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Ogurchenok NE, Khalin KD, Bryukhovetskiy IS. Chemoprophylaxis of precancerous lesions in patients who are at a high risk of developing colorectal cancer (Review). MEDICINE INTERNATIONAL 2024; 4:25. [PMID: 38628384 PMCID: PMC11019464 DOI: 10.3892/mi.2024.149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 03/07/2024] [Indexed: 04/19/2024]
Abstract
The diagnostics of colorectal cancer (CRC) and precancerous lesions in the colon is one of the most urgent matters to be considered for the modern protocols of complex examination, recommended for use from the age of 45 years, and including both instrumental and laboratory methods of research: Colonoscopy, CT colonography, flexible sigmoidoscopy, fecal occult blood test, fecal immunohistochemistry test and stool DNA test Nevertheless, the removal of those precancerous lesions does not solve the issue, and, apart from the regular endoscopic monitoring of patients who are at a high risk of developing CRC, the pharmacological treatment of certain key pathogenic mechanisms leading to the development of CRC is required. The present review to discusses the function of β-catenin in the transformation of precancerous colorectal lesions into CRC, when collaborating with PI3K/AKT/mTOR signaling pathway and other mechanisms. The existing methods for the early diagnostics and prevention of discovered anomalies are described and categorized. The analysis of the approaches to chemoprophylaxis of CRC, depending on the results of endoscopic, morphological and molecular-genetic tests, is presented.
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Affiliation(s)
- Nonna E. Ogurchenok
- Far Eastern Federal University, School of Medicine and Life Sciences, FEFU Medical Center, Russky Island, 690091 Vladivostok, Russian Federation
- Primorskiy Regional Clinical Hospital N1, Medical Center, Russky Island, 690091 Vladivostok, Russian Federation
| | - Konstantin D. Khalin
- Far Eastern Federal University, School of Medicine and Life Sciences, FEFU Medical Center, Russky Island, 690091 Vladivostok, Russian Federation
- Far Eastern Federal University, Medical Center, Russky Island, 690091 Vladivostok, Russian Federation
| | - Igor S. Bryukhovetskiy
- Far Eastern Federal University, Medical Center, Russky Island, 690091 Vladivostok, Russian Federation
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2
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Henson JB, King LY. Post-Transplant Management and Complications of Autoimmune Hepatitis, Primary Biliary Cholangitis, and Primary Sclerosing Cholangitis including Disease Recurrence. Clin Liver Dis 2024; 28:193-207. [PMID: 37945160 PMCID: PMC11033708 DOI: 10.1016/j.cld.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Autoimmune liver diseases have unique post-transplant considerations. These recipients are at increased risk of rejection, and recurrent disease may also develop, which can progress to graft loss and increase mortality. Monitoring for and managing these complications is therefore important, though data on associated risk factors and immunosuppression strategies has in most cases been mixed. There are also other disease-specific complications that require management and may impact these decisions, including inflammatory bowel disease in PSC. Further work to better understand the optimal management strategies for these patients post-transplant is needed.
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Affiliation(s)
- Jacqueline B Henson
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, DUMC Box 3913, Durham, NC 27710, USA
| | - Lindsay Y King
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, DUMC Box 3923, Durham, NC 27710, USA.
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3
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Wheless WH, Russo MW. Treatment of Primary Sclerosing Cholangitis Including Transplantation. Clin Liver Dis 2024; 28:171-182. [PMID: 37945158 DOI: 10.1016/j.cld.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Primary sclerosing cholangitis is a progressive cholestatic liver disease that causes stricturing of the intra and extrahepatic bile ducts that can lead to cirrhosis and end stage liver disease. Effective medical therapy has been elusive, but a course of ursodeoxycholic acid may be prescribed at doses of 17-23 mg/kg/day for up to a year to determine if a reduction in serum alkaline phosphatase is observed. A number of drugs are under investigation, including FXR agonists with choleretic and antimicrobial properties. Liver transplantation for PSC has one of the highest survival rates, but recurrent PSC is seen in up to 25% of recipients.
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Affiliation(s)
- William H Wheless
- Division of Hepatology, Atrium Health Wake Forest, Charlotte, NC, USA
| | - Mark W Russo
- Division of Hepatology, Atrium Health Wake Forest, Charlotte, NC, USA.
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4
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van Munster KN, Bergquist A, Ponsioen CY. Inflammatory bowel disease and primary sclerosing cholangitis: One disease or two? J Hepatol 2024; 80:155-168. [PMID: 37940453 DOI: 10.1016/j.jhep.2023.09.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 09/01/2023] [Accepted: 09/29/2023] [Indexed: 11/10/2023]
Abstract
Primary sclerosing cholangitis (PSC) was declared one of the biggest unmet needs in hepatology during International Liver Congress 2016 in Berlin. Since then, not much has changed unfortunately, largely due to the still elusive pathophysiology of the disease. One of the most striking features of PSC is its association with inflammatory bowel disease (IBD), with the majority of patients with PSC being diagnosed with extensive colitis. This review describes the epidemiology of IBD in PSC, its specific phenotype, complications and potential pathophysiological mechanisms connecting the two diseases. Whether PSC is merely an extra-intestinal manifestation of IBD or if PSC and IBD are two distinct diseases that happen to share a common susceptibility that leads to a dual phenotype is debated. Implications for the management of the two diseases together are also discussed. Overall, this review summarises the available data in PSC-IBD and discusses whether PSC and IBD are one or two disease(s).
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Affiliation(s)
- Kim N van Munster
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Annika Bergquist
- Department of Medicine Huddinge, Division of Hepatology, Karolinska Institutet, Department of Upper GI Disease, Karolinska University Hospital, Stockholm, Sweden
| | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, the Netherlands.
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5
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Nayagam JS, Ahmed W, Farrant M, Jefferies J, Boshell V, Simpson A, Joshi D. Clinical factors associated with illness perception, worry and mental health in sclerosing cholangitis: A single centre prospective study. Clin Res Hepatol Gastroenterol 2024; 48:102251. [PMID: 38006942 DOI: 10.1016/j.clinre.2023.102251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 11/20/2023] [Accepted: 11/23/2023] [Indexed: 11/27/2023]
Abstract
BACKGROUND A reduced quality of life and symptoms of depression and anxiety are reported in patients with primary sclerosing cholangitis (PSC), however specific risk factors and the effect of sclerosing cholangitis (SC) with autoimmune features are not known. OBJECTIVE To integrate mental wellbeing assessment into routine clinical care for patients with SC, and evaluate factors associated with measures relating to quality of life, illness perception and mental health. METHODS A prospective study of adult non-transplant patients with SC attending the outpatient clinic over a 1 year period. Self-reported questionnaires were sent to patients electronically prior to clinic to assess worry, illness perception, depression and anxiety. Demographic and clinical information was collected. RESULTS Questionnaires were completed in 52/130 (40 %) patients with SC who attended clinic. Worry related to quality of life, mental and physical health, and future health were common. There was no difference in overall worry or illness perception in patients treated with ursodeoxycholic acid; whilst patients with PSC had a higher illness perception (P = 0.04) than those with SC and autoimmune features. Both worry (P = 0.047) and illness perception (P = 0.01) were higher in patients with elevated alkaline phosphatase, whilst there was no difference in patients with and without cirrhosis. There were high screening test scores for both depression (21.1 %) and anxiety (9.6 %), with no association with patient factors. CONCLUSIONS We integrated an electronic questionnaire for completion prior to clinic for patients with SC with good uptake. We identified a high prevalence of patient worries and symptoms of depression and anxiety, which may be more common in PSC with elevated alkaline phosphatase and without autoimmune features. We recommend the adoption of similar tools into routine clinical practice for patients with SC.
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Affiliation(s)
- Jeremy S Nayagam
- Institute of Liver Studies, King's College Hospital, London, UK; Department of Inflammation Biology, King's College London, London, UK.
| | - Wafaa Ahmed
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Matthew Farrant
- Institute of Liver Studies, King's College Hospital, London, UK
| | | | - Vanessa Boshell
- IMPARTS Research and Education, King's Health Partners, London, UK
| | - Anna Simpson
- IMPARTS Development Team, King's Health Partners, London, UK
| | - Deepak Joshi
- Institute of Liver Studies, King's College Hospital, London, UK
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6
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Bowlus CL, Arrivé L, Bergquist A, Deneau M, Forman L, Ilyas SI, Lunsford KE, Martinez M, Sapisochin G, Shroff R, Tabibian JH, Assis DN. AASLD practice guidance on primary sclerosing cholangitis and cholangiocarcinoma. Hepatology 2023; 77:659-702. [PMID: 36083140 DOI: 10.1002/hep.32771] [Citation(s) in RCA: 72] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 07/26/2022] [Indexed: 01/28/2023]
Affiliation(s)
- Christopher L Bowlus
- Division of Gastroenterology , University of California Davis Health , Sacramento , California , USA
| | | | - Annika Bergquist
- Karolinska Institutet , Karolinska University Hospital , Stockholm , Sweden
| | - Mark Deneau
- University of Utah , Salt Lake City , Utah , USA
| | - Lisa Forman
- University of Colorado , Aurora , Colorado , USA
| | - Sumera I Ilyas
- Mayo Clinic College of Medicine and Science , Rochester , Minnesota , USA
| | - Keri E Lunsford
- Rutgers University-New Jersey Medical School , Newark , New Jersey , USA
| | - Mercedes Martinez
- Vagelos College of Physicians and Surgeons , Columbia University , New York , New York , USA
| | | | | | - James H Tabibian
- David Geffen School of Medicine at UCLA , Los Angeles , California , USA
| | - David N Assis
- Yale School of Medicine , New Haven , Connecticut , USA
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A Reduction of Calcineurin Inhibitors May Improve Survival in Patients with De Novo Colorectal Cancer after Liver Transplantation. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58121755. [PMID: 36556957 PMCID: PMC9785597 DOI: 10.3390/medicina58121755] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 11/25/2022] [Accepted: 11/28/2022] [Indexed: 12/04/2022]
Abstract
Background and Objectives: After liver transplantation (LT), long-term immunosuppression (IS) is essential. IS is associated with de novo malignancies, and the incidence of colorectal cancer (CRC) is increased in LT patients. We assessed course of disease in patients with de novo CRC after LT with focus of IS and impact on survival in a retrospective, single-center study. Materials and Methods: All patients diagnosed with CRC after LT between 1988 and 2019 were included. The management of IS regimen following diagnosis and the oncological treatment approach were analyzed: Kaplan−Meier analysis as well as univariate and multivariate analysis were performed. Results: A total of 33 out of 2744 patients were diagnosed with CRC after LT. Two groups were identified: patients with restrictive IS management undergoing dose reduction (RIM group, n = 20) and those with unaltered regimen (maintenance group, n = 13). The groups did not differ in clinical and oncological characteristics. Statistically significant improved survival was found in Kaplan−Meier analysis for patients in the RIM group with 83.46 (8.4−193.1) months in RIM and 24.8 (0.5−298.9) months in the maintenance group (log rank = 0.02) and showed a trend in multivariate cox regression (p = 0.054, HR = 14.3, CI = 0.96−213.67). Conclusions: Immunosuppressive therapy should be reduced further in patients suffering from CRC after LT in an individualized manner to enable optimal oncological therapy and enable improved survival.
