Zachary Henry

Meshed capillary vessels found on narrow-band imaging without optical magnification effectively identifies colorectal neoplasia: a North American validation of the Japanese experience.

BACKGROUND The presence of meshed capillary (MC) vessels is highly sensitive (96%) and specific (92%) for diagnosing colorectal neoplasia on colonoscopy by using narrow-band imaging (NBI) with optical magnification, which is not available in North America. However, the efficacy of NBI to identify an MC pattern without optical magnification has not been determined. OBJECTIVE To determine the diagnostic capabilities of NBI colonoscopy without optical magnification in differentiating neoplastic from non-neoplastic colorectal polyps by using the MC pattern. DESIGN Retrospective comparison of prospectively collected colorectal polyp data. SETTING Large, academic medical center. PATIENTS This study involved 126 consecutive colorectal polyps (median size 3 mm) that were found in 52 patients (33 men) with a median age of 59.5 years. INTERVENTION All lesions identified by white-light colonoscopy were prospectively diagnosed in real-time by using the MC pattern as determined on high-definition NBI, with 1.5x zoom but without true optical magnification, and then endoscopically excised. Surgical pathology was used as the criterion standard. MAIN OUTCOME MEASUREMENTS Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of identifying neoplastic polyps were calculated. RESULTS NBI without optical magnification was found to have a sensitivity of 93%, specificity of 88%, positive predictive value of 90%, negative predictive value of 91%, and diagnostic accuracy of 91% when all polyp sizes were considered. For lesions < or =5 mm, sensitivity was 87%, specificity was 93%, positive predictive value was 89%, negative predictive value was 91%, and diagnostic accuracy was 90%. LIMITATIONS Single-center, single-endoscopist experience. CONCLUSION Use of the MC pattern on NBI colonoscopy without optical magnification effectively distinguishes neoplastic from non-neoplastic colorectal polyps. NBI colonoscopy without optical magnification for neoplastic polyp diagnosis appears to be comparable with NBI with optical magnification when the MC pattern is used. A large, prospective trial is needed for further validation.

Prophylactic anticoagulation for venous thromboembolism in hospitalized cirrhosis patients is not associated with high rates of gastrointestinal bleeding

Hospitalized patients with cirrhosis are at risk to develop venous thromboembolism. Although current guidelines support the routine administration of thromboprophylaxis to hospitalized patients, there is limited data regarding the safety or efficacy of this practice in hospitalized cirrhosis patients.

Bleeding after percutaneous endoscopic gastrostomy is linked to serotonin reuptake inhibitors, not aspirin or clopidogrel.

BACKGROUND Percutaneous endoscopic gastrostomy (PEG) is an invasive procedure that can result in bleeding. Guidelines recommend discontinuing clopidogrel for 7 to 10 days, but not withholding aspirin, before PEG. Serotonin reuptake inhibitors (SRIs) have been associated with an increased risk of GI bleeding. OBJECTIVE To determine whether there is an association between periprocedural aspirin, clopidogrel, or SRI use and bleeding in patients who underwent PEG tube placement. DESIGN Retrospective cohort study. SETTING Large quaternary-care academic medical center. PATIENTS A total of 990 patients (525 men) with a median age of 69.8 years who underwent PEG from January 1999 to April 2009. INTERVENTIONS PEG tube placement. MAIN OUTCOME MEASUREMENTS GI bleeding. RESULTS Sixteen patients (1.6%) had evidence of bleeding during the first 48 hours after PEG, and 12 patients (1.2%) had evidence of bleeding between 48 hours and 14 days after PEG. Thirty-six patients (3.6%) received high-dose aspirin (>325 mg), 27 patients (2.7%) received clopidogrel (75 mg), and 99 patients (10%) received an SRI before PEG. Twenty-four patients (2.4%) received high-dose aspirin, 25 patients (2.5%) received clopidogrel, and 130 patients (13.1%) received an SRI after PEG. Multivariate analysis demonstrated no association between periprocedural use of aspirin (at any dose) or clopidogrel and post-PEG bleeding. However, SRIs administered 24 hours or less before PEG were associated with a significantly higher odds of post-PEG bleeding (adjusted odds ratio 4.1; 95% CI, 1.1-13.4; P = .04). LIMITATIONS Retrospective, single-center study with limited statistical power despite a relatively large cohort of patients. CONCLUSIONS Use of aspirin or clopidogrel before or after PEG was not associated with procedure-related bleeding. SRI use in the 24 hours before PEG was associated with an increased risk of bleeding.

