Erik Rahimi

Systematic review of randomized controlled trials of probiotics, prebiotics, and synbiotics in inflammatory bowel disease

Background Probiotics are microorganisms that are ingested either in combination or as a single organism in an effort to normalize intestinal microbiota and potentially improve intestinal barrier function. Recent evidence has suggested that inflammatory bowel disease (IBD) may result from an inappropriate immunologic response to intestinal bacteria and a disruption in the balance of the gastrointestinal microbiota in genetically susceptible individuals. Prebiotics, synbiotics, and probiotics have all been studied with growing interest as adjuncts to standard therapies for IBD. In general, probiotics have been shown to be well-tolerated with few side effects, making them a potential attractive treatment option in the management of IBD. Aim To perform a systematic review of randomized controlled trials on the use of probiotics, prebiotics, and synbiotics in IBD. Results In our systematic review we found 14 studies in patients with Crohn’s disease (CD), 21 studies in patients with ulcerative colitis (UC), and five studies in patients with pouchitis. These were randomized controlled trials using probiotics, prebiotics, and/or synbiotics. In patients with CD, multiple studies comparing probiotics and placebo showed no significant difference in clinical outcomes. Adding a probiotic to conventional treatment improved the overall induction of remission rates among patients with UC. There was also a similar benefit in maintaining remission in UC. Probiotics have also shown some efficacy in the treatment of pouchitis after antibiotic-induced remission. Conclusions To date, there is insufficient data to recommend probiotics for use in CD. There is evidence to support the use of probiotics for induction and maintenance of remission in UC and pouchitis. Future quality studies are needed to confirm whether probiotics, prebiotics, and synbiotics have a definite role in induction or maintenance of remission in CD, UC, and pouchitis. Similar to probiotics, fecal microbiota transplantation provides an alternate modality of therapy to treat IBD by influencing the intestinal flora.

Prognostic models for alcoholic hepatitis

Alcoholic hepatitis (AH) is caused by acute inflammation of the liver in patients that consume excessive amounts of alcohol, usually in a background of cirrhosis. AH can range from mild to severe, life threatening disease with a high rate of short and long-term mortality. Prognostic models have been used to estimate mortality in order to identify those that may benefit from corticosteroids or pentoxifylline. This review focuses on the different prognostic models proposed. While limitations of the prognostic models exist, combining models may be beneficial in order to identify responders to therapy versus non-responders.

Endoscopic ultrasound elastography to diagnose sarcoidosis.

10.4103/2303-9027.183972 A 54-year-old man presented with a 3-month history of sharp intermittent lower abdominal pain along with decreased oral intake, nausea, and a 13.6 kg weight loss. Laboratory results were significant for normocytic anemia (hemoglobin-12.7 g/dL) and hypercalcemia (serum calcium-12.2 mg/dL). Abdominal ultrasound showed a well-defined heterogeneous complex solid mass at the level of the pancreatic head measuring 4.6 cm × 3 cm × 4 cm in size. Subsequently, a computed tomography (CT) abdomen/pelvis was obtained showing lymphadenopathy in the portacaval lymph node chain (5.7 cm × 4.2 cm × 6.4 cm), peripancreatic lymph node chain anterior to the pancreatic head (5.2 cm × 3.8 cm × 5.6 cm), and within the porta hepatis lymph node chain (2.1 cm × 1.4 cm × 2.2 cm) [Figure 1]. Further, blood workup showed an angiotensin-converting enzyme (ACE) level of 144 unit/L (range 8-52 unit/L), and serum protein electrophoresis showed prominent polyclonal hypergammaglobulinemia.

Use of quantitative endoscopic ultrasound elastography for diagnosis of pancreatic neuroendocrine tumors

