Hepatotoxicity of Antibiotics and Antifungals and Their Safe Use in Hepatic Impairment

Idiosyncratic drug-induced liver injury (DILI) is a rare and unpredictable form of hepatotoxicity. While its clinical course is usually benign, cases leading to liver transplantation or death can occur. Based on modern prospective registries, antimicrobials including antibiotics and antifungals are frequently implicated as common causes. Amoxicillin-clavulanate ranks as the most common cause for DILI in the Western World. Although the absolute risk of hepatotoxicity of these agents is low, as their usage is quite high, it is not uncommon for practitioners to encounter liver injury following the initiation of antibiotic or antifungal therapy. In this review article, mechanisms of hepatoxicity are presented. The adverse hepatic effects of well-established antibiotic and antifungal agents are described, including their frequency, severity, and pattern of injury and their HLA risks. We also review the drug labeling and prescription guidance from regulatory bodies, with a focus on individuals with hepatic impairment.

Randomised clinical trial: a leucine-metformin-sildenafil combination (NS-0200) vs placebo in patients with non-alcoholic fatty liver disease

BACKGROUND

Sirtuin 1 (Sirt1) is suppressed in non-alcoholic fatty liver disease (NAFLD), while its' stimulation or overexpression results in reduced disease severity in pre-clinical NAFLD models. Leucine allosterically activates Sirt1 and synergise with other Sirt/AMPK/NO pathway activators. We developed a triple combination of leucine, metformin and sildenafil (NS-0200), which was effective in a mouse model of non-alcoholic steatohepatitis (NASH).

AIM

To report the results from a Phase 2, randomised clinical trial of of NS-0200 in 91 subjects with NAFLD (liver fat ≥15% by magnetic resonance imaging-proton-density fat fraction (MRI-PDFF)).

METHODS

Subjects were randomised to placebo, low-dose (1.1 g leucine/0.5 g metformin/0.5 mg sildenafil) or high-dose NS-0200 (1.1 g leucine/0.5 g metformin/1.0 mg sildenafil) b.d. for 16 weeks; change in hepatic fat was assessed via MRI-PDFF, and lipid metabolism was assessed via changes in the lipidomic signature. Seventy subjects completed the trial and met a priori compliance criteria. Analyses were conducted on the full cohort and on those with alanine aminotransferase (ALT) values above median (50 U/L; n = 35).

RESULTS

In the full cohort, active treatments did not separate from placebo. High dose NS-0200 reduced hepatic fat by 15.7% (relative change from baseline) in the high ALT group (P < 0.005) while low dose NS-0200 and placebo did not significantly change hepatic fat. Lipidomic analysis showed dose-responsive treatment effects in both overall and high ALT cohorts, with significant decreases in metabolically active lipids and up-regulation of fatty acid oxidation.

CONCLUSION

These data support further evaluation of high-dose NS-0200 for treating NASH, especially in those with elevated ALT (NCT 02546609).

Clinical and metabolic effects associated with weight changes and obeticholic acid in non-alcoholic steatohepatitis

BACKGROUND

In a 72-week, randomised controlled trial of obeticholic acid (OCA) in non-alcoholic steatohepatitis (NASH), OCA was superior to placebo in improving serum ALT levels and liver histology. OCA therapy also reduced weight.

AIMS

Because weight loss by itself can improve histology, to perform a post hoc analysis of the effects of weight loss and OCA treatment in improving clinical and metabolic features of NASH.

METHODS

The analysis was limited to the 200 patients with baseline and end-of-treatment liver biopsies. Weight loss was defined as a relative decline from baseline of 2% or more at treatment end.

RESULTS

Weight loss occurred in 44% (45/102) of OCA and 32% (31/98) of placebo-treated patients (P = 0.08). The NAFLD Activity score (NAS) improved more in those with than without weight loss in both the OCA- (-2.4 vs -1.2, P<0.001) and placebo-treated patients (-1.2 vs -0.5, P = 0.03). ALT levels also improved in those with vs without weight loss in OCA- (-43 vs -34 U/L, P = 0.12) and placebo-treated patients (-29 vs -10 U/L, P = 0.02). However, among those who lost weight, OCA was associated with opposite effects from placebo on changes in alkaline phosphatase (+21 vs -12 U/L, P<0.001), total (+13 vs -14 mg/dL, P = 0.02) and LDL cholesterol (+18 vs -12 mg/dL, P = 0.01), and HbA1c (+0.1 vs -0.4%, P = 0.01).

CONCLUSIONS

OCA leads to weight loss in up to 44% of patients with NASH, and OCA therapy and weight loss have additive benefits on serum aminotransferases and histology. However, favourable effects of weight loss on alkaline phosphatase, lipids and blood glucose seen in placebo-treated patients were absent or reversed on OCA treatment. These findings stress the importance of assessing concomitant metabolic effects of new therapies of NASH. Clinical trial number: NCT01265498.

Improvement in liver histology due to lifestyle modification is independently associated with improved kidney function in patients with non-alcoholic steatohepatitis

BACKGROUND

Several recent studies have shown a strong association between non-alcoholic steatohepatitis (NASH) and chronic kidney disease.

AIM

To examine the relationship between changes in liver histology and renal function in patients with NASH.

METHODS

The present analysis represents a post hoc analysis of a recently published trial that included 261 patients with NASH who were treated with lifestyle modifications during 52 weeks. Kidney function was evaluated through Chronic Kidney Disease Epidemiology Collaboration estimated glomerular filtration rates (eGFR, mL/min/1.73 m² ) overtime. We explored correlations between the kidney function and improvement in histological outcomes at 52 weeks.

RESULTS

Interestingly, a one-stage reduction in fibrosis (r = 0.20, P < 0.01) and resolution of NASH (r = 0.17, P < 0.01) were significantly correlated with an improvement in the kidney function. The eGFR values significantly increased in patients with fibrosis improvement (+7.6 ± 6.5 mL/min/1.73 m² ), compared to those without fibrosis improvement (-1.98 ± 6.4 mL/min/1.73 m² ) (P < 0.01) at end of treatment (EOT). Likewise, NASH resolution was associated with an increase in eGFR compared with patients without NASH resolution (2.32 ± 7.8 mL/min/1.73 m² vs. -1.04 ± 5.9 mL/min/1.73 m² , P = 0.04) at EOT. After controlling for the confounders, the association between fibrosis improvement, NASH resolution and eGFR change remained significant (P < 0.05 for both).

CONCLUSIONS

Improvement in liver histology due to lifestyle modification is independently associated with improved kidney function in NASH. As new drugs for NASH emerge, studies should address whether improvement in histology in response to pharmacotherapies yield the same improvement in kidney function as weight loss.

