Surveillance for hepatocellular carcinoma in a mixed-aetiology UK cohort with cirrhosis: does α-fetoprotein still have a role?

Mortality from hepatocellular carcinoma (HCC) in people with cirrhosis is increasing whereas mortality from other causes is declining. Surveillance appears to reduce mortality but the optimal strategy is uncertain. Current guidelines differ by recommending ultrasonography alone or with α-fetoprotein (αFP). Records in three UK hospitals were analysed from 2006 to 2011. Of 111 HCC cases identified, 24 (47.1%) of those eligible were under surveillance: 21 (87.5%) were under combined ultrasonography-αFP, 2 (8.3%) ultrasonography-only and 1 (4.2%) αFP-only surveillance. αFP was elevated in 19 (86.4%), and αFP alone triggered a confirmatory study in 11 (9.9%) overall and 7 (29.1%) under surveillance. Surveillance, but not αFP, correlated with smaller tumours. Survival did not differ significantly between groups. Given that αFP use is associated with identifying smaller HCCs and that several diagnoses would have been delayed without αFP in this real-life cohort, these data support ongoing αFP use. However, further work is necessary with regard to whether αFP translates into improved clinical outcome and overall cost effects. In our area, stopping αFP use would also represent a significant change in practice.

Paediatric endoscopy performed by adult-service gastroenterologists.

BACKGROUND: Children often travel from district hospitals to teaching centres for endoscopic procedures by paediatric gastroenterologists. A 10-year district hospital experience of 'adult-service' gastroenterologists endoscoping children is reported with the aim of quantifying the workload, indications, sedation/anaesthesia practices, findings and safety of paediatric endoscopy performed by adult-service gastroenterologists. METHODS: Data on endoscopic procedures in patients younger than 16 years of age between 1997 and 2006 were obtained from hospital case-notes and computerized endoscopy/histology databases and were analysed. RESULTS: A total of 174 procedures (118 gastroscopies, 41 colonoscopies and 15 flexible sigmoidoscopies) were performed in 162 children. The median (interquartile range) age was 11.5 (5-14) years. Sixty-nine percent of patients were referred by paediatricians and 31% by general practitioners /other adult specialties. Children referred as outpatients waited a total of 50 (23.5-95) days from referral to procedure. Inpatient children waited 3 (1-4) days for their procedure. General anaesthesia was used in 89% (63 of 71) endoscopic procedures in children aged below 11 years and 100% of 47 procedures in children aged below 6 years. In contrast, 96% (99 of 103) procedures in children aged 11 years or older were done in the endoscopy unit with intravenous or no sedation. Organic disease was identified from 90 (52%) procedures. The most common diagnoses were coeliac disease (41), inflammatory bowel disease (26), gastro-oesophageal reflux (six) and foreign body removal (seven). No endoscopic complications occurred. CONCLUSION: General gastroenterologists supported by paediatricians can provide endoscopic services for children safely and promptly in their local hospital. This is appropriate for the management of common gastrointestinal problems affecting children.

A surveillance programme for Barrett's oesophagus in a UK general hospital.

BACKGROUND: Surveillance programmes for oesophageal cancer in patients with Barrett's columnar-lined oesophagus have reported varying efficacies. AIM: To review the effectiveness of an endoscopic surveillance programme for patients with Barrett's oesophagus in a UK general hospital. METHODS: Patients with Barrett's oesophagus (> or =3 cm histologically proven columnar-lined oesophagus) were identified from endoscopic and histological records and outcomes recorded when surveillance was performed with 2-yearly endoscopies and quadrantic biopsies at 3 cm intervals. RESULTS: One hundred and twenty-one patients (24%) entered the surveillance programme (mean age 60.2 years, 69.5% men, mean length of Barrett's mucosa 7.5 cm) of 505 patients identified with Barrett's oesophagus. Two hundred and five endoscopies were performed over a mean follow-up of 3.5 years. Five cases of high-grade dysplasia and two cases of adenocarcinoma were detected during the surveillance. One patient with high-grade dysplasia refused surgery and died of oesophageal carcinoma. The other six patients underwent oesophagectomy and five of the six resected specimens showed early (Tis to T2, N0) adenocarcinoma. All six patients remained well and tumour free at 24 months. No interval oesophageal cancers occurred. CONCLUSION: This surveillance programme for classical Barrett's oesophagus was effective with six cancers being detected early and treated. The detection rate was 1/71 patient-years of surveillance. Endoscopic workload was not excessive and no interval cancers occurred.

Errors of intravenous fluid infusion rates in medical inpatients.

Prescriptions for intravenous (i.v.) fluids in hospitals may not be closely adhered to. This study prospectively examined whether prescribed i.v. fluids are administered at the correct rate. During a four-week period, the i.v. infusion rates in patients requiring continuous i.v. fluids and cared for by a single medical team in a district hospital were studied. The periods over which i.v. crystalloid fluid bags were administered were compared with the time prescribed. Of a total 207 bags, 53 (26%) were correctly administered at the prescribed rate (percentage error 10% to -10%), 138 bags (67%) were infused too slowly and 16 bags (8%) were infused too fast. Overall, the median (interquartile range) absolute percentage error (positive or negative) for all infused bags was 23% (9.7-50). Thirty-nine per cent of bags were infused accurately when a metered pump was used, compared to 21% of bags infused accurately when a metered pump was not used (p < 0.01). Marked inaccuracies in i.v. fluid infusion rates are common, and do not seem to be perceived by staff as important. Metered pumps improve accuracy. Increased awareness of such errors, and the routine use of metered pumps should help improve the accuracy of i.v. fluid infusion rates.