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8
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Hsiao SW, Yen HH, Chen YY. Chemoprevention of Colitis-Associated Dysplasia or Cancer in Inflammatory Bowel Disease. Gut Liver 2022; 16:840-848. [PMID: 35670121 PMCID: PMC9668496 DOI: 10.5009/gnl210479] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 11/20/2021] [Accepted: 12/07/2021] [Indexed: 08/27/2023] Open
Abstract
The association between inflammatory bowel disease and colorectal cancer is well known. Although the overall incidence of inflammatory bowel disease has declined recently, patients with this disease still have a 1.7-fold increased risk of colorectal cancer. The risk factors for developing colorectal cancer include extensive colitis, young age at diagnosis, disease duration, primary sclerosing cholangitis, chronic colonic mucosal inflammation, dysplasia lesion, and post-inflammatory polyps. In patients with inflammatory bowel disease, control of chronic inflammation and surveillance colonoscopies are important for the prevention of colorectal cancer. The 2017 guidelines from the European Crohn's and Colitis Organisation suggest that colonoscopies to screen for colorectal cancer should be performed when inflammatory bowel disease symptoms have lasted for 8 years. Current evidence supports the use of chemoprevention therapy with mesalamine to reduce the risk of colorectal cancer in patients with ulcerative colitis. Other compounds, including thiopurine, folic acid, statin, and tumor necrosis factor-α inhibitor, are controversial. Large surveillance cohort studies with longer follow-up duration are needed to evaluate the impact of drugs on colorectal cancer risks.
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Affiliation(s)
- Shun-Wen Hsiao
- Division of Gastroenterology, Changhua Christian Hospital, Changhua, Taiwan
- Division of Gastroenterology, Yuanlin Christian Hospital, Changhua, Taiwan
| | - Hsu-Heng Yen
- Division of Gastroenterology, Changhua Christian Hospital, Changhua, Taiwan
- General Education Center, Chienkuo Technology University, Changhua, Taiwan
- Department of Electrical Engineering, Chung Yuan Christian University, Taoyuan, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Yang-Yuan Chen
- Division of Gastroenterology, Changhua Christian Hospital, Changhua, Taiwan
- Division of Gastroenterology, Yuanlin Christian Hospital, Changhua, Taiwan
- Department of Hospitality Management, MingDao University, Changhua, Taiwan
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9
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Peterson AR, Srinivasan A, Proud D, Jackett L, Gow P, De Cruz P, Choy MC. Synchronous Multifocal Adenomatous Dysplasia and Post-transplant Lymphoproliferative Disorder Confined to the Colon in a Patient with Ulcerative Colitis After Liver Transplant. Inflamm Bowel Dis 2022; 28:e118-e119. [PMID: 35289846 DOI: 10.1093/ibd/izac034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Adam R Peterson
- Department of Gastroenterology, Austin Health, Melbourne, Australia
| | - Ashish Srinivasan
- Department of Gastroenterology, Austin Health, Melbourne, Australia.,Department of Medicine, Monash University, Melbourne, Australia
| | - David Proud
- Department of Colorectal Surgery, Austin Health, Melbourne, Australia
| | - Louise Jackett
- Department of Anatomical Pathology, Austin Health, Melbourne, Australia
| | - Paul Gow
- Victorian Liver Transplant Unit, Austin Health, Melbourne, Australia.,Austin Academic Centre, University of Melbourne, Melbourne, Australia
| | - Peter De Cruz
- Department of Gastroenterology, Austin Health, Melbourne, Australia.,Austin Academic Centre, University of Melbourne, Melbourne, Australia
| | - Matthew C Choy
- Department of Gastroenterology, Austin Health, Melbourne, Australia.,Austin Academic Centre, University of Melbourne, Melbourne, Australia
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10
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De Novo Malignancy After Liver Transplantation: Risk Assessment, Prevention, and Management-Guidelines From the ILTS-SETH Consensus Conference. Transplantation 2022; 106:e30-e45. [PMID: 34905760 DOI: 10.1097/tp.0000000000003998] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
De novo malignancies (DNMs) following liver transplantation (LT) have been reported as 1 of the major causes of late mortality, being the most common cause of death in the second decade after LT. The overall incidence of DNMs is reported to be in the range of 3.1% to 14.4%, and the incidence is 2- to 3-fold higher in transplant recipients than in age- and sex-matched healthy controls. Long-term immunosuppressive therapy, which is the key in maintaining host tolerance and achieving good long-term outcomes, is known to contribute to a higher risk of DNMs. However, the incidence and type of DNM also depends on different risk factors, including patient demographics, cause of the underlying chronic liver disease, behavior (smoking and alcohol abuse), and pre-existing premalignant conditions. The estimated standardized incidence ratio for different DNMs is also variable. The International Liver Transplantation Society-Spanish Society of Liver Transplantation Consensus Conference working group on DNM has summarized and discussed the current available literature on epidemiology, risk factors, management, and survival after DNMs. Recommendations for screening and surveillance for specific tumors, as well as immunosuppression and cancer-specific management in patients with DNM, are summarized.
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11
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Abstract
Autoimmune liver diseases are characterized by immune-mediated inflammation and eventual destruction of the hepatocytes and the biliary epithelial cells. They can progress to irreversible liver damage requiring liver transplantation. The post-liver transplant goals of treatment include improving the recipient’s survival, preventing liver graft-failure, and decreasing the recurrence of the disease. The keystone in post-liver transplant management for autoimmune liver diseases relies on identifying which would be the most appropriate immunosuppressive maintenance therapy. The combination of a steroid and a calcineurin inhibitor is the current immunosuppressive regimen of choice for autoimmune hepatitis. A gradual withdrawal of glucocorticoids is also recommended. On the other hand, ursodeoxycholic acid should be initiated soon after liver transplant to prevent recurrence and improve graft and patient survival in primary biliary cholangitis recipients. Unlike the previously mentioned autoimmune diseases, there are not immunosuppressive or disease-modifying agents available for patients with primary sclerosing cholangitis. However, colectomy and annual colonoscopy are key components during the post-liver transplant period.
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12
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Martínez Montiel MDP, Casis Herce B. Inflammatory bowel disease and solid organ transplantation. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 113:60-64. [PMID: 33233912 DOI: 10.17235/reed.2020.7361/2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The population of patients with inflammatory bowel disease (IBD) and solid organ transplant (SOT) is increasing. Two clinical scenarios exist, recurrence of pre-existing IBD, which is more common, and de novo development of IBD, with a much higher incidence than in the general population. Their clinical course differs and may have a negative impact on the graft in both cases. The pathophysiological mechanisms remain unknown and no specific treatment recommendations are available. The combined effect of biologic therapy against IBD and immunosuppressive therapy against a potential rejection means that close monitoring is mandatory to identify infection, autoimmune events and malignancies. The colorectal cancer (CRC) rate is higher in this population. The group at greatest risk are patients with IBD undergoing liver transplantation (LT) for primary sclerosing cholangitis (PSC).
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13
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Osiecki M, Kierkuś J, Pawłowska J, Woźniak M, Jankowska I, Teisseyre M, Dądalski M, Jarzębicka D, Stefanowicz M, Czubkowski P. The Course of Ulcerative Colitis After Pediatric Liver Transplantation for Sclerosing Cholangitis. Transplant Proc 2020; 53:244-249. [PMID: 33162100 DOI: 10.1016/j.transproceed.2020.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 08/30/2020] [Accepted: 09/20/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Primary sclerosing cholangitis (PSC) and autoimmune sclerosing cholangitis (ASC) are often associated with ulcerative colitis (UC). The impact on the course of UC remains unclear, and up-to-date evidence in pediatric populations is scarce. The aim of the study was to analyze the course of UC in pediatric patients transplanted owing to PSC or ASC. MATERIAL AND METHODS We retrospectively reviewed data from children with PSC/ASC and UC who underwent orthotopic liver transplantation (OLT). In all patients UC diagnosis was based on clinical presentation, endoscopy, and histology. RESULTS Seventeen patients (9 female) with PSC or ASC underwent OLT from deceased donors at a median age of 16.8 years (range = 11.5-18.2 years). In 15 patients, UC was diagnosed before OLT (median age of diagnosis = 10.6 years; range = 6.6-18.0 years), and 2 patients developed UC after OLT. Ten patients (59%) presented with pancolitis on initial endoscopy. Disease activity was severe in 9 patients (53%) and most patients improved after initial treatment with steroids. Before OLT only 2 patients (13%) had severe disease activity. After OLT, 4 patients developed flares of the disease. These patients were successfully treated and remained in remission at the end of the posttransplant follow-up period (median = 3.76 years; range = 0.4-15.5 years). None of the patients developed colorectal cancer or underwent colectomy during 3.7 years of post-OLT follow-up. CONCLUSION In our experience, the course of UC was not aggravated by OLT for PSC, and UC did not adversely affect patient or graft survival.
