Graft-versus-host disease, a rare complication after orthotopic liver transplantation.

Acute graft-versus-host disease (GVHD) after orthotopic liver transplantation (OLT) is a rare but fatal complication that poses a major diagnostic and therapeutic challenge. Our case highlights the need for further studies to develop therapeutic modalities to improve outcomes in patients who develop GHVD following OLT.

Clinical outcomes in patients with bile leaks treated via ERCP with regard to the timing of ERCP: a large multicenter study.

BACKGROUND AND AIMS: Postsurgical or traumatic bile duct leaks (BDLs) can be safely and effectively managed by endoscopic therapy via ERCP. The early diagnosis of BDL is important because unrecognized leaks can lead to serious adverse events (AEs). Our aim was to evaluate the relationship between timing of endotherapy after BDL and the clinical outcomes, AEs, and long-term results of endoscopic therapy. METHODS: We conducted a multicenter, retrospective study on patients with BDLs who underwent ERCP between 2006 and 2014. Data were assembled on patient demographics, etiology of BDL, and procedural details. Endotherapy for BDLs were classified a priori into 3 groups based on timing of ERCP from time of biliary injury: within 1 day of BDL, on day 2 or 3 after BDL, and greater than 3 days after BDL. The relationship among timing of ERCP after BDL injury and outcomes, procedure-related AEs, and patient AEs and mortality were evaluated. RESULTS: From February 2006 to June 2014, 518 patients (50% male; mean age, 51.7 years) underwent ERCP for therapy of BDLs. The etiology of the BDL was laparoscopic cholecystectomy (70.7%), post-liver transplantation (11.2%), liver resection (14.1%), trauma (2.5%), and other causes (1.5%). Endotherapy was performed by placing a transpapillary stent alone (73.5%) or with a sphincterotomy (26.5%). The timing of ERCPs was as follows: ≤1 day = 57 patients, day 2 or 3 = 140 patients, and >3 days = 321 patients. There was no statistical difference in patient demographics, etiology/site of BDL, or type of endotherapy performed among the 3 groups. On multivariate analysis there was no statistically significant difference in BDL success rate for ERCPs performed within 1 day compared with those performed on day 2 or 3 or after 3 days of bile duct injury (91.2%, 90%, and 88.5%, respectively; P = .77). Similarly, there was no significant difference in the overall patient AE rate among the 3 groups (21.1%, 22.9%, and 24.6%, respectively; P = .81). AEs in men occurred significantly more frequently when compared with women, even after adjusting for age, BDL etiology, and location of leak (27.6% vs 19.9%; OR, 1.53; P = .04). Patients whose BDL was due to a cholecystectomy had a lower AE and mortality rate compared with those who had biliary injury from other etiologies (OR, .42; P < .001). CONCLUSIONS: The overall success rates and AEs after ERCP were not dependent on the timing of the procedure relative to the discovery of the bile leak. This suggests that ERCP in these patients can usually be performed in an elective, rather than an urgent, manner.

Endoscopic mucosal resection of large non-ampullary duodenal polyps: technical aspects and long-term therapeutic outcomes.

BACKGROUND: Our aim was to evaluate the efficacy, safety and long term outcomes of endoscopic mucosal resection (EMR) of large non-ampullary duodenal polyps. METHODS: A retrospective review of patients undergoing EMR of non-ampullary duodenal polyps ≥ 10 mm in size was performed. EMR was performed using standard snare polypectomy using pure coagulation current. Patient demographics, polyp site and histopathology, resection technique, use of adjunctive argon plasma coagulation (APC) ablation, adverse events, and residual/recurrent neoplasia at follow-up were evaluated. RESULTS: 59 duodenal lesions were removed by EMR (mean age 62 years, 55.9% men). 17 (28.8%) polyps were located in the bulb, 31 (50.8%) in the 2nd portion and 12 (20.3%) in the 3rd part of the duodenum. The mean size of lesions resected was. Submucosal saline injection followed by hot snare polypectomy was performed for 29 (49%) endoscopies. Adjunctive ablation of focal residual neoplastic tissue with APC was applied in 18 cases (30.5%). Complete endoscopic eradication during a single session was performed successfully in 46 (79%) patients. En-bloc resection was performed in 40 polyps (67%) and piecemeal resection in 19 (32.2%). Procedure complications were acute bleeding (N.=11) and 1 microperforation that was managed with clip closure and antibiotics. The mean follow-up time was 37 months (range 22-53). The overall endoscopic cure rate was 93%. On follow-up surveillance, residual adenoma was identified in 13 (22%) patients; these were all eradicated endoscopically. CONCLUSIONS: EMR for large non-ampullary duodenal adenomas is a safe and effective technique to achieve complete eradication.

