Impact of obesity and diabetes on waitlist survival, probability of liver transplantation and post-transplant survival among chronic hepatitis C virus patients.

BACKGROUND & AIMS: The rising prevalence of obesity and diabetes mellitus (DM) among hepatitis C virus (HCV) patients contributes to concurrent nonalcoholic fatty liver disease (NAFLD). We aim to evaluate the impact of concurrent obesity or DM on waitlist survival and probability of liver transplantation (LT) among adults with chronic HCV awaiting LT. METHODS: Using 2003-2013 United Network for Organ Sharing data, we evaluated the impact of obesity and DM among adults with chronic HCV awaiting LT: non-obese, non-DM vs. obese, non-DM (obese) vs. non-obese, DM (DM) vs. obese and DM. Overall, LT waitlist survival and probability of receiving LT were evaluated using Kaplan-Meier and multivariate logistic regression models. RESULTS: From 2003-2013, there were 43 478 new LT waitlist registrants with chronic HCV (21.0% with HCC, 79% without HCC). Obesity was associated with lower probability of receiving LT (OR, 0.91; 95% CI, 0.85-0.97; P < 0.01), and lower probability of waitlist mortality (OR, 0.80; 95% CI, 0.72-0.89; P < 0.001) when compared to non-obese patients. DM among HCV patients did not impact probability of waitlist survival or receiving LT. When evaluating post-LT survival, compared to non-obese, non-DM patients, obese HCV patients had significantly lower post-LT mortality (HR 0.86; 95%CI, 0.81-0.92; P < 0.001); whereas, HCV patients with DM had significantly higher post-LT mortality (HR, 1.22; 95% CI, 1.12-1.33; P < 0.001). CONCLUSION: Among adults with chronic HCV awaiting LT in the US, obesity is associated with lower probability of receiving LT, but did not impact waitlist survival. DM among chronic HCV patients did not impact waitlist survival or probability of LT.

Diabetes Mellitus Increases Risk of Hepatocellular Carcinoma in Chronic Hepatitis C Virus Patients: A Systematic Review.

BACKGROUND: Rising rates of obesity, diabetes mellitus (DM), and nonalcoholic fatty liver disease (NAFLD) among chronic hepatitis C (HCV) patients may contribute to higher hepatocellular carcinoma (HCC) risk. AIM: To perform a systematic review evaluating the impact of DM, body mass index (BMI), or steatosis on HCC risk among chronic HCV patients. METHODS: A structured keyword search of PubMed from January 1, 2001, to July 1, 2014, was performed to identify original articles evaluating the association of DM, BMI, or steatosis with HCC among adults with chronic HCV. Studies involving HCV patients co-infected with human immunodeficiency virus, hepatitis B virus, or other chronic liver diseases with the exception of NAFLD were excluded. Quality assessment utilized the Newcastle-Ottawa scale. RESULTS: Nine studies (seven cohorts, two case-controls) met inclusion criteria for the final analysis. Five of seven studies analyzing DM demonstrated significantly increased HCC risk associated with concurrent DM with effect sizes ranging from HR 1.73 (95 % CI 1.30-2.30) to RR 3.52 (95 % CI 1.29-9.24). One of three studies analyzing BMI demonstrated a significant association with HCC risk (BMI ≥ 30.0 vs. BMI < 23: RR 4.13, 95 % CI 1.38-12.40). Two of the three studies analyzing steatosis demonstrated significantly higher risk of HCC associated with steatosis ranging from RR 2.81 (95 % CI 1.49-4.41) to OR 6.39 (95 % CI 1.04-39.35). CONCLUSIONS: Concurrent DM is associated with increased HCC risk among chronic HCV patients. BMI and steatosis may also increase HCC risk, but the limitations of the current studies do not allow us to draw strong conclusions.

Acute Liver Failure Due to Acetaminophen Poisoning in Patients With Prior Weight Loss Surgery: A Case Series.

GOALS: To identify an association between prior weight loss surgery (WLS) and acetaminophen-induced acute liver failure (ALF). BACKGROUND: WLS, which has increased in proportion to the global rise of obesity, alters the absorption and metabolism of many drugs including acetaminophen (APAP) and may predispose to toxicity. No study has identified an association between prior WLS and APAP-ALF. STUDY: We retrospectively reviewed a cohort of patients who presented to our center with ALF. We identified 101 patients who presented to our center with ALF between January 2009 and December 2011. All patients were prospectively enrolled into a database using consensus criteria. A history of WLS was obtained through a retrospective chart review. RESULTS: Fifty-four patients (53.5%) had APAP-ALF and 47 (46.5%) had ALF caused by other etiologies. A prior history of WLS was present in 9 of the 54 patients with APAP-ALF versus 0 of the 47 with non-APAP-ALF (P=0.003). Patients with APAP-ALF and prior WLS did not have higher rates of factors commonly associated with APAP overdose, including depression, alcohol abuse, intent to cause self-harm, or use of APAP-narcotic combination drugs. CONCLUSIONS: A history of WLS may predispose to hepatotoxicity and ALF caused by acetaminophen.