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Affiliation(s)
- Marcin Osiecki
- Department of Gastroenterology, Hepatology, Feeding Disorders and Paediatrics, The Children's Memorial Health Institute, Warsaw, Poland.
| | - Jarosław Kierkuś
- Department of Gastroenterology, Hepatology, Feeding Disorders and Paediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Joanna Pawłowska
- Department of Gastroenterology, Hepatology, Feeding Disorders and Paediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Małgorzata Woźniak
- Department of Gastroenterology, Hepatology, Feeding Disorders and Paediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Irena Jankowska
- Department of Gastroenterology, Hepatology, Feeding Disorders and Paediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Mikołaj Teisseyre
- Department of Gastroenterology, Hepatology, Feeding Disorders and Paediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Maciej Dądalski
- Department of Gastroenterology, Hepatology, Feeding Disorders and Paediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Dorota Jarzębicka
- Department of Gastroenterology, Hepatology, Feeding Disorders and Paediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Marek Stefanowicz
- Department of Paediatric Surgery and Organ Transplantation, The Children's Memorial Health Institute, Warsaw, Poland
| | - Piotr Czubkowski
- Department of Gastroenterology, Hepatology, Feeding Disorders and Paediatrics, The Children's Memorial Health Institute, Warsaw, Poland
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14
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Nebbia M, Yassin NA, Spinelli A. Colorectal Cancer in Inflammatory Bowel Disease. Clin Colon Rectal Surg 2020; 33:305-317. [PMID: 32968366 DOI: 10.1055/s-0040-1713748] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Patients with inflammatory bowel disease (IBD) are at an increased risk for developing colorectal cancer (CRC). However, the incidence has declined over the past 30 years, which is probably attributed to raise awareness, successful CRC surveillance programs and improved control of mucosal inflammation through chemoprevention. The risk factors for IBD-related CRC include more severe disease (as reflected by the extent of disease and the duration of poorly controlled disease), family history of CRC, pseudo polyps, primary sclerosing cholangitis, and male sex. The molecular pathogenesis of inflammatory epithelium might play a critical role in the development of CRC. IBD-related CRC is characterized by fewer rectal tumors, more synchronous and poorly differentiated tumors compared with sporadic cancers. There is no significant difference in sex distribution, stage at presentation, or survival. Surveillance is vital for the detection and subsequently management of dysplasia. Most guidelines recommend initiation of surveillance colonoscopy at 8 to 10 years after IBD diagnosis, followed by subsequent surveillance of 1 to 2 yearly intervals. Traditionally, surveillance colonoscopies with random colonic biopsies were used. However, recent data suggest that high definition and chromoendoscopy are better methods of surveillance by improving sensitivity to previously "invisible" flat dysplastic lesions. Management of dysplasia, timing of surveillance, chemoprevention, and the surgical approaches are all areas that stimulate various discussions. The aim of this review is to provide an up-to-date focus on CRC in IBD, from laboratory to bedside.
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Affiliation(s)
- Martina Nebbia
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center IRCCS, Rozzano, Milano, Italy
| | - Nuha A Yassin
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center IRCCS, Rozzano, Milano, Italy
| | - Antonino Spinelli
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center IRCCS, Rozzano, Milano, Italy.,Deparment of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milano, Italy
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15
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Rządkowski S, Chmielińska A, Pacholczyk M, Łągiewska B. Colonoscopy Surveillance in Liver Transplant Recipients for Primary Sclerosing Cholangitis Associated With Inflammatory Bowel Disease. Transplant Proc 2020; 52:2484-2486. [PMID: 32446687 DOI: 10.1016/j.transproceed.2020.01.116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 01/26/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The aim of this study was to assess gastrointestinal (GI) monitoring in the group of patients who underwent orthotopic liver transplantation (OLTx) because of primary sclerosing cholangitis (PSC) concomitant with inflammatory bowel disease (IBD). METHODS Analysis was performed of data collected from medical histories and telephone calls in 33 patients who underwent OLTx in the Department of General and Transplantation Surgery of the Medical University of Warsaw from 2001 through 2017 because of PSC concomitant with IBD. RESULTS Only 52% of patients claimed they stayed under constant supervision of a GI clinic. The remaining 48% patients were exclusively under transplantation clinic supervision, which controlled graft function. Of 27 patients, 18 (67%) underwent regular colonoscopy examination. According to the American Society of Gastrointestinal Endoscopy and other international organizations' guidelines, patients with PSC and IBD should have yearly screening colonoscopy. Only 9 patients met these guidelines. The median of intervals between colonoscopies among the other 9 patients was 2 years. Among the remaining 9 patients who did not have regular colonoscopy, the gap between endoscopic examinations reached 10-14 years. Fifteen patients (55%) had at least 1 polyp resected during the colonoscopy examination. CONCLUSIONS Fewer than half of patients follow the medical recommendations concerning their health condition and screening. The main reason for not performing regular colonoscopies was remission and/or lack of symptoms of IBD. According to the previously mentioned guidelines, the absence of symptoms of IBD does not exempt patients from annual colonoscopy. Some of the negligence was a result of lack of adequate access to gastroenterology specialists.
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Affiliation(s)
- Stanisław Rządkowski
- Student Research Group 'Kindley', Department of General and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Agnieszka Chmielińska
- Student Research Group 'Kindley', Department of General and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Marek Pacholczyk
- Department of General and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Beata Łągiewska
- Department of General and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland.
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16
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Sakr MA, Ebada HE, Abdelkader S, Dabbous HM, Montasser IF, Bassuny AN, Massoud YM, Abdelmoaty AS. Outcome of Colonoscopic Screening in Potential Liver Transplant Candidates. Transplant Proc 2020; 52:227-232. [PMID: 32000940 DOI: 10.1016/j.transproceed.2019.10.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 10/01/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND Screening for neoplastic lesions is mandatory as a part of the evaluation process of potential candidates for liver transplant (LT). This work aimed at identifying the main findings in screening colonoscopy and their risk factors. METHODS Endoscopic and pathologic findings of the biopsied lesions of 311 potential candidates for living donor liver transplant were collected and analyzed. RESULTS Colorectal polyps (8.7%) were the most common colonoscopic finding, of which 4.18% were diagnosed as adenomas. Other findings included hemorrhoids (7.7%), portal hypertensive colopathies (3.5%), angiomatous malformations (2.6%), rectal varices (1.6%), and diverticulosis (1.6%). The univariate analysis revealed that the prevalence of colonic adenoma was significant in patients 50 years and older (P = .03; odds ratio, 1.178; 95% CI, 1.016-1.365) and in patients who had hepatocellular carcinoma (P = .043; odds ratio, 6.5; 95% CI, 1.002-42.172). In the multivariate analysis, age was found to be the single best predictor of the presence of adenoma (P = .044; odds ratio, 1.178; 95% CI, 1.005-1.382). CONCLUSION We can conclude that a screening colonoscopy prior to liver donor liver transplant should be performed at least in every LT candidate 50 years or older. Colonic polyps were the most common findings on screening colonoscopy prior to LT.
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Affiliation(s)
- Mohammad A Sakr
- Ain Shams University, Department of Tropical Medicine Cairo, Abbasia, Egypt; and Ain Shams Center for Organ Transplantation, Cairo, Abbasia, Egypt
| | - Hend E Ebada
- Ain Shams University, Department of Tropical Medicine Cairo, Abbasia, Egypt; and Ain Shams Center for Organ Transplantation, Cairo, Abbasia, Egypt.
| | - Soheir Abdelkader
- Ain Shams University, Department of Tropical Medicine Cairo, Abbasia, Egypt; and Ain Shams Center for Organ Transplantation, Cairo, Abbasia, Egypt
| | - Hany M Dabbous
- Ain Shams University, Department of Tropical Medicine Cairo, Abbasia, Egypt; and Ain Shams Center for Organ Transplantation, Cairo, Abbasia, Egypt
| | - Iman F Montasser
- Ain Shams University, Department of Tropical Medicine Cairo, Abbasia, Egypt; and Ain Shams Center for Organ Transplantation, Cairo, Abbasia, Egypt
| | - Ahmed N Bassuny
- Ain Shams University, Department of Tropical Medicine Cairo, Abbasia, Egypt; and Ain Shams Center for Organ Transplantation, Cairo, Abbasia, Egypt
| | - Yasmeen M Massoud
- Ain Shams University, Department of Tropical Medicine Cairo, Abbasia, Egypt; and Ain Shams Center for Organ Transplantation, Cairo, Abbasia, Egypt
| | - Ahmed S Abdelmoaty
- Ain Shams University, Department of Tropical Medicine Cairo, Abbasia, Egypt; and Ain Shams Center for Organ Transplantation, Cairo, Abbasia, Egypt
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Interplay of Liver Disease and Gut Microbiota in the Development of Colorectal Neoplasia. ACTA ACUST UNITED AC 2019; 17:378-393. [DOI: 10.1007/s11938-019-00241-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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18
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Rompianesi G, Ravikumar R, Jose S, Allison M, Athale A, Creamer F, Gunson B, Manas D, Monaco A, Mirza D, Owen N, Roberts K, Sen G, Srinivasan P, Wigmore S, Fusai G, Fernando B, Burroughs A, Tsochatzis E. Incidence and outcome of colorectal cancer in liver transplant recipients: A national, multicentre analysis on 8115 patients. Liver Int 2019; 39:353-360. [PMID: 30129181 DOI: 10.1111/liv.13947] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 08/02/2018] [Accepted: 08/16/2018] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS De novo malignancies after liver transplantation represent one of the leading causes of death in the long-term. It remains unclear whether liver transplant recipients have an increased risk of colorectal cancer and whether this negatively impacts on survival, particularly in those patients affected by primary sclerosing cholangitis and ulcerative colitis. METHODS In this national multicentre cohort retrospective study, the incidence of colorectal cancer in 8115 evaluable adult patients undergoing a liver transplantation between 1 January 1990 and 31 December 2010 was compared to the incidence in the general population through standardised incidence ratios. RESULTS Fifty-two (0.6%) cases of colorectal cancer were identified at a median of 5.6 years postliver transplantation, predominantly grade 2 (76.9%) and stage T3 (50%) at diagnosis. The incidence rate of colorectal cancer in the whole liver transplant population was similar to the general UK population (SIR: 0.92), but significantly higher (SIR: 7.0) in the group of patients affected by primary sclerosing cholangitis/ulcerative colitis. One-, five- and ten-year survival rates from colorectal cancer diagnosis were 71%, 48% and 31%, respectively, and the majority of colorectal cancer patients died of cancer-specific causes. CONCLUSIONS Liver transplantation alone is not associated with an increased risk of colorectal cancer development. The primary sclerosing cholangitis/ulcerative colitis liver transplant population showed a significantly higher risk of colorectal cancer development than the general population, with a high proportion of advanced stage at diagnosis and a reduced patient survival.
