Nasobiliary Drain Diverted through a Percutaneous Endoscopic Gastrostomy Tube: A Novel Approach to Nasobiliary Drainage.

Intractable pruritus is a common, debilitating symptom and a well-defined entity occurring in chronic cholestatic disorders. Treatment options include cholestyramine, rifampicin, naltrexone, gabapentin, and sertraline, as well as more interventional measures, such as plasmapheresis, extracorporeal albumin dialysis, nasobiliary drains (NBDs), and UVB phototherapy in patients who fail to respond to medical therapy. Despite the limited data, NBD seems to be a highly effective treatment in the relief of refractory cholestatic pruritus. In this article, we present the case of a 73-year-old woman with primary biliary cholangitis and intractable pruritus, refractory to medical treatment. The patient had a complete resolution of her symptoms following an NBD placement, in which, with a novel approach, the nasal end was redirected and exited through a percutaneous endoscopic gastrostomy port, significantly improving her quality of life.

Adult liver transplantation: A UK clinical guideline - part 1: pre-operation.

Liver transplantation is a highly successful treatment for all types of liver failure, some non-liver failure indications and liver cancer. Most referrals come from secondary care. This first part of a two-part guideline outlines who to refer, and how that referral should be made, including patient details and additional issues such as those relevant to alcohol and drug misuse. The process of liver transplant assessment involves the confirmation of the diagnosis and non-reversibility, an evaluation of comorbidities and exclusion of contraindications. Finally, those making it onto the waiting list require monitoring and optimising. Underpinning this process is a need for good communication between patient, their carers, secondary care and the liver transplant service, synchronised by the transplant coordinator. Managing expectation and balancing the uncertainty of organ availability against the inevitable progression of underlying liver disease requires sensitivity and honesty from all healthcare providers and the assessment of palliative care needs is an integral part of this process.

Adult liver transplantation: UK clinical guideline - part 2: surgery and post-operation.

Survival rates for patients following liver transplantation exceed 90% at 12 months and approach 70% at 10 years. Part 1 of this guideline has dealt with all aspects of liver transplantation up to the point of placement on the waiting list. Part 2 explains the organ allocation process, organ donation and organ type and how this influences the choice of recipient. After organ allocation, the transplant surgery and the critical early post-operative period are, of necessity, confined to the liver transplant unit. However, patients will eventually return to their referring secondary care centre with a requirement for ongoing supervision. Part 2 of this guideline concerns three key areas of post liver transplantation care for the non-transplant specialist: (1) overseeing immunosuppression, including interactions and adherence; (2) the transplanted organ and how to initiate investigation of organ dysfunction; and (3) careful oversight of other organ systems, including optimising renal function, cardiovascular health and the psychosocial impact. The crucial significance of this holistic approach becomes more obvious as time passes from the transplant, when patients should expect the responsibility for managing the increasing number of non-liver consequences to lie with primary and secondary care.

U.K. guidelines on the management of variceal haemorrhage in cirrhotic patients.

These updated guidelines on the management of variceal haemorrhage have been commissioned by the Clinical Services and Standards Committee (CSSC) of the British Society of Gastroenterology (BSG) under the auspices of the liver section of the BSG. The original guidelines which this document supersedes were written in 2000 and have undergone extensive revision by 13 members of the Guidelines Development Group (GDG). The GDG comprises elected members of the BSG liver section, representation from British Association for the Study of the Liver (BASL) and Liver QuEST, a nursing representative and a patient representative. The quality of evidence and grading of recommendations was appraised using the AGREE II tool.The nature of variceal haemorrhage in cirrhotic patients with its complex range of complications makes rigid guidelines inappropriate. These guidelines deal specifically with the management of varices in patients with cirrhosis under the following subheadings: (1) primary prophylaxis; (2) acute variceal haemorrhage; (3) secondary prophylaxis of variceal haemorrhage; and (4) gastric varices. They are not designed to deal with (1) the management of the underlying liver disease; (2) the management of variceal haemorrhage in children; or (3) variceal haemorrhage from other aetiological conditions.

Caution in using a unique technique of banded revision gastric bypass: Successful endosopic and surgical management of a rare complication.

INTRODUCTION: Revision surgery is increasingly performed as result of the increase in primary bariatric procedures. We describe a new technique of revision Roux-en-Y gastric bypass (RYGB) acombining stapled gastroenterostomy with fixed band placement. We report two cases of unique complications and its successful endoscopic and surgical management. PRESENTATION OF CASE: Two out of twenty patients undergoing this revision RYGB procedure presented with gastric outlet obstruction due to band erosion within 10 weeks. Endoscopic band retrieval was successful in the first patient but the second patient required surgical removal. DISCUSSION: We report the new complication of band erosion in 10% patients using a unique revision RYGB technique combining restriction of the gastric outlet and band placement. We advise using one or the other technique but not both in combination. Surgeons need to be aware of this as erosion which occurs early due to close proximity of band with fresh staple line. We report successful endoscopic and surgical management. CONCLUSION: Revision surgery using this technique predisposes to bande erosion, presenting as gastric outlet obstruction. Endoscopic management should be attempted prior to surgical removal.