Diabetes mellitus, and not obesity, is associated with lower survival following liver transplantation.

BACKGROUND AND AIMS: The impact of obesity on survival following liver transplantation is unclear, and existing studies report conflicting results. Our current study aims to further delineate the impact of obesity using population-based registry data from the USA. METHODS: All US adult liver transplant recipients from 2003 to 2012 were evaluated using the United Network for Organ Sharing registry. The impact of obesity on survival following liver transplantation was further stratified into class I obesity [body mass index (BMI) 30.0-34.9 kg/m(2)], class II obesity (BMI 35.0-39.9 kg/m(2)), and class III obesity (BMI ≥ 40 kg/m(2)) and evaluated using Kaplan-Meier methods and multivariate Cox proportional hazards models. RESULTS: Overall, 57,255 patients with chronic liver disease underwent liver transplantation, among which 32.9 % had BMI ≥ 30 kg/m(2). While patients in all obesity classes had similar survival to patients with BMI 18.0-24.9 kg/m(2), the presence of concurrent diabetes mellitus resulted in significantly lower post-transplant survival. After multivariate regression, post-transplant survival in patients with class II obesity (HR 0.97; 95 % CI 0.89-1.05) or class III obesity (HR 0.99; 95 % CI 0.90-1.09) was not significantly lower than patients with BMI 18.0-24.9 kg/m(2), but diabetes mellitus was independently associated with lower post-transplant survival (HR 1.29; 95 % CI 1.21-1.36). CONCLUSION: In conclusion, obesity alone was not associated with lower post-transplant survival. However, DM, either alone or comorbid with obesity, is associated with significantly greater post-transplant mortality.

Concurrent Obesity, Diabetes, and Steatosis Increase Risk of Advanced Fibrosis Among HCV Patients: A Systematic Review.

BACKGROUND: Rising rates of obesity, diabetes mellitus (DM), and nonalcoholic fatty liver disease among patients with chronic hepatitis C virus infection (HCV) may contribute to more rapid disease progression. AIM: To evaluate the impact of concurrent obesity, DM, and steatosis on disease progression among HCV patients. METHODS: A systematic review using structured keyword search of MEDLINE and EMBASE from January 1, 2001, to July 1, 2014, was performed to identify original articles evaluating the association of obesity, DM, and steatosis with advanced fibrosis (AF) among adults with chronic HCV. Studies involving HCV patients coinfected with human immunodeficiency virus, hepatitis B virus, hepatocellular carcinoma, or other chronic liver diseases were excluded. Quality assessment utilized Newcastle-Ottawa Scale. RESULTS: Twenty cohort studies met inclusion criteria for analyses. Obesity was associated with increased risk of AF in seven studies with effect size ranging from OR 1.08 to 7.69. However, four studies did not demonstrate a significant association between obesity and AF. The presence of advanced steatosis among HCV patients was associated with increased risk of AF in 12 studies (OR 1.80-14.3). Concurrent DM was associated with increased risk of AF in six studies (OR 2.25-9.24). Thirteen studies were good quality, and seven studies were fair quality. CONCLUSION: Concurrent DM and steatosis are associated with increased risk of AF among chronic HCV patients. The majority of studies demonstrated significant associations of obesity with AF. Targeted interventions to optimize management of obesity-related diseases among HCV patients may help mitigate HCV disease progression.

Acute liver failure caused by herpes simplex virus in a pregnant patient: is there a potential role for therapeutic plasma exchange?

A young woman presented with a febrile illness in the third trimester of pregnancy. Laboratory investigation revealed severe acute hepatitis with thrombocytopenia and coagulopathy. Liver injury progressed despite emergent caesarian section and delivery of a healthy infant. Therefore, therapeutic plasma exchange (TPE) was performed on three consecutive days post-partum for a presumed diagnosis of acute liver failure (ALF) associated with pregnancy due to hemolysis, elevated liver enzymes, and low platelets (HELLP) or acute fatty liver of pregnancy (AFLP). Treatment with TPE was followed by biochemical and clinical improvement but during her recovery herpes simplex virus type 2 (HSV-2) infection was diagnosed serologically and confirmed histologically. Changes in the immune system during pregnancy make pregnant patients more susceptible to acute HSV hepatitis, HSV-related ALF, and death. The disease is characterized by massive hepatic inflammation with hepatocyte necrosis, mediated by both direct viral cytotoxicity and the innate humoral immune response. TPE may have a therapeutic role in acute inflammatory disorders such as HSV hepatitis by reducing viral load and attenuating systemic inflammation and liver cell injury. Further investigation is needed to clarify this potential effect. The roles of vigilance, clinical suspicion, and currently accepted therapies are emphasized.