How to cite this article: Nemakayala D, Patel P, Rahimi E, Fallon MB, Thosani N. Use of quantitative endoscopic ultrasound elastography for diagnosis of pancreatic neuroendocrine tumors. Endosc Ultrasound 2016;5:342-5. A 63-year-old man with a history of chronic hepatitis C and lung cancer presented for further evaluation of a pancreatic mass found during imaging surveillance of a complex hepatic cyst. Magnetic resonance imaging (MRI) of the abdomen showed a 16 mm × 13 mm T2-weighted hypointense, arterially enhancing lesion within the distal pancreatic body [Figure 1]. Endoscopic ultrasound (EUS), using Pentax EG-3630U endoscope (Montvale, NJ, USA), illustrated a 14 mm × 16 mm well-circumscribed, hypoechoic, and homogeneous mass at the distal body of the pancreas with no communication to the main pancreatic duct or abutment of the surrounding vasculature [Figure 2]. Using EUS elastography, the mass demonstrated a diffuse homogenous blue pattern with an elastography color score of 5 [range: 1 (soft) to 5 (hard/solid)] [Figure 3]. Quantitative EUS elastography revealed a strain ratio (SR) of 16.17 [Figure 4]. Under EUS-guided fine-needle aspiration (EUS-FNA), four samples of the mass were obtained using a 25-gauge needle. Cytopathology identified a well-differentiated neuroendocrine tumor [Figure 5], with Ki-67 proliferative index <2% [Figure 6]. Immunohistochemistry identified positive CAM5.2, synaptophysin [Figure 7], chromogranin A [Figure 8], and was focally positive cytokeratin 7 (CK7). Stains were negative for Caudal Type Homeobox 2, CK20, and thyroid transcription factor-1 (TTF-1). Cytopathology and immunohistochemistry were diagnostic of pancreatic neuroendocrine tumor (PNET). Distal pancreatectomy was recommended as a treatment option.

Refractory bile leak with biliocutaneous fistula treated by endobiliary coil placement

A 38-year-old woman with abdominal gunshot injury underwent hepatorrhaphy, gastrorrhaphy, splenectomy, and hemicolectomy for severe liver, gastric, splenic, and colonic injury. On postoperative day 10, Gastroenterology was consulted for evaluation of a bile leak, after bilious drainage was seen in the perihepatic intra-abdominal drain. Abdominal computed tomography scan showed a fluid collection around the right hepatic lobe. Endoscopic retrograde cholangiopancreatography (ERCP), performed for evaluation of the bile leak, showed contrast leakage from a branch of the right hepatic duct, for which a biliary stent was placed. After prolonged hospitalization, repeat ERCP was performed on an outpatient basis at 3 and 6 months. During this period, there was persistent bile leakage from a branch of the right hepatic duct despite biliary stent exchanges (▶Fig. 1). In the interim, the patient also developed a biliocutaneous fistula, with bilious discharge from the skin over the right upper quadrant. A decision was made to proceed with intrabiliary coil placement [1] after consulting with Hepatobiliary Surgery. Platinum embolization coils (Tornado; Cook Medical, Bloomington, Indiana, USA), 0.035 inches in diameter and 4.1 cm in length, were backloaded into a long-wire 4.4 Fr sphincterotome. The sphincterotome was advanced to the site of the biliary leak, and two coils were deployed by using a 0.035-inch guidewire to push them through the sphincterotome. After deployment, the coils assumed their circular shape, confirming coil deployment at the site of duct disruption (▶Video1). There was resolution of the biliocutaneous fistula within 24 hours. The patient was given oral ciprofloxacin for a week after ERCP. There was no fever or abdominal pain at 2 month follow-up, indicating successful treatment of refractory bile leak by endobiliary coil placement. This case demonstrates an off-label use of platinum embolization coils, which are primarily used by interventional radiologists for endovascular use. Endobiliary coil placement is an effective strategy for managing difficult and refractory bile leaks arising from liver trauma.

Thymic carcinoma diagnosed by using endoscopic ultrasound with fine-needle aspiration

There is a paucity of literature on the use of endoscopic ultrasound (EUS) for evaluating superior mediastinal structures, especially the thymus gland. We report a case of thymic carcinoma diagnosed by using EUS elastography with strain ratio and fine-needle aspiration (FNA). A 64-year-old woman presented with altered mental status and was diagnosed with autoimmune encephalitis. Further work-up suggested a superior mediastinal mass, for which she underwent EUS. A hypoechoic mass was found in the superior mediastinum at the level of the aortic arch. Real-time EUS elastography showed a predominantly blue hue to the mass concerning for malignancy. FNA of the mass was performed, which revealed numerous large neoplastic cells under a background of a small lymphoid infiltrate. Immunohistochemistry was strongly positive for PAX8, pancytokeratin, and CAM5.2. The pathologic and immunohistochemical stains were consistent with thymic carcinoma.