Randomised clinical study: GR-MD-02, a galectin-3 inhibitor, vs. placebo in patients having non-alcoholic steatohepatitis with advanced fibrosis

BACKGROUND

Non-alcoholic steatohepatitis (NASH) and resultant liver fibrosis is a major health problem without approved pharmacotherapy. Pre-clinical results of GR-MD-02, a galectin-3 inhibitor, suggested potential efficacy in NASH with advanced fibrosis/cirrhosis and prompted initiation of a clinical development programme in NASH with advanced fibrosis.

AIM

To evaluate the safety, pharmacokinetics and exploratory pharmacodynamic markers of GR-MD-02 in subjects having NASH with bridging fibrosis.

METHODS

The GT-020 study was a first-in-human, sequential dose-ranging, placebo controlled, double-blinded study with the primary objective to assess the safety, tolerability and dose limiting toxicity of GR-MD-02, in subjects with biopsy-proven NASH with advanced fibrosis (Brunt stage 3). The secondary objectives were to characterise first-dose and multiple-dose pharmacokinetic profiles and to evaluate changes in potential serum biomarkers and liver stiffness as assessed by FibroScan.

RESULTS

GR-MD-02 single and three weekly repeated of 2, 4 and 8 mg/kg revealed no meaningful clinical differences in treatment emergent adverse events, vital signs, electrocardiographic findings or laboratory tests. Pharmokinetic parameters showed a dose-dependent relationship with evidence of drug accumulation following 8 mg/kg (~twofold).

CONCLUSIONS

GR-MD-02 doses were in the upper range of the targeted therapeutic dose determined from pre-clinical data and were safe and well tolerated with evidence of a pharmacodynamic effect. These results provide support for a Phase 2 development programme in advanced fibrosis due to NASH.

Features and Outcomes of 899 Patients With Drug-Induced Liver Injury: The DILIN Prospective Study

BACKGROUND & AIMS

The Drug-Induced Liver Injury Network is conducting a prospective study of patients with DILI in the United States. We present characteristics and subgroup analyses from the first 1257 patients enrolled in the study.

METHODS

In an observational longitudinal study, we began collecting data on eligible individuals with suspected DILI in 2004, following them for 6 months or longer. Subjects were evaluated systematically for other etiologies, causes, and severity of DILI.

RESULTS

Among 1257 enrolled subjects with suspected DILI, the causality was assessed in 1091 patients, and 899 were considered to have definite, highly likely, or probable DILI. Ten percent of patients died or underwent liver transplantation, and 17% had chronic liver injury. In the 89 patients (10%) with pre-existing liver disease, DILI appeared to be more severe than in those without (difference not statistically significant; P = .09) and mortality was significantly higher (16% vs 5.2%; P < .001). Azithromycin was the implicated agent in a higher proportion of patients with pre-existing liver disease compared with those without liver disease (6.7% vs 1.5%; P = .006). Forty-one cases with latency ≤7 days were caused predominantly by antimicrobial agents (71%). Two most common causes for 60 DILI cases with latency >365 days were nitrofurantoin (25%) or minocycline (17%). There were no differences in outcomes of patients with short vs long latency of DILI. Compared with individuals younger than 65 years, individuals 65 years or older (n = 149) were more likely to have cholestatic injury, although mortality and rate of liver transplantation did not differ. Nine patients (1%) had concomitant severe skin reactions; implicated agents were lamotrigine, azithromycin, carbamazepine, moxifloxacin, cephalexin, diclofenac, and nitrofurantoin. Four of these patients died.

CONCLUSIONS

Mortality from DILI is significantly higher in individuals with pre-existing liver disease or concomitant severe skin reactions compared with patients without. Additional studies are needed to confirm the association between azithromycin and increased DILI in patients with chronic liver disease. Older age and short or long latencies are not associated with DILI mortality.

Comparative analysis of portal hepatic infiltrating leucocytes in acute drug-induced liver injury, idiopathic autoimmune and viral hepatitis

Drug-induced liver injury (DILI) is often caused by innate and adaptive host immune responses. Characterization of inflammatory infiltrates in the liver may improve understanding of the underlying pathogenesis of DILI. This study aimed to enumerate and characterize leucocytes infiltrating liver tissue from subjects with acute DILI (n = 32) versus non-DILI causes of acute liver injury (n = 25). Immunostains for CD11b/CD4 (Kupffer and T helper cells), CD3/CD20 (T and B cells) and CD8/CD56 [T cytotoxic and natural killer (NK) cells] were evaluated in biopsies from subjects with acute DILI, either immunoallergic (IAD) or autoimmune (AID) and idiopathic autoimmune (AIH) and viral hepatitis (VH) and correlated with clinical and pathological features. All biopsies showed numerous CD8(+) T cells and macrophages. DILI cases had significantly fewer B lymphocytes than AIH and VH and significantly fewer NK cells than VH. Prominent plasma cells were unusual in IAD (three of 10 cases), but were associated strongly with AIH (eight of nine) and also observed in most with AID (six of nine). They were also found in five of 10 cases with VH. Liver biopsies from subjects with DILI were characterized by low counts of mature B cells and NK cells in portal triads in contrast to VH. NK cells were found only in cases of VH, whereas AIH and VH both showed higher counts of B cells than DILI. Plasma cells were associated most strongly with AIH and less so with AID, but were uncommon in IAD.

Serum proteomic profiling in patients with drug-induced liver injury

BACKGROUND

Idiosyncratic drug-induced liver injury (DILI) is a complex disorder that is difficult to predict, diagnose and treat.

AIM

To describe the global serum proteome of patients with DILI and controls.

METHODS

A label-free, mass spectrometry-based quantitative proteomic approach was used to explore protein expression in serum samples from 74 DILI patients (collected within 14 days of DILI onset) and 40 controls. A longitudinal analysis was conducted in a subset of 21 DILI patients with available 6-month follow-up serum samples.

RESULTS

Comparison of DILI patients based on pattern, severity and causality assessment of liver injury revealed many differentially expressed priority 1 proteins among groups. Expression of fumarylacetoacetase was correlated with alanine aminotransferase (ALT; r = 0.237; P = 0.047), aspartate aminotransferase (AST; r = 0.389; P = 0.001) and alkaline phosphatase (r = -0.240; P = 0.043), and this was the only protein with significant differential expression when comparing patients with hepatocellular vs. cholestatic or mixed injury. In the longitudinal analysis, expression of 53 priority 1 proteins changed significantly from onset of DILI to 6-month follow-up, and nearly all proteins returned to expression levels comparable to control subjects. Ninety-two serum priority 1 proteins with significant differential expression were identified when comparing the DILI and control groups. Pattern analysis revealed proteins that are components of inflammation, immune system activation and several hepatotoxicity-specific pathways. Apolipoprotein E expression had the greatest power to differentiate DILI patients from controls (89% correct classification; AUROC = 0.97).