Fulminant hepatic failure in a patient with advanced extragonadal germ cell tumour.

Fulminant hepatic failure (FHF) in association with metastatic cancer, without evidence of liver metastases, has not been previously reported in the literature. This report concerns a case of FHF in a 36-year-old man with advanced germ cell tumour arising from an extragonadal (retroperitoneal) primary. Liver function and encephalopathy improved following chemotherapy, suggesting prompt diagnosis and treatment may have cured the patient. Following completion of chemotherapy, he developed spontaneous bacterial endocarditis, requiring aortic valve replacement, a rare complication of curative chemotherapy. At 44 months post completion of chemotherapy, he has regained his premorbid performance status and has returned to work.

Emergency subtotal hepatectomy: a new concept for acetaminophen-induced acute liver failure: temporary hepatic support by auxiliary orthotopic liver transplantation enables long-term success.

INTRODUCTION: Acetaminophen (paracetamol) overdose (AOD) has recently emerged as the leading cause of acute liver failure (ALF) in the United States, with an incidence approaching that seen in the United Kingdom. We describe a new way to treat AOD ALF patients fulfilling King's College criteria for "super-urgent" liver transplantation. METHODS: Beginning in June 1998, we have been piloting a clinical program of subtotal hepatectomy and auxiliary orthotopic liver transplantation (ALT) for AOD ALF. Our technique is based on the following principles: (1) subtotal hepatectomy; (2) auxiliary transplantation of a whole liver graft; (3) gradual withdrawal of immunosuppression after recovery. Results were compared with patients who had undergone an orthotopic liver transplantation (OLT) for AOD ALF in the same period. Quality of life comparisons were made using the SF36 questionnaire. RESULTS: Thirteen patients underwent this procedure between June 1998 and March 2005. Median survival is 68 months (range, 0-102 m). Actual survival data show that 9 of 13 patients are alive (69%) compared with 7 of 13 OLT patients (54%). One ALT patient required a retransplantation with an OLT due to hepatic vein thrombosis, and immunosuppression is therefore maintained. The other 8 surviving ALT patients are off immunosuppression. These 8 ALT patients have normal liver function and have a better quality of life compared with the 7 surviving OLT patients. CONCLUSION: Our results with this new technique are encouraging: 69% actual survival, no long-term immunosuppression requirement, and improved quality of life in the 62% successful cases.

Granulomatous infiltration with replacement of liver parenchyma: first case report.

A 76-year-old man presented with fever, weight loss and abnormal liver function tests. Imaging demonstrated a diffusely abnormal liver, and a liver biopsy revealed a fibrosing granulomatous process infiltrating and replacing liver parenchyma. There was no clinical, radiological or laboratory evidence of autoimmune liver disease, sarcoidosis, lymphoma or tuberculosis. Treatment with steroids resulted in a remarkable resolution of the clinical symptoms and radiology. This is the first case of granulomatous infiltration of the liver replacing normal hepatic parenchyma.

Bile duct strictures after hepatobiliary surgery: assessment with MR cholangiography.

PURPOSE: To establish the accuracy of magnetic resonance (MR) cholangiography for diagnosis of postsurgical bile duct strictures. MATERIALS AND METHODS: Sixty-seven patients suspected of having bile duct strictures after liver transplantation (n = 54), cholecystectomy (n = 8), hepatic resection (n = 4), or pancreaticoduodenectomy (n = 1) underwent MR cholangiography. Thick-slab single-shot fast spin-echo (repetition time msec/echo time msec, 4,500/940) imaging was performed in the coronal through sagittal planes with rotation in 10 degrees increments, and contiguous thin-section images were obtained in the transverse and the optimal coronal oblique planes by using half-Fourier rapid acquisition with relaxation enhancement (1,900/96). Three blinded observers independently reviewed the MR images and recorded diagnostic features including presence of biliary stricture by using a five-point confidence scale. Receiver operating characteristic analysis was used to measure the accuracy of MR cholangiography. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Final diagnosis was established at surgery (n = 29) and direct cholangiography (23 of 29) or at direct cholangiography, liver biopsy, and/or serial liver function tests (n = 38). RESULTS: Thirty-three of 67 patients had strictures confirmed with the reference standard. MR cholangiography enabled correct diagnosis and depicted the site of strictures in all cases. Findings of stricture at MR cholangiography were false-positive in five patients with moderate duct dilatation and caliber change at the level of the anastomosis. Mean accuracy, sensitivity, specificity, PPV, and NPV were 94%, 97%, 74%, 86%, and 96%, respectively. CONCLUSION: MR cholangiography is as sensitive as direct cholangiography for the assessment of bile duct strictures after hepatobiliary surgery but may lead to overestimation of the importance of duct dilatation and caliber change.