Prevention of the Osmotic Demyelination Syndrome After Liver Transplantation: A Multidisciplinary Perspective

The osmotic demyelination syndrome (ODS) is a serious neurologic condition that occurs in the setting of rapid correction of hyponatremia. It presents with protean manifestations, from encephalopathy to the "locked-in" syndrome. ODS can complicate liver transplantation (LT), and its incidence may increase with the inclusion of serum sodium as a factor in the Mayo End-Stage Liver Disease score. A comprehensive understanding of risk factors for the development of ODS in the setting of LT, along with recommendations to mitigate the risk of ODS, are necessary. The literature to date on ODS in the setting of LT was reviewed. Major risk factors for the development of ODS include severe pretransplant hyponatremia (serum sodium [SNa] < 125 mEq/L), the magnitude of change in SNa pre- versus posttransplant, higher positive intraoperative fluid balance, and the presence of postoperative hemorrhagic complications. Strategies to reduce the risk of ODS include correcting hyponatremia pretransplant via fluid restriction and/or ensuring an appropriate rate of increase from the preoperative SNa via close attention to fluid and electrolyte management both during and after surgery. Multidisciplinary management involving transplant hepatology, nephrology, neurology, surgery, and anesthesiology/critical care is key to performing LT safely in patients with hyponatremia.

Prevention of allograft HCV recurrence with peri-transplant human monoclonal antibody MBL-HCV1 combined with a single oral direct-acting antiviral: A proof-of-concept study

Patients with active hepatitis C virus (HCV) infection at transplantation experience rapid allograft infection, increased risk of graft failure and accelerated fibrosis. MBL-HCV1, a neutralizing human monoclonal antibody (mAb) targeting the HCV envelope, was combined with a licensed oral direct-acting antiviral (DAA) to prevent HCV recurrence post-transplant in an open-label exploratory efficacy trial. Eight subjects received MBL-HCV1 beginning on the day of transplant with telaprevir initiated between days 3 and 7 post-transplantation. Following FDA approval of sofosbuvir, two subjects received MBL-HCV1 starting on the day of transplant with sofosbuvir initiated on day 3. Combination treatment was administered for 8-12 weeks or until the stopping rule for viral rebound was met. The primary endpoint was undetectable HCV RNA at day 56 with exploratory endpoints of sustained virologic response (SVR) at 12 and 24 weeks post-treatment. Both subjects receiving mAb and sofosbuvir achieved SVR24. Four of eight subjects in the mAb and telaprevir group met the primary endpoint; one subject achieved SVR24 and three subjects relapsed 2-12 weeks post-treatment. The other four subjects experienced viral breakthrough. There were no serious adverse events related to study treatment. This proof-of-concept study demonstrates that peri-transplant immunoprophylaxis combined with a single oral direct-acting antiviral in the immediate post-transplant period can prevent HCV recurrence.

Randomised clinical study: GR-MD-02, a galectin-3 inhibitor, vs. placebo in patients having non-alcoholic steatohepatitis with advanced fibrosis

BACKGROUND

Non-alcoholic steatohepatitis (NASH) and resultant liver fibrosis is a major health problem without approved pharmacotherapy. Pre-clinical results of GR-MD-02, a galectin-3 inhibitor, suggested potential efficacy in NASH with advanced fibrosis/cirrhosis and prompted initiation of a clinical development programme in NASH with advanced fibrosis.

AIM

To evaluate the safety, pharmacokinetics and exploratory pharmacodynamic markers of GR-MD-02 in subjects having NASH with bridging fibrosis.

METHODS

The GT-020 study was a first-in-human, sequential dose-ranging, placebo controlled, double-blinded study with the primary objective to assess the safety, tolerability and dose limiting toxicity of GR-MD-02, in subjects with biopsy-proven NASH with advanced fibrosis (Brunt stage 3). The secondary objectives were to characterise first-dose and multiple-dose pharmacokinetic profiles and to evaluate changes in potential serum biomarkers and liver stiffness as assessed by FibroScan.

