Luis R. Peña

Development of an Instrument to Assess and Predict Satisfaction and Poor Tolerance Among Patients Undergoing Endoscopic Procedures

We aimed to test the reliability of a developed questionnaire that measures and predict aversive endoscopic experience. Two questionnaires (pre- and postprocedure) were given to patients presenting for routine endoscopy. The first questionnaire elicited demographics, prior endoscopic experience, history of drug or alcohol use, patient expectations, and levels of anxiety and nervousness before procedure. After endoscopy, tolerance and willingness to repeat the examination were determined. The primary outcome of “adverse endoscopic experience” (AEE) was defined as a score of ≥5 on the postprocedure overall level of satisfaction or unwillingness to repeat endoscopy. Thirteen of 148 subjects reported an AEE. Items measuring the primary outcome were internally validated by reliability analysis which significantly correlated with measures of aversive experience like pain, nervousness, and suffering during the procedure. Preprocedure factors that were associated with AEE in the univariate analysis and multivariate analysis were nervousness (P = 0.02) and chronic use of psychotropic drugs or alcohol (P = 0.03). In conclusion, we have developed a questionnaire that reliably measures aversive endoscopic experience. Nervousness before procedure and chronic use of psychotropic drugs are reliable predictors of such experience.

Long-term outcome of patients undergoing liver transplantation for mixed hepatocellular carcinoma and cholangiocarcinoma: an analysis of the UNOS database

BACKGROUND Mixed hepatocellular and cholangiocarcinoma (HCC-CC) have been associated with a poor prognosis after liver transplantation (LT). We aimed to evaluate long-term outcomes in patients undergoing LT for HCC-CC versus patients with hepatocellular carcinoma (HCC) or cholangiocarcinoma (CC). METHODS Retrospective analysis of the United Network for Organ Sharing (UNOS) database from 1994-2013. Overall survival (OS) in patients with HCC-CC, HCC, and CC, were compared. RESULTS We identified 4049 patients transplanted for primary malignancy (94 HCC-CC; 3515 HCC; 440 CC). Mean age of patients with HCC-CC was 57 ± 10 years, and 77% were male. MELD score did not differ among the groups (p = 0.637). Hepatitis C virus was the most common secondary diagnosis within the HCC-CC (44%) and HCC (36%) cohorts, with primary sclerosing cholangitis in the CC (16%) cohort. OS rates at 1, 3 and 5 years for HCC-CC (82%, 47%, 40%) were similar to CC (79%, 58%, 47%), but significantly worse than HCC (86%, 72%, and 62% p = 0.002). DISCUSSION Patients undergoing LT for HCC had significantly better survival compared to those transplanted for HCC-CC and CC. LT for mixed HCC-CC confers a survival rate similar to selected patients with CC. Efforts should be made to identify HCC-CC patients preoperatively.

The Sphincter of Oddi

In the last decade and a half, much interest has been focused on disturbances of the sphincter of Oddi as being part of the functional bowel disorder syndrome. This has received particular emphasis in postcholecystectomy patients who have recurrent attacks of biliary or pancreatic type pain. Many studies have shown that severing the musculature of this sphincteric system may improve symptoms in a selected population. Unfortunately, identifying this group of patients has been a challenge. Anatomic and neurophysiologic studies have uncovered an intricate muscular and neural network between the sphincter of Oddi and its surroundings. This may explain the difficulties in trying to propose a pathophysiologic mechanism in the dysfunction of the sphincter of Oddi, and in identifying patients who may benefit from certain therapies. In this paper, we will review the anatomy, physiology and pharmacology of the sphincter of Oddi, paying special attention to its seemingly complex intrinsic innervation. We

REVIEW: Hepatitis C Virus Infection and Lymphoproliferative Disorders

Hepatitis C virus (HCV) is a single positive-strand RNA virus with marked genetic variability. It represents the major causative agent of posttransfusion and sporadic parenterally transmitted hepatitis. Fifty to 75% of HCV-infected patients will develop a chronic infection and up to 20% will develop endstage liver disease and/or hepatocellular carcinoma. Some of these individuals will also show a variable combination of immunological manifestations (1). Oncogenesis is a complicated multifactorial process in which viral infections play a well-known role. There are many examples of viruses linked to human tumors including Epstein-Barr virus, human papilloma virus, and human T-cell leukemia/lymphoma virus, among others (1). Hepatitis B virus (HBV) and HCV have also been implicated in the development of neoplastic diseases, particularly hepatocellular carcinoma. HCV is a hepatotropic virus that also shows lymphotropism (replication in peripheral blood mononuclear cells) (2, 3). This lymphotropism may explain the association between this virus and certain lymphoproliferative disorders (LPD). It is likely that HCV infection of T and B lymphocytes is responsible, at least in part, for the many extrahepatic disorders often observed in individuals chronically infected with the virus (4, 5). The best association between HCV and LPD has been documented for mixed cryoglobulinemia (MC), a condition initially described in 1966 by Meltzer. In 1993 Ferri et al reported the detection of HCV-RNA by PCR in peripheral blood mononuclear cells (PBMC) of patients with MC. Some of these cases later evolved into an overt B-cell non-Hodgkin’s lymphoma (NHL). As a result of this observation, these authors suggested that HCV may be responsible for triggering a clonal B-cell proliferation, that in some cases can progress to a malignant lymphoma (1). Since these early reports, many different groups have documented a relationship between HCV and lymphoproliferative disorders, especially MC and Bcell NHL. In this review, the current evidence for this relationship will be examined.