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Affiliation(s)
- Gianluca Rompianesi
- Sheila Sherlock Liver Unit, UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Reena Ravikumar
- Sheila Sherlock Liver Unit, UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Sophie Jose
- Research Department of Infection and Population Health, University College London, London, UK
| | - Michael Allison
- Cambridge Transplant Unit, Cambridge Biomedical Research Centre, Cambridge University Hospitals, Cambridge, UK
| | - Anuja Athale
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Felicity Creamer
- Department of HPB and Transplant Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Bridget Gunson
- The Liver Unit, University Hospitals Birmingham and NIHR Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK
| | - Derek Manas
- Institute of Transplantation, Freeman Hospital, Newcastle, UK
| | - Andrea Monaco
- Sheila Sherlock Liver Unit, UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Darius Mirza
- The Liver Unit, University Hospitals Birmingham and NIHR Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK
| | - Nicola Owen
- Cambridge Transplant Unit, Cambridge Biomedical Research Centre, Cambridge University Hospitals, Cambridge, UK
| | - Keith Roberts
- The Liver Unit, University Hospitals Birmingham and NIHR Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK
| | - Gourab Sen
- Institute of Transplantation, Freeman Hospital, Newcastle, UK
| | | | - Stephen Wigmore
- Department of HPB and Transplant Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Giuseppe Fusai
- Sheila Sherlock Liver Unit, UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Bimbi Fernando
- Sheila Sherlock Liver Unit, UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Andrew Burroughs
- Sheila Sherlock Liver Unit, UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Emmanuel Tsochatzis
- Sheila Sherlock Liver Unit, UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
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19
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Fousekis FS, Theopistos VI, Mitselos IV, Skamnelos A, Kavvadias A, Katsanos KH, Christodoulou DK. Specific Features of Patients With Inflammatory Bowel Disease and Primary Sclerosing Cholangitis. J Clin Med Res 2019; 11:81-88. [PMID: 30700999 PMCID: PMC6340671 DOI: 10.14740/jocmr3680] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 11/20/2018] [Indexed: 12/12/2022] Open
Abstract
Primary sclerosing cholangitis (PSC) is a chronic and progressive disease of the biliary tract. PSC is strongly associated with inflammatory bowel disease (IBD), mainly with ulcerative colitis, and most PSC patients have underlying IBD. The pathophysiological interactions between IBD and PSC are unclear, although it seems that the patients with IBD and PSC have a distinct phenotype. IBD with coexisting PSC is more extensive and is characterized by milder activity compared to IBD alone. The coexistence of PSC increases the risk for colorectal cancer in IBD patients and lifelong annual surveillance colonoscopy is recommended. Also, liver transplantation (LT) for PSC may affect the course of IBD. In addition, the management of IBD after LT includes many specific problems. On the other hand, the effect of IBD on the natural history of PSC appears to be milder. However, IBD may increase the risk of postsurgical complications after LT and is a risk factor for recurrent PSC after LT. Overall, the coexistence of IBD with PSC changes the management, natural history and prognosis of both diseases.
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Affiliation(s)
- Fotios S. Fousekis
- Department of Gastroenterology and Hepatology, Faculty of Medicine, University of Ioannina, Ioannina, Greece
| | - Vasileios I. Theopistos
- Department of Gastroenterology and Hepatology, Faculty of Medicine, University of Ioannina, Ioannina, Greece
| | - Ioannis V. Mitselos
- Department of Gastroenterology and Hepatology, Faculty of Medicine, University of Ioannina, Ioannina, Greece
| | - Alexandros Skamnelos
- Department of Gastroenterology and Hepatology, Faculty of Medicine, University of Ioannina, Ioannina, Greece
| | - Athanasios Kavvadias
- Department of Gastroenterology and Hepatology, Faculty of Medicine, University of Ioannina, Ioannina, Greece
| | - Konstantinos H. Katsanos
- Department of Gastroenterology and Hepatology, Faculty of Medicine, University of Ioannina, Ioannina, Greece
| | - Dimitrios K. Christodoulou
- Department of Gastroenterology and Hepatology, Faculty of Medicine, University of Ioannina, Ioannina, Greece
- Corresponding Author: Dimitrios K. Christodoulou, Department of Gastroenterology and Hepatology, Faculty of Medicine, University of Ioannina, Ioannina 45100, Greece.
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20
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Laborda TJ, Jensen MK, Kavan M, Deneau M. Treatment of primary sclerosing cholangitis in children. World J Hepatol 2019; 11:19-36. [PMID: 30705716 PMCID: PMC6354124 DOI: 10.4254/wjh.v11.i1.19] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 12/19/2018] [Accepted: 01/06/2019] [Indexed: 02/06/2023] Open
Abstract
Primary sclerosing cholangitis (PSC) is a rare disease of stricturing and destruction of the biliary tree with a complex genetic and environmental etiology. Most patients have co-occurring inflammatory bowel disease. Children generally present with uncomplicated disease, but undergo a variable progression to end-stage liver disease. Within ten years of diagnosis, 50% of children will develop clinical complications including 30% requiring liver transplantation. Cholangiocarcinoma is a rare but serious complication affecting 1% of children. Ursodeoxycholic acid and oral vancomycin therapy used widely in children as medical therapy, and may be effective in a subset of patients. Gamma glutamyltransferase is a potential surrogate endpoint for disease activity, with improved survival in patients who achieve a normal value. Endoscopic retrograde cholangiopancreatography is a necessary adjunct to medical therapy to evaluate mass lesions or dominant strictures for malignancy, and also to relieve biliary obstruction. Liver transplantation remains the only option for patients who progress to end-stage liver disease. We review special considerations for patients before and after transplant, and in patients with inflammatory bowel disease. There is presently no published treatment algorithm or guideline for the management of children with PSC. We review the evidence for drug efficacy, dosing, duration of therapy, and treatment targets in PSC, and provide a framework for endoscopic and medical management of this complex problem.
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Affiliation(s)
- Trevor J Laborda
- Department of Pediatrics, University of Utah, Salt Lake City, UT 84113, United States
| | - M Kyle Jensen
- Department of Pediatrics, University of Utah, Salt Lake City, UT 84113, United States
| | - Marianne Kavan
- Department of Pediatrics, University of Utah, Salt Lake City, UT 84113, United States
| | - Mark Deneau
- Department of Pediatrics, University of Utah, Salt Lake City, UT 84113, United States
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21
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Palmela C, Peerani F, Castaneda D, Torres J, Itzkowitz SH. Inflammatory Bowel Disease and Primary Sclerosing Cholangitis: A Review of the Phenotype and Associated Specific Features. Gut Liver 2018; 12:17-29. [PMID: 28376583 PMCID: PMC5753680 DOI: 10.5009/gnl16510] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 12/19/2016] [Accepted: 01/05/2017] [Indexed: 02/06/2023] Open
Abstract
Primary sclerosing cholangitis (PSC) is a chronic, progressive cholestatic disease that is associated with inflammatory bowel disease (IBD) in approximately 70% of cases. Although the pathogenesis is still unknown for both diseases, there is increasing evidence to indicate that they share a common underlying predisposition. Herein, we review the epidemiology, diagnosis, disease pathogenesis, and specific clinical features of the PSC-IBD phenotype. Patients with PSC-IBD have a distinct IBD phenotype with an increased incidence of pancolitis, backwash ileitis, and rectal sparing. Despite often having extensive colonic involvement, these patients present with mild intestinal symptoms or are even asymptomatic, which can delay the diagnosis of IBD. Although the IBD phenotype has been well characterized in PSC patients, the natural history and disease behavior of PSC in PSC-IBD patients is less well defined. There is conflicting evidence regarding the course of IBD in PSC-IBD patients who receive liver transplantation and their risk of recurrent PSC. IBD may also be associated with an increased risk of cholangiocarcinoma in PSC patients. Overall, the PSC-IBD population has an increased risk of developing colorectal neoplasia compared to the conventional IBD population. Lifelong annual surveillance colonoscopy is currently recommended.