RESULTS

GR-MD-02 single and three weekly repeated of 2, 4 and 8 mg/kg revealed no meaningful clinical differences in treatment emergent adverse events, vital signs, electrocardiographic findings or laboratory tests. Pharmokinetic parameters showed a dose-dependent relationship with evidence of drug accumulation following 8 mg/kg (~twofold).

CONCLUSIONS

GR-MD-02 doses were in the upper range of the targeted therapeutic dose determined from pre-clinical data and were safe and well tolerated with evidence of a pharmacodynamic effect. These results provide support for a Phase 2 development programme in advanced fibrosis due to NASH.

High baseline bilirubin and low albumin predict liver decompensation and serious adverse events in HCV-infected patients treated with sofosbuvir-containing regimens

To conduct surveillance and determine the safety profile of new hepatitis C virus treatments in real-world clinical practice. Hepatic decompensation and other serious adverse events were investigated in an observational cohort study of 511 patients treated with regimens containing sofosbuvir, December 2013-June 2014. Among 499 previously stable patients (no history of hepatic decompensation during the previous 12 months), a nested case-control study was performed to identify predictors of decompensation/serious adverse event. Cases and controls were matched 1:5 based on treatment regimen and duration. Matched conditional logistic regression was used for analysis. Providers scored the likelihood that events were treatment-related (scale = 0-4). The cumulative incidence of decompensation/events was 6.4% for the total cohort. Among 499 previously stable patients, the incidence of decompensation/events was 4.5%; the mortality rate was 0.6%. Sixteen of the 499 experienced one or more serious complications considered to be at least potentially treatment-related, and the sustained virological response rate was 7/16 (44%). Two cases, both on sofosbuvir/simeprevir (without interferon or ribavirin), had complications consistent with autoimmune events (score 3, 'likely treatment-related'), and one experienced a flare of autoimmune hepatitis. Compared to controls, cases had higher baseline median model for end-stage liver disease scores (14 vs 8, P < 0.01). Decompensation/events was independently associated with lower baseline albumin (OR = 0.12/g/dL, P = 0.01) and higher total bilirubin (OR = 4.31/mg/dL, P = 0.01). Reduced hepatic function at baseline increased the risk of liver decompensation/events.

Early Liver Transplantation for Severe Alcoholic Hepatitis in the United States--A Single-Center Experience

Early liver transplantation (LT) in European centers reportedly improved survival in patients with severe alcoholic hepatitis (AH) not responding to medical therapy. Our aim was to determine if a strategy of early LT for severe AH could be applied successfully in the United States. We reviewed 111 patients with severe AH at our center from January 2012 to January 2015. The primary end point was mortality at 6 months or early LT, with a secondary end point of alcohol relapse after LT. Survival was compared between those receiving early LT and matched patients who did not. Using a process similar to the European trial, 94 patients with severe AH not responding to medical therapy were evaluated for early LT. Overall, 9 (9.6%) candidates with favorable psychosocial profiles underwent early LT, comprising 3% of all adult LT during the study period. The 6-month survival rate was higher among those receiving early LT compared with matched controls (89% vs 11%, p<0.001). Eight recipients are alive at a median of 735 days with 1 alcohol relapse. Early LT for severe AH can achieve excellent clinical outcomes with low impact on the donor pool and low rates of alcohol relapse in highly selected patients in the United States.

Clinical characteristics of human immunodeficiency virus patients being referred for liver transplant evaluation: a descriptive cohort study

BACKGROUND

Liver transplantation (LT) is a treatment option for select human immunodeficiency virus (HIV)-infected patients with advanced liver disease. The aim of this study was to describe LT evaluation outcomes in HIV-infected patients.

METHODS

All HIV-infected patients referred for their first LT evaluation at the Mount Sinai Medical Center were included in this retrospective, descriptive cohort study. Multivariable logistic regression was used to identify factors independently associated with listing.

