Gursimran Kochhar

Biliary complications following liver transplantation.

Biliary tract complications are the most common complications after liver transplantation. These complications are encountered more commonly as a result of increased number of liver transplantations and the prolonged survival of transplant patients. Biliary complications remain a major source of morbidity in liver transplant patients, with an incidence of 5%-32%. Post liver transplantation biliary complications include strictures (anastomotic and non-anastomotic), leaks, stones, sphincter of Oddi dysfunction, and recurrence of primary biliary disease such as primary sclerosing cholangitis and primary biliary cirrhosis. The risk of occurrence of a specific biliary complication is related to the type of biliary reconstruction performed at the time of liver transplantation. In this article we seek to review the major biliary complications and their relation to the type of biliary reconstruction performed at the time of liver tranplantation.

Severe disease on endoscopy and steroid use increase the risk for bowel perforation during colonoscopy in inflammatory bowel disease patients.

BACKGROUND AND AIM Colonoscopic perforation is a rare complication. We sought to determine its risk factors in patients with inflammatory bowel disease (IBD). MATERIALS AND METHODS The study group consisted of 19 IBD patients who had perforation secondary to diagnostic or therapeutic colonoscopy from January 2002 to October 2010. The control group consists of 76 IBD patients undergoing colonoscopy and no perforations that were matched based on indication in a 4:1 ratio to the study group. Demographic and clinical variables as well as perforation outcomes were analyzed by univariate and multivariate analyses. RESULTS There were a total of 5295 colonoscopies done during the study period in IBD patients of which 19 patients had perforation. The prevalence of perforation in IBD patients was 0.3%. Of the 19 patients, 12 had Crohns disease (CD) and 7 had ulcerative colitis (UC). Patients in the perforation group were more likely treated with steroids (68.4% vs. 21.1%, p<0.001) and had severe disease on endoscopy (31.6% vs. 10.1%, p=0.03) than that in the control groups. On multivariate analysis, severe disease on endoscopy (adjusted odds ratio [aOR]=3.82, 95% confidence interval [CI]=1.03-15.24) and steroid treatment (aOR=7.68; 95% CI=1.48, 39.81) were independently associated with the risk of perforation. The median length of stay in the perforation group was 10 days (range 2-23 days). There was no mortality in our study. CONCLUSIONS There appears to be a higher risk of colonoscopy-associated perforation in IBD patients with active disease and on steroids.

Duration and severity of primary sclerosing cholangitis is not associated with risk of neoplastic changes in the colon in patients with ulcerative colitis

BACKGROUND Annual surveillance colonoscopy to detect colon cancer is recommended for patients with primary sclerosing cholangitis (PSC) and ulcerative colitis (UC). Limited data currently support these recommendations. OBJECTIVE To study whether a relationship exists between the severity and duration of PSC and the risk of colon cancer and dysplasia (colon neoplasia). DESIGN Retrospective, longitudinal study. SETTING Tertiary-care referral center. PATIENTS Information pertaining to duration of PSC, UC, requirement for orthotopic liver transplantation, and time to diagnosis of colon neoplasia was obtained for patients with PSC and UC. Patients were evaluated and followed-up from 1985 to 2011 at a single institution. MAIN OUTCOME MEASUREMENTS Association between the severity and duration of PSC-UC and the time of occurrence of colon neoplasia. RESULTS Of 167 patients with a combined diagnosis of PSC-UC, 55 had colonic neoplasia on colonoscopy. Colonic neoplasia occurred more frequently within 2 years of a combined diagnosis of PSC-UC (6.6/100 patient-years of follow-up) than after 8 years from PSC-UC (2.7/100 patient-years of follow-up). On proportional hazards analysis, older age at PSC diagnosis (hazard ratio 1.23 for every 5 years; 95% confidence interval, 1.03-1.34; P = .014) increased the risk of colon neoplasia. LIMITATIONS Retrospective study. CONCLUSION In this study, the severity of PSC was not significantly associated with the risk of colon neoplasia. Patients with PSC and UC have a high risk of colon neoplasia soon after the coexistence of the two diseases is discovered. Older age at PSC diagnosis increases this risk.

