Hirsh D Trivedi

Review article: the diagnostic approach and current management of chylous ascites

Chylous ascites is rare, accounting for less than 1% of cases. An appropriate and stepwise approach to its diagnosis and management is of key importance.

Management of Pruritus in Primary Biliary Cholangitis: A Narrative Review

Primary biliary cholangitis is an autoimmune condition characterized by destruction of intrahepatic bile ducts. It causes debilitating symptoms that dramatically affect the patients quality of life. Pruritus affects 60% to 70% of individuals with primary biliary cholangitis and leads to sleep disturbances, fatigue, depression, and suicidal ideation. A complete search was performed with studies from PubMed, EMBASE, Web of Science, Cochrane database, Countway Library, and CINAHL with specific search terms. This narrative review was prepared after a comprehensive literature review. Treating patients with cholestatic pruritus is challenging and may have a profound impact on quality of life. The standard of therapy for primary biliary cholangitis, ursodeoxycholic acid, does not have a beneficial effect in cholestatic pruritus. Patients often do not respond to conventional therapies such as cholestyramine, rifampicin, opioid antagonists, and sertraline. These therapies lack long-term efficacy and have side effects. Patients who have not responded to these initial treatments can be considered for experimental therapies or clinical trials. This review outlines the current and emerging treatment modalities for patients with primary biliary cholangitis who have pruritus.

Interventions to improve physical function and prevent adverse events in cirrhosis

Abstract Cirrhosis is associated with debilitating complications that significantly impact on a patient’s physical function and reduce quality of life. Owing to highly prevalent sarcopenia, malnutrition and hepatic encephalopathy, functional impairment or frailty is a common complication of cirrhosis. Frailty in turn increases the patient’s risk of hospitalization, accidental falls and fractures, and death. The management of frailty and its associated adverse effects is imperative in improving the overall prognosis of patients with advanced liver disease. The cornerstone of therapy revolves around optimizing physical function with appropriate nutrition and exercise. Nutritional therapy with protein supplementation has shown significant benefit, while studies on exercise have been controversial. However, newly emerging studies trend towards a beneficial effect of physical exercise with improvement in quality of life. The implementation of technology in liver disease management shows future promise. Fitbits and other wearable devices can be used to help monitor a patient’s personal progress in physical exercise and nutritional optimization. Additionally, the progressive development of new smartphone applications to help aid in the diagnosis and monitoring of complications of cirrhosis provides a sophisticated avenue for improving care of patients with cirrhosis.

Primary biliary cholangitis: new treatments for an old disease

Primary biliary cholangitis (PBC) is an immunological condition that causes a significant health disturbance and dramatically reduces the quality of life for those affected with the disease. It is a potentially fatal disease that can lead to multiple hepatic and extrahepatic complications. Having adequate therapeutic interventions that can improve the course of the disease is imperative in reducing the associated morbidity and mortality. Ursodeoxycholic acid (UDCA) is the gold standard therapy. However, it has been associated with suboptimal response rates in a significant proportion of patients. Despite UDCA, approximately 35%–40% of individuals with PBC still experience a progression of the disease, leading to liver failure and requiring liver transplantation. Recent studies of new pharmacological approaches have shown beneficial outcomes. Some of these agents can now be applied to a clinical scenario. In this review article, we will outline the new and emerging treatments for PBC.

Editorial: combining elastography with blood test for fibrosis assessment in chronic hepatitis C

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Osteoporosis in primary biliary cholangitis

Primary biliary cholangitis (PBC) is an autoimmune cholestatic liver disease with multiple debilitating complications. Osteoporosis is a common complication of PBC resulting in frequent fractures and leading to significant morbidity in this population, yet evidence for effective therapy is lacking. We sought to summarize our current understanding of the pathophysiology of osteoporosis in PBC, as well as current and emerging therapies in order to guide future research directions. A complete search with a comprehensive literature review was performed with studies from PubMed, EMBASE, Web of Science, Cochrane database, and the Countway Library. Osteoporosis in PBC is driven primarily by decreased bone formation, which differs from the increased bone resorption seen in postmenopausal osteoporosis. Despite this fundamental difference, current treatment recommendations are based primarily on experience with postmenopausal osteoporosis. Trials specific to PBC-related osteoporosis are small and have not consistently demonstrated a benefit in this population. As it stands, prevention of osteoporosis in PBC relies on the mitigation of risk factors such as smoking and alcohol use, as well as encouraging a healthy diet and weight-bearing exercise. The primary medical intervention for the treatment of osteoporosis in PBC remains bisphosphonates though a benefit in terms of fracture reduction has never been shown. This review outlines what is known regarding the pathogenesis of bone disease in PBC and summarizes current and emerging therapies.

