Nazira Chatur

Transplant immunosuppressive agents in non‐transplant chronic autoimmune hepatitis: the Canadian association for the study of liver (CASL) experience with mycophenolate mofetil and tacrolimus

Background: Conventional treatment of autoimmune hepatitis consists of either prednisone alone or in combination with azathioprine. Ten to 20% of patients do not respond to or are intolerant of this treatment. Novel drug treatments include immunosuppressive drugs such as tacrolimus (TAC), mycophenolate mofetil (MMF), methotrexate and cyclosporine. We describe a multi‐centre Canadian experience with MMF and TAC.

Gastric polyps in patients with portal hypertension.

Objectives Gastric hyperplastic polyps are usually associated with chronic gastritis including Helicobacter pylori gastritis and postantrectomy stomachs. Here, we report on a series of 12 patients with portal hypertension secondary to liver cirrhosis, who were found to have a unique histological type of gastric polyp on endoscopy. Methods Retrospective chart review of 12 patients with portal hypertension, who presented with histologically diagnosed gastric hyperplastic polyps. These polyps were reviewed and compared with hyperplastic polyps from 21 patients who did not have portal hypertension. Results The endoscopic appearances of portal hypertension-associated polyps varied considerably, with sizes ranging up to 18 mm. They were sessile or pedunculated, singular or multiple, found in the antrum or body of the stomach, and endoscopically appeared to be typical hyperplastic polyps. Histopathological examination, however, showed mucosal hyperplasia and extensive vascular proliferation and granulation tissue formation. Conclusion The unique histological appearance of gastric hyperplastic polyps in patients with portal hypertension polyps is described. The exact pathogenetic mechanism of polyp formation is unclear although it seems possible that the underlying cause is mucosal injury that is vascular in nature rather than being secondary to surface inflammation. Although there is an emerging evidence of the neoplastic potential of usual hyperplastic polyps, the natural history of portal hypertension-associated polyps is unknown. Identification and management of portal hypertension-associated gastric polyps present a particular dilemma, as these patients often have coagulopathies and vascular ectasias. Therefore, the natural history and endoscopic features of gastric polyps arising in portal hypertensive patients warrants further exploration.

Clozapine-induced fatal fulminant hepatic failure: A case report

Fulminant hepatic failure (FHF) refers to the rapid development of severe acute liver injury with impaired synthetic function and encephalopathy in a person who previously had a normal liver or had wellcompensated liver disease. The potential causes of FHF are numerous, but viral or toxin-induced hepatitis are the most common. Clozapineinduced hepatotoxicity has rarely been reported in the literature, occurs via an unknown mechanism and results in liver biochemical abnormalities that are usually of no clinical significance. In approximately 30% to 50% of patients treated with clozapine, there is an asymptomatic rise in serum aminotransaminase levels; however, there are no current guidelines for routine monitoring of liver function tests and liver enzymes during its use. Fatal fulminant hepatitis has only been reported in three patients receiving clozapine. A case of fatal FHF that occurred in a schizophrenic woman who began clozapine therapy shortly before her illness developed is described.

A Case of Rothia dentocariosa Bacteremia in a Patient Receiving Infliximab for Ulcerative Colitis

A Case of Rothia dentocariosa Bacteremia in a Patient Receiving Infliximab for Ulcerative Colitis

Low volume polyethylene glycol with ascorbic acid, sodium picosulfate-magnesium citrate, and clear liquid diet alone prior to small bowel capsule endoscopy

