Labor-associated eosinophilic gastroenteritis.

A 30-year-old woman who was 2 weeks postpartum presented with intermittent dysphagia since delivery. Esophagogastroduodenoscopy (EGD) revealed linear furrowing, trachealization, and a B-type distal esophageal ring with normal appearing stomach and duodenum. Biopsies showed eosinophilic esophagitis. Over 3 weeks, she developed severe midepigastric pain. Laboratory studies revealed an elevated absolute eosinophil count of 990/dL (normal 0-450/dL), and a computed tomography scan showed proximal jejunal thickening. Repeat esophagogastroduodenoscopy showed gastric erythema and edema of the duodenal mucosa. Biopsies revealed greater than 50 eosinophils per high power field in the intraepithelial mucosa with extension into the muscularis and serosa, consistent with eosinophilic gastroenteritis (EG). EG represents an uncommon inflammatory disease marked by gastrointestinal symptoms, eosinophilic infiltration in one or more areas of the gastrointestinal tract, and absence of parasitic or extraintestinal disease. Approximately 300 cases have been reported since 1937. This case contains two unique aspects. First, the clinical and endoscopic progression of gastrointestinal eosinophilic disease from the esophagus to the stomach and small bowel was chronologically documented. This proximal to distal luminal progression has not been previously reported. The possible link to her pregnancy is also notable as only two previous cases of labor-associated EG have been published.

Histopathologic variability between the right and left lobes of the liver in morbidly obese patients undergoing Roux-en-Y bypass.

BACKGROUND & AIMS: Nonalcoholic fatty liver disease (NAFLD) has been shown to occur in >90% of significantly obese patients. At present, diagnosis of the more severe form of NAFLD, nonalcoholic steatohepatitis (NASH), requires a liver biopsy. Conflicting data exist on the degree of sampling variability seen with percutaneous liver biopsy. Our aim was to assess for significant regional differences in histopathology between the right and left lobes of the liver in morbidly obese patients undergoing bariatric surgery. METHODS: Morbidly obese patients undergoing bariatric surgery at Wilford Hall Medical Center were eligible for study enrollment. Patients with chronic liver disease other than NAFLD were excluded. All patients underwent intraoperative liver biopsy, one from the right lobe and one from the left lobe, with a 14-gauge Tru-cut biopsy needle. Histopathologic features of NAFLD were compared by a hepatopathologist who examined biopsy specimens from the 2 hepatic lobes and was blinded to patient identification and site of origin of biopsy. Agreement between the 2 biopsy specimens was assessed by using the kappa coefficient. RESULTS: Forty-three patients (predominantly female) with body mass index median of 46.2 kg/m2 were enrolled. Agreement for steatosis was 93% (kappa = 0.91), inflammation 74% (kappa = 0.58), ballooning necrosis 84% (kappa = 0.73), fibrosis 98% (kappa = 0.96), and for the NAFLD activity score > or =5 was 93% (kappa = 0.83). CONCLUSIONS: Minimal variability was found for steatosis, NAFLD activity score > or =5, and fibrosis in samples of liver obtained from the right and left lobes of the liver in a group of morbidly obese, predominately female patients undergoing bariatric surgery. Histopathologic findings of necroinflammation appear to have the greatest degree of sampling variability. In contrast with previously published data, excellent agreement was seen for fibrosis in biopsy specimens obtained at surgery from right and left lobes of the liver.

Clinical model for distinguishing nonalcoholic steatohepatitis from simple steatosis in patients with nonalcoholic fatty liver disease.

Nonalcoholic fatty liver disease (NAFLD) encompasses both simple steatosis and nonalcoholic steatohepatitis (NASH). Differentiation of these two entities requires histopathologic evaluation. The aim of this study was to establish a reliable diagnostic model for differentiating steatosis from steatohepatitis utilizing both clinical characteristics and a panel of biochemical markers of lipid peroxidation and fibrosis. Eighty subjects with biopsy proven NAFLD were enrolled, 39 with simple steatosis and 41 with histopathologic evidence of NASH. Demographic and laboratory data to include serologic testing for 8-epi-PGF(2alpha), transforming growth factor-beta (TGF-beta), adiponectin, and hyaluronic acid (HA) were obtained and compared between the two groups. There were significant differences between the two groups with respect to age (P=0.004), female gender (P=0.024), aspartate aminotransferase (AST) (P=0.028), body mass index (BMI) (P=0.003), fasting insulin (0.018), AST/alanine aminotransferase (ALT) ratio (AAR) (P=0.017), quantitative insulin sensitivity check index (QUICKI) (P=0.002), and HA (P=0.029). A composite index for distinguishing steatosis from NASH was calculated by summing the risk factors of age >or=50 years, female gender, AST>or=45 IU/l, BMI >or=30 mg/kg2, AAR>or=0.80, and HA>or=55 microg/l, and its accuracy was determined by receiver operating characteristic (ROC) analysis to be 0.763 (95% CI: 0.650-0.876). The presence of three or more risk factors had a sensitivity, specificity, PPV, and NPV of 73.7%, 65.7%, 68.2%, and 71.4%, respectively. In addition, HA at a cutoff of 45.3 microg/l was a good predictor of advanced fibrosis. In conclusion, we propose a noninvasive screening model for distinguishing simple steatosis from NASH. Identifying patients at risk for NASH will allow clinicians to more accurately determine who may benefit from liver biopsy.

