Jeffrey D. Bornstein

Clinical trial : asimadoline in the treatment of patients with irritable bowel syndrome

Background  In models of irritable bowel syndrome (IBS), asimadoline, a kappa‐opioid agonist, improves pain and abnormal bowel function.

Evaluation of APRI and FIB-4 scoring systems for non-invasive assessment of hepatic fibrosis in chronic hepatitis B patients

BACKGROUND & AIMS While the gold standard in the assessment of liver fibrosis remains liver biopsy, non-invasive methods have been increasingly used for chronic hepatitis B (CHB). This study aimed to evaluate the performance of two commonly used non-invasive scoring systems (aspartate aminotransferase-to-platelet ratio index (APRI) and fibrosis index based on four factors (FIB-4)) to predict fibrosis stage in CHB patients. METHODS Demographic, histologic and clinical laboratory data from two trials investigating tenofovir disoproxil fumarate in CHB were analyzed. Predicted fibrosis stage, based on established scales and cut-off values for APRI and FIB-4 scores, was compared with Ishak scores obtained from liver biopsy at baseline and at 240 week follow-up. RESULTS In the 575 patients with a baseline liver biopsy, APRI and FIB-4 scores correlated with Ishak stage (p<0.01); however extensive overlap in the distribution of both scores across Ishak stages prevented accurate determination of fibrosis. The majority (81-89%) of patients with advanced fibrosis or cirrhosis were missed by the scores. Similarly, 71% patients without fibrosis were misclassified as having clinically significant fibrosis. APRI and FIB-4 scores at week 240 tended to be low and underestimate fibrosis stage in the patients with liver biopsies after 240 weeks of therapy. APRI or FIB-4 reduction did not correlate with fibrosis regression after 240 weeks of antiviral therapy. CONCLUSIONS APRI and FIB-4 scores are not suitable for use in clinical practice in CHB patients for assessment of hepatic fibrosis according to Ishak stage, especially in gauging improvements in liver fibrosis following therapy.

CYSTIC FIBROSIS MUTATIONS AND GENETIC PREDISPOSITION TO IDIOPATHIC CHRONIC PANCREATITIS

Idiopathic chronic pancreatitis is a leading cause of chronic pancreatitis. Work from this and other groups has shown that idiopathic chronic pancreatitis is associated with mutations of the cystic fibrosis gene (CFTR). Many idiopathic pancreatitis patients have compound heterozygote genotypes in which both copies of the CFTR gene are abnormal. In these patients, the pancreatic disease can be viewed as a mild variant of cystic fibrosis, in which there is sufficient residual CFTR function to prevent lung disease. This article summarizes the evidence associating these abnormal CFTR genotypes with idiopathic chronic pancreatitis and reviews the implications of this association for the pathogenesis, classification, and prevention of pancreatitis.

Nonoperative imaging techniques in suspected biliary tract obstruction

Evaluation of suspected biliary tract obstruction is a common clinical problem. Clinical data such as history, physical examination, and laboratory tests can accurately identify up to 90% of patients whose jaundice is caused by extrahepatic obstruction. However, complete assessment of extrahepatic obstruction often requires the use of various imaging modalities to confirm the presence, level, and cause of obstruction, and to aid in treatment plan. In the present summary, the literature on competing technologies including endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiopancreatography (PTC), endoscopic ultrasound (EUS), intraductal ultrasonography (IDUS), magnetic resonance cholangiopancreatography (MRCP), helical CT (hCT) and helical CT cholangiography (hCTC) with regards to diagnostic performance characteristics, technical success, safety, and cost-effectiveness is reviewed. Patients with obstructive jaundice secondary to choledocholithiasis or pancreaticobiliary malignancies are the primary focus of this review. Algorithms for the management of suspected obstructive jaundice are put forward based on current evidence. Published data suggest an increasing role for EUS and other noninvasive imaging techniques such as MRCP, and hCT following an initial transabdominal ultrasound in the assessment of patients with suspected biliary obstruction to select candidates for surgery or therapeutic ERCP. The management of patients with a suspected pancreaticobiliary condition ultimately is dependent on local expertise, availability, cost, and the multidisciplinary collaboration between radiologists, surgeons, and gastroenterologists.

De‐Novo Cholangiocarcinoma in the Setting of Recurrent Primary Sclerosing Cholangitis Following Liver Transplant

Orthotopic liver transplantation is the only definitive therapeutic option in patients with primary sclerosing cholangitis (PSC) and end‐stage liver disease. However, PSC recurs in up to 20% of patients transplanted for this indication. To date, no patient has been reported to develop cholangiocarcinoma (CCA) post‐transplant, without biliary tract cancer having been present pretransplant. Here, we report recurrent PSC complicated by de‐novo CCA in a 31‐year‐old man transplanted for PSC 8 years earlier. Cholangiocarcinoma was confirmed using a combination of computed tomography, cholangiography, positron emission tomography and histological examination of biliary cytology. He has since been successfully re‐transplanted following preoperative chemo‐radiotherapy. No viable tumor was identified in the explanted liver. This case establishes that long‐term complications associated with PSC and biliary‐enteric surgery such as CCA may become apparent in new grafts post‐transplant.

S1298 AST-120 (Spherical Carbon Adsorbent) Improves Pain and Bloating in a Randomized, Double-Blind, Placebo-Controlled Trial in Patients With Non-Constipating Irritable Bowel Syndrome (IBS)

female ratio was 1 : 1.02. The preoperative diagnosis was gallbladder cancer(67%), cholecystitis(24%), gallbladder polyp(7%), stone and cholecystitis(6%), stone(3%), gallbladder cancer and stone(2%), adenomyomatosis(1%). 15 patients of stage IA, 22 of stage IB, 9 of stage IIA, 23 of stage IIB, 3 of stage III and 6 of stage IV were confirmed by postoperative analysis. Age, sex, white blood cell count, hemoglobin, AST, ALT, total bilirubin, alkaline phosphatase, CEA, symptoms, and TNM stage were not statistically different from two groups (preoperative GBC Vs. non GBC). Conclusions : A third of the GBC patients who had a LC got a diagnosis as Cholecystitis, gallbladder polyp, gallstone or adenomyomatosis. Therefore, a careful diagnosis is required in the first workup. However, there turn out to be no difference in the illness stage not matter whether the patient has got an earlier diagnosis as the GBC. We think that LC does not deteriorate the prognosis of patients with incidentally detected GBC if appropriate re-operation is carried out according to the cancer staging.

A Report of a Gastrinoma Localized Preoperatively by Endoscopic Ultrasound Only and a Review of the Approach to Imaging in Zollinger-Ellison Syndrome

The addition of somatostatin receptor scintigraphy and endoscopic ultrasound to the preoperative assessment of patients with Zollinger-Ellison syndrome has improved the ability to localize gastrinomas. We report a patient with Zollinger-Ellison syndrome with a gastrinoma localized preoperatively by endoscopic ultrasound only. We review the literature regarding the sensitivity of somatostatin receptor scintigraphy and endoscopic ultrasound and discuss the approach to imaging in Zollinger-Ellison syndrome.