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Affiliation(s)
- Carolina Palmela
- Division of Gastroenterology, Surgical Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Farhad Peerani
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Daniel Castaneda
- Division of Internal Medicine, Mount Sinai St. Luke's and Mount Sinai West Hospitals, New York, NY, USA
| | - Joana Torres
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Steven H Itzkowitz
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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22
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Altwegg R, Combes R, Laharie D, De Ledinghen V, Radenne S, Conti F, Chazouilleres O, Duvoux C, Dumortier J, Leroy V, Treton X, Durand F, Dharancy S, Nachury M, Goutorbe F, Lamblin G, Boivineau L, Peyrin-Biroulet L, Pageaux GP. Effectiveness and safety of anti-TNF therapy for inflammatory bowel disease in liver transplant recipients for primary sclerosing cholangitis: A nationwide case series. Dig Liver Dis 2018; 50:668-674. [PMID: 29655972 DOI: 10.1016/j.dld.2018.02.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 02/16/2018] [Accepted: 02/21/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND There is a lack of consensus regarding the treatment of inflammatory bowel disease (IBD) after liver transplantation (LT) forprimary sclerosing cholangitis (PSC). AIM To investigate the safety and effectiveness of anti-TNF therapy in patients with IBD after a LT for PSC. METHODS We reviewed the medical files of all of the IBD patients who underwent a LT for PSC and who were treated with anti-TNF therapy at 23 French liver transplantation centers between 1989 and 2012. RESULTS Eighteen patients (12 with ulcerative colitis and 6 who had Crohn's disease) were recruited at 9 LT centers. All of these patients received infliximab or adalimumab following their LT, and the median duration of their anti-TNF treatment was 10.4 months. The most frequent concomitant immunosuppressive treatment comprised a combination of tacrolimus and corticosteroids. Following anti-TNF therapy induction, a clinical response was seen in 16/18 patients (89%) and clinical remission in 10 (56%). At the end of the anti-TNF treatment or at the last follow-up examination (the median follow-up was 20.9 months), a clinical response was achieved in 12 patients (67%) and clinical remission in 7 (39%). A significant endoscopic improvement was observed in 9 out of 14 patients and a complete mucosal healing in 3 out of 14 patients (21%). Six patients experienced a severe infection. These were due to cholangitis, cytomegalovirus (CMV) infection, Clostridium difficile, cryptosporidiosis, or Enterococcus faecalis. Three patients developed colorectal cancer after LT, and two patients died during the follow-up period. CONCLUSIONS Anti-TNF therapy proved to be effective for treating IBD after LT for PSC. However, as 17% of the patients developed colorectal cancer during the follow-up, colonoscopic annual surveillance is recommended after LT, as specified in the current guidelines.
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Affiliation(s)
- Romain Altwegg
- University Hospital of St Eloi, Department of Hepatology and Gastroenterology, Montpellier, France.
| | - Roman Combes
- University Hospital of St Eloi, Department of Hepatology and Gastroenterology, Montpellier, France
| | - David Laharie
- University Hospital of Bordeaux, Haut-Leveque Hospital, Hepato-Gastroenterology, Bordeaux, France
| | - Victor De Ledinghen
- University Hospital of Bordeaux, Haut-Leveque Hospital, Hepato-Gastroenterology, Bordeaux, France
| | | | - Filomena Conti
- University Hospital of Saint Antoine, APHP, Hepato-Gastroenterology, Paris, France
| | | | - Christophe Duvoux
- University Hospital of Henri Mondor, APHP, Hepato-Gastroenterology, Creteil, France
| | | | - Vincent Leroy
- University Hospital of Grenoble, Hepato-Gastroenterology, Grenoble, France
| | - Xavier Treton
- University Hospital of Beaujon, APHP, Gastroenterology, Clichy, France
| | - François Durand
- University Hospital of Beaujon, APHP, Gastroenterology, Clichy, France
| | | | - Maria Nachury
- University Hospital of Lille, Hepato-Gastroenterology, Lille, France
| | - Félix Goutorbe
- University Hospital of Clermont-Ferrand, Hepato-Gastroenterology, Clermont-Ferrand, France
| | - Géraldine Lamblin
- University Hospital of Clermont-Ferrand, Hepato-Gastroenterology, Clermont-Ferrand, France
| | - Lucile Boivineau
- University Hospital of St Eloi, Department of Hepatology and Gastroenterology, Montpellier, France
| | - Laurent Peyrin-Biroulet
- Inserm U954 and Department of Gastroenterology, Nancy University Hospital of Nancy, Lorraine University, Nancy, France
| | - Georges-Philippe Pageaux
- University Hospital of St Eloi, Department of Hepatology and Gastroenterology, Montpellier, France
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23
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Fousekis FS, Theopistos VI, Katsanos KH, Tsianos EV, Christodoulou DK. Hepatobiliary Manifestations and Complications in Inflammatory Bowel Disease: A Review. Gastroenterology Res 2018; 11:83-94. [PMID: 29707074 PMCID: PMC5916631 DOI: 10.14740/gr990w] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 03/12/2018] [Indexed: 12/12/2022] Open
Abstract
Liver and biliary track diseases are common extraintestinal manifestations of inflammatory bowel disease (IBD), reported both in Crohn’s disease and ulcerative colitis, and may occur at any time during the natural course of the disease. Their etiology is mainly related to pathophysiological changes induced by IBD, and secondary, due to drugs used in IBD. Fatty liver is considered as the most frequent hepatobiliary manifestation in IBD, while primary sclerosing cholangitis (PSC) is the most correlated hepatobiliary disorder and is more prevalent in patients with ulcerative colitis. PSC can cause serious complications from the liver, biliary tree, and gallbladder and can lead to liver failure. Less frequently, IBD-associated hepatobiliary manifestations include cholelithiasis, granulomatous hepatitis, portal vein thrombosis, IgG4-related cholangiopathy, pyogenic liver abscess, hepatic amyloidosis and primary biliary cirrhosis. Most of the drugs used for IBD treatment may cause liver toxicity. Methotrexate and thiopurines carry the higher risk for hepatotoxicity, and in many cases, dose adjustment may normalize the liver biochemical tests. Reactivation of hepatitis B and C virus during immunosuppressive use, especially during use of biological agents, is a major concern, and adequate screening, vaccination and prophylactic treatment is warranted.
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Affiliation(s)
- Fotios S Fousekis
- Department of Gastroenterology and Hepatology, Medical School of Ioannina, Greece
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24
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Rao BB, Lashner B, Kowdley KV. Reviewing the Risk of Colorectal Cancer in Inflammatory Bowel Disease After Liver Transplantation for Primary Sclerosing Cholangitis. Inflamm Bowel Dis 2018; 24:269-276. [PMID: 29361103 DOI: 10.1093/ibd/izx056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Indexed: 02/07/2023]
Abstract
The presence of concomitant primary sclerosing cholangitis (PSC) with inflammatory bowel disease (IBD) represents a distinct disease phenotype that carries a higher risk of colorectal cancer (CRC) than the average IBD patient. Given that liver transplantation (LT) is the only treatment that offers a survival benefit in PSC patients with hepatic dysfunction, management decisions in IBD patients' post-LT for PSC are frequently encountered. One such consideration is the risk of CRC in this immunosuppressed cohort. With most studies showing an increased risk of CRC post-LT in these IBD patients, a closer look at the associated risk factors of CRC and the adopted surveillance strategies in this subset of patients is warranted. Low-dose ursodeoxycholic acid has shown a potential chemopreventive effect in PSC-IBD patients pre-LT; however, a favorable effect remains to be seen in post-LT group. Also, further studies are necessary to assess the benefit of 5 aminosalicylate therapy. Annual surveillance colonoscopy in the post-LT period is recommended for PSC-IBD patients subset given their high risk for CRC.
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Affiliation(s)
- Bhavana Bhagya Rao
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Bret Lashner
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Kris V Kowdley
- Liver Care Network and Organ Care Research, Swedish Medical Center, Seattle, Washington
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Risk Factors and Outcomes of De Novo Cancers (Excluding Nonmelanoma Skin Cancer) After Liver Transplantation for Primary Sclerosing Cholangitis. Transplantation 2017; 101:1859-1866. [PMID: 28272287 DOI: 10.1097/tp.0000000000001725] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients with primary sclerosing cholangitis (PSC) may be at higher risk of malignancy after liver transplantation (LT) compared to other LT recipients. We aimed to determine the cumulative incidence of/risk factors for long-term cancer-related mortality in patients with PSC after LT. METHODS All adult patients underwent LT for PSC without cholangiocarcinoma from 1984 to 2012, with follow-up through June 2015. We estimated cumulative incidence, risk factors, and mortality from de novo malignancies after LT. RESULTS Two hundred ninety-three patients were identified (mean [SD] age, 47 [12] years; 63.3% males; 2.4% smoking at LT). Over a median of 11.5 years (range, 6.4-18.6 years), 64 patients (21.8%) developed 73 nonskin cancers, including 46 solid-organ cancers (renal, 11; colorectal, 11; prostate, 7; breast, 5; pancreas, 5; ovarian/endometrial/vulvar cancers, 3; and de novo cholangiocarcinoma, 4). Twenty-two patients developed hematologic malignancies (posttransplant lymphoproliferative diseases, 18; Hodgkin disease, 2; and myelodysplastic syndrome, 2). Five patients developed melanoma. The 1-, 5-, 10-, and 20-year cumulative incidences of cancer were 2.1%, 8.6%, 18.7%, and 27%, respectively. Mortality of patients with PSC who developed cancer was higher than that of patients with PSC without cancer (hazard ratio, 2.2; P < 0.01). On multivariate analysis, recipient's age and elevated pre-LT international normalized ratio were associated with increased risk of de novo (nonskin) malignancy. CONCLUSION The 10-year cumulative risk of cancer after LT for advanced-stage PSC was 18.7%, with posttransplant lymphoproliferative diseases, colorectal cancer, and renal cell cancer being the most common. Post-LT de novo nonskin cancer decreased overall posttransplant survival. Only recipient's age and elevated international normalized ratio at LT were associated with increased nonskin cancer risk.
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26
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Ma AT, Therrien A, Giard JM, von Renteln D, Bouin M. Alcoholic liver disease is a strong predictor of colorectal polyps in liver transplant recipients. Endosc Int Open 2017; 5:E918-E923. [PMID: 28924600 PMCID: PMC5597935 DOI: 10.1055/s-0043-114660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 05/02/2017] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND AND AIMS Colorectal cancer (CRC) is associated with a significantly reduced survival rate in transplant recipients. The prevalence and risk factors of CRC and of colorectal polyps after orthotopic liver transplant (OLT) remain unclear. The study aim was to determine the prevalence of colorectal polyps in OLT recipients. A secondary objective was to explore possible risk factors of polyps. PATIENTS AND MATERIALS This was a retrospective single center study of all OLT recipients transplanted between 2007 and 2009. All patients who underwent a colonoscopy 5 ± 5 years after OLT were included. The outcome was colorectal polyps, as identified on colonoscopy. A logistic regression model was performed to identify potential predictors of polyps. RESULTS Of 164 OLT recipients, 80 were included in this study. Polyps were diagnosed in 37 % of patients before transplant and in 33 % afterwards. With regard to post-transplant lesions, 22 % were advanced adenomas or cancerous. In the regression analysis, the odds of post-transplant polyps were 11 times higher in patients with alcoholic liver disease (OR 11.3, 95 %CI 3.2 - 39.4; P < 0.001). CONCLUSION Patients with end-stage liver disease may be at high risk of colorectal polyps before and after liver transplant, and screening should be continued in both contexts. Those with alcoholic liver disease are particularly at risk for post-OLT polyps and may benefit from more intensive screening.
