Equivalent survival following liver transplantation in patients with non-alcoholic steatohepatitis compared with patients with other liver diseases.

BACKGROUND: Orthotopic liver transplantation (LT) in non-alcoholic steatohepatitis (NASH) is increasing in parallel with the obesity epidemic. METHODS: This study retrospectively reviewed the clinical outcomes of LTs in NASH (n = 129) and non-NASH (n = 775) aetiologies carried out at a single centre between 1999 and 2009. RESULTS: Rates of 1-, 3- and 5-year overall survival in NASH (90%, 88% and 85%, respectively) were comparable with those in non-NASH (92%, 86% and 80%, respectively) patients. Mortality within 4 months of LT was twice as high in NASH as in non-NASH patients (8.5% vs. 4.2%; P = 0.04). Compared with non-NASH patients, post-LT mortality in NASH patients was more commonly caused by infectious (38% vs. 26%; P < 0.05) or cardiac (19% vs. 7%; P < 0.05) aetiologies. Five-year survival was lower in NASH patients with a high-risk phenotype (age >60 years, body mass index >30 kg/m(2), with hypertension and diabetes) than in NASH patients without these characteristics (72% vs. 87%; P = 0.02). Subgroup analyses revealed that 5-year overall survival in NASH was equivalent to that in Laennec's cirrhosis (85% vs. 80%; P 0.87), but lower than that in cirrhosis of cryptogenic aetiology (85% vs. 96%; P = 0.04). CONCLUSIONS: Orthotopic LT in NASH was associated with increased early postoperative mortality, but 1-, 3- and 5-year overall survival rates were equivalent to those in non-NASH patients.

The misclassification of gastric antral vascular ectasia.

Background: Gastric antral vascular ectasia (GAVE) is characterized by angiodysplastic lesions and is a rare form of gastrointestinal bleeding. Given the multiple patterns, GAVE can be misclassified. Aim: We analyzed the misclassification of GAVE among patients undergoing esophagogastroduodenoscopy (EGD). Methods: We performed a retrospective review of 941 EGDs between 2017 and 2019. Inclusion criteria included findings of GAVE on EGD±biopsy. Correct classification was based on visual EGD findings. Outcome variables included misclassification rate, endoscopist's background, and concordance between EGD and pathology. Cohen's Kappa test was used for concordance analysis. Results: A total of 110 patients had EGD findings of GAVE with a corresponding 184 EGDs. The misclassification rate among EGDs was 74/184 (40%). Furthermore, 81/110 patients were correctly classified with their first workup, whereas 29/110 patients needed repeat testing. In cases of misclassification, GAVE was mostly referred to as erythema (43%), with ulceration, gastritis, or polyps. Sixty-six (60%) patients had biopsies with a concordance of 76% between EGD and biopsy (κ=0.35). Conclusions: Our findings indicate GAVE was misclassified up to 40% on EGDs with hepatologists and gastroenterologists having similar misclassification rates. Proper identification is crucial given susceptibility to upper gastrointestinal bleeding. Relevance for Patients: This study emphasizes the importance of accurate classification of GAVE to ensure proper treatment of these lesions which can improve clinical outcomes.

Prevalence of metabolic syndrome in cirrhotics with gastric antral vascular ectasia.

BACKGROUND AND AIMS: Gastric antral vascular ectasia (GAVE) is characterized by angliodysplastic lesions that can cause upper gastrointestinal bleeding (UGIB). The mechanism behind GAVE and its association with other diseases remains unknown. We investigated the association of metabolic syndrome in cirrhotic GAVE patients when compared to esophageal variceal hemorrhage (EVH) patients. METHODS: We performed a retrospective review of 941 consecutive esophagogastroduodenoscopies (EGDs) for UGIB at a medical center between 2017 and 2019. The GAVE group consisted of EGD or biopsy diagnosed cirrhotic GAVE patients, and the EVH group consisted of EVH patients with active bleeding or stigmata of recent hemorrhage on EGD. Baseline variables including co-morbidities and cirrhotic etiology were recorded. Continuous variables were compared using Wilcoxon test and categorical variables were compared using Chi-square or Fisher's exact test. Multiple logistic regression analysis evaluated the association between GAVE and covariates. RESULTS: The final cohort had 96 GAVE and 104 EVH patients. Mean BMI was significantly higher in the GAVE cohort (32.6 vs 27.9, p < 0.0001) in addition to diabetes, hypertension, and hyperlipidemia (53.1% vs 37.5%; 76% vs 47.1%; 38.5% vs 14.4%; respectively, all p < 0.05). Non-alcoholic steatohepatitis (NASH) cirrhosis was more prevalent in GAVE than EVH patients (50% vs 24%, p = 0.0001). Multiple logistics regression revealed female sex, increased BMI, hypertension, and hyperlipidemia all having significantly higher risk of GAVE (all p < 0.05). CONCLUSION: Our data indicates that when compared to cirrhotics patients with EVH, cirrhotics with GAVE have increased risk of metabolic syndrome. This may play a role in the underlying pathophysiology of GAVE.

