Samarth S. Patel

Coronary artery disease in decompensated patients undergoing liver transplantation evaluation

Coronary artery disease (CAD) is an important contributor to morbidity and mortality in patients undergoing liver transplantation (LT). However, the current literature is limited by sampling bias and nondefinitive assessment of CAD. The current study examines the prevalence of CAD via per protocol coronary angiography and its relationship to etiology of liver disease in patients undergoing liver transplantation evaluation (LTE). Data on 228 patients were prospectively collected who had coronary angiography as part of LTE between 2011 and 2014. Coronary angiography was done in all patients age ≥50 years or with CAD risk factors. CAD was defined as any coronary artery stenosis, whereas stenosis ≥ 70% in distribution of 1 or 3 major coronary arteries was considered as single‐ or triple‐vessel disease. CAD was detected in 36.8% of patients, with the highest prevalence among nonalcoholic steatohepatitis (NASH) patients with cirrhosis (52.8%). Prevalence of single‐vessel disease was higher among patients with NASH compared with hepatitis C virus (HCV) and alcoholic cirrhosis (15.1% versus 4.6% versus 6.6%; P = 0.02). Similarly, patients with NASH were more likely to have triple‐vessel disease when compared with HCV and alcoholic cirrhosis (9.4% versus 0.9% versus 0%; P = 0.001). While adjusting for traditional risk factors for CAD, only NASH as etiology of liver disease remained significantly associated with CAD. Complications from diagnostic coronary angiography or percutaneous coronary intervention were low (2.6%). In conclusion, patients undergoing LTE have a high prevalence of CAD, which varies widely depending on etiology of liver cirrhosis. The procedural complications from coronary angiography are low. Liver Transplantation 24 333–342 2018 AASLD.

Automated recall system for colonoscopy: a generalizable informatics solution for procedures requiring timely follow-up

Specifically, at most institutions, pathology systems do not integrate with the main electronic health record (EHR) or endoscopic electronic record system (EERS) in a way that allows for discrete data capture. Given that EHR is the primary tool used by physicians and, as such, becomes the legal record of choice, any registry or reporting tool that does not incorporate EHR in some way forces the physician to enter data redundantly, and adversely impacts work flow and efficiency. These barriers impede quality measurement and risk stratification and thereby limit adoption of nationwide quality improvement initiatives like GIQUIC. This pilot study presents a programming solution that is able to marry patient communication with capturing of discrete data within EHR, which can be bundled with quality metrics captured within EERS, and can be uploaded to registry and reporting tools in an automated fashion. Additionally, the programming solution populates a recall registry that can be used to generate reminder letters to patients, all without any significant disruption to physician work-flow or manual input. The solution is now being piloted in a second institution and uses a generalizable approach that can be adopted by most institutions or practices, irrespective of the type of EHR or EERS used.