Clinical Updates in Primary Biliary Cholangitis: Trends, Epidemiology, Diagnostics, and New Therapeutic Approaches.

Primary biliary cholangitis, formerly known as primary biliary cirrhosis, is a chronic, autoimmune, and cholestatic disease ameliorating the biliary epithelial system causing fibrosis and end-stage liver disease, over time. Patients range from an asymptomatic phase early in the disease course, to symptoms of decompensated cirrhosis later in its course. This review focuses on the current consensus on the epidemiology, diagnosis, and management of patients with primary biliary cholangitis. We also discuss established medical management as well as novel and investigational therapeutics in the pipeline for management of PBC.

Race/ethnicity is an independent risk factor for autoimmune hepatitis among the San Francisco underserved.

Although autoimmune hepatitis (AIH) is more common in women and affects people of all races/ethnicities, there is currently limited information regarding the relationship between race/ethnicity and AIH, especially in the context of underserved populations. We aim to evaluate the relationship between race/ethnicity and AIH and better characterize its clinical features among different racial groups. We conducted a 15-year retrospective analysis, from January 2002 to June 2017, of patients seen at Zuckerberg San Francisco General Hospital (ZSFG). Sixty-three AIH patients and 2049 non-AIH controls were eligible for the study. The main predictor of interest was race/ethnicity, and the main outcome of interest was AIH diagnosis; other secondary measures recorded include clinical features such as ALT, bilirubin, and biopsy fibrosis at presentation. In a multivariable model adjusting for age and sex, we found that black (OR 9.6, 95% CI 1.8-178), Latino (OR 25.0, 95% CI 5.3-448), and Asian/Pacific Islander (API) (OR 10.8, 95% CI 2.2-196) race/ethnicity were associated with increased odds of an AIH diagnosis compared to the white reference group. Among people of colour with AIH, there were no significant differences in baseline ALT (p = .45), total bilirubin at presentation (p = .06), fibrosis at presentation (p = .74), and hospitalization (p = .27). Race/ethnicity is an independent risk factor for AIH. The clinical features of AIH did not differ significantly among black, Latino, and API patients.

Low skin carotenoid concentration measured by resonance Raman spectroscopy is associated with metabolic syndrome in adults.

Oxidative stress is increased in patients with metabolic syndrome (MS). Antioxidants, including carotenoids, are decreased in MS. We hypothesized that a low skin carotenoid score (SCS), calculated using resonance Raman spectroscopy, would correlate with the presence of MS. We retrospectively reviewed consecutive patients referred for dietary assessment between 2010 and 2012. For each patient, a nutrition history, medical history, and SCS were recorded. χ(2) and Student t test were used to determine factors associated with MS. Multivariate logistic regression was used to identify factors associated with MS. One hundred fifty-five patients were included. The mean age was 54.1 ± 13.1 years, and the mean body mass index was 28.3 ± 6.1 kg/m(2). Metabolic syndrome was present in 43.9% of patients. The mean SCS was 28 084 ± 14 006 Raman counts (RC), including 23 058 ± 9812 RC for patients with MS and 32 011 ± 15 514 RC for patients without MS (P = .0001). In a multivariate analysis, SCS less than 25 000 RC (odds ratio, 3.71; 95% confidence interval, 1.36-10.7; P = .01) was independently associated with MS. A higher number of MS components was associated with a progressively lower SCS (P = .004). In a consecutive sample of patients referred for dietary assessment, a noninvasively measured SCS was lower among patients with MS.

Successful single-session endosonography-based endoscopic retrograde cholangiopancreatography without fluoroscopy in pregnant patients with suspected choledocholithiasis: a case series.

