John Nasr

Severe Cholestasis and Renal Failure Associated with the Use of the Designer Steroid Superdrol™ (Methasteron™): A Case Report and Literature Review

The use of over the counter (OTC) nutritional supplements is widespread among amateur bodybuilders. Reports suggest that up to 30% of people who train regularly with weights use androgenic/anabolic steroids (AAS) and that a significant percentage of male high school students use AAS, not just for muscle gain but also to improve their physical appearance [1, 2]. The use of AAS is associated with a variety of potential liver injuries including toxic hepatitis and cholestasis [3, 4] but is often under-reported because of its clandestine use. Renal toxicity with the use of AAS has recently been demonstrated, which was thought to be related to IgA nephropathy [5]. We report a case of liver and renal injury secondary to a nutritional supplement called Superdrol, with the anabolic steroidmethasteron as its active ingredient.

Spontaneous Bacterial Peritonitis Before Liver Transplantation Does Not Affect Patient Survival

BACKGROUND & AIMS Spontaneous bacterial peritonitis (SBP) is a devastating complication of cirrhosis with high mortality. The impact of a prior episode of SBP on the outcome of liver transplantation (LT) is not well known. We aimed to determine the short- and long-term morbidity and mortality of patients who received LT, with and without a history of SBP. METHODS We reviewed the records of all adult patients who underwent LT at a single center between June 1999 and June 2009. Patients with SBP were compared with all other patients who underwent LT during the same time period, without prior episodes of SBP. RESULTS A total of 1491 adult patients underwent LT in the study period; 80 (5.4%) had at least 1 episode of SBP before LT. The mean follow-up time for all patients in the study was just over 4 years. Patients in the SBP cohort were more likely to be male (74%) and to have alcoholic liver disease. Patients with SBP had higher Child-Pugh and model for end-stage liver disease scores at the time of transplantation compared with controls, but there was no difference in long-term mortality between the 2 groups. Patients with SBP, however, were more likely to require surgery for complications related to LT within 1 year and were more likely to die of sepsis. CONCLUSIONS Despite higher Child-Pugh and model for end-stage liver disease score at the time of LT, survival times of patients with SBP before LT are similar to those patients without SBP.

Prevalence of adenocarcinoma at esophagectomy for Barrett’s esophagus with high grade dysplasia

BACKGROUND Barretts esophagus with high grade dysplasia (HGD) may require surgical resection because of the risk of concomitant adenocarcinoma. The prevalence of invasive, occult carcinoma (≥stage 1B) in this setting has varied. We investigated the association of adenocarcinoma at operative resection for high grade dysplasia. METHODS Using an electronic medical record, we identified patients who underwent esophagectomy for high grade dysplasia at the University of Pittsburgh Medical Center between 1993 and 2007. Preoperative diagnosis was confirmed by reviewing endoscopic, radiologic and pathology reports. Postoperative pathology reports were compared to the preoperative diagnosis. RESULTS 68 patients (12 females and 56 males) with a preoperative diagnosis of high grade dysplasia underwent operative resection. The mean age was 64 years (range 36 to 86 years). Of 68 patients, 12 (17.6%) had adenocarcinoma, 2 (2.9%) were downgraded to low grade dysplasia, and 54 (79.4%) were confirmed as HGD. Of the 12 patients with adenocarcinoma, 4 (5.9% of total cohort) had intramucosal cancer (Stage 1A) and 8 (11.7% of total cohort) had invasive cancer with submucosal invasion or more advanced disease. Of the 8 patients with invasive adenocarcinoma, 4 did not have preoperative endoscopic or radiologic testing suggestive of advanced disease. CONCLUSION The overall prevalence of adenocarcinoma in association with a preoperative diagnosis of HGD was 17.6%. Invasive adenocarcinoma was present in 11.7% of subjects and was clinically occult in 5.9%.

Rendezvous procedure for the treatment of bile leaks and injury following segmental hepatectomy.