RESULTS

Between February 2000 and April 2012, 366 patients were evaluated for LT, with 66 (18.0%) listed for LT and 300 (82.0%) not listed. Fifty-one patients (13.9%) died before completing evaluation and 85 (23.2%) were too early for listing. Reasons patients were declined for listing were psychosocial (15.8%), HIV-related (10.4%), loss to follow-up (9.6%), surgical/medical (6.0%), liver-related (4.4%), patient choice (3.4%), and financial (1.6%). Listed patients were more likely to have hepatocellular carcinoma (HCC) (43.1% vs. 17.1%; P < 0.0001) and less likely to have hepatitis B (6.2% vs. 15.7%; P = 0.04) or a psychiatric history (19.7% vs. 35.2%; P = 0.02) than those not listed. In multivariable analysis, HCC (odds ratio [OR] 5.79; 95% confidence interval [95% CI]: 2.97-11.28), model for end-stage liver disease (MELD) score at referral (OR 1.06; 95% CI 1.01-1.11), and hepatitis B (OR 0.26; 95% CI 0.08-0.79) were associated with listing.

CONCLUSION

MELD score and HCC were positive predictors of listing in HIV-infected patients referred for LT evaluation and, therefore, timely referrals are vital in these patients. As MELD is a predictor for death while undergoing evaluation, rapid evaluation should be performed in HIV-infected patients with a higher MELD score.

Effect of fibrosis on adverse events in patients with hepatitis C treated with telaprevir

BACKGROUND

Data about adverse events are needed to optimise telaprevir-based therapy in a broad spectrum of patients.

AIM

To investigate adverse events of telaprevir-based therapy in patients with and without advanced fibrosis or cirrhosis in a real-world setting.

METHODS

Data on 174 hepatitis C-infected patients initiating telaprevir-based therapy at Mount Sinai and Montefiore medical centres were collected. Biopsy data and FIB-4 scores identified patients with advanced fibrosis. Multivariable fully adjusted models were built to assess the effect of advanced fibrosis on specific adverse events and discontinuation of treatment due to an adverse event.

RESULTS

Patients with (n = 71) and without (n = 103) advanced fibrosis were similar in BMI, ribavirin exposure, gender, prior treatment history, haemoglobin and creatinine, but differed in race. Overall, 47% of patients completed treatment and 40% of patients achieved SVR. Treated patients with and without advanced fibrosis or cirrhosis had similar rates of adverse events; advanced fibrosis, however, was independently associated with ano-rectal discomfort (P = 0.03). Three patients decompensated and had advanced fibrosis. The discontinuation of all treatment medications due to an adverse event was significantly associated with older age (P = 0.01), female gender (P = 0.01) and lower platelets (P = 0.03).

CONCLUSIONS

Adverse events were common, but were not significantly related to the presence of advanced fibrosis or cirrhosis. More critical monitoring in older and female patients with low platelets throughout treatment may reduce adverse event-related discontinuations.

Human monoclonal antibody MBL-HCV1 delays HCV viral rebound following liver transplantation: a randomized controlled study

Rapid allograft infection complicates liver transplantation (LT) in patients with hepatitis C virus (HCV). Pegylated interferon-α and ribavirin therapy after LT has significant toxicity and limited efficacy. The effect of a human monoclonal antibody targeting the HCV E2 glycoprotein (MBL-HCV1) on viral clearance was examined in a randomized, double-blind, placebo-controlled pilot study in patients infected with HCV genotype 1a undergoing LT. Subjects received 11 infusions of 50 mg/kg MBL-HCV1 (n=6) or placebo (n=5) intravenously with three infusions on day of transplant, a single infusion on days 1 through 7 and one infusion on day 14 after LT. MBL-HCV1 was well-tolerated and reduced viral load for a period ranging from 7 to 28 days. Median change in viral load (log10 IU/mL) from baseline was significantly greater (p=0.02) for the antibody-treated group (range -3.07 to -3.34) compared to placebo group (range -0.331 to -1.01) on days 3 through 6 posttransplant. MBL-HCV1 treatment significantly delayed median time to viral rebound compared to placebo treatment (18.7 days vs. 2.4 days, p<0.001). As with other HCV monotherapies, antibody-treated subjects had resistance-associated variants at the time of viral rebound. A combination study of MBL-HCV1 with a direct-acting antiviral is underway.