CONCLUSION

This proteomic analysis identified differentially expressed proteins that are components of pathways previously implicated in the pathogenesis of idiosyncratic drug-induced liver injury.

The effects of midodrine on the natriuretic response to furosemide in cirrhotics with ascites

BACKGROUND

Resistance to loop diuretics is common in patients with ascites. Diminished glomerular filtration rate (GFR) is thought to mediate resistance to loop diuretics. Midodrine, a commonly used alpha-1 agonist, has been shown to improve GFR in non-azotemic patients with cirrhosis.

AIM

To conduct a randomized, double-blind, placebo-controlled, cross-over study to test the hypothesis that midodrine significantly increases natriuretic response of IV furosemide in non-azotemic cirrhotics with ascites.

METHODS

All subjects participated in both phases, which were (i) furosemide IV infusion + oral midodrine 15 mg administered 30 min before furosemide (ii) furosemide IV infusion + oral placebo administered 30 min before furosemide. Primary outcomes were 6-h urine sodium excretion and 6-h total urine volume.

RESULTS

A total of 15 patients (men: 8; age: 52.7 ± 7.6 years; serum creatinine: 1.06 ± 0.2 mg/dL) were studied. Total 6-h urine sodium excretion was 109 ± 42 mmol in the furosemide + midodrine treatment phase and was not significantly different from that in the furosemide + placebo treatment phase (126 ± 69 mmol, P = 0.6). Similarly, mean 6-h total urine volume was not significantly different between two groups (1770 ± 262 mL vs. 1962 ± 170 mL, P = 0.25).

CONCLUSIONS

Oral midodrine does not increase the natriuretic response to furosemide in non-azotemic cirrhotic patients with ascites. Orally administered midodrine does not increase natriuretic response to furosemide in non-azotemic cirrhotic patients with ascites.

Predictors of outcome in patients with unresectable hepatocellular carcinoma receiving transcatheter arterial chemoembolization

BACKGROUND

Transcatheter arterial chemoembolization (TACE) has been shown to improve survival in patients with unresectable hepatocellular carcinoma (HCC).

AIM

To identify pretreatment factors that predicts increased mortality in HCC patients receiving TACE.

METHODS

Retrospective review of all patients who underwent TACE for HCC from January 1999 to November 2004. Patient demographics, aetiology of liver disease, laboratory and imaging data regarding tumour characteristics were obtained.

RESULTS

Eighty-eight patients (57 +/- 1 years age) received 1-4 sessions of TACE (1.4 +/- 0.1). Tumour size was 3.3 +/- 0.2 cm (range 1-13 cm, median 3 cm) with mean number of lesions 1.9 +/- 0.1 (range 1-7). Mean model for the end stage liver disease score: 11 +/- 0.4; cancer of the liver Italian program score: 1.3 +/- 0.1. Survival post-TACE (excluding those underwent orthotopic liver transplantation) was 12 +/- 0.3 months. By multivariate analysis, tumour size (HR = 1.37, 95% CI: 1.11-1.68, P = 0.003), hypovascularity (HR = 12.62, 95% CI: 1.79-88.92, P = 0.01) and elevated international normalized ratio (HR = 1.46, 95% CI: 1.10-1.92 P = 0.008) are shown to be significant risk factors for increased mortality.

CONCLUSION

TACE therapy leads to a mean survival of 12 months in patients not receiving orthotopic liver transplantation. Tumour size, hypovascularity on imaging, and elevated international normalized ratio are predictors of increased mortality after TACE therapy for HCC.

Diltiazem inhibits human intestinal cytochrome P450 3A (CYP3A) activity in vivo without altering the expression of intestinal mRNA or protein

AIMS

To determine the effect of diltiazem on intestinal CYP3A activity and protein and mRNA expression in vivo in healthy subjects.

METHODS

Intestinal biopsies were obtained from ten healthy controls and from ten healthy subjects after receiving diltiazem 120 mg bid for 7 days. Intestinal CYP3A activity, CYP3A4 protein and mRNA concentrations were quantified in both groups. Intestinal CYP3A activity was determined by incubation of small bowel homogenate with midazolam (25 microM) and NADPH for 5 min and the rate of formation of 1'-hydroxymidazolam was quantified.

RESULTS

All subjects in the treatment group had detectable diltiazem concentration in the serum. While there was no significant difference in CYP3A4 protein and mRNA expression between the control and treatment groups, the formation of 1'-hydroxymidazolam (446 pmol min(-1) mg(-1) 6 (control) vs. 170 (CI 112, 228) pmol min(-1) mg(-1) 95% confidence interval (CI 269, 623) (diltiazem group)) was significantly reduced (P < 0.05).

CONCLUSION

Diltiazem decreased small bowel CYP3A activity by 62% as a result of irreversible inhibition with no corresponding change in intestinal CYP3A4 mRNA or protein concentrations.

Positron emission tomography for detecting occult hepatocellular carcinoma in hepatitis C cirrhotics awaiting for liver transplantation

Patients with hepatitis C cirrhosis may sometimes have persistently elevated alpha feto protein (AFP) despite a lack of evidence for disease by ultrasound or computed tomography (CT). While this pattern may represent a benign manifestation of hepatitis C cirrhosis (HCC), it raises concern for the possibility of an occult hepatocellular carcinoma. It has previously been shown that positron emission tomography (PET scan) may detect occult cholangiocarcinoma in high-risk patients with primary sclerosing cholangitis. We hypothesized that PET scanning might similarly serve for occult HCC in hepatitis C cirrhotics. PET scanning was performed on eight hepatitis C cirrhotics who were on the liver transplantation list and displayed persistently elevated AFP (>100 ng/mL) but no detectable lesions on abdominal CT scan. The results of PET detection of occult HCC were compared to those obtained with lipiodol-enhanced CT scanning and with histologic examination of the live explant. Explant histology or prolonged clinical follow-up showed two subjects to have conclusive evidence of HCC; the remainder, no evidence of malignancy. Although PET imaging did not reveal abnormal lesions in any subject; lipiodol-enhanced CT scans revealed abnormal lipiodol retention in both subjects with HCC. These preliminary findings suggest that PET has no role in detecting occult HCC in high-risk patients. Additionally, these data suggest that some hepatitis C cirrhotics with persistently elevated AFP but no detectable lesions by conventional CT scan may show occult HCC using lipiodol-enhanced CT scans.