BACKGROUND Endoscopic retrograde cholangiopancreatography is a minimally invasive procedure used for the evaluation and management of biliary injuries. At times, ERCP fails and percutaneous modalities may be required. Rendezvous procedures are combined endoscopic and percutaneous techniques that have been used to restore anatomic continuity and biliary drainage in cases where retrograde and/or transhepatic access alone has failed either due to anatomic variation or traumatic injury with biloma formation. AIMS To assess if the Rendezvous technique plays a role in establishing biliary continuity in patients with a bile leak after segmental hepatectomy. METHODS We herby present a series of 3 patients who had complex bile leaks after segmental liver resection and underwent a combined percutaneous and endoscopic Rendezvous procedure to establish biliary continuity. RESULTS This technique was successful in restoring biliary continuity and avoiding hepaticojejunostomy in 2 of the 3 patients. CONCLUSION The Rendezvous technique may play a role in establishing biliary continuity in patients with biliary leak secondary to hepatic surgery.

Killer cell immunoglobulin-like receptor genotypes in Behçet's disease patients: any role for the 3DP1*001/002 pseudogene?

AIMS Genotypic profiles of the natural killer cell immunoglobulin-like receptors (KIR) have been reported to vary among different ethnic groups and variable clinical entities. This study represents the second report on its distribution among patients with Behçets disease (BD). We studied 43 unrelated Lebanese Behçets patients, had their DNA typed using sequence-specific primer technique for the presence of 16 KIR genes and pseudogenes loci, and compared them to the general Lebanese population. RESULTS In addition to sharing common features with the general population, the AA genotype was still the most frequent--however, with five new KIR profiles identified. There was no statistically significant distribution of the different KIR genes between the cases (BD patients) and controls (Lebanese population); however, KIR3DP1*001/002 was found to be significantly different between the BD patients and the Lebanese population, but this significance was lost after correction for all KIR loci. CONCLUSION The results lead to an interesting future research question of whether or not KIR genotype is involved in the predisposition to or pathogenesis of BD especially that a pseudogene is controversially in question. This is the second report that describes the KIR genotypic profile in such an important clinical disease but the first to shed a light on the possible role of a pseudogene.

Implementation and Implication of Ignoring Small Polyps at Colonoscopy

Background and Aim: CT colonography has promoted a new paradigm, that up-to 2 polyps ≤5mm can be left in-situ and followed. In contrast, endoscopists identify and remove all colorectal polyps, regardless of size. We evaluated whether and how endoscopists might implement a plan of ignoring small polyps in clinical practice. Methods: We prospectively queried endoscopists as they encountered small polyps with a hypothetical question: “If you accepted and believed in a new paradigm that a polyp ≤5mm does not need to be endoscopically removed, would you remove this polyp?” We assessed how the new paradigm would be implemented by gastroenterologists and the pathologic impact of ignoring polyps’ ≤5mm. Results: Of 141 patients undergoing colonoscopy, 55 (39%) had polyps and 35 (24.8%) had only small polyps ≤5mm. Endoscopists were agreeable to implementing the new paradigm of not removing small polyps in 17/35 (48.6%) patients. Of patients with only small polyps where endoscopists agreed to forego removal, 13/17 (76.5%) had ≥1 adenomatous polyp. Among the 18/35 subjects for whom the endoscopists would remove the small polyp because of appearance or clinical situation, 12/18 (66.7%) had ≥1 adenoma (p=0.521). If polyps in subjects with only diminutive polyps were ignored, 35/55 (64%) of colonoscopies with therapy would be obviated, at an impact of not removing small adenomas in approximately 75% (25/35). Conclusion: Ignoring polyps’ ≤5mm reduces therapeutic colonoscopy at a price of missing a substantial number of small adenomas.