AIM To compare low volume polyethylene glycol with ascorbic acid, sodium picosulfate-magnesium citrate and clear liquid diet alone as bowel preparation prior to small bowel capsule endoscopy (CE). METHODS We retrospectively collected all CE studies done from December 2011 to July 2013 at a single institution. CE studies were reviewed only if low volume polyethylene glycol with ascorbic acid, sodium picosulfate-magnesium citrate or clear liquid diet alone used as the bowel preparation. The studies were then reviewed by the CE readers who were blinded to the preparation type. Cleanliness and bubble burden were graded independently within the proximal, middle and distal small bowel using a four-point scale according to the percentage of small bowel mucosa free of debris/bubbles: grade 1 = over 90%, grade 2 = between 90%-75%, grade 3 = between 50%-75%, grade 4 = less than 50%. Data are expressed as mean ± SEM. ANOVA and Fishers exact test were used where appropriate. P values < 0.05 were considered statistically significant. RESULTS A of total of 123 CE studies were reviewed. Twenty-six studies were excluded from analysis because of incomplete small bowel examination. In the remaining studies, 39 patients took low volume polyethylene glycol with ascorbic acid, 31 took sodium picosulfate-magnesium citrate and 27 took a clear liquid diet alone after lunch on the day before CE, followed by overnight fasting in all groups. There was no significant difference in small bowel cleanliness (1.98 ± 0.09 vs 1.84 ± 0.08 vs 1.76 ± 0.08) or small bowel transit time (213 ± 13 vs 248 ± 14 ± 225 ± 19 min) for clear liquid diet alone, MoviPrep and Pico-Salax respectively. The bubble burden in the mid small bowel was significantly higher in the MoviPrep group (1.6 ± 0.1 vs 1.9 ± 0.1 vs 1.6 ± 0.1, P < 0.05). However this did not result in a significant difference in diagnosis of pathology. CONCLUSION There was no significant difference in small bowel cleanliness or diagnostic yield of small bowel CE between the three preparations regimens used in this study.

Regression of cirrhosis associated with hepatitis B e (HBe) antigen-negative chronic hepatitis B infection with prolonged lamivudine therapy.

In theory, hepatic fibrosis should be a dynamic process with the potential for remodelling after the injury-provoking stimulus has been removed. Clinically, there has been an accumulation of a small number of cases, including hepatitis B e (HBe) antigen-positive chronic hepatitis B infection, in which cirrhosis regressed after successful treatment. We report a 42-year-old HBe antigen-negative Chinese man with detectable serum hepatitis B virus DNA and histologically established cirrhosis (Ludwig score 4) who, after 4 years of successful lamivudine therapy, was found to have regression of cirrhosis on repeat liver biopsy. The repeat biopsy revealed normal liver architecture with fibrosis confined to the portal tracts and short fibrosis septae extending into the lobule without bridging (Ludwig score 1-2). Although cirrhosis may take many years to develop, our experience suggests that successful treatment may reverse the process within a relatively short time.

A bleeding vallecular varix, visualized by GI endoscopy, confirmed with CT angiography, and treated with sclerotherapy and cyanoacrylate

Figure 1. A, Varix. B, Base of tongue. C, Epiglottis. Upper-GI bleeding is most commonly secondary to peptic ulcer disease, Mallory-Weiss tear, esophagitis, or variceal hemorrhage. Significant hemorrhage from an oropharyngeal source such as vallecular varices is rare, with only a few case reports available in the literature. Sublingual varices have been described commonly in patients with cardiovascular disease and smoking; however, the pathogenesis of vallecular varices is poorly understood and believed to be secondary to chronic coughing resulting from respiratory conditions such as bronchitis and tuberculosis. Only 1 case of base-of-the-tongue varices in a patient with portal hypertension due to liver cirrhosis has been reported. The diagnosis and treatment of the majority of these patients is based on an otolaryngology approach, with laryngoscopy-based or bronchoscopybased diathermy coagulation or laser. Only a solitary case has been treated with laryngoscopy-based injection sclerotherapy of 4 mL of tetradecyl sulfate. A 59-year-old woman with autoimmune hepatitis complicated by cirrhosis and portal hypertension, who had undergone esophageal variceal ligation to obliteration within the preceding year, presented with episodes of “spitting up blood” without vomiting, melena stools, or coughing. She had experienced 3 similar presentations within 5 months, and no bleeding source had been identified by upper endoscopies performed on each occasion. After extensive investigations, including an evaluation by a pulmonary specialist, she was labeled to have “pseudohemoptysis.” At this presentation, an otorhinolaryngologist performed an otorhinolaryngology evaluation and did not identify a source but stated that “abnormal-appearing” vessels were seen in the oropharynx. The patient’s hemoglobin dropped from 9.9 g/dL to 7.9 g/dL within 8 hours; her blood urea was normal at 2.9 mmol/L. EGD with an Olympus therapeutic gastroscope revealed no blood in the distal esophagus, stomach, or duodenum; however, fresh blood was visualized in the oral cavity. The patient’s hemoglobin fell further to 6.4 g/dL, requiring transfusions of red blood cells. Therefore, a

