Complications, symptoms, quality of life and pregnancy in cholestatic liver disease.

Cholestatic liver diseases (CLDs) encompass a variety of disorders of bile formation and/or flow which generally result in progressive hepatobiliary injury and ultimately end-stage liver disease. Many patients with CLD are diagnosed between the ages of 20-50 years, a particularly productive period of life professionally, biologically and in other respects; it is not surprising, thus, that CLD is often associated with impaired health-related quality of life (HRQOL) and uncertainty regarding implications for and outcomes of pregnancy. Primary sclerosing cholangitis (PSC) and primary biliary cholangitis (PBC) are the most prominent CLDs, both having considerable morbidity and mortality and representing major indications for liver transplantation. These disorders, as a consequence of their complications (eg ascites, hepatic osteodystrophy), associated conditions (eg inflammatory bowel disease) and symptoms (eg pruritus and fatigue), can significantly impair an array of domains of HRQOL. Here we review these impactful clinical aspects of PSC and PBC as well as the topics of fertility and pregnancy.

Prospective Clinical Trial of Rifaximin Therapy for Patients With Primary Sclerosing Cholangitis.

Primary sclerosing cholangitis (PSC) is a rare, chronic, cholestatic liver disease in which emerging data suggest that oral antibiotics may offer therapeutic effects. We enrolled patients with PSC in a 12-week, open-label pilot study to investigate the efficacy and safety of 550 mg of oral rifaximin twice daily. The primary end point was serum alkaline phosphatase (ALK) at 12 weeks. Secondary end points included (1) serum bilirubin, gamma-glutamyl transpeptidase, and Mayo PSC risk score; (2) fatigue impact scale, chronic liver disease questionnaire, and short form health survey (SF-36) scores; and (3) adverse effects (AEs). Analyses were performed with nonparametric tests. Sixteen patients were enrolled, among whom the median age was 40 years; 13 (81%) were male, 13 had inflammatory bowel disease, and baseline ALK was 342 IU/mL (interquartile range, 275-520 IU/mL). After 12 weeks of treatment, there were no significant changes in ALK (median increase of 0.9% to 345 IU/mL; P = 0.47) or any of the secondary biochemical end points (all P > 0.05). Similarly, there were no significant changes in fatigue impact scale, chronic liver disease questionnaire, or SF-36 scores (all P > 0.05). Three patients withdrew from the study due to AEs; 4 others reported mild AEs but completed the study. In conclusion, although some antibiotics may have promise in treating PSC, oral rifaximin, based on the results herein, seems inefficacious for this indication. Future studies are needed to understand how the antimicrobial spectra and other properties of antibiotics might determine their utility in treating PSC.

Predictors of health-related quality of life and adherence in Crohn's disease and ulcerative colitis: implications for clinical management.

BACKGROUND AND AIMS: Inflammatory bowel disease (IBD) is associated with impaired health-related quality of life (HRQOL) and adherence. Our aim was to identify demographic, clinical, and psychosocial predictors of impaired HRQOL and non-adherence to provider recommendations. METHODS: Adults with Crohn's disease (CD) or ulcerative colitis (UC) residing within the USA were recruited from online IBD support groups for participation in this cross-sectional study. Data were collected online through standardized instruments, including the Inflammatory Bowel Disease Questionnaire and the Medical Outcomes Study (MOS) general adherence scale. Bivariate analyses and multivariate linear regression were used to assess predictors of HRQOL and adherence. RESULTS: We recruited 136 individuals, among whom median age was 35 years (range 18-75), and 82 % were female. 57 % had CD, and 43 % had UC. Predictors of lower HRQOL among CD patients were perceived stress (p < 0.0001), number of CD relapses (p < 0.0001), and female gender (p = 0.0015), while among UC patients they were perceived stress (p < 0.0001) and number of UC relapses (p = 0.0017). Predictors of lower adherence to provider recommendations in CD were perceived stress (p = 0.0007) and older age (p = 0.041), while in UC, perceived stress was the only predictor of lower adherence (p = 0.022). CONCLUSIONS: Among patients with IBD, a higher level of perceived stress is a strong predictor of lower HRQOL and lower adherence to provider recommendations. Additionally, females with CD and patients with higher number of IBD relapses may be at risk of lower HRQOL. Psychological interventions, including physician-facilitated conversations, psychological screeners, and a multidisciplinary approach, may help address impaired HRQOL and adherence and merit further study.

Bariatric Surgery Patients' Response to a Chronic Pain Rehabilitation Program.

BACKGROUND: Chronic pain (CP) is a prevalent and disabling diagnosis in obese individuals, but how bariatric surgery patients respond to chronic pain rehabilitation treatment programs has not previously been described. OBJECTIVES: The aim of this study was to compare treatment outcomes of a chronic pain rehabilitation program (psychological and pain variables, medication use, treatment completion rates) for post-bariatric surgery patients to those of a non-bariatric surgery control group. SETTING: Three week outpatient multidisciplinary chronic pain program in an academic medical center. METHODS: This was a retrospective case-control study. Medical records of patients admitted to the Pain Rehabilitation Center at Mayo Clinic from 2008 to 2012 were reviewed. One hundred six patients with a history of bariatric surgery (cases) were identified and matched to 106 patients without a history of bariatric surgery (controls) on age, gender, and smoking status (n = 202). Matched t tests and McNemar's tests were used for analyses. RESULTS: Mean age was 46 years; 91% were female and 58% were non-smokers. The majority of cases (71%) had undergone Roux-en-Y gastric bypass. Bariatric patients had higher rates of benzodiazepine use at discharge (33 vs. 19%, p = 0.0433) and were less likely to complete treatment (87 vs. 97%, p = 0.007) compared to controls. Morphine equivalent use for cases was 127.3 mg ± 135.4 (n = 62) compared to 88.3 mg ± 95.3 (n = 62), p = 0.12, for controls at admission. CONCLUSIONS: These results suggest that bariatric patients may be at risk for treatment non-adherence and have difficulty reducing medication use in the treatment of chronic pain.