Hepatic and intestinal cytochrome P450 3A activity in cirrhosis: effects of transjugular intrahepatic portosystemic shunts

Transjugular intrahepatic portosystemic shunt (TIPS) is performed to treat some complications of cirrhosis. This study investigated the effects of cirrhosis and TIPS on intestinal and hepatic cytochrome P450 3A (CYP3A) activity. Nine volunteers were cirrhotic patients with TIPS, 9 were cirrhotic controls (matched for sex, age, etiology, and Child-Pugh class), and 9 were sex- and age-matched healthy volunteers. Simultaneous doses of midazolam were given intravenously (0.05 mg/kg) and orally (3 mg of [15N3]midazolam). Peripheral and portal venous blood samples were assayed for midazolam and [15N3]midazolam. The systemic clearance of midazolam was significantly greater (P <.05) in healthy volunteers (0.42 +/- 0.10 L x h(-1) x kg(-1)) compared with cirrhotic controls (0.20 +/- 0.05) and with cirrhotic patients with TIPS (0.21 +/- 0.09). Hepatic availability followed the same trend. The bioavailability of midazolam was significantly higher (P <.05) in cirrhotic patients with TIPS (0.76 +/- 0.20) compared with cirrhotic controls (0.27 +/- 0.14) and with healthy volunteers (0.30 +/- 0.10). The intestinal availability was significantly greater (P <.05) in cirrhotic patients with TIPS (0.83 +/- 0.17) compared with cirrhotic controls (0.32 +/- 0.16) and with healthy volunteers (0.42+/-0.15). As expected, hepatic CYP3A activity was reduced in cirrhosis. However, in cirrhotic patients with TIPS, there was a marked loss in first-pass metabolism of midazolam as a result of diminished intestinal CYP3A activity.

Increase in hepatic arterial blood flow after transjugular intrahepatic portosystemic shunt creation and its potential predictive value of postprocedural encephalopathy and mortality

PURPOSE

To determine (i) whether there is a significant increase in hepatic artery blood flow (HABF) after transjugular intrahepatic portosystemic shunt (TIPS) creation and (ii) whether the extent of incremental increase in HABF is predictive of clinical outcome after TIPS creation.

MATERIALS AND METHODS

Prospective, nonrandomized, nonblinded duplex Doppler ultrasound (US) examinations were performed on 24 consecutive patients (19 men; Child Class A/B/C: 4/12/8, respectively) with a mean age of 52.8 years who were referred for TIPS creation for variceal bleeding. Peak hepatic artery velocity and vessel dimensions were used to calculate the hepatic arterial blood flow (HABF) before and after TIPS creation. Patients were clinically followed in the gastrohepatology clinic and TIPS US surveillance was performed at 1 and 3 months to assess shunt function. The extent of incremental increase in HABF was analyzed as a predictor of post-TIPS encephalopathy and/or death.

RESULTS

The technical success rate of TIPS creation was 100%. The shunt diameters were either 10 mm (n = 11) or 12 mm (n = 13). TIPS resulted in a significant reduction in the portosystemic gradient from 24.3 mm Hg +/- 5.7 to 9.3 mm Hg +/- 2.9 (P <.001). The hepatic artery peak systolic velocity and HABF increased significantly after TIPS creation, from 60.8 cm/sec +/- 26.7 to 121 cm/sec +/- 51.5 (P <.001) and from 254.2 mL/min +/- 142.2 to 507.8 mL/min +/- 261.3 (P <.001), respectively. The average incremental increase in HABF from pre-TIPS to post-TIPS was 253.6 mL/min +/- 174.2 and the average decremental decrease in portosystemic gradient was 15.0 mm Hg +/- 5.3, but there was no significant correlation (r = 0.04; P =.86) between the two. All shunts were patent at 30 and 90 days without sonographic evidence of shunt dysfunction. After TIPS creation, new or worsened encephalopathy developed in five patients at 30 days and in an additional three at 90 days. They were all successfully managed medically. Three patients (12.5%) died within 30 days of the TIPS procedure. The extent of incremental increase in HABF after TIPS was variable and did not correlate with the development of 30-day and 90-day encephalopathy (P =.41 and P =.83, respectively) or 30-day mortality (P =.2).

CONCLUSIONS

HABF increases significantly after TIPS but is not predictive of clinical outcome. The significance of the incremental increase is yet to be determined.

Predictors of inadequate bowel preparation for colonoscopy

OBJECTIVE

Inadequate preparation of the bowel for colonoscopy can result in both missed pathological lesions and cancelled procedures. We looked prospectively at the quality of colonic preparation and evaluated potential associations between specific patient characteristics and inadequate colonic preparation.

METHODS

Data were gathered on consecutive patients presenting for colonoscopy who received either a polyethylene glycol lavage or oral sodium phosphate bowel preparation. Patient demographic and medical history information was gathered before scheduled colonoscopy. The endoscopist evaluated the preparation quality during the procedure. Complete data were gathered on 649 of 714 eligible patients (90.8%). Possible predictors of inadequate colonic preparation were analyzed using univariate statistics and multivariate logistic regression models.

RESULTS

An inadequate colonic preparation was reported in 21.7% of observed colonoscopies. Only 18% of patients with an inadequate colonic preparation reported a failure to adequately follow preparation instructions. A later colonoscopy starting time, a reported failure to follow preparation instructions, inpatient status, a procedural indication of constipation, taking tricyclic antidepressants, male gender, and a history of cirrhosis, stroke or dementia were all independent predictors of an inadequate colon preparation (all p < 0.05). A procedural indication of previous polypectomy was a negative predictor of inadequate colonic preparation (p < 0.05).

CONCLUSION

Several patient characteristics were significantly associated with colonic preparation quality independent of preparation type, compliance with preparation instructions, and procedure starting time. This information may help to identify patients at an increased risk for inadequate colonic preparation for whom alternative preparation protocols would be appropriate.