A Trial of Rectal Indomethacin to Prevent Post-ERCP Pancreatitis in Patients with Suspected Type 3 Sphincter of Oddi Dysfunction.

BACKGROUND AND AIM: Recent data have suggested that rectal indomethacin can also reduce the incidence of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). The aim of this study was to determine whether prophylactic rectal indomethacin with PD stenting would reduce the incidence and severity of PEP compared to PD stenting alone in patients undergoing manometry for suspected SOD type 3. PATIENTS AND METHODS: A retrospective review of consecutive patients who underwent an ERCP with manometry for suspected SOD type 3 was performed. Patients were divided into two groups: (a) those who received a prophylactic PD stent (n = 285) and (b) those who received a prophylactic PD stent and a single dose of 100-mg indomethacin suppositories after ERCP (n = 57). The rate of PEP was compared between the two groups. RESULTS: The two patient groups were similar with regard to patient and procedure risk factors for PEP. Post-ERCP pancreatitis developed in 22 % patients. There was no significant difference in the incidence of PEP in the PD stent group compared to the PD stent and indomethacin group (23 vs. 18 %, respectively; p = 0.39). Moderate-to-severe pancreatitis developed in 21 (7 %) patients in the PD stent group compared to 5 (9 %) patients in the PD stent and indomethacin group (p = 0.78). Among patients with PEP, the median length of hospital stay was not significantly longer in the PD stent group compared to the PD stent and indomethacin group (6 vs. 4 days, respectively; p = 0.11). CONCLUSIONS: In patients with suspected SOD type 3, prophylactic rectally administered indomethacin with PD stenting was not observed to affect the incidence or severity of post-ERCP pancreatitis when compared to PD stenting alone.

Performance of endoscopic ultrasound in staging rectal adenocarcinoma appropriate for primary surgical resection.

BACKGROUND & AIMS: Endoscopic ultrasound (EUS) often is used to stage rectal cancer and thereby guide treatment. Prior assessments of its accuracy have been limited by small sets of data collected from tumors of varying stages. We aimed to characterize the diagnostic performance of EUS analysis of rectal cancer, paying particular attention to determining whether patients should undergo primary surgical resection. METHODS: We performed a retrospective observational study using procedural databases and electronic medical records from 4 academic tertiary-care hospitals, collecting data on EUS analyses from 2000 through 2012. Data were analyzed from 86 patients with rectal cancer initially staged as T2N0 by EUS. The negative predictive value (NPV) was calculated by comparing initial stages determined by EUS with those determined by pathology analysis of surgical samples. Logistic regression models were used to assess variation in diagnostic performance with case attributes. RESULTS: EUS excluded advanced tumor depth with an NPV of 0.837 (95% confidence interval [CI], 0.742-0.908), nodal metastasis with an NPV of 0.872 (95% CI, 0.783-0.934), and both together with an NPV of 0.767 (95% CI, 0.664-0.852) compared with pathology analysis. Incorrect staging by EUS affected treatment decision making for 20 of 86 patients (23.3%). Patient age at time of the procedure correlated with the NPV for metastasis to lymph node, but no other patient features were associated significantly with diagnostic performance. CONCLUSIONS: Based on a multicenter retrospective study, EUS staging of rectal cancer as T2N0 excludes advanced tumor depth and nodal metastasis, respectively, with an approximate NPV of 85%, similar to that of other modalities. EUS has an error rate of approximately 23% in identifying disease appropriate for surgical resection, which is lower than previously reported.

Atypical stress-induced cardiomyopathy: a case series.

Stress-induced cardiomyopathy (SIC) is characterized by reversible left ventricular (LV) systolic dysfunction, which appears to be triggered by an intense, stressful event in the absence of significant coronary artery disease. It manifests typically with transient left ventricular wall motion abnormalities (WMA) involving the apical and/or mid-ventricular myocardial segments, associated with minimal troponin rise (<5 ng/ml), and typical EGG changes. Described are 3 cases of stress-induced cardiomyopathy with atypical distribution of wall motion abnormalities. Possible contributing mechanisms to the pathogenesis and the variability in WMA are discussed.