Stanley M. Cohen

Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis

Prevention and Management of Gastroesophageal Varices and Variceal Hemorrhage in Cirrhosis Guadalupe Garcia-Tsao, M.D.,1 Arun J. Sanyal, M.D.,2 Norman D. Grace, M.D., FACG,3 William D. Carey, M.D., MACG,4 the Practice Guidelines Committee of the American Association for the Study of Liver Diseases and the Practice Parameters Committee of the American College of Gastroenterology 1Section of Digestive Diseases, Yale University School of Medicine and VA-CT Healthcare System, New Haven, Connecticut; 2Division of Gastroenterology, Virginia Commonwealth University Medical Center, Richmond, Virginia; 3Division of Gastroenterology, Brigham and Women’s Hospital, Boston, Massachusetts; 4The Cleveland Clinic, Cleveland, Ohio

Autoimmune hepatitis associated with the use of black cohosh: a case study.

Herbal remedies generate more than

ACG Clinical Guideline: Evaluation of Abnormal Liver Chemistries

1.8 billion in annual sales in the United States. Herbal products have been associated with a wide spectrum of hepatic toxicities. With the recent Women’s Health Initiative Study demonstrating increased risk of breast cancer and cardiovascular events associated with hormone therapy, many women may resort to herbal remedies for persistent menopause symptoms. We report a case of autoimmune hepatitis likely triggered by the use of black cohosh (Actaea racemosa), an agent marketed to treat menopause symptoms. Given this case report, we recommend close monitoring of women using this herbal preparation.

Varicella Infection Following Varicella Vaccination in a Liver Transplant Recipient

Clinicians are required to assess abnormal liver chemistries on a daily basis. The most common liver chemistries ordered are serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase and bilirubin. These tests should be termed liver chemistries or liver tests. Hepatocellular injury is defined as disproportionate elevation of AST and ALT levels compared with alkaline phosphatase levels. Cholestatic injury is defined as disproportionate elevation of alkaline phosphatase level as compared with AST and ALT levels. The majority of bilirubin circulates as unconjugated bilirubin and an elevated conjugated bilirubin implies hepatocellular disease or cholestasis. Multiple studies have demonstrated that the presence of an elevated ALT has been associated with increased liver-related mortality. A true healthy normal ALT level ranges from 29 to 33u2009IU/l for males, 19 to 25u2009IU/l for females and levels above this should be assessed. The degree of elevation of ALT and or AST in the clinical setting helps guide the evaluation. The evaluation of hepatocellular injury includes testing for viral hepatitis A, B, and C, assessment for nonalcoholic fatty liver disease and alcoholic liver disease, screening for hereditary hemochromatosis, autoimmune hepatitis, Wilson’s disease, and alpha-1 antitrypsin deficiency. In addition, a history of prescribed and over-the-counter medicines should be sought. For the evaluation of an alkaline phosphatase elevation determined to be of hepatic origin, testing for primary biliary cholangitis and primary sclerosing cholangitis should be undertaken. Total bilirubin elevation can occur in either cholestatic or hepatocellular diseases. Elevated total serum bilirubin levels should be fractionated to direct and indirect bilirubin fractions and an elevated serum conjugated bilirubin implies hepatocellular disease or biliary obstruction in most settings. A liver biopsy may be considered when serologic testing and imaging fails to elucidate a diagnosis, to stage a condition, or when multiple diagnoses are possible.

Acute sinusoidal obstruction syndrome after 6‐thioguanine therapy for Crohn's disease

Varicella infection may result in significant morbidity and mortality in patients who have received an orthotopic liver transplant (OLT). It is unclear if vaccinating these patients against varicella‐zoster virus (VZV) infection is safe or effective. We report on a liver transplant recipient with no prior history of VZV infection who was given the varicella vaccine after an indirect VZV exposure. The patient was subsequently hospitalized twice for treatment of cutaneous varicella infection. We will discuss VZV infection, particularly in relation to liver transplantation, and review the prophylaxis and management of VZV infection after OLT.