Liver transplantation is possible in some patients with liver metastasis of colon cancer

Liver metastases from colorectal cancer are an absolute contraindication for liver transplantation. Aggressive therapy with liver resection and local chemotherapy in selected patients may be able to provide long-term cure. Given the risks of tumor recurrence, whether patients with post chemotherapy complications leading to liver failure should be offered transplantation is a challenging question in an era of limited organ availability. Herein we have presented 2 cases of liver transplantation performed in patients with colorectal cancer metastases treated with liver resection followed by hepatic artery infusion chemotherapy leading to development of sclerosing cholangitis and eventual liver failure. This report demonstrates that liver transplantation may be an option in selected patients with colorectal cancer liver metastases that have been well treated.

Pneumatosis intestinalis and mesenteric venous gas - a manifestation of bacterascites in a patient with cirrhosis

We herein report a patient with decompensated cirrhosis secondary to autoimmune hepatitis, who presented with pneumatosis intestinalis (PI) and portal venous gas. Mesenteric ischemia has been recognized as a common and life-threatening cause of PI which portends a grave prognosis. The patient was found to have bacterascites and recovered after appropriate antibiotic therapy. Spontaneous bacterial peritonitis/bacterascites with gas-forming organisms manifesting as PI has not been previously reported.

Effect of ischemia-reperfusion on the incidence of acute cellular rejection and timing of histologic hepatitis C virus recurrence after liver transplantation

BACKGROUND

Because of a critical shortage of deceased donor (DD) livers, more extended criteria allografts are being utilized; these allografts are at increased risk for ischemia-reperfusion injury (IRI). We assessed whether, in a large cohort of patients transplanted for hepatitis C virus (HCV) either via a DD or live donor (LD), there was a relationship between the degree of IRI and the frequency and timing of acute cellular rejection (ACR) and histologic HCV recurrence.

METHODS

During an 8-year study, patients were separated into four groups based on peak alanine aminotransferase (ALT) levels and three groups based on severity of IRI on postreperfusion liver biopsy.

RESULTS

The mean follow-up time of 433 DD and 44 LD recipients was 1212 days. We noted a strong correlation in DD between peak ALT and the histologic degree of IRI (P = .01). There was no difference in the incidence or grade of ACR among the four groups. There was no correlation between the severity of IRI and the incidence or time to histologic recurrence of HCV.

CONCLUSIONS

The magnitude of peak ALT correlated with the severity of IRI on postreperfusion liver biopsy. Among this large HCV cohort, there was no correlation between the severity of IRI and the incidence or timing of histologic HCV recurrence or incidence of ACR.

Comparison of hepatitis C histological recurrence rates and patient survival between split and deceased donor liver transplantation

INTRODUCTION

Controversy exists as to whether there is an increased severity or frequency of recurrent hepatitis C viral (HCV) infection in recipients of adult living donor liver transplantation (LDLT) grafts. We sought to examine the time to histological recurrence and survival in HCV (+) patients who underwent split liver transplantation (SLT), which is technically similar to what occurs in the LDLT procedure.

METHODS

Twenty four HCV (+) adult recipients were identified through the UNOS database as having had SLT procedures at three centers: Mount Sinai Medical Center, University of Chicago, and University of California at Los Angeles. Of these, 17 patients with comprehensive data were matched to 32 HCV (+) patients who underwent whole deceased donor liver transplantation (DDLT) during the same time period. Outcome and time to initial HCV recurrence as documented by liver biopsy were assessed. Liver biopsy was performed when clinically indicated.

RESULTS

Patients who had SLT were significantly older (P=.01). There was no difference in number of rejection episodes (P=.40). Fifteen of 17 SLT (88%) versus 24/32 DDLT (75%) patients had documented HCV recurrence by biopsy (P=.46). The time to median cumulative incidence of recurrence of HCV post-liver transplantation was 12.6 months (SLT) versus 39.8 months (DDLT) patients. There was no difference in survival between SLT and DDLT patients (47 vs 70 months, P=.62) nor in cumulative incidence of histological HCV recurrence at 1, 2, and 3 years (P=.198, .919, and .806, respectively).

