Vinit Shah

Impact of endoscopic ultrasound-guided fine-needle aspiration in prospective liver transplant recipients with hepatocellular carcinoma and lymphadenopathy

BackgroundDiagnosis of metastatic disease is important in patients with cirrhosis and hepatocellular carcinoma (HCC) to prevent futile liver transplantation. Some of these patients have metastatic lymphadenopathy; however, it is difficult to perform percutaneous fine-needle aspiration due to presence of collateral and anatomic location. Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) of lymph nodes offers several advantages like real-time vision, proximity to target, and avoidance of collaterals.AimThe aim of this study was to look for metastatic lymphadenopathy by EUS-guided FNA (EUS-FNA) in prospective liver transplant recipients with HCC.MethodsA prospective study was conducted from January 2013 to January 2016 at a tertiary care center. All prospective liver transplant recipients with HCC had PET-CT and bone scan to look for metastatic disease. EUS-FNA was done in patients with abdominal or mediastinal lymphadenopathy and no evidence of extrahepatic disease. Data is shown as median (25–75 interquartile range).ResultsEUS-guided FNA was done for 50 patients (42 abdominal and 8 mediastinal lymph nodes), age 57 (53–62) years, Child-Turcotte-Pugh 7 (6–9), and model for end-stage liver disease 10 (7–16). FNA material was adequate in 92% patients, metastasis in 15 (30%), granulomatous lymphadenopathy in 4 (8%), and reactive change in 27 patients (54%). The material was inadequate for diagnosis in 4 (8%) patients. Thus, EUS-guided FNA precluded transplantation in 30% of patients with lymphadenopathy, and 4 (8%) patients received anti-tubercular therapy before liver transplantation.ConclusionIn patients with HCC and lymphadenopathy, EUS-guided FNA detected metastatic disease and precluded liver transplantation in approximately one third of patients.

Intrahepatic Cholangiocarcinoma Masquerading as Liver Abscess

Malignancy masquerading as liver abscess, and presenting with fever, is mainly described in patients with colorectal cancers with liver metastasis. Primary liver tumors such as hepatocellular carcinoma or intrahepatic cholangiocarcinoma presenting as non-resolving liver abscess is extremely uncommon and carries a dismal prognosis. We present a rare case of non-resolving liver abscess as a presenting manifestation of intrahepatic cholangiocarcinoma.

Prospective evaluation of yield of endoscopic ultrasonography in the etiological diagnosis of "idiopathic" acute pancreatitis

Background: Etiology of acute pancreatitis (AP) remains idiopathic in 30% of patients. Endoscopic ultrasound (EUS) has been shown to increase the diagnostic yield in patients with idiopathic AP (IAP). Aim: The aim of this study was to evaluate the role of EUS in achieving etiological diagnosis in patients with IAP. Materials and Methods: Consecutive 192 patients with IAP were evaluated prospectively with EUS over a period of 2 years. Patients who had no etiological diagnosis for AP after detailed history, clinical examination, laboratory investigations, and magnetic resonance cholangiopancreatography were included in the study. Results: The mean age of patients was 34.6 ± 12 and male:female ratio was 2.1:1. Of these, 135 patients had gallbladder intact (Group A) and 57 patients had undergone cholecystectomy (Group B). In Group A, EUS identified a possible cause in 79 (58.5%) patients; microlithiasis (n = 48), chronic pancreatitis (CP) (n = 23), common bile duct (CBD) and gallbladder stone (n = 3), pancreatic divisum (n = 3), small pancreatic tumor (n = 1), and anomalous pancreaticobiliary junction (n = 1). In Group B, EUS yielded diagnosis in 28 (49.1%) patients; CP (n = 22), ascariasis (n = 3), CBD stone (n = 2), and pancreatic divisum (n = 1). Overall EUS helped in achieving etiological diagnosis in 107 (55.1%) of patients with IAP. The presence of intact gallbladder showed a tendency for increased diagnostic yield (P = 0.06). Conclusion: EUS is a useful modality to establish the diagnosis in IAP and this technique should be incorporated in the evaluation of IAP.

Impact and safety of endoscopic ultrasound guided fine needle aspiration on patients with cirrhosis and pyrexia of unknown origin in India

Background and aims: Etiologic diagnosis of pyrexia of unknown origin is important in patients with cirrhosis for optimal management and to prevent flare up of infectious disease after liver transplantation. However, there is very limited literature available on this subject. The present study aimed to examine the safety and impact of endoscopic ultrasound (EUS) guided fine needle aspiration (FNA) in patients with cirrhosis. Methods: The study was conducted between January 2014 and January 2016 at a tertiary care center. A total of 50 (47 lymph nodes, 3 adrenal) EUS guided FNAs were performed in 46 patients. Data are presented as median (25 – 75 IQR). Results: The study included 46 patients (40 males) whose mean age was 47.9 ± 11.1 (SD) years; mean Child-Turcotte-Pugh (CTP) score and mean MELD (Model for End-Stage Liver Disease) score were 10 (8 – 11) and 18 (12 – 20), respectively. The Child Pugh class was A in 4, B in 14, and C in 28 (including three patients with adrenal FNAs). Indications for FNA were pyrexia of unknown origin and lymphadenopathy on CT imaging. The cytopathological diagnoses were metastatic disease in 1 (adrenal), granulomatous change in 10 (6 positive with acid fast bacilli stain), histoplasmosis in three (two adrenals, one lymph node), 32 lymph nodes were reactive and four lymph node FNAs showed inadequate cellularity. The pathologic nodes had significantly lower long-to-short axis ratio [1.25 (1.09 – 1.28) versus 1.46 (1.22 – 1.87), P = 0.020]; a higher proportion of hypoechoic echotexture (5 versus 3, P = 0.017), and sharply defined borders (4 versus 2, P = 0.029). Complications included mild hepatic encephalopathy related to sedation in two patients with Child’s C status. Conclusion: EUS guided FNA is safe in patients with cirrhosis and modified the management in 14/46 (30.4 %) patients.

Is Treatment of Hepatic Osteodystrophy With Bisphosphonate Possible

Hepatic artery thrombosis (HAT) is a serious complication after liver transplantation (LT) which often resulted in biliary complication, early graft loss and patient death. According to the time course, HAT within 30 days is defined as early HAT, while HAT occurs more than 30 days after LT is defined as late HAT. In a large review of 21,822 patients underwent LT, the overall incidence of early HAT is 4.4%, with higher incidence in children than in adult (8.3 vs 2.9%), and a median time of diagnosis on POD7. Early HAT resulted in an overall re-transplantation rate of 53.1% (children higher than adult, 62 vs. 50%) and an overall mortality rate of 33.3% (adult higher than children, 34.3 vs 25%). It is generally thought that early HAT without urgent re-vascularization or re-transplantation almost always leads to mortality, especially those occuring within a few days of posttransplant. Here we presented 3 cases of early HAT after living donor LT, in which the attempts of arterial revascularization failed through surgical or endovascular intervention. Unexpectedly, these 3 patients survive well with acceptable graft function and followed up for 32 months, 11 months, and 4 months, respectively. Possible explanations from anatomical aspect were reviewed and discussed. Our experience showed that early HAT occuring within one week postoperatively, without successful re-vascularization or urgent re-transplantation, may not always lead to mortality, and re-transplantation may be preserved for selective patients who had irreversible liver failure. Prevalence of Hypothyroidism in Nonalcoholic Fatty Liver Disease in