Portal vein thrombosis: When to treat and how?

Portal vein thrombosis is an unusual thrombotic condition not frequently seen in the general population; however, it has a higher prevalence in special circumstances such as in liver cirrhosis and hepatic or pancreatic malignancy. It also can be associated with significant morbidity and mortality. In this review, we discuss the current data available to guide therapy in the setting of different associated co-morbidities, hypercoagulable states, and associated thrombosis of the remaining splanchnic circulation. We discuss indications for anticoagulation, including the choice of anticoagulants, as well as the role of conservative ‘wait and watch’ and invasive therapies, such as thrombolysis, thrombectomy, and transjugular intrahepatic portosystemic shunt.

Editorial: “Lean” NAFLD: Metabolic Obesity with Normal BMI… Is It in the Genes?

Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease. “Lean” NAFLD represents a patient subpopulation with hepatic steatosis evident on imaging with normal BMI. This paper by Feldman and Eder et al. illustrates the mild but clear metabolic differences and genetic connections in Caucasian lean NAFLD patients compared with obese NAFLD and healthy controls. Their findings highlight key similarities of lean and obese NAFLD compared with lean healthy subjects. This paper characterizes “lean” NAFLD as a unique phenotype with specific genetic associations deserving of further investigation in the greater scheme of elucidating the pathophysiology of fatty liver.

Management of Gastric Varices

Gastric varices (GV) present a challenge not always amenable to conventional approaches applied to esophageal varices (EV). Several types of GV classification systems exist including the familiar Sarin system and lesser-known vascular classifications which provide a foundation for management triage. While GV bleeding is less frequent than EV bleeding, it is often more pronounced. Initial management follows that for EV including very cautious volume replacement and early use of vasoactive medications. Urgent temporizing measures, if needed, may include balloon tamponade, sclerosants, banding, clipping and possibly procoagulants. Imaging is important in early management as optimal modalities such as balloon retrograde transvenous obliteration (BRTO), transhepatic porto-systemic shunts (TIPS), cyanoacrylate or combination modalities are contingent on the underlying vascular anatomy. Each of these is associated with particular advantages and disadvantages as discussed below.

Baclofen for the treatment of muscle cramps in patients with cirrhosis: A new alternative.

Painful muscle cramps are a common complication of cirrhosis. Current therapies used in clinical practice mainly focus on vitamin repletion, electrolyte repletion, or altered energy metabolism with variable results, often leaving patients with no viable therapeutic options. Previous studies with quinidine and eperisone hydrochloride act on a proposed disruption of the nervous system leading to muscle cramps and showed moderate benefit, but have not been further assessed. Based upon these results and the potential interaction of the nervous system in the etiology of muscle cramps in patients with cirrhosis, we evaluated the antispasmodic medication, baclofen, for treatment of muscle cramps in patients with cirrhosis. Subjects with a diagnosis of cirrhosis and a complaint of muscle cramps were enrolled in a pilot study using low-dose baclofen. Subjects underwent a muscle cramps questionnaire to identify frequency (days per week) and severity (1-10 analog scale) of muscle cramps. All previous medications aimed at treating muscle cramps were held for the duration of the study. Subjects were then given baclofen 5 mg three times a day (TID) for 1 week, and, if tolerated, the dose was then increased to 10 mg TID. At the end of a 4-week treatment period, the muscle cramps survey was repeated. Baclofen was tapered off, a 2-week washout period was observed, and the muscle cramps survey was repeated. Side effects were assessed weekly throughout the study period by telephone. A total of 10 subjects underwent treatment with baclofen, with 8 subjects completing the treatment protocol. One subject dropped out of the study after 1 week because of somnolence, and 1 subject passed away secondary to complications of an incarcerated umbilical hernia. A third patient completed the treatment protocol, but underwent liver transplantation before completing the washout period. Rates of efficacy and common side effects are shown in Table 1. Routine blood tests were not performed during the study period, but 1 subject was diagnosed with hyponatremia during the study period by their primary hepatologist. This resolved without stopping baclofen and was not considered to be related to therapy. There were no reports from subjects or their primary hepatologists of drug-induced liver injury. Three subjects were put back on baclofen by their primary hepatologist after the study period, ranging from 1 additional month of therapy to an additional year of therapy, with anecdotal reports of continued efficacy in treating their muscle cramps and no reported side effects leading to stopping baclofen. This is the first study to evaluate baclofen for the treatment of muscle cramps in cirrhosis. The safety profile of low-dose baclofen noted in this study is similar to previous studies evaluating the use of baclofen in patients with cirrhosis. Baclofen is a readily available prescription medication that appears to be a safe, effective alternative for treament of muscle cramps in this patient population. Though larger, randomized, placebo-controlled trial data are needed to verify the effect observed here, we believe that baclofen can serve as a reasonable alternative therapy for muscle cramps in patients with cirrhosis.