A meta-analysis of endoscopic variceal ligation for primary prophylaxis of esophageal variceal bleeding

Despite publication of several randomized trials of prophylactic variceal ligation, the effect on bleeding-related outcomes is unclear. We performed a meta-analysis of the trials, as identified by electronic database searching and cross-referencing. Both investigators independently applied inclusion and exclusion criteria, and abstracted data from each trial. Standard meta-analytic techniques were used to compute relative risks and the number needed to treat (NNT) for first variceal bleed, bleed-related mortality, and all-cause mortality. Among 601 patients in 5 homogeneous trials comparing prophylactic ligation with untreated controls, relative risks of first variceal bleed, bleed-related mortality, and all-cause mortality were 0.36 (0.26-0.50), 0.20 (0.11-0.39), and 0.55 (0.43-0.71), with respective NNTs of 4.1, 6.7, and 5.3. Among 283 subjects from 4 trials comparing ligation with beta-blocker therapy, the relative risk of first variceal bleed was 0.48 (0.24-0.96), with NNT of 13; however, there was no effect on either bleed-related mortality (relative risk [RR], 0.61; confidence interval [CI], 0.20-1.88) or all-cause mortality (RR, 0.95; CI, 0.56-1.62). In conclusion, compared with untreated controls, prophylactic ligation reduces the risks of variceal bleeding and mortality. Compared with beta-blockers, ligation reduces the risk for first variceal bleed but has no effect on mortality. Prophylactic ligation should be considered for patients with large esophageal varices who cannot tolerate beta-blockers. Subsequent research should further compare ligation and beta-blockers to determine the effect on mortality, and measure ligation's cost-effectiveness.

Impact of endoscopic therapy on the survival of patients with primary sclerosing cholangitis

BACKGROUND

Endoscopic measures such as balloon dilation can relieve obstruction and improve symptoms in patients with primary sclerosing cholangitis (PSC). However, the influence of repeated endoscopy to maintain biliary patency on the survival of patients with PSC is unclear.

METHODS

This study evaluated the impact of endoscopic therapy on the survival of consecutive patients with PSC undergoing endoscopic therapy. During a 6-year period 63 patients underwent endoscopic therapy. After initial therapy, patients were followed for a median of 34 months. Endoscopic therapy primarily consisted of repeated balloon dilation of dominant biliary strictures. The observed survival of this cohort was estimated (Kaplan-Meier). The predicted survival of the cohort was estimated by using the Mayo Clinic survival model based on clinical information obtained within 3 months before first endoscopic therapy. The Mayo Risk Score was calculated by using the equation R = (0.03 Age, years) + (0.54 log(e) Bilirubin mg/dL) + (0.54 log(e) Aspartate aminotransferase U/mL) + (1.24 Bleed history) - (0.84 Albumin gm/dL).

RESULTS

The observed survival over 5 years was significantly higher than the predicted 5-year survival (83% vs. 65%, respectively; p = 0.027).

CONCLUSION

These data suggest that repeated endoscopic attempts to maintain biliary patency may improve the survival of patients with PSC and dominant strictures.

Determinants of mortality in patients with advanced cirrhosis after transjugular intrahepatic portosystemic shunting

BACKGROUND & AIMS

Transjugular intrahepatic portosystemic shunt (TIPS) placement is effective in the treatment of complications of portal hypertension. This study evaluated the predictors of mortality in a group of cirrhotic patients with advanced liver disease after placement of TIPS.

METHODS

A retrospective analysis of all patients undergoing TIPS placement over a 21/2-year period was undertaken.

RESULTS

Fifty-six patients had TIPS placement for variceal hemorrhage, 49 for refractory ascites, and 24 for hepatic hydrothorax (total, 129). Of 21 variables available before TIPS placement, variceal hemorrhage requiring emergent TIPS placement (relative risk [RR], 37.5; 95% confidence interval [CI], 5.4-259) and bilirubin concentration > 3.0 mg/dL (RR, 5.4; 95% CI, 1.4-10.2) were independent predictors of 30-day mortality. Variceal hemorrhage requiring emergent TIPS placement (hazard ratio [HR], 5.1, 95% CI, 2. 2-9.1), alanine aminotransferase level > 100 IU/L (HR, 2.5; 95% CI, 1.2-5.5), bilirubin level > 3.0 mg/dL (HR, 2.6; 95% CI, 1.1-4.6), and pre-TIPS encephalopathy unrelated to bleeding (HR, 2.2; 95% CI, 1.2-4.8) independently predicted death during the follow-up period. A model was developed that separated the patients into 3 groups with significantly different survival rates.

CONCLUSIONS

A clinical index consisting of 4 pre-TIPS variables can reliably predict outcome after TIPS.

Cholangiocarcinoma in patients with primary sclerosing cholangitis: a multicenter case-control study

Patients with primary sclerosing cholangitis (PSC) have a significantly increased risk of developing cholangiocarcinoma (CCA). Risk factors for developing such a complication are not well defined. We conducted a multicenter, case-control study to determine the risk factors and possible predictors for CCA in patients with PSC. The demographic, clinical, and laboratory features of 26 PSC patients with CCA diagnosed over a 7-year period at eight academic centers were compared with 87 patients with PSC but no CCA (controls). There was no statistically significant difference in demographics, smoking, signs or symptoms or complications of PSC, indices of disease severity (Mayo Risk score or Child-Pugh score), frequency or duration or complications of inflammatory bowel disease (IBD), frequency of biliary surgery, or therapeutic endoscopy between the two groups. Alcohol consumption was significantly associated with CCA in patients with PSC (odds ratio: 2.95; 95% CI: 1.04-8.3). Serum carbohydrate antigen 19-9 (CA 19-9) was significantly higher in patients with CCA than those without (177 +/- 89 and 61 +/- 58 U/mL, respectively; P =.002). A serum CA 19-9 level > 100 U/mL had 75% sensitivity and 80% specificity in identifying PSC patients with CCA. In conclusion, alcohol consumption was a risk factor for having CCA in PSC patients. The indices of severity of liver disease were not associated with CCA in patients with PSC. Serum CA 19-9 appeared to have good ability to discriminate PSC patients with and without CCA.

Vaccination against hepatitis B in patients with chronic liver disease awaiting liver transplantation

BACKGROUND

Most transplant centers in the United States immunize patients awaiting liver transplantation against hepatitis B to prevent acquisition of hepatitis B through transplantation (de novo hepatitis B). A recent study showed that only 16% of patients with cirrhosis awaiting liver transplantation responded to single-dose recombinant vaccine.

METHODS

We studied the immunogenicity of double-dose recombinant vaccine in patients with cirrhosis awaiting liver transplantation.

RESULTS

Over a 4-year period (January 1994 to December 1997), 140 patients with cirrhosis without past or current hepatitis B infection were given double-dose recombinant vaccine (40 microg of Engerix B; SmithKline Beecham, Philadelphia, PA) at 0, 1 to 2, and 2 to 4 months. Hepatitis B surface antibody (HBsAb) was measured 1 to 3 months after completing vaccination. The response rate was 37%. However, HBsAb titers became undetectable in 35% of the responders during the post-transplant follow-up period. One hundred and thirty-seven patients underwent 144 liver transplantation procedures during the study period, and 3 patients developed de novo hepatitis B (2.2%). Livers transplanted from hepatitis B core antibody (HBcAb)-positive donors was the source of de novo hepatitis B in all cases. Two of the 3 patients who developed de novo hepatitis B were immunized before transplantation and one of them was a responder.