CONCLUSION

There is no difference in the cumulative incidence of histological recurrence of HCV post-liver transplant or in survival between recipients of deceased donor and split liver transplants.

Development of hepatic granulomas in patients receiving pegylated interferon therapy for recurrent hepatitis C virus post liver transplantation

Infrequently, hepatitis C (HCV) appears to be the cause of hepatic granulomas. Interferon therapy for HCV has been increasingly associated with the development of sarcoidosis.

AIMS

We sought to determine the incidence of hepatic granulomas in patients with recurrent HCV post liver transplantation (LT).

METHODS

Between 1994 and 2005, 820 patients were transplanted for HCV at our institution. The pathology database was searched for patients having recurrent HCV and granulomas. At Mount Sinai Medical Center, protocol biopsies have been performed for the last 2 years in patients receiving pegylated interferon-alpha2b and ribavirin (PEG) for recurrent HCV. Review of slides from explanted livers, pre- and post-perfusion biopsies, and all allograft biopsies were evaluated. Lipogranulomas were excluded because of their frequent association with steatosis.

RESULTS

A total of 10,225 liver biopsies were performed on HCV patients, and 25 (0.24%) showed non-caseating epithelioid granulomas. Hepatic granulomas were detected in 14 post-LT HCV patients; 9 patients received PEG. Typically, only 1 lobular granuloma was found. None of these patients had granulomas in the native liver or in any biopsy before interferon therapy; 6/9 patients had undetectable HCV-RNA levels, and 4 had sustained viral response. No other cause for granuloma formation was identified in the 6 patients.

CONCLUSIONS

Hepatic granulomas are infrequently found in HCV liver biopsies and rarely found in post-LT biopsies with recurrent HCV. When present, they occur more commonly in patients receiving and virologically responding to PEG therapy. The presence of granulomas in patients with HCV being treated with PEG may not warrant an extensive etiologic work-up for granulomatous hepatitis unless otherwise clinically indicated.

Review article: drug hepatotoxicity

BACKGROUND

Drug toxicity is the leading cause of acute liver failure in the United States. Further understanding of hepatotoxicity is becoming increasingly important as more drugs come to market.

AIMS

(i) To provide an update on recent advances in our understanding of hepatotoxicity of select commonly used drug classes. (ii) To assess the safety of these medications in patients with pre-existing liver disease and in the post-liver transplant setting. (iii) To review relevant advances in toxicogenomics which contribute to the current understanding of hepatotoxic drugs.

METHODS

A Medline search was performed to identify relevant literature using search terms including 'drug toxicity, hepatotoxicity, statins, thiazolidinediones, antibiotics, antiretroviral drugs and toxicogenomics'.

RESULTS

Amoxicillin-clavulanic acid is one of the most frequently implicated causes of drug-induced liver injury worldwide. Statins rarely cause clinically significant liver injury, even in patients with underlying liver disease. Newer thiazolidinediones are not associated with the degree of liver toxicity observed with troglitazone. Careful monitoring for liver toxicity is warranted in patients who are taking antiretrovirals, especially patients who are co-infected with hepatitis B and C. Genetic polymorphisms among enzymes involved in drug metabolism and HLA types may account for some of the differences in individual susceptibility to drug hepatotoxicity.

CONCLUSIONS

Drug-induced hepatotoxicity will remain a problem that carries both clinical and regulatory significance as long as new drugs continue to enter the market. Future results from ongoing multicentre collaborative efforts may help contribute to our current understanding of hepatotoxicity associated with drugs.

Identification of Ultrastructural Changes in Liver Allografts of Patients Experiencing Primary Nonfunction

BACKGROUND

Primary nonfunction (PNF) after liver transplantation is fatal without timely retransplantation. PNF has been associated with many risk factors, but the etiology remains unknown in most cases. Using electron microscopy, we examined the hepatic ultrastructure of donor allografts in patients experiencing PNF and compared the findings with a well-matched group of other donor allografts.