The Effect of Prucalopride on Small Bowel Transit Time in Hospitalized Patients Undergoing Capsule Endoscopy

Background The inpatient status is a well-known risk factor for incomplete video capsule endoscopy (VCE) examinations due to prolonged transit time. We aimed to evaluate the effect of prucalopride on small bowel transit time for hospitalized patients undergoing VCE. Methods We included all hospitalized patients who underwent VCE at a tertiary academic center from October 2011 through September 2016. A single 2 mg dose of prucalopride was given exclusively for all patients who underwent VCE between March 2014 and December 2015. VCE studies were excluded if the capsule was retained or endoscopically placed, if other prokinetic agents were given, in cases with technical failure, or if patients had prior gastric or small bowel resection. Results 442 VCE were identified, of which 68 were performed in hospitalized patients. 54 inpatients were included, of which 29 consecutive patients received prucalopride. The prucalopride group had a significantly shorter small bowel transit time compared to the control group (92 versus 275.5, p < 0.001). There was a trend for a higher completion rate in the prucalopride group (93.1% versus 76%, p = 0.12). Conclusions Our results suggest that the administration of prucalopride prior to VCE is a simple and effective intervention to decrease small bowel transit time.

An Unexpected Cause of Anemia in a Kidney Transplant Recipient.

Gastroenterology 2015;149:e12–e13 Question: A 76-yearold woman with a 2-week history of diarrhea, nausea, vomiting, and constitutional symptoms, presented with acute kidney injury and severe anemia requiring transfusions. She denied abdominal pain, rashes, melena, hematochezia, and hematemesis. Review of systems was otherwise negative. Her physical examination was significant only for signs of volume depletion. Of note, the patient had undergone living-related kidney transplant for membranous glomerulonephritis 2 years before this presentation. Her additional past medical history included hypertension, dyslipidemia, previous cholecystectomy and gastroesophageal reflux disease. Her regular medications were mycophenolate mofetil, tacrolimus, prednisone, and ranitidine. Clostridium difficile and hemolytic uremic syndrome were ruled out by the appropriate investigations and her kidney function improved with intravenous fluids. During her hospital stay, she required multiple transfusions to maintain her hemoglobin levels above 70 g/L. Nonenhanced computed tomography of abdomen and pelvis showed multiple, ill-defined, low-density lesions in the liver consistent with metastatic lesions without a primary source; there was also mild periaortic and mesenteric lymphadenopathy, benign ovarian cyst, and multiple nonobstructive bladder masses (Figure A). Fine needle aspiration of 1 of the liver lesions, although nondiagnostic because of low number of liver cells, was in favor of poorly differentiated carcinoma. Transurethral resection of bladder tumors took place and pathology of the latter was in keeping with benign tissue with no evidence of malignant cells. Her dermatologic examination was negative for any skin lesions. Mammogram ruled out primary breast cancer. Gastroscopy was performed and showed 2 small hyperemic nodules in the duodenum that were biopsied (Figure B). Colonoscopy and endoscopic ultrasonography were unremarkable. What is the most likely diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Male contraception use during valganciclovir treatment for cytomegalovirus colitis.

In response to an article describing cytomegalovirus (CMV) infection in patients with active inflammatory bowel disease (IBD) the authors review a specific case of a male patient with IBD and its importance for patient education for patient education for patients with IBD. The authors highlight the importance of communicating to male IBD patients prescribed ganciclovir for treatment of CMV infection the need for contraception because of potential teratogenic effects. For other mainstay of IBD treatments paternal use of these agents is associated with either unknown or no increased risk of adverse fetal outcomes.