Random biopsies during surveillance colonoscopy increase dysplasia detection in patients with primary sclerosing cholangitis and ulcerative colitis

BACKGROUND AND AIM Patients with primary sclerosing cholangitis (PSC) and ulcerative colitis (UC) are at increased risk of colon dysplasia. The role of random vs. target biopsies in these patients has not been investigated. Our aim was to evaluate the yield and clinical impact of random biopsies during surveillance colonoscopies in patients with PSC-UC. METHODS Data from 71 patients (267 colonoscopies) with PSC and UC, who underwent surveillance colonoscopies and followed-up from 2001 to 2011 was obtained. Colonoscopy and pathology reports were reviewed to assess the yield of random biopsies. RESULTS A total of 3975 (median 12) random biopsies were taken during surveillance colonoscopies. Overall, neoplasia was detected in 22 colonoscopies (16 patients): in 8 colonoscopies (36.4%) by targeted biopsies only and in 4 (18.2%) by both targeted and random biopsies. Neoplasia was detected in random biopsies only in 10 (45.5%) colonoscopies in 8 patients. On multivariate analysis, duration of UC (Odds ratio [OR]=1.40; 95% confidence interval [CI], 1.08-1.81; P=0.01), number of random biopsies (per increase by 8) (OR=1.64; 95% CI, 1.18-2.28; P=0.003) and target biopsies during colonoscopy (OR=9.08; 95% CI, 3.18-26.0; P<0.001) independently predicted the presence of dysplasia; endoscopic features of prior inflammation did not. CONCLUSIONS Random biopsies significantly increase the yield of dysplasia in patients with PSC and UC even in the absence of endoscopic features of prior inflammation and significantly impact clinical outcomes.

Capnographic Monitoring in Routine EGD and Colonoscopy With Moderate Sedation: A Prospective, Randomized, Controlled Trial

Objectives:Regulatory changes requiring the use of capnographic monitoring for endoscopic procedures using moderate sedation have placed financial challenges on ambulatory and hospital endoscopy centers across the United States due to the increased cost of training endoscopy personnel and purchasing both capnography-monitoring devices and specialized sampling ports. To date, there has been no published data supporting the use of capnographic monitoring in adult patients undergoing routine endoscopic procedures with moderate sedation. The aim of this randomized, parallel group assignment trial was to determine whether intervention based on capnographic monitoring improves detection of hypoxemia in patients undergoing routine esophagogastroduodenoscopy (EGD) or colonoscopy with moderate sedation.Methods:Healthy patients (ASA Physical Classification (ASAPS) I and II)) scheduled for routine outpatient EGD or colonoscopy under moderate sedation utilizing opioid and benzodiazepine combinations were randomly assigned to a blinded capnography alarm or open capnography alarm group. In both study arms, standard cardiopulmonary monitoring devices were utilized with additional capnographic monitoring. The primary end point was the incidence of hypoxemia defined as a fall in oxygen saturation (SaO2) to <90% for ≥10 s. Secondary outcomes included severe hypoxemia, apnea, disordered respirations, hypotension, bradycardia, and early procedure termination for any cause.Results:A total of 452 patients were randomized; 218 in the EGD and 234 in the colonoscopy groups; 75 subjects in the EGD group (35.9%) and 114 patients (49.4%) in the colonoscopy group were male, and average body mass index was 27.9 and 29.1 (kg/m2), respectively. The blinded and open alarm groups in each study arm were similar in regards to use of opioids and/or benzodiazepines and ASAPS classification. There was no significant difference in rates of hypoxemia between the blinded and open capnography arms for EGD (54.1% vs. 49.5; P=0.5) or colonoscopy (53.8 vs. 52.1%; P=0.79).Conclusions:Capnographic monitoring in routine EGD or colonoscopy for ASAPS I and II patients does not reduce the incidence of hypoxemia (ClinicalTrials.gov number, NCT01994785).

Celiac disease: Managing a multisystem disorder.

Celiac disease is a multisystem autoimmune disorder that can cause symptoms involving the gastrointestinal tract and other organ systems such as the skin and bones. This paper reviews the pathogenesis, diagnosis, and management of celiac disease and associated diseases. This autoimmune disorder can cause symptoms that involve not only the gastrointestinal tract but also the skin and bones.

Comparative study of endoscopy vs. transjugular intrahepatic portosystemic shunt in the management of gastric variceal bleeding

Background and Aim: Gastric varices are associated with high mortality. There have been conflicting reports on whether endoscopic treatment with cyanoacrylate or the placement of a transjugular intrahepatic portosystemic shunt (TIPS) is more effective in the treatment of gastric varices. We compared the outcomes of patients treated with cyanoacrylate glue or TIPS for the management of acute gastric variceal bleeding. Methods: The study was designed as a retrospective cohort analysis of patients undergoing either TIPS or endoscopic treatment with cyanoacrylate for acute gastric variceal bleeding at our institution from 2001 to 2011. Primary compared to studied between the two treatment modalities were the short-term treatment outcomes, including re-bleeding within 30 days, length of hospital stay and in-hospital mortality. Kaplan-Meier survival analysis was performed to assess factors associated with in-hospital mortality. Results: A total of 169 patients were included in the analysis. The TIPS arm contained 140 patients and the cyanoacrylate arm contained 29 patients. There was no evidence to suggest any significant differences in demographics or disease severity. There were no differences between the TIPS arm and the cyanoacrylate armtwo groups in treatment outcomes including re-bleeding within 30 days (17.4% vs. 17.2%; P = 0.98), median length of stay in the hospital (4.5 days vs. 6.0 days; P = 0.35) or in-hospital mortality (9.0% vs. 11.1%; P = 0.74). In-hospital mortality was evaluated for 149 patients and lower albumin (P = 0.015), higher MELD score (P < 0.001), higher CTP score (P = 0.005) and bleeding (P = 0.008) were all significantly associated with in-hospital death. Conclusion: These findings suggest that both treatments are equally effective. Cyanoacrylate offers a safe, effective alternative to TIPS for gastric varices, and physician may choose the best therapy for each patient, factoring in the availability of TIPS or cyanoacrylate, the individual patient’s presentation, and cost.