Hepatitis C Virus and Inflammatory Bowel Disease

Gastroenterologists frequently treat patients with complex illnesses such as chronic hepatitis C infections and inflammatory bowel disease (IBD). Occasionally, a patient will present with these two diseases which behave very differently and the treatment for one may potentially exacerbate the other. The purpose of this article is to review the current literature regarding hepatitis C virus therapy in the setting of IBD as well as the effects of common IBD therapies on the hepatitis C virus. Based on limited data, anti-viral therapy is probably safe in patients with well-controlled IBD, but there might be a risk of causing new onset of IBD. Also, it does not appear that the commonly used medications for IBD have much of an effect on the hepatitis C virus (HCV) or its course.

Abnormal Liver Tests as an Initial Presentation of Celiac Disease

A 19-year-old woman presented to her primary care physician complaining of right flank pain and dark urine for 2 days. Because of a history of complicated urinary tract infection (UTI) and no improvement for 2 days with medical treatment, she underwent noncontrasted computed tomography (CT) scan of the abdomen. The CT scan (Fig. 1) revealed no evidence of nephrolithiasis; however, note was made of diffuse low attenuation of the liver consistent with fatty infiltration. Liver tests were then ordered showing elevated transaminases. Her abdominal discomfort resolved after completing a course of antibiotics. The patient was then referred to us because of elevated transaminases and CT scan findings. Upon interview, the patient had no complaints. She denied any history of jaundice, persistent abdominal pain, nausea, emesis, weight loss, diarrhea, rash, or fever. Additionally, no risk factors for viral hepatitis could be identified. Her medical history was notable for arthroscopic knee surgery 4 years prior and complicated UTI requiring hospitalization

Acute pancreatitis secondary to hemobilia after percutaneous liver biopsy

Percutaneous liver biopsy (PLB) is a valuable diagnostic tool. Complication rates vary depending on the technique used, experience of the physician, number of passes, bleeding parameters and other factors. Hemorrhage is a common complication after PLB and can present as intraperitoneal bleeding, intrahepatic or subcapsular hematoma, or rarely as hemobilia. Acute pancreatitis is a rare complication of hemobilia. We describe a single case of acute pancreatitis caused by biliary obstruction due to hemobilia following PLB. The obstruction was successfully managed with biliary stent drainage.

Role of Transplantation in the Treatment of Benign Solid Tumors of the Liver: A Review of the United Network of Organ Sharing Data Set

IMPORTANCE The role of orthotopic liver transplantation for the treatment of benign solid liver tumors (BSLT) is not well defined. OBJECTIVE To analyze outcomes in the United Network of Organ Sharing data set of patients with a diagnosis of BSLT who underwent transplantation. DESIGN, SETTING, AND PARTICIPANTS A retrospective analysis of the United Network of Organ Sharing data set was performed for all (N = 87,280) patients who underwent transplantation for BSLT in the United States from October 1, 1988, through January 31, 2013. MAIN OUTCOMES AND MEASURES Demographics, clinicopathological characteristics, distribution of the procedures by region and state, and overall survival rates. RESULTS During the study period, 147 liver transplants (0.17%) were to treat BSLT. Sixty-two patients (42.2%) had adenomas, 29 (19.7%) had focal nodular hyperplasia, 25 (17.0%) had hemangiomas, 11 (7.5%) had hepatic epithelioid hemangioendotheliomas, and 20 (13.6%) were classified as having unknown benign tumors. The overall 1-, 3-, and 5-year survival rates were 90.9%, 85.2%, and 81.8%, respectively. Using multivariable analysis, we found that age was the only independent factor associated with patient survival. The overall 5-year survival rate for patients older than 50 years was 88% compared with 91% in younger individuals (95% CI, 148-384; P = .005). Region 3 (Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, and Puerto Rico) contributed the maximum number (33 [22.4%]) of these transplants. CONCLUSIONS AND RELEVANCE Although liver transplantation cannot be considered a first-line treatment, it is a valid therapeutic option in selected patients who are not amenable to resection. Only 0.17% of the transplants in the United States are performed for this indication, with satisfying long-term results. Age was an independent predictor of patient survival. Further studies are needed to better understand the role of liver transplantation in the treatment of BSLT.

The Role of Diagnosis and Treatment of Underlying Liver Disease for the Prognosis of Primary Liver Cancer

Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related deaths worldwide. Underlying chronic liver disease has been associated with an increased risk of developing HCC. This study is a review of the current literature regarding the diagnosis, prognostic significance, and role of treating underlying liver disease in patients who are at risk of primary liver cancer. Relevant peer review of the English literature between 1980 and 2017 within PubMed and the Cochrane library was conducted for scientific content on current advances in managing chronic liver diseases and the development of hepatocellular carcinoma. Hepatitis C virus, hepatitis B virus (HBV), nonalcoholic steatohepatitis, autoimmune hepatitis, hereditary hemochromatosis, Wilson disease, primary biliary cirrhosis, α 1-antitrypsin deficiency, and certain drugs lead to an increased risk of developing HCC. Patients with underlying liver disease have an increased incidence of HCC. Hepatitis C virus, HBV, and hemochromatosis can directly lead to HCC without the presence of cirrhosis, while HCC related to other underlying liver diseases occurs in patients with cirrhosis. Treating the underlying liver disease and reducing the progression to cirrhosis should lead to a decreased incidence of HCC.