CONCLUSION

Although the response rate to double-dose recombinant vaccines is higher than the previously reported response to single-dose vaccine, it still is less than optimal.

Predictors of large esophageal varices in patients with cirrhosis

OBJECTIVE

Recent guidelines recommend that all cirrhotics undergo screening upper endoscopy to identify those patients at risk for bleeding from varices. However, this practice may not be cost effective as large esophageal varices are seen only in 9-36% of these patients. The aim of this study was to determine whether clinical variables were predictive of the presence of large esophageal varices.

METHODS

This is a retrospective analysis of cirrhotics who had a screening upper endoscopy during an evaluation for liver transplantation at three different centers and who had not previously bled from varices. A multivariate model was derived on the combined cohort using logistic regression. Three hundred forty-six patients were eligible for the study.

RESULTS

The prevalence of large esophageal varices was 20%. On multivariate analysis, splenomegaly detected by computed tomographic scan (odds ratio: 4.3; 95% confidence interval: 1.6-11.5) or by physical examination (odds ratio: 2.0; 95% confidence interval: 1.1-3.8), and low platelet count were independent predictors of large esophageal varices. On the basis of these variables, cirrhotics were stratified into high- and low-risk groups for the presence of large esophageal varices. Patients with a platelet count of > or = 88,000/mm3 (median value) and no splenomegaly by physical examination had a risk of large esophageal varices of 7.2%. Those with splenomegaly or platelet count < 88,000/mm3 had a risk of large esophageal varices of 28% (p < 0.0001).

CONCLUSIONS

Our data show that clinical predictors could be used to stratify cirrhotic patients for the risk of large esophageal varices and such stratification could be used to improve the cost effectiveness of screening endoscopy.

Screening for hepatocellular carcinoma in patients with advanced cirrhosis

OBJECTIVE

Most available data on screening for hepatocellular carcinoma (HCC) in patients with cirrhosis originate from Asia and Europe. These data may not be applicable to patients from the United States because of geographic variation in the underlying etiology and other factors. Our aim was to assess the risk of HCC in U.S. patients with cirrhosis undergoing standardized screening.

METHODS

All cirrhotic patients evaluated for liver transplantation at our institution from January 1, 1994-December 31, 1997 were included in this study. The screening strategy included initial screening, which was offered to all patients and consisted of alpha-fetoprotein (AFP), abdominal ultrasound, and computed tomography (CT) scan, and extended screening, which was performed only on transplant-eligible patients and consisted of semiannual AFP and ultrasound.

RESULTS

During the study period, 285 patients with cirrhosis were evaluated for transplantation and underwent initial screening. Of these, 166 were eligible for transplantation and underwent extended screening during a median follow-up of 15 months (range 6-42 months). Twenty-seven HCC were found, 22 during initial screening and five during extended screening. The cancer-free proportions of the cohort who underwent extended screening at 1, 2, and 3.5 yr were 98.6% +/- 1.4%, 96.4 +/- 1.8%, and 77.1% +/- 1.7%, respectively (mean +/- SE). Hepatitis C, either alone or in part, was the etiology in 63% of patients with HCC. The sensitivity of CT scan (88%) was significantly higher than AFP >20 ng/ml (62%) and ultrasound (59%) for detecting HCC (p < 0.001).

CONCLUSIONS

In patients with established cirrhosis, the risk of detecting HCC is maximal at the baseline screening (7%). Hepatitis C was the most common etiology for cirrhosis in study. In U.S. patients with established cirrhosis, CT scan exhibited higher sensitivity for detecting HCC than ultrasound or AFP.

Screening for hepatocellular carcinoma in patients with cirrhosis in the United States: results of a national survey

OBJECTIVE

Hepatocellular carcinoma (HCC) is one of the dreaded complications of cirrhosis. Although there are no randomized controlled studies showing improved survival with screening, patients with cirrhosis are screened for HCC. Little is known about the practice of HCC screening in the United States. Our aim was to describe the practice of HCC screening in patients with cirrhosis in the United States.

METHODS

In March 1998, we mailed a standard questionnaire to 1021 physician members of the American Association of Study for Liver Diseases and the same questionnaire was re-sent to nonrespondents 4 weeks later.

RESULTS

We received a response from 554 members (54%). After excluding those not involved in active adult patient care, 473 responses were eligible for analysis. Eighty-four percent of the respondents routinely screened patients with cirrhosis for HCC (screening respondents). Nearly half of the screening respondents limited the HCC screening to patients with high-risk etiologies such as hepatitis B or C or hemochromatosis. Although alpha-fetoprotein (99.7%) and ultrasound (93%) were the two most frequently used screening methods, a sizable proportion of the screening respondents (25%) used abdominal computed tomography for routine screening. On multivariate analysis, the following variables predicted screening for HCC by the respondents: seeing more than one new cirrhotic per week (odds ratio [OR]: 5.4, 95% confidence interval [CI]: 2.5-11.7); practicing for < 10 yr (OR: 4.0, 95% CI: 1.2-13.4); an opinion that screening is cost-effective (OR: 6.4, 95% CI: 1.6-25); an opinion that screening prolongs survival (OR: 5.7, 95% CI: 1.8-17.9); and an opinion that not screening poses malpractice liability (OR: 9.3, 95% CI: 4.2-20.8).

CONCLUSIONS

The majority of respondents routinely screen patients with cirrhosis for HCC. Approximately half of the screening respondents limit their screening to only patients with high-risk etiologies. On multivariate analysis, several variables predicted screening for HCC by the respondents.

Gastrointestinal hemorrhage in patients with AIDS

Gastrointestinal (GI) bleeding is a relatively infrequent complication seen in patients with AIDS. As with non-HIV-infected individuals, upper GI bleeding is much more common than lower GI bleeding. In patients with AIDS, upper GI bleeding can result from etiologies related to underlying HIV infection [cytomegalovirus (CMV), Kaposi's sarcoma, idiopathic esophageal ulcers, etc] or be unrelated to HIV infection (peptic ulcer, portal hypertension, Mallory-Weiss tear, etc.). Lower GI bleeding is caused predominantly by etiologies related to underlying HIV disease; CMV colitis is the most common cause. In contrast to non-HIV-infected individuals, hemorrhoids and anal fissures can result in significant bleeding in AIDS patients because of associated thrombocytopenia. Management of GI bleeding in AIDS patients is similar to patients without HIV infection, and includes resuscitation, identification of the bleeding source, achieving hemostasis, and preventing recurrent bleeding. Several etiologies that cause GI bleeding in patients with AIDS can be diagnosed through endoscopy, either by their characteristic endoscopic appearance or mucosal biopsies.

