Sreeram Parupudi

Graft and Patient Survival After Liver Transplantation of Patients With Cirrhosis Due to Alcohol and Hepatitis C: Comparison to Alcoholic Cirrhosis and Hepatitis C Cirrhosis

Background and Aim: Graft and patient survival after liver transplantation (LT) is poor for hepatitis C virus (HCV) cirrhosis compared to alcoholic cirrhosis (AC). Data on outcome after LT for cirrhotics due to HCV and alcohol are limited. We compared post LT course of patients transplanted for HCV cirrhosis, alcoholic cirrhosis, and cirrhosis due to alcohol and HCV. Methods and Results: United Network for Organ Sharing data (1991-2010) was used to select study population of adult cirrhotics who have undergone first LT for either HCV cirrhosis (group I), alcoholic cirrhosis (group II) or cirrhosis due to alcohol and HCV (group III). Kaplan Meier survival estimates compared graft and patient survival. Results: Of 88368 LT, 19125 (23%), 9926 (12%), 4869 (5%) were performed for group I, II, and III respectively. Three groups were different for recipient (age, gender, race, MELD score, CMV status, and warm ischemia time) and donor (age, gender, race, heart beating status, infection, CMV +ve, HCV +ve, and donor risk index) characteristics. Proportion of recipients on ventilator, on dialysis, being diabetic, with TIPS, having simultaneous kidney transplant, with previous abdominal surgery, with history of portal vein thrombosis, and with HCC were also different across the groups. Five year graft and patient survival for group III were similar to group I (63% vs. 64%; P=0.33 and 69% vs. 70%; P=0.67 respectively) and worse than group II (63% vs. 69%; P<0.0001 and 69% vs. 73%; P=0.0003 respectively). On Cox proportional hazard regression analysis, group was an independent predictor for graft and patient survival after adjusting for recipient and donor characteristics. Graft survival for group III was similar to group I (HR 1.03 [0.97-1.09]) and worse than group II (1.27 [1.191.35]). Patient survival for group III was worse than group I (HR 1.09 [1.02-1.15]) and group II (HR1.27 [1.19-1.36]). Proportion of deaths in groups I, II, and III due to denovo tumors were 10% vs. 15% vs. 11% respectively (group III vs. I; P=0.09 and group III vs. II; P=0.004) and due to metabolic complications were 11% vs. 17% vs. 13% respectively (group III vs. I; P=0.19 and group III vs. II; P=0.001). Proportion of graft loss due to recurrent hepatitis in groups I, II, and III were 41% vs. 7% vs. 36% respectively (group III vs. I; P=0.014 and group III vs. II; P<0.0001). Conclusions: Graft survival of patients undergoing LT for cirrhosis secondary to HCV and alcohol is similar to patients with HCV cirrhosis and worse than AC. Patient survival after LT for patients with cirrhosis due to alcohol and HCV is worse compared to AC and HCV cirrhosis. Strategies to improve antiHCV regimens, screening for tumors, and manage metabolic problems are needed for patients undergoing LT for cirrhosis due to alcohol and HCV.

A Tale of Two Tumors: a Case of Concomitant Esophageal Squamous Papilloma and Granular Cell Tumor

To the editor, Benign esophageal tumors are rare. This includes granular cell tumors (GCTs) which comprise 1% of benign esophageal tumors, and incidence during esophagogastroduodenoscopy (EGD) is estimated at 0.033% [1]. Squamous papillomas (SP) of the esophagus are also rare, with an incidence during EGD estimated from 0.01 to 0.45% [2]. We present a unique case of a patient incidentally found to have esophageal GCTas well as esophageal SP successfully treated with endoscopic mucosal resection (EMR). A 45-year-old male with a past history of renal cell carcinoma status post left nephrectomy was referred to our tertiary care digestive disease center for esophageal polyps seen on EGD. Patient underwent an EGD and colonoscopy for an episode of hematochezia where the EGD showed incidental findings of two polypoid lesions in the midesophagus. One lesion was biopsied and demonstrated a granular cell tumor (GCT), while another more proximal lesion was not biopsied at that time. After evaluation in clinic, an endoscopic ultrasound (EUS) was performed during which two subepithelial lesions in the mid-esophagus were seen. The proximal lesion was 11 mm and the distal lesion was 9 mm in size (Fig. 1). Endoscopic mucosal resection (EMR) of the distal esophageal lesion was performed and pathology was consistent with a GCT (Fig. 2). A repeat EGD was scheduled and EMR of the proximal lesion was performed at that time, with pathology demonstrating esophageal squamous papilloma (SP) (Fig. 2). No complications occurred during the procedures. The patient was discharged and scheduled for surveillance EGD in 1 year. To our knowledge, this is the first reported case of concomitant GCT and SP. In a small, single-center retrospective analysis, GCTs less than 10 mm in diameter underwent successful EMR without complication [3]. In another reported series of patients with esophageal SP resected endoscopically, followup endoscopy between 18 and 48 months demonstrated no further lesions at the site of resection or at any other locations within the esophagus [2]. Transformation of esophageal SP to squamous cell carcinoma has been described, but occurred only in cases where numerous polyps were present. Currently, there are no clear guidelines regarding surveillance of these lesions after resection.

