF. The presence of advanced steatosis among HCV patients was associated with increased risk of AF in 12 studies (OR 1.80–14.3). Concurrent DM was associated with increased risk of AF in six studies (OR 2.25–9.24). Thirteen studies were good quality, and seven studies were fair quality.ConclusionConcurrent DM and steatosis are associated with increased risk of AF among chronic HCV patients. The majority of studies demonstrated significant associations of obesity with AF. Targeted interventions to optimize management of obesity-related diseases among HCV patients may help mitigate HCV disease progression.

Successful single-session endosonography-based endoscopic retrograde cholangiopancreatography without fluoroscopy in pregnant patients with suspected choledocholithiasis: a case series

Same session endosonography (EUS) immediately prior to scheduled endoscopic retrograde cholangiopancreatography (ERCP) may eliminate the need for ERCP and its associated risks in pregnant patients with no evidence of choledocholithiasis on EUS. In patients with choledocholithiasis, EUS provides information regarding the location, size and number of stones present, which helps guide biliary interventions and confirm stone clearance without the use of fluoroscopy.

Low skin carotenoid concentration measured by resonance Raman spectroscopy is associated with metabolic syndrome in adults

Oxidative stress is increased in patients with metabolic syndrome (MS). Antioxidants, including carotenoids, are decreased in MS. We hypothesized that a low skin carotenoid score (SCS), calculated using resonance Raman spectroscopy, would correlate with the presence of MS. We retrospectively reviewed consecutive patients referred for dietary assessment between 2010 and 2012. For each patient, a nutrition history, medical history, and SCS were recorded. χ(2) and Student t test were used to determine factors associated with MS. Multivariate logistic regression was used to identify factors associated with MS. One hundred fifty-five patients were included. The mean age was 54.1 ± 13.1 years, and the mean body mass index was 28.3 ± 6.1 kg/m(2). Metabolic syndrome was present in 43.9% of patients. The mean SCS was 28 084 ± 14 006 Raman counts (RC), including 23 058 ± 9812 RC for patients with MS and 32 011 ± 15 514 RC for patients without MS (P = .0001). In a multivariate analysis, SCS less than 25 000 RC (odds ratio, 3.71; 95% confidence interval, 1.36-10.7; P = .01) was independently associated with MS. A higher number of MS components was associated with a progressively lower SCS (P = .004). In a consecutive sample of patients referred for dietary assessment, a noninvasively measured SCS was lower among patients with MS.

Acute liver failure caused by herpes simplex virus in a pregnant patient: Is there a potential role for therapeutic plasma exchange?

A young woman presented with a febrile illness in the third trimester of pregnancy. Laboratory investigation revealed severe acute hepatitis with thrombocytopenia and coagulopathy. Liver injury progressed despite emergent caesarian section and delivery of a healthy infant. Therefore, therapeutic plasma exchange (TPE) was performed on three consecutive days post‐partum for a presumed diagnosis of acute liver failure (ALF) associated with pregnancy due to hemolysis, elevated liver enzymes, and low platelets (HELLP) or acute fatty liver of pregnancy (AFLP). Treatment with TPE was followed by biochemical and clinical improvement but during her recovery herpes simplex virus type 2 (HSV‐2) infection was diagnosed serologically and confirmed histologically. Changes in the immune system during pregnancy make pregnant patients more susceptible to acute HSV hepatitis, HSV‐related ALF, and death. The disease is characterized by massive hepatic inflammation with hepatocyte necrosis, mediated by both direct viral cytotoxicity and the innate humoral immune response. TPE may have a therapeutic role in acute inflammatory disorders such as HSV hepatitis by reducing viral load and attenuating systemic inflammation and liver cell injury. Further investigation is needed to clarify this potential effect. The roles of vigilance, clinical suspicion, and currently accepted therapies are emphasized. J. Clin. Apheresis, 28:426–429, 2013.

Impact of obesity and diabetes on waitlist survival, probability of liver transplantation and post-transplant survival among chronic hepatitis C virus patients

The rising prevalence of obesity and diabetes mellitus (DM) among hepatitis C virus (HCV) patients contributes to concurrent nonalcoholic fatty liver disease (NAFLD). We aim to evaluate the impact of concurrent obesity or DM on waitlist survival and probability of liver transplantation (LT) among adults with chronic HCV awaiting LT.

Acute Liver Failure Due to Acetaminophen Poisoning in Patients With Prior Weight Loss Surgery: A Case Series.

Goals: To identify an association between prior weight loss surgery (WLS) and acetaminophen-induced acute liver failure (ALF). Background: WLS, which has increased in proportion to the global rise of obesity, alters the absorption and metabolism of many drugs including acetaminophen (APAP) and may predispose to toxicity. No study has identified an association between prior WLS and APAP-ALF. Study: We retrospectively reviewed a cohort of patients who presented to our center with ALF. We identified 101 patients who presented to our center with ALF between January 2009 and December 2011. All patients were prospectively enrolled into a database using consensus criteria. A history of WLS was obtained through a retrospective chart review. Results: Fifty-four patients (53.5%) had APAP-ALF and 47 (46.5%) had ALF caused by other etiologies. A prior history of WLS was present in 9 of the 54 patients with APAP-ALF versus 0 of the 47 with non-APAP-ALF (P=0.003). Patients with APAP-ALF and prior WLS did not have higher rates of factors commonly associated with APAP overdose, including depression, alcohol abuse, intent to cause self-harm, or use of APAP-narcotic combination drugs. Conclusions: A history of WLS may predispose to hepatotoxicity and ALF caused by acetaminophen.