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Affiliation(s)
- Ann T. Ma
- Service de gastroentérologie et d’hépatologie, Hôpital St-Luc, Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada,Corresponding author Ann T. Ma, MD Hôpital St-LucCentre Hospitalier de l’Université de Montréal1058 Rue Saint-DenisMontréalQCCanadaH2X 3J4+1-514-412-7372
| | - Amélie Therrien
- Service de gastroentérologie et d’hépatologie, Hôpital St-Luc, Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada,Centre de Recherche, Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
| | - Jeanne-Marie Giard
- Service de gastroentérologie et d’hépatologie, Hôpital St-Luc, Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada,Centre de Recherche, Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
| | - Daniel von Renteln
- Service de gastroentérologie et d’hépatologie, Hôpital St-Luc, Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada,Centre de Recherche, Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
| | - Mickael Bouin
- Service de gastroentérologie et d’hépatologie, Hôpital St-Luc, Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada,Centre de Recherche, Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
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27
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Abstract
Since 1988 nearly 150,000 liver transplants have been performed in the United States. Over the past 3 decades the indications for liver transplant have changed from end-stage liver disease from alcohol and cholestatic liver diseases to hepatitis C and most recently nonalcoholic fatty liver disease. Liver transplant recipients are living longer with 10-year survival rates exceeding 60%. Gastroenterologists are likely to encounter or consult on postliver transplant recipients as they live longer and seek care closer to home. Complications after liver transplant are related to immunosuppression, malignancy, recurrent disease, and conditions associated with metabolic syndrome. This review will discuss postliver transplant care and complications in liver transplant recipients.
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Affiliation(s)
- Mark W Russo
- Division of Hepatology, Carolinas HealthCare System, Charlotte, NC
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28
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Horsley-Silva JL, Rodriguez EA, Franco DL, Lindor KD. An update on cancer risk and surveillance in primary sclerosing cholangitis. Liver Int 2017; 37:1103-1109. [PMID: 28028930 DOI: 10.1111/liv.13354] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 12/20/2016] [Indexed: 02/13/2023]
Abstract
Malignancy represents substantial morbidity and mortality in patients with primary sclerosing cholangitis (PSC). This subset of patients has been proven to be at increased risk for developing cholangiocarcinoma, gallbladder carcinoma and colorectal cancer in those with overlapping inflammatory bowel disease. Herein, we review the prevalence of these malignancies and recommend screening tools and current knowledge to reduce the disease burden in this population. Cholangiocarcinoma is the most dominant malignancy affecting PSC patients, with a lifetime risk ranging from 5% to 20%. We advocate for serial US or MRI/MRCP and CA 19-9 to screen for cholangiocarcinoma. Gallbladder cancer has a lifetime risk around 2% in this population and we agree with annual imaging for lesions as recommended by national guidelines. Patients with PSC and concomitant IBD are at increased risk of colorectal carcinoma from time of diagnosis and therefore should likely undergo annual surveillance. The low rates of hepatocellular cancer and pancreatic cancer indicate surveillance for these malignancies is less advantageous.
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Affiliation(s)
| | | | - Diana L Franco
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - Keith D Lindor
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA.,College of Health Solutions, Arizona State University, Phoenix, AZ, USA
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29
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Komaki Y, Komaki F, Micic D, Ido A, Sakuraba A. Risk of colorectal cancer in chronic liver diseases: a systematic review and meta-analysis. Gastrointest Endosc 2017; 86:93-104.e5. [PMID: 28011280 DOI: 10.1016/j.gie.2016.12.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 12/01/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS The risk of colorectal cancer (CRC) in various chronic liver diseases compared with the general population remains unclear. We performed a systematic review and meta-analysis to assess the risk of CRC in patients with chronic liver diseases before and after liver transplantation. METHODS Electronic databases were searched for studies assessing the risk of CRC in patients with chronic liver diseases. The primary outcome was the pooled risk of CRC among studies that reported the risk as standardized incidence rate (SIR). RESULTS Fifty studies that included 55,991 patients were identified. Among studies that included hepatitis and cirrhotic patients, the pooled SIR was 2.06 (P < .0001; 95% confidence interval (CI), 1.46-2.90) with moderate heterogeneity (I2 = 49.2%), which appeared to be because of the difference between subgroup of diseases and the power of studies. Three studies reported an increased risk of CRC in primary sclerosing cholangitis patients (pooled SIR 6.70; P < .0001; 95% CI, 3.48-12.91) with moderate heterogeneity (I2 = 36.3%), which appeared to be because of the difference between the power of studies. Among studies that included post-transplant patients, the pooled SIR was 2.16 (P < .0001; 95% CI, 1.59-2.94) with moderate heterogeneity (I2 = 56.4%). Meta-regression showed a correlation between the proportion of autoimmune-related liver diseases and the risk of CRC. CONCLUSIONS Patients with chronic liver diseases had an increased risk of CRC compared with the general population, which persisted after liver transplantation. A more intensive surveillance for CRC is warranted in this population.
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Affiliation(s)
- Yuga Komaki
- Section of Gastroenterology, Hepatology and Nutrition, Department of Medicine, The University of Chicago Medicine, Chicago, Illinois, USA
| | - Fukiko Komaki
- Section of Gastroenterology, Hepatology and Nutrition, Department of Medicine, The University of Chicago Medicine, Chicago, Illinois, USA
| | - Dejan Micic
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Akio Ido
- Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Atsushi Sakuraba
- Section of Gastroenterology, Hepatology and Nutrition, Department of Medicine, The University of Chicago Medicine, Chicago, Illinois, USA
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30
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Filipec Kanizaj T, Mijic M. Inflammatory bowel disease in liver transplanted patients. World J Gastroenterol 2017; 23:3214-3227. [PMID: 28566881 PMCID: PMC5434427 DOI: 10.3748/wjg.v23.i18.3214] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 04/13/2017] [Accepted: 04/21/2017] [Indexed: 02/06/2023] Open
Abstract
Most common hepatobiliary manifestation of inflammatory bowel disease (IBD) are primary sclerosing cholangitis (PSC) and autoimmune hepatitis, ranking them as the main cause of liver transplantation (LT) in IBD setting. Course of pre-existing IBD after LT differs depending on many transplant related factors. Potential risk factors related to IBD deterioration after LT are tacrolimus-based immunosuppressive regimens, active IBD and cessation of 5-aminosalicylates at the time of LT. About 30% patients experience improvement of IBD after LT, while approximately the same percentage of patients worsens. Occurrence of de novo IBD may develop in 14%-30% of patients with PSC. Recommended IBD therapy after LT is equivalent to recommendations to overall IBD patients. Anti-tumor necrosis factor alpha appears to be efficient for refractory IBD. Due to potential side effects it needs to be applied with caution. In average 9% of patients require proctocolectomy due to medically refractory IBD or colorectal carcinoma. The most frequent complication in patients who undergo proctocolectomy with ileal-pouch anal anastomosis is pouchitis. It is still undeterminable if LT adds to risk of developing pouchitis in PSC patients. Annual colonoscopies are recommended as surveillance and precaution of colonic malignancies.
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31
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Larson L, James M, Gossard A. Cholestatic Liver Injury: Care of Patients With Primary Biliary Cholangitis or Primary Sclerosing Cholangitis. AACN Adv Crit Care 2017; 27:441-452. [PMID: 27959300 DOI: 10.4037/aacnacc2016202] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
The most common causes of chronic cholestatic liver disease are primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC). Both disease processes are characterized by a destruction of intrahepatic and/or extrahepatic biliary ducts. The etiology is not entirely clear; however, there is an underlying autoimmune component contributing to both disease processes. Although PBC and PSC are often diagnosed and managed in the outpatient setting, in some instances, a patient may have jaundice, fatigue, and pruritus requiring evaluation and determination of the cholestatic cause. Patients with PSC should be monitored for evidence of cholangiocarcinoma, colon cancer, and gallbladder polyps as they are at an increased risk of malignant neoplasms. Liver transplant has the potential for improving quality of life, although disease recurrence is a risk.
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Affiliation(s)
- Laurie Larson
- Laurie Larson is Nurse Practitioner, Hepatology, 406 Harvard St SE, MMC 36, University of Minnesota, Minneapolis, MN 55455 . Michelle James is Clinical Director of Transplant Services, University of Minnesota, Minneapolis, Minnesota. Andrea Gossard is Nurse Practitioner, Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Michelle James
- Laurie Larson is Nurse Practitioner, Hepatology, 406 Harvard St SE, MMC 36, University of Minnesota, Minneapolis, MN 55455 . Michelle James is Clinical Director of Transplant Services, University of Minnesota, Minneapolis, Minnesota. Andrea Gossard is Nurse Practitioner, Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Andrea Gossard
- Laurie Larson is Nurse Practitioner, Hepatology, 406 Harvard St SE, MMC 36, University of Minnesota, Minneapolis, MN 55455 . Michelle James is Clinical Director of Transplant Services, University of Minnesota, Minneapolis, Minnesota. Andrea Gossard is Nurse Practitioner, Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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32
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de Vries E, Beuers U. Management of cholestatic disease in 2017. Liver Int 2017; 37 Suppl 1:123-129. [PMID: 28052628 DOI: 10.1111/liv.13306] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 10/27/2016] [Indexed: 12/13/2022]
Abstract
Primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC) are the most frequent chronic cholestatic liver diseases and serve as model diseases to discuss the management of cholestasis in 2017 in the lecture that is summarized in this report. PBC and PSC are characterized by inflammation and fibrosis of small intrahepatic (PBC) or larger intra- and/or extrahepatic (PSC) bile ducts. Bile duct damage leads to cholestasis and can progress to liver fibrosis and even cirrhosis. Various genetic, environmental and endogenous factors may contribute to the development of chronic cholestatic liver diseases, but the exact pathogenesis of PBC and PSC has not been clarified. Ursodeoxycholic acid (UDCA) is the standard treatment of PBC and is used also for other cholestatic conditions including PSC, and it exerts anticholestatic effects at adequate doses. Novel anticholestatic therapeutic options for patients not adequately responding to UDCA are under development or have, like obeticholic acid, already been proven to have efficacy when combined with UDCA in the treatment of PBC. The future role of immunomodulating/immunosuppressive drug regimens must be critically reviewed.