Hepatitis C, collagenous colitis, and dermatomyositis occurring in the same patient.

6-Thioguanine (6-TG), the active metabolite of 6-mercaptopurine and its prodrug azathioprine, are thought to be responsible for clinical efficacy in the treatment of active Crohn’s disease. Its use as a therapeutic agent for inflammatory bowel disease (IBD) has been limited to patients who are resistant to or intolerant of other antimetabolites. Short-term experience with this agent has not demonstrated an increased incidence of hematologic or hepatic toxicity; however long-term safety data are scarce. We herein report a patient who developed acute sinusoidal obstruction syndrome after 14 months of successful thioguanine treatment. This is the first report of such a complication in an adult treated with 6-TG for active Crohn’s disease.

Operative Risk of Total Hip and Knee Arthroplasty in Cirrhotic Patients

TO THE EDITOR: Hepatitis C infection is associated with a number of autoimmune diseases including porphyria cutanea tarda, cryoglobulinemia, glomerulonephritis, diabetes, rheumatoid arthritis, thyroid disease, lichen planus, Sjogren’s syndrome, and celiac disease. We present the first case of hepatitis C associated with both dermatomyositis and collagenous colitis. A 40-yr-old white female developed severe erythroderma that improved on prednisone but recurred after steroids were withdrawn. The patient subsequently developed severe myopathy and dysphagia. Laboratory data revealed a creatine phosphokinase of 705 U/L; antinuclear antibody, 1:160; ALP, 215 U/L; AST, 86 U/L; and ALT, 177 U/L. Hepatitis workup revealed positive hepatitis C antibody and viral RNA, negative hepatitis B serologies, normal iron panel, and negative smooth muscle antibody. Other autoimmune markers, including anti-Smith, anti–nuclear ribonucleoprotein, anti–histidyl-t-RNA synthetase, and rheumatoid factor were all negative. Muscle biopsy showed inflammatory myositis, and the patient was diagnosed with dermatomyositis. Further testing included grossly normal upper GI series, colonoscopy, and abdominal CT scan. The patient refused liver biopsy. The patient was started on azathioprine, with improvement in her weakness and dysphagia. Because of concerns of worsening her dermatomyositis, it was elected not to start any interferon-based therapy for her hepatitis C. Within 6 months, the patient developed severe, watery diarrhea. Stool studies were negative. Colonoscopy revealed grossly normal mucosa. However, biopsies were consistent with collagenous colitis (Fig. 1). Collagenous colitis is generally a disorder of middle-aged women presenting with watery diarrhea. The etiology is unknown. Biopsies reveal an enlarged subepithelial collagen layer, inflammation in the lamina propia, and epithelial flattening. It has been associated with several medications. Collagenous colitis has also been found in patients with celiac disease, collagenous sprue, ulcerative colitis, Crohn’s disease, and colon cancer. Associated autoimmune diseases including scleroderma, rheumatoid arthritis, thyroid disease, diabetes, Sjogren’s syndrome, discoid lupus, CREST (calcinosis, Raynaud’s phenomenon, esophageal dysmotility, sclerodactyly, telangiectasias) syndrome, sarcoidosis, and primary biliary cirrhosis are seen in up to 40% of cases. Dermatomyositis is an inflammatory myopathy with specific cutaneous manifestations. Diagnosis requires four of the following five criteria: 1) progressive, proximal muscle weakness; 2) elevated muscle enzymes; 3) an abnormal electromyogram; 4) a muscle biopsy consistent with the disease; and 5) specific skin manifestations. Systemic features may include dysphagia, interstitial pneumonitis, aspiration, and cardiac manifestations. Dermatomyositis is associated with various internal malignancies in 6–60% of cases. The condition has also been linked to several medications, and possibly to various viral agents, including coxsackie, rubella, and HIV. Hepatitis C infection has been associated with myositis. Gomez et al. (1) described a patient with dermatomyositis, hepatocarcinoma, and hepatitis C. Polymyositis has also been seen in a patient with hepatitis C and pulmonary * Work completed at University of Illinois College of Medicine at Peoria.