Hepatocellular carcinoma predicts in-hospital mortality from acute variceal hemorrhage among patients with cirrhosis.

OBJECTIVES: Hepatocellular carcinoma (HCC) is a common complication among patients with cirrhosis. Data are limited on the impact of HCC on in-hospital mortality from acute variceal hemorrhage (AVH) in patients with cirrhosis. METHODS: National in-hospital sample (1998 to 2007) was used to analyze admissions with AVH in cirrhotics to study impact of concomitant HCC on the in-hospital mortality. RESULTS: Of 27,442 admissions with cirrhosis and AVH, 540 had HCC. Admissions with HCC differed from those without HCC for age, sex, race, hospital characteristics, and complications of cirrhosis. A total of 2633 (9.6%) patients died during average hospital stay of 6 days with higher in-hospital mortality among admissions with HCC compared with without HCC (19% vs. 9%; P<0.0001). On logistic regression analysis, in-hospital mortality decreased by about 9%/y during 1998 to 2007 [odds ratio, 0.91 (95% confidence interval, 0.89-0.92)]. Receipt of endoscopic treatment was associated with reduced in-hospital mortality. After adjusting for all variables including calendar year and endoscopic treatment, HCC independently predicted in-hospital mortality from AVH: odds ratio, 2.15 (95% confidence interval, 1.67-2.77). Logistic regression model using clinically important variables predicted in-hospital mortality with area under the receiver operating characteristics of 0.80 with strong predictors being presence of HCC, hepatorenal syndrome, hypovolemic shock, sepsis, portosystemic encephalopathy, and use of Sengstaken Blakemore tube. CONCLUSIONS: HCC predicts in-hospital mortality from AVH in patients with cirrhosis. Studies are needed to examine and understand mechanisms of these findings to further develop better modalities of management of AVH in patients with cirrhosis and HCC.

Percutaneous transesophageal gastrostomy tube placement: an alternative to percutaneous endoscopic gastrostomy in patients with intra-abdominal metastasis.

BACKGROUND: PEG/jejunostomy (PEG/J) is often placed in patients with metastatic gastric cancer for palliating bowel obstruction or for feeding. However, PEG/J placement may not always be possible for many reasons. OBJECTIVE: We wish to bring attention to the percutaneous transesophageal gastrostomy/jejunostomy (PTEG/J) as a viable alternative to nasogastric decompression in patients who are not candidates for PEG/J. PTEG/J is a largely unknown technique in the United States that designed to gain access to the stomach and proximal small bowel in these patients. We describe the use of PTEG/J in 3 patients with metastatic gastric cancer by using resources and techniques readily available in a well-stocked interventional radiology suite. PATIENTS: In the first case, percutaneous transesophageal gastrostomy (PTEG) was placed for palliation of intractable nausea and vomiting in a 37-year-woman with diffuse gastric cancer and peritoneal carcinomatosis. In the second case, PTEG was extended into the jejunum for feeding a 60-year-old woman with metastatic gastric cancer. In the third case, PTEG extending into the jejunum was placed in a 69-year-old man for palliation of bowel obstruction caused by metastatic gastric cancer and peritoneal carcinomatosis. METHODS: After adequate sedation is administered, a 22 x 4-mm balloon catheter is passed into the esophagus over a guidewire just below the thoracic inlet. The balloon is ruptured with a needle passed through the neck under US guidance. A guidewire is then passed through the needle into the balloon and carried into the stomach or proximal small bowel by advancing the balloon catheter. The track is then dilated over the guidewire and a pigtail 45-cm-long 14F nephrostomy tube then passed into the stomach or into the proximal small bowel over the guidewire. The catheter is secured by suturing to the skin of the neck. RESULTS: PTEG/J was effective in achieving palliation or feeding in our patients. No complications occurred. CONCLUSIONS: PTEG/J is a safe and effective alternative to standard percutaneous gastrostomy/jejunostomy tube placement for decompression of bowel obstruction or feeding in appropriately selected patients.

Nonalcoholic Steatohepatitis is the Most Rapidly Growing Indication for Simultaneous Liver Kidney Transplantation in the United States.

BACKGROUND: Frequency of liver transplantation (LT) is increasing in nonalcoholic steatohepatitis (NASH) with good post-transplant outcomes. Similar data on simultaneous liver kidney (SLK) transplants are limited. METHODS: United Network for Organ Sharing database (2002-2011) queried for deceased donor first LT for primary biliary cirrhosis, primary sclerosing cholangitis, or alcoholic cirrhosis (group I), NASH, and cryptogenic cirrhosis with body mass index greater than 30 (group II), and hepatitis C virus with and without alcohol, hepatitis B virus, and hepatocellular carcinoma (group III). RESULTS: Of 38 533 LT (9495, 3665, and 25 383 in groups I-III, respectively), about 5.6% (N = 2162) received SLK with 584 (6.2%), 320 (8.7%), and 1258 (5%) in groups I-III, respectively. The SLK performed for group II increased from 6.3% in 2002 to 2003 to 19.2% in 2010 to 2011. Similar trends remained unchanged in group I (26.1 to 26.6%) and decreased in group III (67.6 to 54.5%). Five-year outcomes were similar comparing group II versus group I for liver graft (78 vs 74%, P = 0.14) and patient survival (81 vs 76%, P = 0.07). In contrast, kidney graft outcome was worse for group II (70 vs 79%, P = 0.002). Risk of kidney graft loss was over 1.5-fold higher among group II SLK recipients compared to group I after controlling for recipient characteristics. Estimated glomerular filtration rate remained lower in group II compared with group I at various time points after SLK transplantation. CONCLUSIONS: The NASH is the most rapidly growing indication for SLK transplantation with poor renal outcomes. Studies are needed to examine mechanisms of these findings and develop strategies to improve renal outcomes in SLK recipients for NASH.

Impact of hepatitis C virus infection on the course and outcome of patients with acute alcoholic hepatitis.

BACKGROUND AND AIMS: Limited information is available on the impact of hepatitis C virus (HCV) infection on the clinical course and outcome of acute alcoholic hepatitis (AH), a condition with a significant mortality. We designed this retrospective study to assess effect of HCV on the outcome of patients with AH. METHODS: Medical charts of patients with a discharge diagnosis of AH (defined using rigorous clinical criteria) were reviewed. Patients were stratified based on the presence or absence of concomitant HCV infection. The disease severity was estimated at admission and at day 7 using model for end-stage disease and discriminant function index scores. Patient survival at 6 months was confirmed with the county death registry. RESULTS: A total of 76 (29 HCV positive) AH cases were analyzed. At admission, disease severity was similar in both groups with severe disease in 53% (49% of AH alone and 59% of AH+HCV; P = 0.18). Although severity scores at day 7 were not available for all patients, disease severity tended to be worse for patients with AH+HCV. Kaplan-Meier survival curves showed a poor survival for AH+HCV compared with AH alone (69 vs. 91%; log-rank P = 0.015). Although patients with AH+HCV were treated less often compared with AH alone (27 vs. 54%; P = 0.05), HCV emerged as an independent risk factor for a poor outcome at 6 months (Cox proportional hazard ratio 8.45; P = 0.01) after controlling for patient demographics, disease severity at admission, and treatment. CONCLUSION: HCV may be a risk factor for patients with AH with a worse outcome at 6 months. If our findings are confirmed in larger databases, prospective studies are needed to examine mechanisms for this effect of HCV on the outcome of AH.