Editorial: Beta-blockers and the prevention of decompensation in cirrhosis: worth the trouble.

Non-selective beta-blockers have been a cornerstone of therapy for prevention of esophageal variceal bleeding in cirrhosis patients for more than two decades. When lowering the hepatic vein portal pressure gradient (HVPG) below 12 mm Hg or decreasing the pressure by 20% from baseline, these drugs are of proven benefit in reducing variceal bleeding and improving survival in this patient population. The recent work by Hendández-Gea et al., suggests that initiation of the beta-blocker nadolol in cirrhosis patients with high-risk varices can delay or prevent the first occurrence of clinically evident ascites. This finding comes with some caveats, however. The beneficial effect was only seen in patients who had an improvement by 10% or more from baseline HVPG pressure (only 51% of the treated patients in this study). This class of medications has some risk and tolerance issues, and many patients do not respond, even when the heart rate is optimally decreased. Despite this, the use of beta-blockers may be beneficial in the primary prevention of the formation of ascites and further decompensation of cirrhosis.

Spontaneous bacterial peritonitis prevalence in pre-transplant patients and its effect on survival and graft loss post-transplant

AIM To investigate the incidence of spontaneous bacterial peritonitis (SBP) in pre-transplant patients and its effect on post transplant mortality and graft failure. METHODS We conducted a retrospective cohort study of patient records from the organ procurement and transplant network data set. Patients were identified by the presence of SBP pre-transplant. Univariate post-transplant survival models were constructed using the Kaplan-Meier technique and multivariate models were constructed using the Cox proportional hazards model. Variables that affected post-transplant graft survival were identified in the SBP population. RESULTS Forty-seven thousand eight hundred and eighty patient records were included in the analysis for both groups, and 1966 (4.11%) patients were identified in the data set as having pre-transplant SBP. Patients that had pre-transplant SBP had higher rates of graft loss from recurrent hepatitis C virus (HCV) (3.6% vs 2.0%, P < 0.0001), infections leading to graft loss (1.9% vs 1.3%, P = 0.02), primary non-function (4.3% vs 3.0%, P < 0.0001) and chronic rejection (1.1% vs 0.7%, P = 0.04). Kaplan-Meier survival analysis showed a statistically significant difference in all-cause survival in patients with a history of SBP vs those without (P < 0.0001). Pre-transplant history of SBP was independently predictive of mortality due to recurrent HCV (HR = 1.11, 95%CI: 1.02-1.21, P < 0.017) after liver transplantation. CONCLUSION HCV patients prior to the advent of directing acting anti-viral agents had a higher incidence of pre-transplant SBP than other patients on the liver transplant wait list. SBP history pre-transplant resulted in a higher rate of graft loss due to recurrent HCV infection and chronic rejection.

Obesity and Hepatocellular Carcinoma: A Complex Relationship

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 Obesity and Hepatocellular Carcinoma: A Complex Relationship 63 64 65 66 67 68 69 70 71 72 See “Early adulthood obesity increases risk and decreases age of onset in hepatocellular carcinoma,” by Hassan M, Abdel-Wahab R, Kaseb A, et al, on page 000.