Mo1025 Risk of Stroke in Cirrhotic Patients With Atrial Fibrillation

Background: Atrial fibrillation (AF) predisposes non-cirrhotic patients to ischemic stroke and requires anticoagulant therapy for prevention. Traditionally, cirrhosis is considered to be a coagulopathic state and may be associated with increased or normal coagulability. The risk of ischemic stroke amongst those with atrial fibrillation and the associated risk scores for predicting ischemic scores are not well studied. We evaluated the risk of ischemic stroke among cirrhotics relative to non-cirrhotics with atrial fibrillation in national inpatient sample (NIS). Methods: A weighted sample of NIS for the year 2008 was analyzed. The risk of stroke associated with cirrhosis, adjusted for demographic and relevant risk factors, was estimated. Using STATA software, among patients with AF, we estimated the risk of cirrhosis with ischemic stroke relative to non-cirrhotic patients using weighted multivariate analysis while adjusting for other risk factors. We also calculated the CHADVasc scores among the sample population. Covariates of interest were characterized using ICD-9 CM codes. Results: The incidence of total stroke (ischemic and hemorrhagic) was significantly lower in cirrhotics when compared to non-cirrhotics. In individuals with AF the risk of ischemic stroke matched by risk factors for stroke demonstrated a lower incidence of ischemic stroke among patients with cirrhosis than non-cirrhotic controls. Multivariate analysis revealed 75% lower risk for stroke among cirrhotic patients with AF than non-cirrhotic AF patients (Odds ratio: 0.24; 95% [CI: 0.12 0.49]). The risk of ischemic stroke was lower among cirrhotics with AF for the same CHADVasc scores amongst non-cirrhotics. However, no difference in the risk of stroke was observed in cirrhotics with AF than non-cirrhotic AF patients with respect to hemorrhagic stroke (Odds ratio: 0.24; 95% CI: 0.0.3 1.7). The detailed analysis is described in the table. Conclusions: Cirrhotics appears to have a protective effect against ischemic stroke with or without AF. The incidence of hemorrhagic stroke was found to be lower in cirrhotics in general but this effect was not seen among those with AF. The risk of stroke amongst cirrhotics with AF is lower than what is predicted by CHADSVasc. Table showing the incidence of Ischemic stroke among cirrhotic and non-cirrhotic patients with atrial fibrillation

Mo1026 Protein Calorie Malnutrition Predicts Acute Kidney Injury and Mortality in Cirrhotics: Analysis of the National Inpatient Sample

Background: Atrial fibrillation (AF) predisposes non-cirrhotic patients to ischemic stroke and requires anticoagulant therapy for prevention. Traditionally, cirrhosis is considered to be a coagulopathic state and may be associated with increased or normal coagulability. The risk of ischemic stroke amongst those with atrial fibrillation and the associated risk scores for predicting ischemic scores are not well studied. We evaluated the risk of ischemic stroke among cirrhotics relative to non-cirrhotics with atrial fibrillation in national inpatient sample (NIS). Methods: A weighted sample of NIS for the year 2008 was analyzed. The risk of stroke associated with cirrhosis, adjusted for demographic and relevant risk factors, was estimated. Using STATA software, among patients with AF, we estimated the risk of cirrhosis with ischemic stroke relative to non-cirrhotic patients using weighted multivariate analysis while adjusting for other risk factors. We also calculated the CHADVasc scores among the sample population. Covariates of interest were characterized using ICD-9 CM codes. Results: The incidence of total stroke (ischemic and hemorrhagic) was significantly lower in cirrhotics when compared to non-cirrhotics. In individuals with AF the risk of ischemic stroke matched by risk factors for stroke demonstrated a lower incidence of ischemic stroke among patients with cirrhosis than non-cirrhotic controls. Multivariate analysis revealed 75% lower risk for stroke among cirrhotic patients with AF than non-cirrhotic AF patients (Odds ratio: 0.24; 95% [CI: 0.12 0.49]). The risk of ischemic stroke was lower among cirrhotics with AF for the same CHADVasc scores amongst non-cirrhotics. However, no difference in the risk of stroke was observed in cirrhotics with AF than non-cirrhotic AF patients with respect to hemorrhagic stroke (Odds ratio: 0.24; 95% CI: 0.0.3 1.7). The detailed analysis is described in the table. Conclusions: Cirrhotics appears to have a protective effect against ischemic stroke with or without AF. The incidence of hemorrhagic stroke was found to be lower in cirrhotics in general but this effect was not seen among those with AF. The risk of stroke amongst cirrhotics with AF is lower than what is predicted by CHADSVasc. Table showing the incidence of Ischemic stroke among cirrhotic and non-cirrhotic patients with atrial fibrillation