Pharmacokinetics and drug interactions of medications used to treat hepatitis C virus infection in the setting of chronic kidney disease and kidney transplantation: DAA pharmacokinetics in CKD & transplant

Hepatitis C infection in patients with chronic kidney disease or kidney transplant carries higher morbidity and mortality compared to noninfected patients. Historically, patients with advanced kidney disease and kidney transplant recipients were undertreated given the multiple adverse effects and limited efficacy of interferon‐based therapies for chronic hepatitis C. The development of direct‐acting antivirals in the past few years has opened an unprecedented opportunity for treating these populations. However, the impaired renal clearance of some of these medications in patients with kidney disease, and the potential interactions of antiviral therapies with immunosuppressants after kidney transplantation, present some challenges in choosing the proper regimen. This review provides an overview of the essential pharmacokinetics and drug interactions of relevant antiviral therapies in the treatment of chronic hepatitis C in patients with advanced kidney disease and after kidney transplantation.

Ethnicity Influences Phenotype and Outcomes in Inflammatory Bowel Disease: A Systematic Review and Meta-analysis of Population-based Studies

BACKGROUND & AIMS: Inflammatory bowel diseases (IBDs) (Crohn’s disease [CD], ulcerative colitis) are global diseases. Similarities and differences in disease presentation and outcomes across different geographic regions and ethnic groups have not been compared previously. METHODS: We performed a systematic review and meta‐analysis of population‐based cohort studies examining the phenotype and outcome of IBD across ethnic groups categorized as Whites, Blacks, Hispanics, and Asians. Further stratification was performed by migration status (native or immigrant). Pooled proportions of disease location, behavior, medication, and surgery use were calculated by using a random‐effects model and compared statistically. RESULTS: Our final analysis included 198 unique studies reporting outcomes on 525,425 IBD patients (Caucasian, 65%; Asian, 30%; Hispanic, 2%; and Black, 1%). CD in Asians but not other ethnicities demonstrated a strong male predominance. Family history of IBD was infrequent in Asian patients. Both Black and Asian CD patients demonstrated perianal involvement more frequently. Surgery for both CD and UC was less common in Asians than Caucasians. Compared with native residents, a family history of IBD was reported more often among immigrant IBD patients, but no significant differences were noted in phenotype. CONCLUSIONS: We demonstrate significant variation in the demographic distribution, familial predisposition, phenotype, and outcomes of IBD between Caucasians, Blacks, Hispanics, and Asians. There is need for further study to understand the biology behind this variation.

Intrasplenic Pancreatic Pseudocyst: A Rare Complication of Acute Pancreatitis

Splenic involvement secondary to acute pancreatitis is rare (approximately 2%), but can include hemorrhage, splenic rupture, vascular injury, or pseudocyst formation.1 A 46-year-old man presented with left upper quadrant (LUQ) abdominal pain 3 months after a moderately severe case of acute alcoholic pancreatitis. He was afebrile, hemodynamically stable, and with LUQ tenderness on exam. Labs were significant for an amylase level of 113 U/L and a normal lipase. Right upper quadrant (RUQ) ultrasound was unremarkable. Contrast-enhanced computed tomography (CT) revealed residual changes consistent with prior pancreatitis and an ill-defined, 1-cm focal hypodensity in the tail of pancreas consistent with a developing pancreatic pseudocyst (Figure 1). He was treated conservatively with bowel rest, pain control, and intravenous fluids, and his symptoms resolved. Five months later, the patient presented with similar complaints. Repeat CT demonstrated an interval progression of the pancreatic tail lesion with extension into the spleen, and increased peripancreatic inflammation at the splenic flexure with short segmental colonic wall thickening (Figure 2). Endoscopic ultrasound (EUS) revealed chronic pancreatitis, a 2.7 cm x 2.8 cm thin-walled cystic lesion in the pancreatic tail with extension into the spleen, and another 2.3 cm x 2.1 cm cystic lesion in the spleen. EUSguided fine needle aspiration yielded 5 mL of turbid, viscous fluid with an amylase level of 3,100 U/L, rare white blood cells, and inflammatory cells without evidence of malignancy, consistent with a pancreatic pseudocyst. The patient responded to conservative measures, and follow-up imaging after 3 months revealed resolution of the pseudocyst.