PURPOSE: Same session endosonography (EUS) immediately prior to scheduled endoscopic retrograde cholangiopancreatography (ERCP) may eliminate the need for ERCP and its associated risks in pregnant patients with no evidence of choledocholithiasis on EUS. In patients with choledocholithiasis, EUS provides information regarding the location, size and number of stones present, which helps guide biliary interventions and confirm stone clearance without the use of fluoroscopy. METHODS: We retrospectively identified 10 pregnant patients referred to our tertiary endoscopy center for suspected choledocholithiasis between June 2008 and January 2012. All patients underwent same-session EUS-based ERCP. RESULTS: Of 10 pregnant patients managed with EUS-guided ERCP, six were found to have common bile duct stones and went on to ERCP. Four patients with no evidence of choledocholithiasis on EUS did not undergo ERCP. Patients with confirmed choledocholithiasis underwent ERCP without the use of fluoroscopy using the additional information provided by EUS. CONCLUSIONS: Same-session EUS immediately prior to scheduled ERCP may eliminate the need for ERCP and its risks in pregnant patients with no evidence of choledocholithiasis on EUS. In patients with confirmed choledocholithiasis, EUS provided additional information regarding the location, number and size of bile duct stones, which enabled the successful clearance of the bile duct without the use of fluoroscopy.

Patient tolerability of bowel preparation is associated with polyp detection rate during colonoscopy.

BACKGROUND & AIMS: A number of factors have been identified that influence the yield of screening colonoscopy. The perceived tolerability of bowel preparation has not been studied as a predictor of quality outcomes in colonoscopy. We aimed to characterize the association between patient-perceived tolerability of bowel preparation and polyp detection during colonoscopy. METHODS: We performed a cross-sectional cohort study of 413 consecutive adult patients presenting for outpatient colonoscopy at two outpatient endoscopy centers at our institution. We developed a standardized questionnaire to assess the patient's experience with bowel preparation. Bowel preparation quality was measured using the validated Ottawa scale and colonoscopic findings were recorded for each patient. The primary outcome was polyp detection and the secondary outcome was the quality of bowel preparation. RESULTS: Patient-reported clarity of effluent during bowel preparation correlated poorly with Ottawa score during colonoscopy, ĸ=0.15. Female gender was an independent risk factor for a poorly tolerated bowel prep (OR 3.93, 95% CI 2.30 - 6.72, p<0.001). Report of a poorly tolerated bowel prep was independently associated with the primary outcome, polyp detection (OR 0.39, 95% CI 0.18 - 0.84, p=0.02) and also with the secondary outcome, lower quality bowel preparation (OR 2.39, 95% CI 1.17 - 4.9, p=0.02). CONCLUSIONS: A patient-perceived negative experience with bowel preparation independently predicted both a lower quality bowel preparation and a lower rate of polyp of detection. Assessment of the tolerability of bowel preparation before colonoscopy may be a clinically useful predictor of quality outcomes during colonoscopy.

Esophageal adenocarcinoma in a 40-year-old man with cystic fibrosis: coincidence or not?

OBJECTIVE: To report a case of esophageal cancer in an adult patient with cystic fibrosis (CF) and review the relationship between these 2 diseases. CASE REPORT: A 40-year-old man with CF presented with worsening epigastric pain, weight loss, and upper gastrointestinal (GI) bleeding. Endoscopy revealed innumerable masses in the distal esophagus. The workup revealed esophageal adenocarcinoma metastatic to the liver and the lungs. DISCUSSION: Abnormal mucous secretions in CF patients impair the innate GI mucosal barriers. The incidence of both gastroesophageal reflux disease and GI malignancies is higher in patients with CF. Patients with CF now survive long enough to potentially experience the consequences of long-term acid exposure, including esophagitis, Barrett esophagus, and esophageal cancer. CONCLUSION: Our case report adds to a small but growing body of evidence that CF is a significant risk factor for GI malignancies, including esophageal adenocarcinoma. Controlled studies are needed to determine whether a causal relationship truly exists.

Long-term clinical outcomes after endoscopic minor papilla therapy in symptomatic patients with pancreas divisum.

OBJECTIVES: To assess the long-term outcomes of endoscopic minor papilla therapy in a spectrum of symptomatic patients with pancreas divisum. METHODS: Patients with pancreas divisum coded in a prospective database as having had minor papilla endotherapy (July 1997-May 2003, n = 145) were grouped into 3 categories: (1) acute recurrent pancreatitis, (2) chronic pancreatitis, and (3) chronic/recurrent epigastric pain. Telephone follow-up was conducted (78% of patients), including questions regarding interval co-interventions and narcotic use. Primary success was defined as clinical improvement (better or cured on a Likert scale), without needing narcotics, after 1 therapeutic endoscopic retrograde cholangiopancreatography. Fisher exact and Mann-Whitney U tests and multivariate logistic regression were used to identify predictors of success. RESULTS: Primary success rates in acute recurrent pancreatitis, chronic pancreatitis, and chronic/recurrent epigastric pain were achieved in 53.2%, 18.2%, and 41.4%, respectively; and secondary success rates (