Endoscopic Approach to the Post Liver Transplant Patient

Biliary complications occur after liver transplantation. These complications can be effectively and safely managed using endoscopic approaches and can prevent unnecessary and potentially morbid surgery.

EUS-directed transgastric ERCP (EDGE) with use of a 20-mm × 10-mm lumen-apposing metal stent in a patient with Roux-en-Y gastric bypass

re 1. A, MRCP showing marked intrahepatic and extrahepatic biliary ductal dilation with abrupt cutoff of the mid common bile duct. B, EUS image ing insertion of 19-gauge EUS needle into the excluded stomach. C, EUS image of contrast material and sterile water being injected through 19-gauge needle to distend the excluded stomach. D, EUS image of 20-mm 10-mm electrocautery-enhanced lumen-apposing metal stent (LAMS) inserted the gastric remnant through the gastric pouch, creating a gastrogastric fistula. E, Endoscopic image confirming placement of the proximal flange of AMS within the gastric pouch. F, Ampulla visualized by duodenoscope. G, Cholangiogram demonstrating distal stricture of the common bile duct ) with upstream dilation of the CBD up to 15 mm. H, Fluoroscopic image of placement of a 10F 7-cm plastic biliary stent.

Clinical Outcomes of Colonic Stent in a Tertiary Care Center

Introduction. Colonic obstruction is one of the manifestations of colon cancer for which self-expanding metal stents (SEMS) have been effectively used, to restore the luminal patency either for palliative care or as a bridge to resective surgery. The aim of our study is to evaluate the efficacy and safety of large diameter SEMS in patients with malignant colorectal obstruction. Methods and Results. A four-year retrospective review of the Medical Archival System was performed and identified 16 patients. The average age was 70.8 years, of which 56% were females. The most common cause of obstruction was colon cancer (9/16, 56%). Rectosigmoid was the main site of obstruction (9/16) and complete obstruction occurred in 31% of cases. The overall technical and clinical success rates were 100% and 87%, respectively. There were no immediate complications (<24 hours), but stent stenosis due to kinking occurred within one week of stent placement in 2 patients. Stent migration occurred in 2 patients at 34 and 91 days, respectively. There were no perforations or bleeding complications. Conclusion. Large diameter SEMS provide a safe method for palliation or as a bridge to therapy in patients with malignant colonic obstruction with high technical success and very low complication rates.

Umbilical Varix in a Cirrhotic Patient.

A 46-year-old male with alcohol-induced Child’s class A liver cirrhosis (MELD 10) presented with profuse bleeding from his umbilicus. The patient described being at his usual state of health until 2 hours prior to presentation, at which time he experienced blood spurting from his umbilicus. He immediately applied local pressure to his abdomen and presented to our hospital. The patient denied associated abdominal pain, chest pain, nausea, vomiting, or gastrointestinal bleeding. He denied prior similar bleeding episodes, lightheadedness, dizziness, visual blurriness, or palpitations. On examination, he had normal vitals signs and a small, reducible umbilical hernia with an overlying blood clot, but no active bleeding. He had mild splenomegaly and evidence of caput medusae without ascites. He had a normal complete blood count, comprehensive metabolic panel, and an INR of 1.2. Abdominal and pelvic computed tomography (CT) revealed umbilical varices as the cause of the bleeding (Figure 1). The umbilical varices appeared to originate from the splenic vascular bed. The patient was taken to surgery for ligation of the umbilical variceal feeding vessel. He had no recurrence of bleeding over the next 12 months. Portal hypertension-associated bleeding is one of the well-known complications of liver cirrhosis. Cutaneous bleeding from umbilical varices, however, is an extremely rare complication of portal hypertension, and bleeding from ruptured umbilical varices tend to be severe and fatal.1 Management of bleeding umbilical varices has been surgical, but one reported case was treated with creation of a transjugular intrahepatic portosystemic shunt for portal venous pressure decompression.2 Our case is unique in that the origin of the umbilical varix was the splenic venous system.