Improving the quality of bowel preparation: one step closer to the holy grail?

Colonoscopy is associated with a reduction in colorectal cancer (CRC) incidence and mortality [1], although this association may be limited to cancers arising in the distal colon [2]. Recently, a prospective randomized controlled trial showed that flexible sigmoidoscopy reduces CRC mortality [3], but a comparable prospective randomized trial for colonoscopy is currently in phase III and will not be completed until 2036 [4]. Nevertheless, the American Cancer Society and the US Preventive Services Task Force recommend screening colonoscopy every 10 years starting at age 50 for patients with average risk of CRC. Likewise, Medicare has covered a majority of the costs of this screening procedure since 2001 for patients at average risk. The molecular basis for the adenoma–carcinoma sequence in CRC is well described [5]. More recently it was proposed that a genetic pathway characterized by microsatellite instability (MSI) accounts for a number of sporadic CRC [6]. Many of these lesions arise from nonpolypoid lesions in the proximal colon [7]. Although proximal cancers occur less frequently than distal ones, they may more frequently result from a missed precursor lesion at colonoscopy, as an association between interval cancers and both the presence of MSI and proximal location has been reported [8]. This evidence represents a significant challenge to colonoscopists. Distal CRC represents the low-hanging fruit, so to speak, in that its precursor lesions are more numerous, more polypoid and reachable with a shorter, cheaper and safer procedure. Removal of a sufficient number of precursor lesions to significantly reduce mortality from proximal CRC may require a more consistent level of training and expertise than is currently reported in the literature. In some of the retrospective trials that failed to show a reduction in CRC mortality from proximal lesions removed at colonoscopy, gastroenterologists comprised a minority of the colonoscopists [2]. In an effort to further lower CRC mortality, many approaches to quality improvement in colonoscopy have been proposed including standards for withdrawal time, withdrawal technique, operator experience, optical enhancement and measurement of adenoma detection rate. However, none of these quality standards will succeed if the colonoscopist cannot consistently visualize an adequate amount of the colonic mucosa. In the end, the quality of the bowel preparation may determine whether screening colonoscopy, rather than flexible sigmoidoscopy, continues to be so universally recommended and reimbursed. It remains to be seen how to best administer bowel preparation before colonoscopy so that the colonoscopist has greatest opportunity to reduce CRC mortality. We have known for decades that both polyethylene glycol (PEG) and bile take approximately 1 h to reach the cecum [9, 10]. It is the goal of a bowel preparation, then, to deliver a sufficient quantity of fluid to the cecum to cleanse the entire colon, allow enough time for the cleansing agent to pass completely through the colon, but not wait so long that the proximal colon is again coated in a film of bilious secretions. With respect to the latter two goals, timing is everything. There have been a number of recent studies, including the present one, which investigated the relationship between timing and quality of bowel preparation [11–18]. In this issue of Digestive Diseases and Sciences, Eun et al. [11] draw an association between the quality of bowel preparation and the interval between the time of last PEG intake and the start of colonoscopy. In this single-center E. W. Holt (&) M. S. Verhille California Pacific Medical Center, San Francisco, CA, USA e-mail: edholt@gmail.com

Race/ethnicity is an independent risk factor for autoimmune hepatitis among the San Francisco underserved

Abstract Although autoimmune hepatitis (AIH) is more common in women and affects people of all races/ethnicities, there is currently limited information regarding the relationship between race/ethnicity and AIH, especially in the context of underserved populations. We aim to evaluate the relationship between race/ethnicity and AIH and better characterize its clinical features among different racial groups. We conducted a 15-year retrospective analysis, from January 2002 to June 2017, of patients seen at Zuckerberg San Francisco General Hospital (ZSFG). Sixty-three AIH patients and 2049 non-AIH controls were eligible for the study. The main predictor of interest was race/ethnicity, and the main outcome of interest was AIH diagnosis; other secondary measures recorded include clinical features such as ALT, bilirubin, and biopsy fibrosis at presentation. In a multivariable model adjusting for age and sex, we found that black (OR 9.6, 95% CI 1.8–178), Latino (OR 25.0, 95% CI 5.3–448), and Asian/Pacific Islander (API) (OR 10.8, 95% CI 2.2–196) race/ethnicity were associated with increased odds of an AIH diagnosis compared to the white reference group. Among people of colour with AIH, there were no significant differences in baseline ALT (p = .45), total bilirubin at presentation (p = .06), fibrosis at presentation (p = .74), and hospitalization (p = .27). Race/ethnicity is an independent risk factor for AIH. The clinical features of AIH did not differ significantly among black, Latino, and API patients.

Su1046 Early-Onset Colorectal Cancer Is Independently Associated With Shorter Overall Survival

BACKGROUND: Colorectal cancer (CRC) is the third most common cancer, as well as the third most common cause of cancer deaths in the United States. Bisphosphonates are antiresorptive agents widely used in treating and preventing osteoporosis. Several large studies have recently reported a reduced risk of CRC with bisphosphonate use, however no meta-analysis on the subject exists. AIM: We aimed to conduct a meta-analysis of existing observational studies and thus provide a quantitative estimate of the association between bisphosphonate use and the risk of CRC. METHODS: We followed the Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines in performing our systematic review. A search was conducted through Medline, PubMed, Embase, and Current