Renal cell carcinoma presenting with malignant ascites.

It is rare for renal cell carcinoma to involve the peritoneum and cause malignant ascites. Furthermore, it is uncommon for malignant ascites to be a presenting feature of this cancer. An unusual case of renal cell carcinoma presenting with malignant ascites is reported, and its response to sunitinib described.

Enteral nutrition in Crohn's disease: fat in the formula.

Enteral nutrition is effective in inducing remission in active Crohn's disease. Speculation on the underlying mechanism of action has moved away from the presentation of nitrogen and towards the fat content of the various enteral feeds. Evidence is accumulating that additional long-chain triglyceride in such feeds impairs the response rate in active Crohn's disease, whereas no deleterious effects of additional medium-chain triglyceride have been identified. It has been proposed that long-chain triglycerides composed from n-6 fatty acids may be the most harmful, since such fatty acids are substrates for inflammatory eicosanoid production. However, recent studies comparing different enteral feeds are not consistent in identifying which additional fatty acids impair response rates to the greatest extent. Despite meta-analyses concluding that polymeric diets (typically containing large amounts of fat) are as effective as elemental diets, it would seem sensible to use enteral feeds with minimal fat content when treating active Crohn's disease.

Persistently elevated alkaline phosphatase.

A 32-year-old overweight asymptomatic man was found to have a persistently raised serum alkaline phosphatase at 250-300 U/l (normal range <130). Other liver function tests were unremarkable apart from an initial marginally elevated alanine transaminase, which normalised with weight reduction. Abdominal imaging revealed a fatty liver but an extensive serological search for significant hepatobiliary disease was negative. Subsequent isoenzyme electrophoresis revealed normal liver and bone fractions of alkaline phosphatase but a grossly elevated intestinal fraction. Elevated intestinal fraction of alkaline phosphatase should be considered in the investigation of unexplained alkaline phosphatase, particularly when the usual associated hepatobiliary and bony pathologies are not present. Although an elevated intestinal fraction of alkaline phosphatase can be linked to significant gastrointestinal pathology, this case report highlights that it can be a benign biochemical finding.

Autoimmune hepatitis triggered by nitrofurantoin: a case series.

INTRODUCTION: Drugs can occasionally trigger the onset of autoimmune liver disease. CASE PRESENTATION: Three Caucasian women (aged 65, 42 and 74 years old) who were receiving long-term nitrofurantoin as prophylaxis against recurrent urinary tract infections developed hepatitic liver disease. Serological auto-antibody profiles and liver histology appearances were consistent with autoimmune hepatitis. Two of the patients presented with jaundice, and one required a prolonged hospital admission for liver failure. In all three patients nitrofurantoin was withdrawn, and long-term immunosuppressive therapy with prednisolone and azathioprine or mycophenolate was given. The patients responded well, with liver biochemistry returning to normal within a few months. CONCLUSIONS: Although nitrofurantoin rarely causes autoimmune hepatitis, this antimicrobial is increasingly used as long-term prophylaxis against recurrent urinary tract infection. General practitioners and urologists who prescribe long-term nitrofurantoin therapy should be aware of this adverse effect.

Toxic shock syndrome responsive to steroids.

BACKGROUND: Toxic Shock Syndrome is a dangerous disease with clinical features mimicking bacterial sepsis. The best management of Toxic Shock Syndrome is not determined. CASE PRESENTATION: A 28 year-old woman presenting with high fever, tachycardia and widespread erythroderma is described. She failed to respond to intravenous antibiotics and required ITU admission. High dose corticosteroids dramatically improved her clinical condition. CONCLUSION: Toxic Shock Syndrome should be considered in the differential diagnosis of unexplained fever, rash and features resembling septic shock. Corticosteroids should be considered in the treatment of Toxic Shock Syndrome.

Reducing admission times in the endoscopy unit.

Pre-procedural admission of outpatients to a day-case endoscopy facility is time-consuming. Collecting and recording routine but necessary information distracts nurses from spending time that could be used to counsel patients. This study assessed whether patients can record some pre-procedural details and whether such self-recording quickens nurse admission times. A new admission document was devised and posted to patients. Patients completed personal/administrative details and information about drugs and allergies and brought the document with them when attending for outpatient endoscopy. Endoscopy nurses anonymously timed 100 admissions, 50 using the new admission form and 50 using the old admission form. Overall, the median (range) time to admit using the old form was 6 (3-15.5) min. Using the new form, the median time to admit was lower at 4 (0.5-10) min. No patient completing the new form reported any particular difficulties. An admission document that patients partially complete at home leads to a faster pre-procedural admission in the endoscopy unit. This allows more nursing time to discuss patients' anxieties and answer patient queries, helps to prevent delays and facilitates increased capacity in the endoscopy unit.