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Affiliation(s)
- Elsemieke de Vries
- Department of Gastroenterology and Hepatology, Tytgat Institute for Liver and Intestinal Research, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Ulrich Beuers
- Department of Gastroenterology and Hepatology, Tytgat Institute for Liver and Intestinal Research, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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33
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Åberg F, Abdulle A, Mäkelä A, Nissinen M. Asymptomatic De Novo Inflammatory Bowel Disease Late After Liver Transplantation for Primary Sclerosing Cholangitis: A Case Report. Transplant Proc 2016; 47:2775-7. [PMID: 26680092 DOI: 10.1016/j.transproceed.2015.09.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 09/17/2015] [Indexed: 01/20/2023]
Abstract
Guidelines recommend colonoscopy screening for possible asymptomatic inflammatory bowel disease (IBD) in all patients diagnosed with primary sclerosing cholangitis (PSC). PSC-IBD warrants regular dysplasia-surveillance colonoscopy. However, no consensus exists regarding follow-up colonoscopy in PSC patients without IBD who remain asymptomatic. We describe a 43-year-old female who had undergone liver transplantation (LT) due to advanced PSC. Previous colonoscopies had been normal. The post-transplantation course was uneventful, with no rejections and signs of PSC recurrence. Immunosuppression was by tacrolimus monotherapy. She was asymptomatic with normal inflammation markers. A protocol colonoscopy, performed as general dysplasia surveillance 8 years post-transplantation, revealed mucopurulent-covered small superficial ulcerations and erythema diffusely distributed from the cecal to sigmoid colon with intervening normal mucosa and rectal sparing. Histologic examination showed patchy chronic colitis with crypt architectural distortion and mild-moderate inflammation activity. Infection samples were negative. Findings complied with de novo IBD, type unclassified. In conclusion, the link between PSC and clinically silent IBD may manifest after the PSC diagnosis and even several years after LT. Given the increased colorectal cancer risk associated with PSC, IBD, and LT, repeat colonoscopy might be warranted in PSC patients without IBD at initial assessment, and also after LT.
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Affiliation(s)
- F Åberg
- Clinic of Gastroenterology, Helsinki University Hospital, Helsinki University, Finland.
| | - A Abdulle
- Clinic of Gastroenterology, Helsinki University Hospital, Helsinki University, Finland
| | - A Mäkelä
- HUSLAB, Meilahti Laboratories of Pathology, Helsinki, Finland
| | - M Nissinen
- Clinic of Gastroenterology, Helsinki University Hospital, Helsinki University, Finland
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34
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Halilbasic E, Fuchs C, Traussnigg S, Trauner M. Farnesoid X Receptor Agonists and Other Bile Acid Signaling Strategies for Treatment of Liver Disease. Dig Dis 2016; 34:580-8. [PMID: 27332721 DOI: 10.1159/000445268] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The intracellular nuclear receptor farnesoid X receptor (FXR) and the transmembrane G protein-coupled receptor 5 (TGR5) respond to bile acids (BAs) by activating transcriptional networks and/or signaling cascades. These cascades affect the expression of a great number of target genes relevant for BA, cholesterol, lipid and carbohydrate metabolism, as well as genes involved in inflammation, fibrosis and carcinogenesis. FXR activation in the liver tissue and beyond, such as the gut-liver axis, kidney and adipose tissue, plays a role in metabolic diseases. These BA receptors activators hold promise to become a new class of drugs to be used in the treatment of chronic liver disease, hepatocellular cancer and extrahepatic inflammatory and metabolic diseases. This review discusses the relevant BA receptors, the new drugs that target BA transport and signaling and their possible applications.
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Affiliation(s)
- Emina Halilbasic
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
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35
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Doycheva I, Amer S, Watt KD. De Novo Malignancies After Transplantation: Risk and Surveillance Strategies. Med Clin North Am 2016; 100:551-67. [PMID: 27095645 DOI: 10.1016/j.mcna.2016.01.006] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
De novo malignancies are one of the leading causes of late mortality after liver and kidney transplantation. Nonmelanoma skin cancer is the most common malignancy, followed by posttransplant lymphoproliferative disorder and solid organ tumors. Immunosuppression is a key factor for cancer development, although many other transplant-related and traditional risk factors also play a role. In this review, the authors summarize risk factors and outcomes of frequently encountered de novo malignancies after liver and kidney transplantation to stratify recipients at highest risk. Future efforts in prospectively validated, cost-effective surveillance strategies that improve survival of these complex patients are greatly needed.
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Affiliation(s)
- Iliana Doycheva
- Division of Gastroenterology and Hepatology, Medical University-Sofia, 1 G. Sofiisky Boulevard, Sofia 1431, Bulgaria
| | - Syed Amer
- Division of Internal Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Kymberly D Watt
- Division of Gastroenterology and Hepatology, Mayo Clinic and Foundation, CH-10, 200 First Street Southwest, Rochester, MN 55905, USA.
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36
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Rathi S, Dhiman RK. Hepatobiliary Quiz (Answers)-16 (2015). J Clin Exp Hepatol 2015; 5:357-60. [PMID: 26900280 PMCID: PMC4723713 DOI: 10.1016/j.jceh.2015.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
| | - Radha K. Dhiman
- Address for correspondence: Radha K. Dhiman, Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.Department of Hepatology, Postgraduate Institute of Medical Education and ResearchChandigarh160012India
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37
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Abstract
Primary sclerosing cholangitis (PSC) is a frequently progressive and fatal disease. Death from cancer occurs in a significant subset of patients with PSC. Patients with PSC have a 10 to 15 % lifetime risk of developing cholangiocarcinoma (CCA). About one third of CCAs are present in the first year after a diagnosis of PSC; the remainder are present with a frequency of about 1.5 % each year. Patients with concomitant PSC and inflammatory bowel disease (IBD) have a 4-fold higher risk of colorectal cancer (CRC) than patients with IBD alone and a 10-fold higher risk of CRC than the general population. The risk does not diminish with liver transplantation. This patient population also has a high frequency of carcinoma in gallbladder mass lesions. The risk for hepatocellular carcinoma (HCC) in the presence of cirrhosis is uncertain-two large cohort studies suggest that HCC is not as common as in other causes of cirrhosis. Although AASLD guidelines do not recommend routine screening for liver tumors in patients with PSC, we recommend MRI/MRCP and serum CA 19-9 levels in patients with PSC every 6 months to screen for CCA, HCC, pancreatic cancer, and gallbladder cancer. Screening colonoscopy at the diagnosis of PSC and surveillance colonoscopies every 1-2 years should be performed in those with PSC and IBD.
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38
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Abstract
Improvements in overall survival early after liver transplantation result in a growing number of patients with the potential for long-term survival. Data available on long-term survival, to date, reflect the situation of patients who received their liver transplant during a very different health-care era. Translating these data into the current medical era of liver transplantation is an important task, as a better understanding of aspects associated with morbidity and mortality is fundamental in improving the long-term outcome of liver transplant recipients. Malignancy screening, optimal treatment of recurrent disease and adequate management of metabolic disease are crucial contributions to advance patient care. In this Review, data specific to the liver transplant recipient will be evaluated and, in the absence of sufficient evidence at this time, recommendations and guidelines for the general population on management of long-term concerns will be assessed for their applicability after liver transplantation. In addition, other preventive strategies relating to pregnancy, contraception and vaccination are reviewed in detail.
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39
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Abstract
BACKGROUND AND AIMS The inflammatory bowel diseases (IBD), Crohn's disease (CD) and ulcerative colitis (UC), are chronic relapsing disorders of unknown aetiology. The aim of this review is to present the latest epidemiology data on occurrence, disease course, risk for surgery, as well as mortality and cancer risks. MATERIAL AND METHODS Gold standard epidemiology data on the disease course and prognosis of patients with inflammatory bowel disease (IBD) are based on unselected population-based cohort studies. RESULTS The incidence of ulcerative colitis (UC) and Crohn's disease (CD) has increased overall in Europe from 6.0 per 100,000 person-years in UC and 1.0 per 100,000 person-years in CD in 1962 to 9.8 per 100,000 person-years and 6.3 per 100,000 person-years in 2010, respectively. The highest incidence of IBD is found on the Faroe Islands. Overall, surgery rates have been declining over the last decades, partly due to aggressive medical therapy. Among IBD patients, mortality risk is increased by up to 50% in CD when compared to the background population, but this is not the case for UC. In CD, 25 - 50% deaths are disease-specific deaths, e.g. malnutrition, postoperative complications and intestinal cancer. In UC, disease-specific causes of deaths include colorectal cancer (CRC), and surgical and postoperative complications. The risk of CRC and small bowel cancer is increased two- to eightfold among IBD patients. Various subgroups carry increased risk of malignancy, e.g. those with persistent inflammation, long-standing disease, extensive disease, young age at diagnosis, family history of CRC and co-existing primary sclerosing cholangitis. The risk of extra-intestinal cancers, including lymphoproliferative disorders (LD) and intra- and extrahepatic cholangio carcinoma, is significantly higher among IBD patients. CONCLUSION In recent years, self-management and patient empowerment, combined with evolving eHealth solutions, has utilized epidemiological knowledge on disease patterns and has been improving compliance and the timing of adjusting therapies, thus optimizing efficacy by individualizing medication in the community setting.