Non-alcoholic steatohepatitis: effect of Roux-en-Y gastric bypass surgery.

OBJECTIVE: Non-alcoholic steatohepatitis (NASH) is an increasingly prevalent problem. Treatment options are still under investigation. The primary aim of the study was to determine whether weight loss, achieved through Roux-en-Y gastric bypass (RYGBP), improved histopathology in obese patients with biopsy proven NASH. METHODS: One hundred and forty-nine patients were identified from a surgical database as having RYGBP for obesity and concomitant intra-operative liver biopsies from October 2001 to September 2003. Thirty-five patients were found to have evidence of NASH at the time of surgery. Nineteen patients were contacted and underwent repeat percutaneous liver biopsies. Biopsies were evaluated and compared in blinded fashion by an experienced hepatopathologist. Fasting lipid panel, insulin and glucose, hemoglobin A1c (HgbA1c), and liver enzymes were obtained. RESULTS: Significant differences were noted in the following variables pre- and post-bypass surgery: body mass index 46.8-28.8 kg/m2 (p < 0.001); body weight in kilograms 132.1-79.7 (p < 0.001); glucose 102.9-94.1 mg/dL (p = 0.015); Hgb A1c 5.79-5.15% (p = 0.026); high density lipoprotein 45.7-64.4 mg/dL (p < 0.001); low density lipoprotein 112-88.6 mg/dL (p = 0.003); triglycerides 132.1-97 mg/dL (p = 0.013). Significant improvements in steatosis, lobular inflammation, portal, and lobular fibrosis were noted. Histopathologic criteria for NASH were no longer found in 17/19 patients (89%). CONCLUSIONS: Weight loss after gastric bypass surgery in obese patients with NASH results in significant improvement in glucose, HgbA1c. and lipid profiles. Furthermore, RYGBP results in significant improvement in the histological features of NASH with resolution of disease in a majority of these patients.

Extrahepatic manifestations of hepatitis C.

Hepatitis C affects approximately 170 million people worldwide. Extrahepatic manifestations of chronic hepatitis C infection are clinically evident in nearly 40% of patients. Much research has been done over the last decade to better understand their incidence, clinical presentation, mechanism of disease, and the role of antiviral therapy in their treatment. Of the commonly reported manifestations, cryoglobulinemia, membranoproliferative glomerulonephritis, and porphyria cutanea tarda remain the best understood manifestations. More recently, the association of insulin resistance and diabetes mellitus with chronic hepatitis C has been demonstrated. This paper serves to review the growing body of literature detailing the extrahepatic manifestations of chronic hepatitis C.

Safety of band ligator use in the small bowel and the colon.

BACKGROUND: Endoscopic band ligation for bleeding small-bowel vascular lesions has been reported as safe and efficacious based on small case series. There have been several other published case reports of band ligators used for bleeding lesions, usually Dieulafoy's lesions, in the stomach, the proximal small bowel, and the colon. In addition, this method has been used for postpolypectomy bleeding stalks. There has never been a critical look at the anatomic consequences of banding in the thinner sections of bowel. METHOD: The purpose of this study is to define the anatomic and histologic consequences of applying band ligator devices to the small and the large bowel. Fresh surgical specimens, both large and small bowel, that were excised because of neoplastic lesions were transported to our endoscopy unit where one end of the intact bowel was sutured shut. A standard upper endoscope was passed via the open end, and the bowel was closed tightly with rubber band ties. The bowel then was insufflated, and band ligators were applied to unaffected mucosa by using a standard technique. Photodocumentation from inside and outside the bowel was obtained. Some of the band polyps were cut above the band, and some were cut below the band in the fresh state. Some were fixed in formalin and examined microscopically. Histologic sectioning occurred at the level of the bands. RESULTS: The results were striking in that there were large holes (1 cm) in the fresh ileum specimen. There was gross serosal entrapment manifested by visible puckers on the outer surfaces of the specimens, especially in the small bowel and the right colon. The left colon, anatomically thicker, was less affected. The histologic evaluation revealed inclusion by the band ligator of the muscularis propria and serosa on the small bowel, the muscularis propria in the right colon, and the submucosa in the left colon. CONCLUSIONS: Based on these findings, we conclude that band ligator devices are not safe in the small bowel and the right colon but probably are safe in the thicker left colon.