Therapeutic management options for patients with obscure gastrointestinal bleeding.

Obscure gastrointestinal bleeding (OGIB) is one of the most challenging disorders faced by gastroenterologists because of its evasive nature and difficulty in identifying the exact source of bleeding. Recent technological advances such as video capsule endoscopy and small bowel deep enteroscopy have revolutionized the diagnosis and management of patients with OGIB. In this paper, we review the various diagnostic and therapeutic options available for the management of patients with OGIB.

Vedolizumab for Ulcerative Colitis: Treatment Outcomes from the VICTORY Consortium

OBJECTIVES: We aimed to quantify the safety and effectiveness of vedolizumab (VDZ) when used for UC, and to identify predictors of response to treatment. METHODS: Retrospective review (May 2014‐December 2016) of VICTORY Consortium data. Adults with follow‐up after starting VDZ for clinically active UC were included. Primary effectiveness outcomes were cumulative rates of clinical remission (resolution of all UC‐related symptoms) and endoscopic remission (Mayo endoscopic sub‐score 0). Key secondary effectiveness outcomes included cumulative rates of corticosteroid‐free remission and deep remission (clinical remission and endoscopic remission). Cox proportional hazard analyses were used to identify independent predictors of treatment effectiveness. Non‐response imputation (NRI) sensitivity analyses were performed for effectiveness outcomes. Key safety outcomes were rates of serious infection, serious adverse events, and colectomy. RESULTS: We included 321 UC patients (71% prior TNF&agr; antagonist exposure, median follow‐up 10 months). The 12‐month cumulative rates of clinical remission and endoscopic remission were 51% and 41%, respectively. Corresponding rates for corticosteroid‐free remission and deep remission were 37% and 30%, respectively. Using NRI, 12‐month rates were 20% (n = 64/321) for clinical remission, 17% (n=35/203) for endoscopic remission, 15% (n=30/195) for corticosteroid‐free remission, and 14% (n = 28/203) for deep remission. A majority of the patients without adequate follow‐up at 12 months who were deemed non‐responders using NRI had already achieved clinical remission (n = 70) or a significant clinical response (n=36) prior to 12 months. VDZ discontinuation prior to 12 months was observed in 91 patients, for lack of response (n =56), need for surgery (n=29), or adverse event (n=6). On multivariable analyses, prior exposure to a TNF&agr; antagonist was associated with a reduced probability of achieving clinical remission (HR 0.53, 95% CI 0.38–0.75) and endoscopic remission (HR 0.51, 95% CI 0.29–0.88). Serious adverse events and serious infections were reported in 6% and 4% of patients, respectively. Overall cumulative rates of colectomy over 12 months were 13%, with lower rates observed in patients naive to TNF&agr; antagonist therapy (2%) than those who had been exposed to TNF&agr; antagonists (19%). CONCLUSION: In this large real‐world cohort we observed that VDZ was well tolerated and effective in achieving key clinical outcomes.

Endoscopic treatment of leak at the tip of the “J” ileal pouch

Background and study aims The tip of the “J” of the ileal pouch is the vulnerable location for leak after restorative proctocolectomy, which has normally been treated with surgery. We aimed to describe a novel endoscopic method to treat the same. Patients and methods A cohort of 12 consecutive patients with a leak at the tip of the “J” was identified in our prospectively maintained Pouch Registry. The endoscopic over-the-scope clipping (OTSC) system was used for the closure of the leak. Results Eight patients (66.6 %) achieved complete closure of the leak documented by endoscopy confirmed with guidewire and/or contrasted pouchogram, with 6 requiring a single endoscopic session and 2 undergoing a repeat session. Four patients (33.3 %) had a persistent leak and required surgical intervention, of whom 1 developed abscess in the pre-spine region 14 days after the endoscopic procedure and underwent pouch revision surgery. Conclusions OSTC appears to be safe and effective in treating the leak at the tip of the “J” in the majority of patients.