MATERIALS AND METHODS

Archival paraffin-embedded pre- and post-reperfusion donor liver biopsies were examined by electron microscopy in 10 patients with PNF and in 10 controls, matched by donor age +/- 5 years, gender, cold ischemic time +/- 1 hour, and donor cause of death. Mitochondria, endoplasmic reticulum, sinusoidal endothelial cells, and the glycogen content of the cells were assessed. The donors' serum peak transaminases, bilirubin and sodium levels, as well as the recipient age and serum creatinine were compared.

RESULTS

There were no significant differences in recipient age at the time of transplantation, peak recipient serum creatinine, donor peak serum transaminase, sodium or bilirubin levels. In all cases, the endoplasmic reticulum and sinusoidal endothelial cells were ultrastructurally normal. Hepatocytes had variable degrees of glycogen pooling. Hepatic steatosis and intramitochondrial inclusions cells were present in 5/10 PNF compared to 0/10 controls patients on preperfusion liver biopsy (P = .17).

CONCLUSION

Liver allografts from patients suffering from PNF can have mitochondrial ultrastructural changes on preperfusion biopsies.

Results of steroid-based therapy for the hepatitis C-autoimmune hepatitis overlap syndrome

OBJECTIVE

Overlap syndromes in which persons manifest clinical, histological, or immunological features of both hepatitis C infection and autoimmune hepatitis are well described. The discordant forms of treatment for hepatitis C and autoimmune hepatitis have made medical management of these patients difficult. We report our experience in using corticosteroids as first line therapy for the hepatitis C-autoimmune hepatitis overlap syndrome.

METHODS

Seven patients with this overlap syndrome (diagnosis based on the presence of serum hepatitis C antibody by RIBA and serum hepatitis C RNA by polymerase chain reaction, and serum hypergammaglobulinemia, elevated ANA or ASMA titers, or histological findings consistent with autoimmune hepatitis) were treated with prednisone with or without azathioprine or cyclosporine, and followed for a median duration of 44.5 months.

RESULTS

Five patients (71%) showed improvement of median serum ALT level from 162 U/L to 38 U/L (p = 0.04) and median serum gamma-globulin from 2.1 g/dl to 1.4 g/dl (p = 0.04) by 6 months of therapy. The mean modified histological activity index score also decreased from 11.4 +/- 2.5 to 6.6 +/- 2.6 (p = 0.04) by at least 1 yr of therapy. One patient discontinued prednisone while taking azathioprine and experienced a rebound elevation of serum ALT that did not respond to retreatment with prednisone. Antiviral therapy was subsequently administered and resulted in biochemical and virologic response. Hepatitis C virus RNA remained detectable in all other patients.

CONCLUSION

Corticosteroids are beneficial as a first line therapy for some patients with the hepatitis C-autoimmune overlap syndrome, resulting in appreciable biochemical and histological response but without viral eradication.

Portal hypertension and hepatopulmonary syndrome in a middle-aged man with hepatitis B infection

A 55-year-old Turkish man with a history of chronic hepatitis B for 35 years, presented with incapacitating fatigue and worsening shortness of breath. He was hospitalized several times because of hepatic encephalopathy. He underwent liver transplantation for a clinical diagnosis of Child's C cirrhosis complicated by hepatopulmonary syndrome. The explanted liver, however, was not cirrhotic and demonstrated features of hepatoportal sclerosis. Although treatment for hepatoportal sclerosis is relief of portal hypertension; in rare cases such as in this patient with liver failure, liver transplantation is indicated.

Hepatic effects of long-term methotrexate use in the treatment of inflammatory bowel disease

OBJECTIVE

Methotrexate is currently used as a treatment for refractory inflammatory bowel disease. This study sought to evaluate the hepatic effects of long-term methotrexate therapy in patients with inflammatory bowel disease and to determine whether the established guidelines for monitoring methotrexate-related hepatotoxicity with surveillance liver biopsy in patients with psoriasis or rheumatoid arthritis are applicable to these patients.

METHODS

Thirty-two patients with inflammatory bowel disease receiving cumulative methotrexate doses of > or = 1500 mg were studied. Liver chemistry tests were obtained before and during therapy. Twenty patients underwent liver biopsies as recommended for methotrexate-treated patients with psoriasis; the biopsies were reviewed and graded according to Roenigk's criteria for methotrexate-induced hepatotoxicity (a grading system for methotrexate hepatotoxicity in psoriasis patients) by a liver pathologist blinded to the methotrexate dose.