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Affiliation(s)
- Johan Burisch
- Gastrounit, Medical Section, Hvidovre University Hospital , Hvidovre , Denmark
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40
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Jeschek P, Ferlitsch A, Salzl P, Heinze G, Györi G, Reinhart K, Waldmann E, Britto-Arias M, Trauner M, Ferlitsch M. A greater proportion of liver transplant candidates have colorectal neoplasia than in the healthy screening population. Clin Gastroenterol Hepatol 2015; 13:956-62. [PMID: 25151257 DOI: 10.1016/j.cgh.2014.08.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2014] [Revised: 08/13/2014] [Accepted: 08/13/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Various types of liver disease are associated with an increased prevalence of colorectal adenomas. We investigated whether cirrhosis is a risk factor for colorectal neoplasia by analyzing colonoscopy findings from 2 cohorts of patients awaiting liver transplantation. METHODS We performed a retrospective analysis to compare findings from colorectal cancer screenings of 567 adult patients with cirrhosis placed on the waitlist for liver transplantation with those from controls (matched for age, sex, body mass index, smoking, and diabetes). Rates of adenoma and advanced adenoma detection were adjusted owing to differences in rates of polypectomies performed in the 2 cohorts. RESULTS Adenomas were detected in a significantly higher percentage of patients with cirrhosis (29.3%) than in controls (21.5%) (P = .0057; relative risk [RR], 1.36; 95% confidence interval [CI], 1.09-1.69); and patients with cirrhosis had a higher rate of advanced adenoma detection than controls (13.9% vs 7.7%; P = .0015; relative risk, 1.82; 95% CI, 1.25-2.64). A greater percentage of patients with alcoholic cirrhosis had neoplasias (34.3%) than controls (25.3%; P = .0350; RR, 1.36), and rates of advanced adenoma detection were 16.7% vs 10.2% (P = .0409; RR, 1.63). Adenomas were detected in 27.8% of patients with viral cirrhosis vs 15.9% of controls (P = .0061; RR, 1.74), with rates of advanced adenoma detection of 13.6% vs 5.0% (P = .0041; RR, 2.73). Similar proportions of patients with cirrhosis of other etiologies and controls were found to have colorectal neoplasias. CONCLUSIONS Based on a retrospective analysis of colonoscopy findings from patients awaiting liver transplantation, those with alcoholic or viral cirrhosis are at higher risk of developing colorectal neoplasia and should be considered for earlier colonoscopy examination.
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Affiliation(s)
- Philip Jeschek
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria; Quality Assurance Working Group of the Austrian Society of Gastroenterology and Hepatology, Vienna, Austria
| | - Arnulf Ferlitsch
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria; Quality Assurance Working Group of the Austrian Society of Gastroenterology and Hepatology, Vienna, Austria
| | - Petra Salzl
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria; Quality Assurance Working Group of the Austrian Society of Gastroenterology and Hepatology, Vienna, Austria
| | - Georg Heinze
- Section for Clinical Biometrics, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Georg Györi
- Department of Surgery, Division of Transplantation, Medical University of Vienna, Vienna, Austria
| | - Karoline Reinhart
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria; Quality Assurance Working Group of the Austrian Society of Gastroenterology and Hepatology, Vienna, Austria
| | - Elisabeth Waldmann
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria; Quality Assurance Working Group of the Austrian Society of Gastroenterology and Hepatology, Vienna, Austria
| | - Martha Britto-Arias
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria; Quality Assurance Working Group of the Austrian Society of Gastroenterology and Hepatology, Vienna, Austria
| | - Michael Trauner
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Monika Ferlitsch
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria; Quality Assurance Working Group of the Austrian Society of Gastroenterology and Hepatology, Vienna, Austria.
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41
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Sarkar M, Watt KD, Terrault N, Berenguer M. Outcomes in liver transplantation: does sex matter? J Hepatol 2015; 62:946-55. [PMID: 25433162 PMCID: PMC5935797 DOI: 10.1016/j.jhep.2014.11.023] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 11/05/2014] [Accepted: 11/16/2014] [Indexed: 02/06/2023]
Abstract
A growing literature has highlighted important differences in transplant-related outcomes between men and women. In the United States there are fewer women than men on the liver transplant waitlist and women are two times less likely to receive a deceased or living-related liver transplant. Sex-based differences exist not only in waitlist but also in post-transplant outcomes, particularly in some specific liver diseases, such as hepatitis C. In the era of individualized medicine, recognition of these differences in the approach to pre and post-liver transplant care may impact short and long-term outcomes.
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Affiliation(s)
- Monika Sarkar
- Division of Gastroenterology and Hepatology, University of California, San Francisco, 513 Parnassus Avenue, S-357, San Francisco, CA 94143, USA.
| | - Kymberly D Watt
- Division of Gastroenterology and Hepatology, Mayo Clinic and Foundation, 200 First St, Rochester, MN 55905, USA
| | - Norah Terrault
- Division of Gastroenterology and Hepatology, University of California, San Francisco, 513 Parnassus Avenue, S-357, San Francisco, CA 94143, USA
| | - Marina Berenguer
- Hepatology and Liver Transplantation Unit, La Fe Hospital and Ciberehd, Universidad Valencia, C/Bulevar Sur sn (Torre F-5) 46026 Valencia, Spain
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42
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Venkat VL, Ranganathan S, Sindhi R. The challenges of liver transplantation in children with primary sclerosing cholangitis. Expert Rev Gastroenterol Hepatol 2015; 9:289-94. [PMID: 25592492 DOI: 10.1586/17474124.2015.1002085] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Primary sclerosing cholangitis (PSC) in children can progress to end-stage liver disease requiring liver transplantation. PSC poses many challenges beginning with evaluation and classification of ductal involvement and overlap syndromes, few options for medical management and unique risks in the post-transplant period. The construct that PSC may be an autoimmune disease is based on positive autoantibodies, association with inflammatory bowel disease, linkage to HLA type and overlap/autoimmune sclerosing cholangitis; however, PSC is not responsive to standard immunosuppression. Study of PSC and post-transplant outcomes in children may provide a unique background in which to study this challenging disease. This is particularly intriguing in the subset of patients diagnosed in the first decade of life, suggesting a strong link to predisposing genetic susceptibility and immune dysregulation. Long-term, multicenter effort is likely to be the only mechanism to study this rare disease in children and to improve outcomes in the future.
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Affiliation(s)
- Veena L Venkat
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Pittsburgh of UPMC, Pediatrics, 4401 Penn Avenue, Pittsburgh, PA 15224, USA
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43
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Colorectal cancer surveillance in patients with inflammatory bowel disease and primary sclerosing cholangitis: an economic evaluation. Inflamm Bowel Dis 2014; 20:2046-55. [PMID: 25230162 DOI: 10.1097/mib.0000000000000181] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The cost-effectiveness of annual colonoscopy for detection of colorectal neoplasia among patients with inflammatory bowel disease (IBD) and primary sclerosing cholangitis (PSC) is uncertain. The aim of this study was to determine whether annual colonoscopy among patients with IBD-PSC is cost-effective compared with less frequent intervals from the perspective of a publicly funded health care system. METHODS A cost-utility analysis using a Markov model was used to simulate a 35-year-old patient with a 10-year history of well-controlled IBD and a recent diagnosis of concomitant PSC. The following strategies were compared: no surveillance, colonoscopy every 5 years, biennial colonoscopy, and annual colonoscopy. Outcome measures included: costs, number of cases of dysplasia found, number of cancers found and missed, deaths, quality-adjusted life-years (QALYs) gained, and the incremental cost per QALY gained. RESULTS In the base-case analysis, no surveillance was the least expensive and least effective strategy. Compared with no surveillance, the cost per QALY of surveillance every 5 years was CAD $15,021. The cost per QALY of biennial surveillance compared with surveillance every 5 years was CAD $37,522. Annual surveillance was more effective than biennial surveillance, but at an incremental cost of CAD $174,650 per QALY gained compared with biennial surveillance. CONCLUSIONS More frequent colonoscopy screening intervals improve effectiveness (i.e., detects more cancers and prevents additional deaths), but at higher cost. Health systems must consider the opportunity costs associated with different surveillance colonoscopy intervals when deciding which strategy to implement among patients with IBD-PSC.
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Wang R, Leong RM. Primary sclerosing cholangitis as an independent risk factor for colorectal cancer in the context of inflammatory bowel disease: A review of the literature. World J Gastroenterol 2014; 20:8783-8789. [PMID: 25083052 PMCID: PMC4112886 DOI: 10.3748/wjg.v20.i27.8783] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2013] [Revised: 01/21/2014] [Accepted: 04/09/2014] [Indexed: 02/06/2023] Open
Abstract
To examine and evaluate recent evidence regarding the epidemiology, pathogenesis and management of colorectal cancer (CRC) development in inflammatory bowel disease (IBD)-primary sclerosing cholangitis (PSC) patients. Using the PubMed database, a literature search was conducted for relevant articles in English from the past 10 years. Relevant studies investigating PSC as a risk factor for CRC in IBD in the context of incidence and prevalence, pathogenesis, prevention and prognosis were included in this review. Recent evidence increasingly points to PSC as a significant risk factor in the development of CRC in patients with concomitant IBD. PSC may be an important risk factor for CRC in different populations worldwide. The mechanism for this increase in risk is still unclear. The efficacy of UDCA as a chemopreventive agent remains controversial. Liver transplantation does not halt the development of CRC, although there is not enough evidence to suggest that it is associated with increased incidence of CRC. While routine colonoscopic surveillance should be performed in patients with concurrent PSC and IBD, more high-level evidence is required to support the benefits of the procedure. While many new developments have taken place in the last decade, the pathogenesis and optimal management of CRC development in IBD-PSC patients remain unclear.
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