Current status of transjugular intrahepatic portosystemic shunts

The use of the transjugular intrahepatic portosystemic shunt (TIPS) has emerged as an important nonoperative modality for variceal bleeding, intractable ascites, and for selected cases of hepatic venous obstruction. We believe that TIPS should be viewed as a 'bridge' to liver transplantation and should be carried out only in experienced centres. The adverse haemodynamic changes on the cardiopulmonary system after TIPS should be borne in mind. Prospective trials to evaluate the role of TIPS versus sclerotherapy in variceal bleeding will be watched with interest. There is, however, an urgent need to improve long-term results of TIPS as stent thrombosis and stenosis occur frequently. We advocate routine surveillance to detect these problems at an early stage.

Cytomegalovirus colitis in acquired immunodeficiency syndrome: a clinical and endoscopic study

BACKGROUND

Cytomegalovirus colitis is an important complication of the acquired immunodeficiency syndrome (AIDS), although the clinical and colonoscopic manifestations of this disease have not been systematically characterized.

METHODS

Patients with AIDS and cytomegalovirus colitis were prospectively identified at two medical centers. The diagnosis of cytomegalovirus disease was based on established endoscopic and histologic criteria. At the time of sigmoidoscopic and/or colonoscopic examination, clinical features were recorded; the location, size, and appearance of all endoscopic abnormalities were documented; and multiple biopsies of any lesions were performed.

RESULTS

Fifty-six patients were studied. The majority of the patients were homosexual men with severe immunodeficiency (median CD4 lymphocyte count 15/mm3, range 1 to 294/mm3). Chronic diarrhea and abdominal pain were the most frequent clinical manifestations, seen in 45 (80%) and 28 (50%) patients, respectively. Five patients (9%) presented with lower gastrointestinal hemorrhage, three of whom had no antecedent history of diarrhea. The colonoscopic abnormalities could be categorized into three main groups: colitis associated with ulcer (39%), ulceration alone (38%), or colitis alone (20%). Subepithelial hemorrhage was a prominent endoscopic manifestation of disease. Of the 31 patients undergoing colonoscopy to the cecum, in four (13%) endoscopic evidence of disease was limited to the colon proximal to the splenic flexure.

CONCLUSIONS

Cytomegalovirus colitis in AIDS appears to have variable but stereotypical clinical and colonoscopic manifestations. Distal colitis associated with ulceration is the most common colonoscopic pattern.

The prevalence and significance of leukocytosis in upper gastrointestinal bleeding

Although leukocytosis has long been recognized to occur in patients with hemorrhage, there are no data regarding leukocytosis in patients with upper gastrointestinal bleeding. We evaluated the prevalence and significance of the admission white blood cell count in consecutive patients admitted to Grady Memorial Hospital with upper gastrointestinal bleeding seen prospectively over a 50-month period. Any white count greater than 8.5 x 10(3)/mm3 was considered abnormal. Of the 731 patients eligible for the study, leukocytosis was seen in 463 (63%). When compared to patients with a normal white count, patients with leukocytosis on admission were more likely to be tachycardic (31.4% versus 24.3%, P = 0.04) and hypotensive (10.9% versus 5.7%, P = 0.018), required more units of blood (4.6+/-5.9 versus 3.5+/-6.0, P = 0.01), had a longer hospital stay (7.3+/-9.7 versus 5.9+/-6.2 days, P = 0.01), and required more frequent surgical intervention for bleeding (8.0% versus 4.2%, P = 0.04). No significant difference in mortality was seen between patients with leukocytosis and those with a normal white count (8.7% versus 6.4%, P = 0.27). Leukocytosis is common in patients with upper gastrointestinal bleeding, appears to reflect the severity of the bleeding episode, and is associated with a more complicated course.

Is vaccination against hepatitis B infection indicated in patients waiting for or after orthotopic liver transplantation?

It is a common practice to immunize patients against hepatitis B infection while they are waiting for liver transplantation, but the efficacy of this practice is unclear. This is a retrospective analysis of the antibody response to 20 microg of a recombinant hepatitis B vaccine in patients waiting for and after liver transplantation. The response to vaccination was measured 1-3 months after completion of the vaccination series. The risk of acquiring hepatitis B virus after liver transplant was determined by reviewing the results of tests for hepatitis B infection in 171 patients who underwent transplantation for non-hepatitis B diseases and who had not been vaccinated. Fifty-seven patients awaiting transplantation were eligible for the study, and a response to vaccination was observed in only 9 (16%). Patients with cholestatic liver disease had a significantly higher response (6 of 14; 43%) compared with noncholestatic liver disease (3 of 43; 7%; P = .004). Forty-five liver transplant recipients were immunized against hepatitis B after transplantation, and only 3 (6.7%) developed an antibody response. The frequency of posttransplant hepatitis B infection in the 171 patients who were not immunized and who lacked any evidence of hepatitis B infection pretransplantation was 4 of 171 (2.3%). The response rate to immunization with a recombinant hepatitis B vaccine in patients with chronic liver disease who are waiting for a liver transplant and after transplantation is poor. Given the poor response to vaccination and the low risk of acquiring hepatitis B virus after transplantation, centers need to reconsider the routine use of the hepatitis B virus vaccine in patients awaiting liver transplantation.

Etiology and outcome of lower gastrointestinal bleeding in patients with AIDS

OBJECTIVE

The objective of the study was to investigate bleeding (LGIB) in patients with acquired immunodeficiency syndrome (AIDS).

METHODS

All hospitalized AIDS patients with LGIB evaluated by the gastroenterology service at a large city-county hospital during a 6 yr period were identified by database review and by endoscopy and consultation records.

RESULTS

Of the 691 AIDS patients seen during the study period, 18 (2.6%) (median age 41+/-7 years) were evaluated for LGIB. In these patients, LGIB was caused by human immunodeficiency virus type 1 (HIV)-associated disorders in 72% including cytomegalovirus colitis in seven patients, idiopathic colonic ulcers in five patients, and intestinal Kaposi's sarcoma in one patient. HIV-associated thrombocytopenia contributed to substantial bleeding from hemorrhoidal disease in two patients. Rebleeding occurred in four patients (22%), including hemorrhoids in three and idiopathic colonic ulcers in one. Surgery was not performed in any patient. Following the institution of ganciclovir therapy, no patient with CMV colitis had recurrent bleeding. The in-hospital mortality was high (28%), although bleeding was the direct cause of death in only one patient.

CONCLUSIONS

LGIB is infrequent in patients with AIDS and is usually caused by opportunistic diseases specifically related to immunodeficiency. Although some of these conditions are potentially treatable medically, in-hospital mortality is high and long-term prognosis is poor because of AIDS-related comorbidity.