RESULTS

In patients who had liver biopsies, the mean cumulative methotrexate dose was 2633 mg (range, 1500-5410 mg), given for a mean of 131.7 wk (range, 66-281 wk). Nineteen of 20 patients (95%) had mild histological abnormalities (Roenigk's grade I and II), and one patient had hepatic fibrosis (Roenigk's grade IIIB). Abnormal liver chemistry tests, present in 6 of 20 (30%) patients, did not identify the patient with Roenigk's grade IIIB hepatotoxicity.

CONCLUSIONS

Cumulative methotrexate doses up to 5410 mg given up to 281 wk in patients with inflammatory bowel disease are associated with little hepatotoxicity. Surveillance liver biopsies based on cumulative methotrexate doses are not warranted in these patients.

Donor liver uridine diphosphate (UDP)-glucuronosyltransferase-1A1 deficiency causing Gilbert's syndrome in liver transplant recipients

BACKGROUND

Uridine diphosphate-glucuronosyltransferase-1A1 deficiency, causing Gilbert's syndrome, has been attributed to two extra (TA) bases in the TATAA-box of the promoter region of its gene, where the A(TA)6TAA allele corresponds to the normal gene and A(TA)7TAA corresponds to a gene with reduced expression. Our aim was to determine whether isolated hyperbilirubinemia in liver transplant recipients was due to Gilbert's syndrome acquired through the liver allograft.

METHODS

From 305 patients followed in our Liver Transplant Clinic, five patients with isolated unconjugated hyperbilirubinemia in the absence of hemolysis, recurrent viral hepatitis, and biliary tract pathology were identified; 10 other post-orthotopic liver transplantion patients with normal liver chemistry tests were randomly selected as a control group. DNA was extracted from paraffin-embedded liver allograft tissue and peripheral lymphocytes and was genotyped for the TA repeat at the uridine diphosphate glucononosyltransferase-lA1 promoter region by polymerase chain reaction and acrylamide gel electrophoresis. Homozygosity for the (TA)7 allele was considered diagnostic of Gilbert's syndrome.

RESULTS

The mean serum total bilirubin level of the study patients was 2.28 mg/dl (range 1.8-3.0), consisting predominantly of the unconjugated form; that of the control patients was 0.76 mg/dl (range 0.4-1.1). The liver tissue from all five patients in the study group possessed the homozygous A(TA)7TAA genotype that was not observed in their lymphocytes. None of the liver tissue from the control patients demonstrated homozygosity for the A(TA)7TAA allele.

CONCLUSION

Uridine diphosphate-glucuronosyltransferase-1A1 deficiency, causing Gilbert's syndrome, may be carried by the donor liver and present with isolated unconjugated hyperbilirubinemia in liver transplant recipients.

Alpha1-antichymotrypsin globules within hepatocytes in patients with chronic hepatitis C and cirrhosis

Alpha1-antichymotrypsin (A1AC) is an acute phase serine protease inhibitor, similar to alpha1-antitrypsin (A1AT) in amino acid sequence. A1AT deficiency is known to be associated with emphysema and cirrhosis; deficiency of serum A1AC has been reported to be associated with emphysema, childhood asthma, and cryptogenic cirrhosis. The hepatocyte globules associated with A1AT deficiency have been well described; A1AC deficiency also has been reported to be associated with hepatocyte globules. The aim of this study was to describe the globules of A1AC and to compare them with A1AT globules. Immunohistochemistry for A1AC and A1AT was performed on liver biopsy specimens from 15 hepatitis C virus (HCV)-positive cirrhotic patients, 14 non-HCV cirrhotic patients, and 12 other patients with chronic hepatitis C but no cirrhosis, all of whom had known serum levels of A1AC; most had known serum levels of A1AT. Five of 15 HCV-positive cirrhotic patients, 1 of 14 non-HCV cirrhotic patients, and 1 of 12 noncirrhotic chronic hepatitis C patients had A1AC globules. Two of 15 HCV-positive cirrhotic patients and 2 of 14 non-HCV cirrhotic patients had A1AT globules. Histologically, the globules of A1AC were similar to those of A1AT but were smaller and fewer; the PAS/D stain was not as helpful for A1AC as it was for A1AT; immunohistochemistry was most useful. There was not a good correlation between serum levels of A1AC and its globules in hepatocytes. A1AC globules should be included in the differential diagnosis of hepatocyte inclusions.

