Wuttiporn Manatsathit

Management of gastrointestinal bleeding in patients anticoagulated with dabigatran compared with warfarin: a retrospective, comparative case review

BACKGROUND Dabigatran etexilate, was found to be effective for stroke prevention in patients with non-valvular atrial fibrillation. Given its predictable pharmacodynamics, laboratory monitoring is not required. Moreover, the risks of overall bleeding, intracranial bleeding, and life-threatening hemorrhage from dabigatran were found to be lower than warfarin. However, a higher risk of gastrointestinal (GI) bleeding caused by dabigatran from the randomized evaluation of long-term anticoagulant therapy (RE-LY) trial has raised the concern regarding clinical outcomes of patients with GI bleeding caused by dabigatran compared with warfarin. METHODS We retrospectively studied patients who were hospitalized for GI bleeding from dabigatran compared with warfarin with therapeutic anticoagulation monitoring during 2009 to 2012. Initial laboratory findings at presentation, number of transfused packed red blood cells (PRBCs), acute kidney injury, clinical outcomes (e.g., hypotension, tachycardia), length of stay, and death were compared. RESULTS Thirteen patients taking dabigatran and 26 patients who were on warfarin with therapeutic international normalized ratio (INR) were hospitalized during the study period. Demographic data and baseline parameters between the two groups were not significantly different except for concurrent aspirin use (84.6% vs. 50%, P=0.036). Fifty-four percent of patients taking dabigatran did not have activated partial thromboplastin time (aPTT) level performed at presentation (7/13). The patients with GI bleeding from warfarin received significantly more PRBC transfusions compared with the dabigatran group (1.92±2.2 vs. 0.69±1.1 units, P=0.024). After controlling for initial hemoglobin and history of chronic kidney disease by using multivariate analysis, the patients in the warfarin group were likely to receive more PRBC. Hypotension at presentation was more common in GI bleeding caused by warfarin than dabigatran but the P value was insignificant (30.8% vs. 7.7%, P=0.11). Nevertheless, no differences in clinical outcomes or length of stay were found between the two groups. CONCLUSIONS From our data, the patients with GI bleeding from dabigatran were likely to receive fewer PRBC transfusions; however, clinical outcomes and length of stay were comparable to GI bleeding caused by warfarin. Our sample generalizes to an elderly population (mean age of 77.9±10 years old) with creatinine clearance (CrCl) >30 mL/min who experience GI bleeding during chronic anticoagulation.

The incidence of cholelithiasis after sleeve gastrectomy and its association with weight loss: A two-centre retrospective cohort study

INTRODUCTION Gallstones commonly develop after Roux-en-Y gastric bypass and other bariatric surgery; however, incidence of gallstone development after SG has not been adequately studied. METHODS We conducted a retrospective cohort study of patients who underwent SG at two institutions from January 1, 2011 to December 31, 2012. Patients with previous cholecystectomy, preexisting gallstones, gallbladder polyps, or the absence of preoperative abdominal imaging were excluded. Follow-up abdominal ultrasonography was performed once the patients achieved 80-lb weight loss, became symptomatic, or reached one-year post-surgery. The incidence of gallstones and symptomatic gallstones and/or bile sludge was calculated. Different parameters of early and late postoperative weight loss were compared between the patients who developed gallstones and those who did not. RESULTS During the study period, 253 underwent laparoscopic sleeve gastrectomy. Ultimately, 96 patients met inclusion criteria and were evaluated. The incidence of gallstone formation was 47.9% (46/96), and the incidence of symptomatic gallstones was 22.9% (22/96). None of the weight loss parameters during the early and late postoperative period were significantly different between the patients who developed gallstones and those who did not. CONCLUSION Gallstones are a common complication after rapid weight loss from SG. Our data suggest that gallstone formation during the weight loss period is not associated with amount or rate of weight loss both during the early or late postoperative period.

A Case of Recurrent Acute Pancreatitis Due to Intra-Articular Corticosteroid Injection

CONTEXT Corticosteroid is a well-established cause of drug-induced pancreatitis. However, acute pancreatitis from intra-articular injection of corticosteroid has never been described. CASE REPORT A 69-year-old male presented with acute abdominal pain and was diagnosed with acute pancreatitis. The patient had one episode of acute pancreatitis two year earlier. Both episodes occurred after intra-articular cortisone injection. Investigations for other causes of pancreatitis were negative. CONCLUSION We report the first case of acute pancreatitis from intra-articular corticosteroid injection. Physicians should be aware of this adverse reaction of corticosteroid that can even occur with local administration.

Hepatitis B virus infection and risk of gallstones: a systematic review and meta-analysis.

Background/objectives Gallstone disease and its complications are common, particularly in Western populations. Recent studies have reported a significantly increased risk of gallstones among hepatitis C virus-infected patients. However, the data on patients with hepatitis B virus (HBV) infection are still limited. This meta-analysis was carried out with the aim of summarizing all available evidence. Patients and methods A literature search was performed using MEDLINE and the EMBASE database from inception to May 2016. Studies that reported relative risks, odd ratios, or hazard ratios comparing the risk of gallstones among HBV-infected patients versus patients without HBV infection were included. Pooled odds ratio (OR) and 95% confidence interval (CI) were calculated using a random-effect, generic inverse-variance method. Results Nine studies fulfilled our eligibility criteria and were included in the analysis. We found no significant association between HBV infection and the risk of gallstones, with a pooled OR of 1.10 (95% CI, 0.91–1.33). The statistical heterogeneity was moderate, with an I2 of 69%. Subgroup analysis was carried out. The pooled OR of cross-sectional studies was 1.01 (95% CI, 0.91–1.12; I2 0%), whereas the pooled OR of case–control studies was 1.53 (95% CI, 0.85–2.74; I2 80%). Conclusion A significant association between HBV infection and the risk of gallstones was not observed in this study.

