Russell Rosenblatt

Herpes Simplex Virus Hepatitis in an Immunocompetent Host Resembling Hepatic Pyogenic Abscesses

Herpes simplex virus (HSV) hepatitis represents a rare complication of HSV infection, which can progress to acute liver failure and, in some cases, death. We describe an immunocompetent 67-year-old male who presented with one week of fever and abdominal pain. Computed tomography (CT) scan and magnetic resonance imaging (MRI) of the abdomen showed multiple bilobar hepatic lesions, some with rim enhancement, compatible with liver abscesses. Subsequent liver biopsy, however, revealed hepatocellular necrosis, HSV-type intranuclear inclusions, and immunostaining positive for herpes virus type 2 (HSV-2). Though initially treated with broad-spectrum antibiotics, following histologic diagnosis of HSV hepatitis, the patient was transitioned to intravenous acyclovir for four weeks and he achieved full clinical recovery. Given its high mortality and nonspecific presentation, one should consider HSV hepatitis in all patients with acute hepatitis with multifocal hepatic lesions of unknown etiology. Of special note, this is only the second reported case of HSV liver lesions mimicking pyogenic abscesses on CT and MRI.

To Scope or Not to Scope? The Safety of Upper Endoscopy in the Setting of Pulmonary Embolism

OBJECTIVES: We aimed to describe the frequency of upper endoscopy and associated outcomes in subjects hospitalized with upper GI bleeding (UGIB) and pulmonary embolism (PE). METHODS: We performed a cross-sectional study using the Nationwide Inpatient Sample from 2007 to 2014. The association between upper endoscopy and in-hospital mortality was evaluated using propensity score matching. RESULTS: A total of 44,412 subjects had a coexistent PE and UGIB. 63.5% had an inpatient upper endoscopy with a lower likelihood of in-hospital death and a shorter length of stay. CONCLUSIONS: A substantial proportion of inpatients with PE and UGIB undergo endoscopy with a relatively lowmortality rate.

Liver Transplantation for HCC Beyond Milan

Purpose of the ReviewTo describe how the field of liver transplantation (LT) for hepatocellular carcinoma (HCC) has expanded beyond the Milan criteria.Recent FindingsThe Milan criteria have been the gold standard selection tool for patients with HCC undergoing LT since 1996. However, soon after its creation, the tumor size and number limits imposed by the Milan criteria were expanded upon by new models, such as the University of California-San Francisco criteria and the Metroticket. Still, these models were always limited by radiological inaccuracy in measuring tumor size and number and, more importantly, did not include any measurement of tumor behavior. Biomarkers, such as alpha-fetoprotein and neutrophil-lymphocyte ratio, provide that missing link and act as effective predictors of biological behavior and, therefore, provide an ability to predict tumor recurrence in patients undergoing LT for HCC, allowing for successful expansion beyond Milan.SummaryMore recently, newer scoring systems combine morphometric tumor data with markers of biology. These scoring systems, such as the MORAL score, AFP model, RETREAT score, and Metroticket 2.0, are providing the most accurate pre-LT assessments for HCC recurrence and hold the key to the continued improvement of LT outcomes.

Nonviral or Drug-Induced Etiologies of Acute Liver Failure

Acute liver failure (ALF) is a rare but highly fatal condition. The most common causes include drug-induced and viral hepatitis, but other less common etiologies, especially autoimmune hepatitis, Budd-Chiari syndrome, and Wilson disease, need to be considered. Because diagnosis is frequently tied to potential for reversibility of ALF and prognosis, early identification in a timely manner is crucial. Other causes of ALF are more easily recognizable based on specific circumstances, such as ALF in pregnancy or ischemic hepatitis. Ultimately, maintaining a wide differential diagnosis in patients with ALF is essential to identifying the proper treatment and prognosis.

Cost-Effectiveness of Early Insertion of Transjugular Intrahepatic Portosystemic Shunts for Recurrent Ascites

Background & Aims Treatment options for recurrent ascites resulting from decompensated cirrhosis include serial large‐volume paracentesis and albumin infusion (LVP+A) or insertion of a transjugular intrahepatic portosystemic shunt (TIPS). Insertion of TIPSs with covered stents during early stages of ascites (early TIPS, defined as 2 LVPs within the past 3 weeks and <6 LVPs in the prior 3 months) significantly improves chances of survival and reduces complications of cirrhosis compared with LVP+A. However, it is not clear if TIPS insertion is cost effective in these patients. Methods We developed a Markov model using the payer perspective for a hypothetical cohort of patients with cirrhosis with recurrent ascites receiving early TIPSs or LVP+A using data from publications and national databases collected from 2012 to 2018. Projected outcomes included quality‐adjusted life‐year (QALY), costs (2017 US dollars), and incremental cost‐effectiveness ratios (ICERs;

An Overt, Obscure Gastrointestinal Bleed Caused by a Primary Small Bowel Fibroblastic Reticular Cell Sarcoma

/QALY). Sensitivity analyses (1‐way, 2‐way, and probabilistic) were conducted. ICERs less than

Role of inflammatory markers as hepatocellular cancer selection tool in the setting of liver transplantation

100,000 per QALY were considered cost effective. Results In base‐case analysis, early insertion of TIPS had a higher cost (

Su1464 Baseline Creatinine Clearance Is a Predictor of Worsening Renal Function While on Treatment With Sofosbuvir-Ledipasvir

22,770) than LVP+A (

The Impact of Opioid Epidemic Trends on Hospitalised Inflammatory Bowel Disease Patients

19,180), but also increased QALY (0.73 for early TIPSs and 0.65 for LVP+A), resulting in an ICER of

7 FRAGMENTED CARE IS PREVALENT AMONG IBD HOSPITALIZATIONS AND IS ASSOCIATED WITH WORSE OUTCOME

46,310/QALY. Results were sensitive to cost of uncomplicated TIPS insertion and transplant, need for LVP+A, probability of transplant, and decompensated QALY. In probabilistic sensitivity analysis, TIPS insertion was the optimal strategy in 59.1% of simulations. Conclusions Based on Markov model analysis, early placement of TIPSs appears to be a cost‐effective strategy for management of specific patients with cirrhosis and recurrent ascites. TIPS placement should be considered early and as a first‐line treatment option for select patients.