Adherence to appropriate nutrition in acute alcoholic hepatitis is low

Malnutrition is a common cause of impeding recovery in patients with acute alcoholic hepatitis (AAH). Previous reports have shown that appropriate nutritional supplementation reduce short and long-term mortality in patients with AAH. Despite these clear recommendations, the element of nutrition in AAH is often neglected. We designed a quality improvement project to evaluate and improve compliance with appropriate nutrition in patients presenting with AAH at our institution. Patients admitted with AAH between December 2015 to December 2016 were included. Our primary outcome was compliance with appropriate nutrition. Secondary outcomes included nutrition consultation and hepatology consultation. A total of fifty-four patients were included. Nine of the 53 patients (17%) received high calorie and high protein diets. Hepatology was consulted in 72% (38/53) of the patients, and 21% (8/38) of these patients received appropriate nutrition as compared to only 8.3% (1/12) in whom hepatology was not consulted. Nutrition was consulted in 55% (29/53) of these patients and 67% (19/28) of those patients received appropriate nutrition. In conclusion, our compliance of appropriate nutrition in AAH is low. Our initial investigation suggests that hepatology and nutrition consultation improved compliance with appropriate nutrition. The next step will be to implement protocolized care for appropriate nutrition in AAH by incorporating consultation of hepatology and nutrition services, assess the effect on adherence to appropriate nutrition, and determine the impact on patient outcomes.Malnutrition is a common cause of impeding recovery in patients with acute alcoholic hepatitis (AAH). Previous reports have shown that appropriate nutritional supplementation reduce short and long-term mortality in patients with AAH. Despite these clear recommendations, the element of nutrition in AAH is often neglected. We designed a quality improvement project to evaluate and improve compliance with appropriate nutrition in patients presenting with AAH at our institution. Patients admitted with AAH between December 2015 to December 2016 were included. Our primary outcome was compliance with appropriate nutrition. Secondary outcomes included nutrition consultation and hepatology consultation. A total of fifty-four patients were included. Nine of the 53 patients (17%) received high calorie and high protein diets. Hepatology was consulted in 72% (38/53) of the patients, and 21% (8/38) of these patients received appropriate nutrition as compared to only 8.3% (1/12) in whom hepatology was not consulted. Nutrition was consulted in 55% (29/53) of these patients and 67% (19/28) of those patients received appropriate nutrition. In conclusion, our compliance of appropriate nutrition in AAH is low. Our initial investigation suggests that hepatology and nutrition consultation improved compliance with appropriate nutrition. The next step will be to implement protocolized care for appropriate nutrition in AAH by incorporating consultation of hepatology and nutrition services, assess the effect on adherence to appropriate nutrition, and determine the impact on patient outcomes.

Dieulafoy of cecum: A rare cause of a refractory gastrointestinal bleeding in an uncommon location

Dieulafoy lesion in the gastrointestinal (GI) tract, initially escribed by Gallard in 1884 [1] and later named by the French urgeon Dieulafoy in 1898, is a rare yet an important cause of GI leeding [2]. By definition, it is a vascular abnormality consisting of large-caliber, aberrant tortuous submucosal artery that protrudes hrough a small mucosal defect without the presence of any overying ulceration [3,4]. Reported incidence of Dieulafoy lesion as a ause of acute GI bleeding is 1–2% [2]. Although this entity can be iagnosed and treated by endoscopy and angiography, the knowldge of its existence in the colon and of its deceptive presentation s critical to making the diagnosis because of its small size [5].