Racial differences in the histology, location, and risk factors of esophageal cancer

Although esophageal cancer is uncommon in the united states, its high mortality rate and recent increased incidence make it an important malignancy. Because there appears to be significant racial variation in the types of esophageal cancer, we examined a group of black patients with esophageal cancer and compared their risk factors, histology, and location with those of a cohort of white patients with esophageal cancer seen during the same period. We retrospectively reviewed patients with esophageal cancer seen at three major hospitals in Atlanta, Georgia from January 1990 to April 1996. Patients of races other than white or black were excluded from this study, the esophagus was separated into upper, middle, and lower thirds by defined criteria. Of the eligible 234 patients, 129 were black and 105 were white. In blacks with esophageal cancer, squamous cell cancer was the predominant type (92%), and adenocarcinoma was infrequent in whites, adenocarcinoma was more common than squamous cell cancer (66% vs. 32%). Although Barrett's esophagus was distinctly uncommon, smoking and alcohol consumption were significantly more common in blacks. Only 43% of the patients with adenocarcinoma had evidence of barrett's esophagus, all adenocarcinomas were located in the lower third of the esophagus. There appear to be significant racial differences in the types, risk factors, and location of esophageal cancer. Adenocarcinoma and Barrett's esophagus are uncommon in blacks.

Blood urea nitrogen to creatinine concentration in gastrointestinal bleeding: a reappraisal

BACKGROUND

The blood urea nitrogen to creatinine ratio (BUN/CREAT) is believed to reliably discriminate upper gastrointestinal bleeding (UGIB) from lower gastrointestinal bleeding (LGIB). However, studies evaluating subsets of bleeders in whom this ratio may have real diagnostic utility are lacking.

METHODS

Over a 50-month period, all patients evaluated for UGIB and LGIB by our gastroenterology consultative service had demographic, clinical, and laboratory findings recorded on admission. Endoscopic evaluation was performed in most patients for diagnosis.

RESULTS

A total of 790 patients with UGIB and 162 with LGIB were studied. Peptic ulcer disease (57%) and esophageal varices (10%) were the most common causes of UGIB, whereas diverticulosis was etiologic in 54% of LGIB episodes. The mean (+/- SD) BUN/CREAT ratio was significantly higher in UGIB than LGIB (22.5 +/- 11.5 vs 15.9 +/- 8.2; p = 0.0001). When comparing UGIB patients without hematemesis or diagnostic nasogastric aspirate to patients with LGIB, significant differences were found for patients with melena (20.1 +/- 8.4 vs 15.9; p = 0.001) but not hematochezia (18.6 +/- 9.1 vs 15.9; p = 0.12), and overlap was great. Using a ratio of < or = 33, the sensitivity and specificity for LGIB was 96 and 17%, respectively. There was a significant correlation of transfusion requirements and admission hematocrit to this ratio, whereas admission vital signs were not found to correlate significantly.

CONCLUSIONS

Although the BUN/CREAT ratio is higher in UGIB compared with LGIB, the degree of overlap, especially in patients without hematemesis, suggests this value to have poor discriminatory ability. The degree of elevation correlates best with transfusion requirements rather than admission vital signs.

Kernicterus in an adult who is heterozygous for Crigler-Najjar syndrome and homozygous for Gilbert-type genetic defect

Gilbert syndrome is a common genetic disorder associated with mild unconjugated hyperbilirubinemia and no clinical illness. In contrast, Crigler-Najjar syndrome types I and II are rare genetic disorders associated with severe unconjugated hyperbilirubinemia and a life-long risk of kernicterus. Patients with Gilbert syndrome have low levels of a normal form of uridinediphosphoglucuronate glucuronosyltransferase because of a defect in the promoter region of both alleles, whereas patients with Crigler-Najjar syndrome are homozygous for a defect that yields an abnormal form of the enzyme that has limited or no activity. This case report describes a young adult with Crigler-Najjar syndrome type II in whom kernicterus developed after a laparoscopic cholecystectomy. The development of kernicterus was the result of a largely preventable series of events that lead to an increase in the free fraction of his serum bilirubin. Analysis of his genetic defect showed that he was homozygous for the mutation associated with Gilbert syndrome and heterozygous for a second mutation in the open reading frame of one allele of the bilirubin uridinediphosphoglucuronate glucuronosyltransferase gene. The combined defect leads to severe hyperbilirubinemia and shows how seemingly benign genetic defects, when combined, can cause serious clinical disease.

Spontaneous rupture of a bile duct and its endoscopic management in a patient with Caroli's syndrome

Caroli's syndrome is a condition of cystic dilation of intrahepatic bile ducts that communicate with the extrahepatic biliary tree. Patients with Caroli's syndrome are prone to develop several complications. These include bacterial cholangitis, biliary sludge, calculi, and cholangiocarcinoma. We describe an adult patient with Caroli's syndrome in whom spontaneous rupture of a bile duct developed with consequent biliary peritonitis, which was successfully managed with endoscopic stent placement.

Significance of intestinal metaplasia in different areas of esophagus including esophagogastric junction

Over the past two decades, the incidence of adenocarcinoma of the esophagus and gastric cardia has increased at a rate exceeding that of any other cancer. Barrett's esophagus is the only known risk factor for these malignancies. Recently, emphasis has been placed on the significance of specialized intestinal metaplasia (SIM) on esophageal biopsies. Our aim was to compare the prevalence of SIM at different esophageal locations in patients who are at higher risk of developing esophageal adenocarcinoma (Caucasians) and patients with lower risk of developing esophageal adenocarcinoma (African-Americans). Eighty-seven unselected patients (42 Caucasians and 45 African-Americans) underwent routine upper endoscopy with biopsies from the proximal margin of columnar mucosa. We classified patients into those with a columnar-lined esophagus with SIM (CLE with SIM); CLE without SIM; or SIM with a normal-appearing gastroesophageal junction (SIM-GEJ). The prevalence of CLE with SIM, CLE without SIM, and SIM-GEJ was 28%, 10%, and 10% in Caucasians compared to 0%, 18% and 11% in African-Americans (P = 0.0001, 0.26, and 0.81, respectively). We found CLE with SIM only in patients with reflux symptoms at least twice a week. It is concluded that CLE with SIM is seen most commonly in patients thought to be at risk for esophageal adenocarcinoma (Caucasians with reflux symptoms). It is rarely seen in other groups with lower risk for this malignancy (African-Americans, nonrefluxers). Conversely, SIM-GEJ and CLE without SIM are common in all groups and are of questionable significance.