Diet, Gut Microbiome, and Their End Metabolites Associate With Acute Pancreatitis Risk.

INTRODUCTION: Diet and decreased gut microbiome diversity has been associated with acute pancreatitis (AP) risk. However, differences in dietary intake, gut microbiome, and their impact on microbial end metabolites have not been studied in AP. We aimed to determine differences in (i) dietary intake (ii) gut microbiome diversity and sulfidogenic bacterial abundance, and (iii) serum short-chain fatty acid (SCFA) and hydrogen sulfide (H 2 S) concentrations in AP and control subjects. METHODS: This case-control study recruited 54 AP and 46 control subjects during hospitalization. Clinical and diet data and stool and blood samples were collected. 16S rDNA sequencing was used to determine gut microbiome alpha diversity and composition. Serum SCFA and H 2 S levels were measured. Machine learning (ML) model was used to identify microbial targets associated with AP. RESULTS: AP patients had a decreased intake of vitamin D 3 , whole grains, fish, and beneficial eicosapentaenoic, docosapentaenoic, and docosahexaenoic acids. AP patients also had lower gut microbiome diversity ( P = 0.021) and a higher abundance of sulfidogenic bacteria including Veillonella sp. and Haemophilus sp., which were associated with AP risk. Serum acetate and H 2 S concentrations were significantly higher in the AP group ( P < 0.001 and P = 0.043, respectively). ML model had 96% predictive ability to distinguish AP patients from controls. DISCUSSION: AP patients have decreased beneficial nutrient intake and gut microbiome diversity. An increased abundance of H 2 S-producing genera in the AP and SCFA-producing genera in the control group and predictive ability of ML model to distinguish AP patients indicates that diet, gut microbiota, and their end metabolites play a key role in AP.

Primary Gastrointestinal T-cell Lymphoma Presenting as Spontaneous Perforation Peritonitis.

Primary T-cell non-Hodgkin lymphoma (NHL) of the gastrointestinal tract (GIT) is a rare, poorly-characterized clinical entity. A well-known complication of intestinal NHL is perforation due to chemotherapy, but perforation as a presenting sign of GIT lymphoma is extremely rare. Here we present a case of spontaneous intestinal perforation secondary to primary intestinal T-cell lymphoma and highlight the importance of early recognition of this uncommon cause of perforation as a crucial step to ensure expedited hematology referral and initiation of appropriate treatment.

Balloon Tamponade Utilization for Severe Esophagitis Causing Hemorrhagic Shock.

Esophagitis causing upper gastrointestinal bleeding (UGIB) is associated with significant morbidity. We present a case report of two patients with hemorrhagic shock secondary to esophagitis. Both patients underwent esophagogastroduodenoscopy demonstrating severe bleeding pan-esophagitis complicated by hemodynamic instability. Balloon tamponade for hemostasis was performed with resultant hemodynamic improvement. Severe UGIB secondary to esophagitis is difficult to control, with a high risk of complications and limited available endoscopic therapies in extensive mucosal injury. Treatments such as angiography are ineffective due to collateralization and surgery carries high morbidity and mortality. Balloon tamponade provides a rescue option for severe, refractory UGIB secondary to esophagitis.

Evaluating the conversion to extended-release tacrolimus from immediate-release tacrolimus in liver transplant recipients.

BACKGROUND: A new formulation of once daily extended-release tacrolimus (LCP-tac, Envarsus XR) was approved for use in the USA for kidney transplant recipients in 2015. There are limited data regarding real-world observations with conversion to LCP-tac in liver transplant recipients. METHODS: We performed a retrospective analysis of liver transplant recipients treated with LCP-tac. Data collection included (1) reasons for switching to LCP-tac; (2) conversion ratio used; (3) kidney function at time of conversion and 3 months after; (4) outcomes of conversion [acute cellular rejection rates and cytomegalovirus (CMV) viremia] within 3 months of conversion. RESULTS: Average conversion ratio used to achieve therapeutic drug level without further dose adjustment was 1:0.73 (SD 0.11). Median time after transplant was 508 days (IQR 736). Common reasons patients were switched to LCP-tac were from fluctuations in tacrolimus levels (44%) and adverse effect of tremor (32%). Among patients who were switched due to tremors 88% noted significant improvement. There was no difference in serum creatinine (P = 0.55) or glomerular filtration rate (P = 0.64) from baseline to 3 months postconversion. There were no episodes of acute cellular rejections or CMV viremia postconversion. CONCLUSION: This observational study demonstrated that conversion of immediate-release tacrolimus to LCP-tac in liver transplant recipients was well tolerated and effective.