Postbariatric Surgery Hyperammonemia: A Rare Cause of Encephalopathy.

Hyperammonemic encephalopathy is an under-recognized and potentially fatal complication of Roux-en-Y gastric bypass surgery. We present a case of a 42-year-old woman with no known history of liver disease who experienced worsening encephalopathy 1 year after bariatric surgery. She presented with elevated ammonia and severe encephalopathy requiring intubation. A complete workup led to the diagnosis of a urea cycle disorder. The patient was managed with lactulose, ammonia scavenging agents, and nutritional supplementation with a favorable outcome. We report this case to increase awareness of this condition and urge providers to maintain a high clinical suspicion in the appropriate setting.

Orthotopic liver transplantation changes the course of gastric antral vascular ectasia: a case series from a transplant center.

BACKGROUND AND AIM: Gastric antral vascular ectasia (GAVE) is an important cause of upper gastrointestinal bleeding and anemia in patients with cirrhosis. The aim of our study was to evaluate the effect of orthotopic liver transplantation (OLT) on GAVE and associated anemia. PATIENTS AND METHODS: We performed a chart review and identified all cirrhotic patients with GAVE who underwent OLT at the University Of Alabama at Birmingham between 2005 and 2013. Population's demographics, etiology of cirrhosis, comorbidities, presentation and treatment modalities of GAVE, endoscopic and histopathologic reports, hemoglobin values before and after transplant, and immunosuppressive regimens were collected. RESULTS: Twelve patients were identified, mean age 52.4±4.4 years; seven were men (58.3%); 11 (91.7%) were White; and 6 of 12 patients had biopsy-proven GAVE. The most common etiology of cirrhosis in the cohort was chronic hepatitis C and obesity was the most common chronic condition in 50 and 83.3%, respectively. Anemia resolution was observed in 9/12 (75%) patients who underwent OLT with an increase in hemoglobin from 8.1±2.4 (5.7-13.1) before transplant to 12.0±1.4 (10-15) after transplant (P<0.0001). Esophagogastroduodenoscopy after transplant was performed in all 12 (100%) patients. The mean time between transplant and post-OLT esophagogastroduodenoscopy was 13.8±18.28 (2-57) months; complete resolution of GAVE was observed in 10 (83.3%) patients, with resolving GAVE in one (8.3%) patient. CONCLUSION: GAVE is an important cause of anemia and upper gastrointestinal bleeding in patients with liver cirrhosis. Our findings show that liver transplantation can resolve GAVE and related anemia.

Endoscopic closure of a gastrocolic fistula using the over-the-scope-clip-system.

Gastrointestinal (GI) defects such as fistulas and leaks can be potentially closed endoscopically using hemoclips and loops. However, hemoclips may not allow for closure of large defects and they do not exert enough tensile force to keep fibrotic defects larger than 5 mm approximated. Herein we present a case of successful endoscopic closure of a gastrocolic fistula in a severely malnourished patient with complex post-surgical upper GI anatomy. We strongly believe that this device is a major breakthrough for the management of various types of discontinuity defects or fistulas. In addition, we show the usefulness of placing a direct jejunostomy using the double balloon enteroscopy (DBE) technique during the same procedure. The concept of providing direct jejunal feedings while allowing for upper gastrointestinal bowel rest to promote the healing of the minimally invasive endoscopic operation is novel. Thus, our case is unique and exemplifies the utility of minimally invasive endoscopic endoluminal surgery.