Acute Esophageal Necrosis and Duodenal Disease in the Setting of Recently Initiated Chemotherapy.

Introduction: Acute esophageal necrosis (AEN), commonly referred to as "black esophagus" or Gurvits syndrome, is a rare condition characterized by diffuse black mucosa in the distal esophagus. Most often, the patient is an older male with multiple comorbidities, presenting with upper gastrointestinal bleeding. The exact pathogenesis is unclear, but it is often thought to be secondary to acute vascular hypo-perfusion or ischemia of the esophageal mucosa in critically ill patients with certain secondary comorbid conditions such as renal insufficiency, diabetes mellitus, dyslipidemia, coronary artery disease, malnourishment, alcohol abuse, or association with an underlying malignancy. Case Presentation: We present a case of AEN in a 78-year-old female following the recent start of a chemotherapy regimen with carboplatin and paclitaxel two weeks prior. The patient underwent EGD and was found to have AEN throughout the entirety of her esophagus with necrosis and eschars seen up to the second part of the duodenum. The patient initially improved after receiving blood transfusions, being made nil-per-os, and starting proton pump inhibitor (PPI) therapy, but she ultimately died given the severity of her clear cell uterine cancer and other comorbidities. Conclusion: Although it is rare that initiation of chemotherapy leads to AEN, it should be considered as a potential etiology.

Comparison of circulating DNA in malignant neoplasia from diverse locations: Investigating a diagnostic role.

CONTEXT: Circulating free DNA (cfDNA) analysis has emerged as novel noninvasive diagnostic biomarker in several solid tumors. Raised levels have been reported in several malignancies and may correlate with clinicopathological and treatment response. The current study was designed to assess the diagnostics of cfDNA in different tumor types of malignancies correlating with tumor (T), nodes (N), and metastases (M) stage. DESIGN: Serum samples were collected from treatment naïve cases with histologically diagnosed tumors including 23 brain tumors, 48 breasts, 50 gallbladder carcinoma (GBC), 13 lungs, 68 oral squamous cell carcinoma (OSCC), and 25 normal controls. CfDNA was quantified with real-time polymerase chain reaction (PCR), Invasive ductal carcinoma (IDC) using beta-globin gene amplification. Cut off values for diagnostics were calculated using receiver operating curve analysis. RESULTS: Contrary to other cfDNA studies where it was postulated that cfDNA would not cross the blood-brain barrier and reach the systemic circulation, we found detectable cfDNA in glioma with median (Q1-Q3) of 349.22 ng/ml (19.87-1276.58). Median cfDNA concentration in breast, gallbladder, lung, oral and normal controls was 328.72 (128.38-624.44), 778.50 (589.88-1864.35), 348.73 (194.67-483.61), 386.27 (47.88-959.67), and 74.12 (49.66-120.00), respectively. Grades I and II glioma had significantly lower levels compared to Grades III and IV (P = 0.0001). Significant difference in median cfDNA values in IDC and GBC was observed with increasing tumor grades, stage, T stage, nodal stage and metastasis and with stage of OSCC cases. CONCLUSION: CfDNA levels showed good diagnostic discrimination in glioma, GBC, breast, lung carcinoma, and OSCC. Significant increase in titers was evident with increase in cancer stage from I to IV in breast, GBC and OSCC.

Alcohol Relapse After Liver Transplantation for Alcoholic Cirrhosis-Impact on Liver Graft and Patient Survival: A Meta-analysis.

AIM: We performed meta-analysis to determine effect of alcohol relapse after liver transplantation (LT) for alcoholic cirrhosis on graft histology and survival. METHODS: Studies were selected using following criteria: (a) LT for alcoholic cirrhosis, (b) reporting data on liver histology and/or patient survival among relapsers and abstainers, (c) minimum follow-up of 3 years. Random effects model was used to pool data to compare relapsers and abstainers on liver histology and patient survival. RESULTS: On analysis of seven studies, pooled prevalence of self-reported alcohol relapse was 26.3% (18.0-36.7%) over median (range) follow-up of 6.0 (3.7-8.3) years, with annual alcohol relapse rate of 4.7% (3.0-6.4%) for any alcohol use and 2.9% (0.5-5.3%) for heavy alcohol use. Relapsers compared to abstainers had higher odds for graft steatosis [4.1 (2.4-6.9)], steatohepatitis [4.5 (1.4-14.2)], alcoholic hepatitis [9.3 (1.01-85)], advanced fibrosis or cirrhosis [8.4 (3.5-20)]. Relapsers were over 3-fold more likely to die at 10 years of follow-up: [3.67 (1.42-9.50)] without differences in overall or 5-year survival. Recurrent alcoholic cirrhosis occurring in 9% of biopsied patients and 2% of all transplants was responsible for about 20% of all deaths on follow-up after LT. Extra-hepatic malignancy, and cardiovascular events were common causes for patient mortality. CONCLUSION: Alcohol relapse after LT for alcoholic cirrhosis negatively impacts the graft and long-term patient survival. Studies are needed to develop strategies to reduce alcohol relapse after LT for alcoholic cirrhosis. SHORT SUMMARY: Alcohol relapse in liver transplant recipients can negatively affect graft histology and patient survival. Strategies to reduce alcohol relapse are needed to preserve graft function?

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.

Significance of 18F-Fluorodeoxyglucose Uptake at the Gastroesophageal Junction: Comparison of PET to Esophagogastroduodenoscopy.

BACKGROUND: Positron emission tomography-computed tomography (PET/CT) occasionally reveals unexpected uptake of (18)F-fluorodeoxyglucose ((18)F-FDG) at the gastroesophageal junction (GEJ). The aim of this study was to determine the importance of unexpected (18)F-FDG uptake at the GEJ on PET/CT by correlating this finding with endoscopy results. METHODS: We reviewed medical records from June 2009 to October 2012 to identify patients in our Veterans Affairs Medical Center who had an esophagogastroduodenoscopy (EGD) performed within 6 months of a PET/CT. Metabolic activity at the GEJ was quantified with standardized uptake values (SUV) and correlated with EGD and histopathology results. RESULTS: A total of 219 patients were identified and assigned to one of five groups based upon EGD findings: esophageal malignancy (n = 34), esophagitis (n = 21), Barrett's esophagus (n = 8), other non-malignant disorders (n = 5), and normal (n = 151). The mean SUV Max for the groups was 6.72, 2.47, 2.40, 3.48, and 2.06, respectively. SUV Max and SUV Mean were significantly higher in the esophageal malignancy group than in all other groups (p < 0.001). SUV for patients with high-grade esophagitis was greater than in patients with low-grade esophagitis. A SUV Max ≥ 3.5 was found to predict necessity for EGD with a positive predictive value of 79 %. A SUV Max ≤ 2.2 yielded a negative predictive value of 86 %. CONCLUSION: Differentiation between benign and potentially significant disease at the GEJ may be possible with quantification of incidental (18)F-FDG uptake at PET/CT. Our results suggest thresholds that may help determine need for further endoscopic evaluation in patients with abnormal metabolic activity at the GEJ.