Pseudomembranes Do Not Always Indicate Clostridium difficile Infection

54-year-old woman presented with ongoing diarArhea for 3 months characterized by 10–12 episodes of non-bloody, foul smelling, watery diarrhea every day, occasionally accompanied by abdominal pain. She denied any history of nausea, vomiting, recent medication change, recent antibiotic use, travel, preceding illness, or weight loss. Stool studies were positive for lactoferrin and erythrocytes. Stool exam was negative for Clostridium difficile, Salmonella, Shigella, Giardia, Yersinia, ova, and parasites. She had normal thyroid panel, celiac serology, qualitative stool fat, and low stool osmotic gap. Vital signs and physical exam were normal. Colonoscopy was notable for congested, erythematous mucosa with non-confluent pseudomembranes in the rectosigmoid colon (Figure A). The rest of the endoscopic exam was normal. Biopsies from the rectosigmoid reported pseudomembranous collagenous colitis (PCC) characterized by accumulation of lymphocytes in the colonic epithelium and thickened subepithelial collagen bands (Figure A, arrows) suggestive of collagenous component and a “volcano” pattern of fibrinopurulent exudates erupting from the mucosal surface (Figure A) suggestive of pseudomembrane. Biopsies from the remaining colon reported collagenous colitis (CC), and terminal ileal biopsies reported intraepithelial lymphocytosis with partial villous atrophy and patchy increase in collagen table, which are findings occasionally associated with PCC. After medication review, potential culprit medications (nonsteroidal anti-inflammatory drugs and proton pump inhibitor) were discontinued. After 3 weeks of unsuccessful trial of bismuth subsalicylate, oral budesonide was initiated, with complete symptom resolution in a few days. However, the disease relapsed on tapering budesonide after 8 weeks. An oral mesalamine was introduced as a bridge to steroid taper with success, and patient was maintained on mesalamine only. A repeat endoscopy after 6 months of therapy confirmed the complete resolution of histologic and endoscopic changes observed earlier (Figure B). PCC, a variant of CC, is notable for formation of pseudomembranes in addition to thickened subepithelial collagen. The exact mechanism of CC remains obscure. Of all medications suggested to play a role in etiology of CC, the strongest evidence exists for nonsteroidal antiinflammatory drugs and proton pump inhibitor. Colonic pseudomembranes have usually been associated with Clostridium difficile colitis, but they may present in ischemic colitis, uremia, radiation, chemotherapy, and bacterial infections, most notably verocytotoxin producing Escherichia coli 0157-H7. Because PCC is believed to be a variant of CC, it should be approached similarly. For mild to moderate disease, antidiarrheal agents such as loperamide or bismuth subsalicylate can be useful. The average response time for bismuth subsalicylate is 2 weeks. For severe

Utilization of aspirin and statin in management of coronary artery disease in patients with cirrhosis undergoing liver transplant evaluation

Coronary artery disease (CAD) assessment is a vital part of liver transplantation (LT) evaluation, as it allows for identification and medical optimization prior to transplantation. Although aspirin and statins are standard of care for CAD, they are not universally used in cirrhosis due to concerns about adverse events. Per protocol, coronary angiography was performed as part of the LT evaluation in all patients over the age of 50 years or with CAD risk factors, even if they were younger than 50. Optimal CAD medical management was defined as the use of both statin and aspirin, unless a contraindication was documented. Impact of these medications on hepatic decompensation, renal function, gastrointestinal bleeding, and need for transfusion was evaluated. CAD was detected in 84/228 (36.8%) patients. Lipid profile was similar in patients with and without CAD. In patients with CAD, statins were started in 19 (23%), while aspirin was used in 30 (36%) patients. In patients with obstructive or multivessel CAD, statin therapy was used only in 41% and 65%, respectively. Statins were more likely to be prescribed in patients with diabetes (32% versus 15%, P = 0.05) and history of dyslipidemia (38% versus 15%, P = 0.02). Use of statin therapy was not linked to hepatic decompensation, hospitalization, or rise in Model for End‐Stage Liver Disease (MELD). Similarly, use of aspirin therapy was not associated with increased risk acute variceal hemorrhage, gastrointestinal bleeding, or worsening anemia. In conclusion, in decompensated cirrhosis, lipid profile alone is unable to risk stratify patients with CAD. Statin and aspirin appear to be safe. However, they are significantly underutilized for the management of CAD in this patient population. Liver Transplantation 24 872–880 2018 AASLD.

Distribution and histopathology of colorectal polyps in the Asian population in the United States.

436 Background: Limited data exists for colorectal polyps in Asian population in U.S. Advanced polyps are considered as a high risk for CRC and require close surveillance. The aim of the study was to evaluate and compare the characteristics of polyps based on patient demographics, anatomic distribution, size, and histopathology in the Asian population living in one of the most heavily populated and diverse communities in U.S. Methods: We conducted a retrospective, single center chart review study of all asymptomatic Asian patients who underwent screening colonoscopy at a New York City hospital from Jan 2006 to Dec 2010. The patients without polyps were excluded from the study. Based on histopathology and size, polyps were divided into 2 groups: advanced and non-advanced. Results: Of the total 1,300 patients, 311 were found to have colon polyps. Mean age of the study population was 60.8 years (range 50-82). There were 173 males and 138 females, with male to female ratio 1.3:1. In gender analysis, 61% of th...