Outcomes following SARS-CoV-2 infection in liver transplant recipients: an international registry study.

BACKGROUND: Despite concerns that patients with liver transplants might be at increased risk of adverse outcomes from COVID-19 because of coexisting comorbidities and use of immunosuppressants, the effect of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection on this patient group remains unclear. We aimed to assess the clinical outcomes in these patients. METHODS: In this multicentre cohort study, we collected data on patients with laboratory-confirmed SARS-CoV-2 infection, who were older than 18 years, who had previously received a liver transplant, and for whom data had been submitted by clinicians to one of two international registries (COVID-Hep and SECURE-Cirrhosis) at the end of the patient's disease course. Patients without a known hospitalisation status or mortality outcome were excluded. For comparison, data from a contemporaneous cohort of consecutive patients with SARS-CoV-2 infection who had not received a liver transplant were collected from the electronic patient records of the Oxford University Hospitals National Health Service Foundation Trust. We compared the cohorts with regard to several outcomes (including death, hospitalisation, intensive care unit [ICU] admission, requirement for intensive care, and need for invasive ventilation). A propensity score-matched analysis was done to test for an association between liver transplant and death. FINDINGS: Between March 25 and June 26, 2020, data were collected for 151 adult liver transplant recipients from 18 countries (median age 60 years [IQR 47-66], 102 [68%] men, 49 [32%] women) and 627 patients who had not undergone liver transplantation (median age 73 years [44-84], 329 [52%] men, 298 [48%] women). The groups did not differ with regard to the proportion of patients hospitalised (124 [82%] patients in the liver transplant cohort vs 474 [76%] in the comparison cohort, p=0·106), or who required intensive care (47 [31%] vs 185 [30%], p=0·837). However, ICU admission (43 [28%] vs 52 [8%], p<0·0001) and invasive ventilation (30 [20%] vs 32 [5%], p<0·0001) were more frequent in the liver transplant cohort. 28 (19%) patients in the liver transplant cohort died, compared with 167 (27%) in the comparison cohort (p=0·046). In the propensity score-matched analysis (adjusting for age, sex, creatinine concentration, obesity, hypertension, diabetes, and ethnicity), liver transplantation did not significantly increase the risk of death in patients with SARS-CoV-2 infection (absolute risk difference 1·4% [95% CI -7·7 to 10·4]). Multivariable logistic regression analysis showed that age (odds ratio 1·06 [95% CI 1·01 to 1·11] per 1 year increase), serum creatinine concentration (1·57 [1·05 to 2·36] per 1 mg/dL increase), and non-liver cancer (18·30 [1·96 to 170·75]) were associated with death among liver transplant recipients. INTERPRETATION: Liver transplantation was not independently associated with death, whereas increased age and presence of comorbidities were. Factors other than transplantation should be preferentially considered in relation to physical distancing and provision of medical care for patients with liver transplants during the COVID-19 pandemic. FUNDING: European Association for the Study of the Liver, US National Institutes of Health, UK National Institute for Health Research.

Atypical Presentation of Cardiac Tamponade as a Cause of Acute Liver Injury: Case Report and Review of Literature.

Pericardial tamponade is a rare cause of acute liver injury due to the compressive effects of an effusion resulting in a poor cardiac output which ultimately leads to ischemia-induced injury. We present a patient with chronic hepatitis C infection and end-stage renal disease who was transferred to our center for further evaluation and management of acute liver injury after presenting to an outside hospital with left upper quadrant abdominal pain, nausea and vomiting. The patient was discovered to have tamponade physiology on transthoracic echocardiogram as an underlying cause of his acute liver injury despite lack of clinical tamponade features. He required pericardiocentesis which eventually led to resolution of the acute liver injury and he was discharged home on day twelve after full recovery. We review the existing literature regarding the epidemiology, pathophysiology, clinical presentation, diagnosis, and treatment of ischemic hepatitis, which is associated with high mortality; therefore early recognition and treatment of the underlying cause are paramount.