LAMS use in malignant stricture of duodenal apex with synchronous malignant biliary obstruction: a potentially effective and simpler endoscopic approach.

We report the first case of lumen apposing metal stent (LAMS) use in malignant stricture of the duodenal apex to treat gastric outlet obstruction (GOO) and to facilitate endoscopic retrograde management of synchronous malignant biliary obstruction due to pancreatic head adenocarcinoma. This technique may be an effective alternative and a simpler approach than current methodology to this endoscopically challenging condition.

Autoimmune hepatitis and metabolic syndrome-associated disease development: a U.S. cohort study.

BACKGROUND: Autoimmune hepatitis (AIH) may coexist with metabolic syndrome-associated diseases (MSADs) given patients' inherent need for corticosteroid therapy, as well as general population trends. AIM: To examine the impact of MSAD risk factors on AIH or its treatment, and vice versa METHODS: This was a multi-centre retrospective cohort study of 552 patients with AIH diagnosed between January 2000 and December 2019. Data relating to demographic factors, laboratory values, AIH medications and MSADs were collected at diagnosis and at 1- and 3-year follow-up. Statistical relationships were analysed and reported. RESULTS: We included 552 patients in the study cohort (median age 50 years, 76.1% female). All MSADs, including hypertension, dyslipidaemia, diabetes and a gain of BMI ≥3 kg/m2 , increased within the AIH cohort over time. Initial treatment regimen impacted de novo diabetes but not other MSAD development. AIH biochemical remission was less frequent at 3 years post-diagnosis among patients with ≥1 MSAD. The incidence of new MSADs could be predicted by baseline factors in certain cases. CONCLUSION: In the largest US-based cohort of patients newly diagnosed with AIH, there was a considerable burden of pre-existing and de novo MSADs that may affect AIH treatment outcomes. Identifying those at highest risk of co-morbid MSADs allows for an individualised approach to management to reduce its long-term sequelae in patients with AIH.

A Multimodal Intervention Using Nonopioid Analgesics Is Associated With Reduced Intravenous Opioid Exposure Among Hospitalized Patients With Inflammatory Bowel Diseases.

INTRODUCTION: Opioid use in patients with inflammatory bowel disease (IBD) is associated with increased mortality. Previous interventions targeting reduced intravenous opioid (IVOPI) exposure for all patients admitted to a general medical unit have decreased total opioid use without compromising pain control. We therefore performed a prospective evaluation of a multimodal intervention encouraging the use of nonopioid alternatives to reduce IVOPI exposure among patients with IBD hospitalized at our institution. METHODS: This was a prospective evaluation of a multimodal intervention to reduce IVOPI use among patients with IBD aged ≥18 years admitted to a general medical unit at a large urban academic medical center from January 1, 2019, to June 30, 2019. Intravenous and total (all routes) opioid exposures were measured as proportions and intravenous morphine milligram equivalents/patient day and compared with preintervention (January 1, 2018, to December 31, 2018) data. Hospital length of stay (LOS), 30-day readmission rates (RRs), and pain scores (1-10 scale) were also assessed. RESULTS: Our study involved 345 patients with IBD with similar baseline characteristics in preintervention (n = 241) and intervention (n = 104) periods. Between study periods, we observed a significant reduction in the proportion of patients receiving IVOPIs (43.6% vs 30.8%, P = 0.03) and total opioid dose exposure (15.6 vs 8.5 intravenous morphine mg equivalents/d, P = 0.02). We observed similar mean pain scores (3.9 vs 3.7, P = 0.55) and significantly reduced mean LOS (7.2 vs 5.3 days, P = 0.03) and 30-day RRs (21.6% vs 11.5%, P = 0.03). DISCUSSION: A multimodal intervention was associated with reduced opioid exposure, LOS, and 30-day RRs for hospitalized patients with IBD. Additional research is needed to determine long-term benefits of reduced opioid exposure in this population.

Liver Transplantation for Hepatic Epithelioid Hemangioendothelioma Is Facilitated by Exception Points With Acceptable Long-term Outcomes.

BACKGROUND: Hepatic epithelioid hemangioendothelioma (HEHE) is a rare vascular tumor with a high mortality rate. HEHE is now a formally recognized indication for exception point priority in the United States under the new National Liver Review Board. The role of liver transplantation (LT) and exception point waitlist priority in the United States for patients with HEHE remains understudied. METHODS: This was a retrospective cohort study using the United Network for Organ Sharing transplant database. From February 27, 2002 to January 31, 2018, 131 adults waitlisted for LT with HEHE were identified by free-text entry. RESULTS: Exception point applications were submitted for 91.6% (120/131) of patients. All patients with fully reviewed applications received exception points at least once during waitlisting, and 85% (103/120) upon first submission. Among the 88 patients transplanted, median model for end-stage liver disease score at LT was 7 ((interquartile range [IQR]: 6-11) and waiting time 78.5 days (IQR: 29.5-237.5). Unadjusted post-LT survival of HEHE recipients at 1-, 3-, and 5-years from LT was 88.6%, 78.9%, and 77.2%. Unadjusted post-LT patient and graft survival of HEHE patients was not different from patients with hepatocellular carcinoma within Milan receiving exception point priority (P = 0.08). An increased rate of graft failure due to hepatic artery thrombosis ≤14 days from initial LT was observed in HEHE versus non-HEHE patients (4.6% versus 0.5%). CONCLUSIONS: The majority of HEHE recipients receive exception points at a universal approval rate allowing prompt access to deceased donor LT.

Coffee: The magical bean for liver diseases.

Coffee has long been recognized as having hepatoprotective properties, however, the extent of any beneficial effect is still being elucidated. Coffee appears to reduce risk of hepatocellular carcinoma, reduce advancement of fibrotic disease in a variety of chronic liver diseases, and perhaps reduce ability of hepatitis C virus to replicate. This review aims to catalog the evidence for coffee as universally beneficial across a spectrum of chronic liver diseases, as well as spotlight opportunities for future investigation into coffee and liver disease.