IgG4-related inflammatory pseudotumour mimicking a hepatic abscess impending rupture

A 50-year-old man presenting with sudden onset right upper quadrant pain and no constitutional symptoms was found to have two necrotic liver masses on imaging, consistent with hepatic abscesses unresponsive to systemic antibiotics and percutaneous drainage. The patient deteriorated and developed symptoms consistent with impending rupture. He therefore subsequently underwent right hepatic segmentectomy. All cultures were negative and histopathology confirmed IgG4 related disease/inflammatory pseudotumour of the liver. Postoperatively, the patient was asymptomatic with no IgG4 disease activity in other organs.

Association Between Juxtapapillary Duodenal Diverticula and Risk of Choledocholithiasis: a Systematic Review and Meta-analysis

Background/ObjectivesStudies have suggested that the presence of juxtapapillary duodenal diverticula (JDD) could be a predisposing factor for choledocholithiasis. This systematic review and meta-analysis was conducted with the aims to summarize all available evidence to better characterize the risk.MethodsA literature search was performed using MEDLINE and EMBASE database from inception to January 2018. Cross-sectional studies that reported odd ratios (OR) comparing the risk of choledocholithiasis among individuals with JDD versus individuals without JDD were included. Pooled OR and 95% confidence interval (CI) were calculated using a random-effect, generic inverse variance method.ResultsOf 527 retrieved articles, 11 studies met our eligibility criteria and were included in analysis. We found a significant association between the presence of JDD and choledocholithiasis with the pooled OR of 2.30 (95% CI, 1.84–2.86). The statistical heterogeneity was moderate with an I2 of 60%.ConclusionsA significantly increased risk of choledocholithiasis among individuals with JDD was observed in this study.

Accuracy of liver stiffness, spleen stiffness, and LS-spleen diameter to platelet ratio score in detection of esophageal varices: Systemic review and meta-analysis: Elastography in detection of varices

There is increasing evidence of non‐invasive measurement using elastography such liver stiffness (LS), spleen stiffness (SS), and LS‐spleen diameter to platelet ratio score (LSPS) for detection of esophageal varices (EV); however, data regarding comparison between these three parameters are limited.

Spontaneous Tear After Insufflation: A Unique Finding of Collagenous Colitis

*Nazih Zuhdi Transplant Institute, Integris Baptist Medical Center, Oklahoma City, Oklahoma; University of Nebraska Medical Center, Department of Gastroenterology and Hepatology, Nebraska Medical Center, Omaha, Nebraska; Children’s Hospital and Medical Center Omaha, Department of Gastroenterology, Hepatology, and Nutrition, Omaha, Nebraska 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 74-year-old Caucasian woman was hospitalized

Graft selection strategy in adult‐to‐adult living donor liver transplantation: When both hemiliver grafts meet volumetric criteria

We read with great interest the article published in Liver Transplantation by Kurihara et al. This present article demonstrated that outcomes of recipient are not significantly different between right lobe (RL) and left lobe (LL) living donor liver transplantation (LDLT) when both lobes are available. In fact, the title of this study could somehow mislead readers to think that the study evaluates differences in outcomes of RL and LL when both lobes are appropriate for LDLT. However, although all LLs meet volumetric criteria, in real-world situations, not all LLs are appropriate for LDLT for several reasons. In order to understand this, one has to understand the basis of graft selection in LDLT. Historically, a graft-to-recipient weight ratio (GRWR) between 0.8 to 1.0 is required for good outcomes in LDLT. Several studies subsequently showed that LDLT can be safely performed with GRWR as low as 0.6. However, this is true only in patients with lower Model for End-Stage Liver Disease (MELD) and in young donors. As a result, it is a common practice for a surgeon to favor the RL when performing LDLT in a patient with a higher MELD score or when donors are 50 years old to avoid smallfor-size syndrome. In this study, although both lobes meet volumetric criteria, the LL is not always appropriate for LDLT especially in patients with higher MELD scores or older donors ( 50 years) due to low mean LL GRWR (0.626 0.04 for the RL and 0.766 0.03 for the LL group). It is, therefore, not surprising that patients in the RL group had significantly higher MELD scores and that donors were also significantly older mainly due to the tendency of surgeons to select RLs in these circumstances. Additionally, the study omitted a mention of RL GRWR in the RL group, which could be helpful in explaining good outcomes in this group. Instead, the study went on to use the predictive score and demonstrated that the predictive score is better than the GRWR. Although the predictive score appears to be promising, it was derived from a study with only 22 patients. Therefore, it should be interpreted with caution. In summary, although this study did not provide new information, it, at least, shows that the strategy of selecting RLs among high-MELD patients and older donors is effective. Utilization of the predictive score seems encouraging, but it needs to be validated in a bigger study.

Corrigendum to "The incidence of cholelithiasis after sleeve gastrectomy and its association with weight loss: A two-centre retrospective cohort study" [Int. J. Surg. 30 (2016) 13-18].

Corrigendum to “The incidence of cholelithiasis after sleeve gastrectomy and its association with weight loss: A two-centre retrospective cohort study” [Int. J. Surg. 30 (2016) 13e18] Wuttiporn Manatsathit , Pornchai Leelasinjaroen , Hussein Al-Hamid , Susanna Szpunar , Abdelkader Hawasli c, d, * a Department of Internal Medicine, St John Hospital and Medical Center, Detroit, MI, USA b Department of Medical Education, St John Hospital and Medical Center, Detroit, MI, USA c Division of Minimally Invasive Surgery, Department of General Surgery, St John Hospital and Medical Center, Detroit, MI, USA d Department of General Surgery, Beaumont Hospital, Grosse Pointe, MI, USA