Contemporary Policies Regarding Alcohol and Marijuana Use Among Liver Transplant Programs in the United States.

BACKGROUND: Alcoholic liver disease is a common indication for orthotopic liver transplantation (OLT). Although OLT has been shown to confer survival benefit to patients with acute alcoholic hepatitis (AAH), historically most programs require a 6-month abstinence period before OLT which excludes patients with AAH. Marijuana has become legal in more than half the states in the United States. This survey of liver transplant programs was conducted to evaluate current policies regarding alcohol, marijuana and methadone use. METHODS: A questionnaire was distributed to 100 United Network for Organ Sharing-approved liver transplant programs in North America that have performed at least 30 liver transplants/year in the last 5 years. RESULTS: Forty-nine programs responded. Only 43% of the programs required a specific period of abstinence before transplant for alcoholic liver disease and only 26% enforced 6-month abstinence policy. For patients with AAH, 71% programs waived the 6-month abstinence requirement and considered psychosocial factors, such as family support, patient's motivation, or commitment to rehabilitate. Few programs used validated instruments to assess risk of relapse in AAH patients. Fourteen percent of programs transplant patients actively using marijuana and an additional 28% of programs listed patients using marijuana provided they discontinue by the time of OLT. Active methadone users were accepted in 45% of the programs. CONCLUSIONS: Policies regarding alcohol use have become more flexible particularly toward patients with AAH. Marijuana use is also more accepted. Although policies regarding alcohol and marijuana have changed significantly in the last decade, they remain highly variable among programs.

Unusual cases of jaundice secondary to non-neoplastic bile duct obstruction.

Obstructive jaundice secondary to common bile duct stricture is most commonly attributed to malignancy. Here we present three unusual cases that mimicked carcinoma in presentation but were histologically diagnosed as benign inflammatory processes during operative care. The first case was attributed to obstruction-induced chronic pancreatitis secondary to Crohn's disease of the head of the pancreas, the second was due to sarcoidosis within periportal and extrahepatic biliary lymph nodes and distal common bile duct, and the third case was due to tuberculosis of biliary lymph nodes. All were successfully managed surgically, but potentially these patients may have been effectively treated pharmacologically, without the need for invasive surgical intervention, if an earlier diagnosis were available to the clinicians. A retrospective and comparative review of the data of each case demonstrated subtle clues such as multiple enlarged biliary lymph node involvement and only moderately elevated bilirubin levels that pointed toward possible nonmalignant processes.

Surgical management of complicated hydatid disease of the liver.

Increased worldwide travel and immigration have led to an increase in the incidence of hepatic hydatid disease outside of endemic areas. In nonendemic areas lack of familiarity with the disease may lead to a delay in diagnosis with increased risk for development of complicated disease. Complicated disease is defined as: infected cysts, cysts with a hyperechoic solid pattern or calcified walls, or cysts with biliary rupture. Over a 6-month period six patients with complicated hydatid disease were referred to our institution. All six patients were immigrants from endemic areas and were found to have complicated hepatic hydatid disease including cholangitis and intrabiliary rupture. Patients were treated with oral albendazole for 3 weeks before operation and oral praziquantel for 2 days preoperatively. Surgical therapy consisted of subtotal cystectomy, cholecystectomy in all patients, and cystic duct biliary decompression-drainage in five patients. The one patient without biliary drainage developed a postoperative bile leak that resolved with endoscopic biliary stenting. All patients received albendazole for 3 months postoperatively and were free of disease at 6 to 24 months follow-up. We conclude that although nonoperative management with percutaneous drainage or medical management alone may be successful in patients with uncomplicated disease operation remains the therapy of choice for complicated hydatid disease.