Correlation between increased colloid osmotic pressure and the resolution of refractory ascites after transjugular intrahepatic portosystemic shunt

BACKGROUND

This study compared the changes in serum albumin, globulin, and colloid osmotic pressure (COP) before and after transjugular intrahepatic portosystemic shunt (TIPS) or large volume paracentesis (LVP) in patients with ascites.

METHODS

Of 23 patients with refractory ascites, 17 had TIPS and 6 had LVP with infusion of albumin. Colloid osmotic pressure measurements were calculated, using the formula previously proposed by Hoefs: COP = A (1.058G + 0.163A + 3.11) where A = serum albumin and G = serum globulin.

RESULTS

After 1 month, ascites resolved in 9 of the 17 patients who had TIPS and in none of the 6 who had LVP. Colloid osmotic pressure increased significantly in patients whose ascites resolved after TIPS. Colloid osmotic pressure did not change in the patients whose ascites did not resolve after TIPS, and COP decreased significantly in the LVP group. A statistically significant difference was found in the pre-TIPS COP measurements between those patients who had resolution of ascites and those who did not. A pre-TIPS COP of < or =20 mm Hg predicted resolution of ascites with an 88% sensitivity and a 78% specificity.

CONCLUSIONS

Serum COP increased significantly in patients with resolution of ascites but remained unchanged in patients with persistent ascites after TIPS. Serum COP decreased after LVP. A statistically significant difference in the pre-TIPS COP was found between patients whose ascites resolved and patients having persistent ascites.

Accuracy and significance of computed tomographic scan assessment of hepatic volume in patients undergoing liver transplantation

BACKGROUND

A small liver volume is considered to be a poor prognostic factor in cirrhosis, often indicative of advanced liver disease. Radiologic assessment of liver volume before liver transplant is routinely performed in many transplant centers. We sought to assess the accuracy and significance of computed tomographic (CT) scanning in hepatic volumetric analysis by correlating CT-derived estimation of liver volume with that of corresponding liver explants.

METHODS

A chart review of all patients aged 17 years or older undergoing liver transplant at Mount Sinai Medical Center between 1989 and 1995 was performed. Each patient underwent conventional CT scanning with measurement of liver volume (CTLV). Recipient liver volume (RLV) was defined as weight of liver explant after all attached ligaments, portal structures, and gallbladder were dissected free. Expected liver volume was calculated pretransplant based on age, gender, height, and weight. Patients were categorized into three groups based on etiology of liver disease: (1) hepatocellular (e.g., viral hepatitis, alcohol-related), (2) cholestatic (e.g., primary biliary cirrhosis), and (3) cryptogenic. The ratio of CTLV to RLV was used as a measure of the accuracy of CT volumetric analysis.

RESULTS

A total of 579 patients was studied (group 1=376, group 2=139, group 3=64). All three groups were statistically similar with regard to age, prothrombin time and total bilirubin. Median CT liver volume was 1308 ml (range: 338-3847), 1651 ml (range: 641-3861), and 1210 ml (range: 348-2575) in groups 1-3, respectively; median ratio of CTLV to RLV was 1.02 (range: 0.50-2.31), 1.05 (range: 0.52-2.22), and 1.05 (range: 0.50-1.56) for groups 1-3, respectively. When RLV was small, it tended to be overestimated by CTLV. In contrast, when RLV was large, it was often underestimated. Clinical features such as history of esophageal variceal bleed, encephalopathy or ascites, and laboratory data did not influence accuracy of CT volumetric analysis.

CONCLUSIONS

CT-derived estimation of liver volume appears to correlate closely with actual weight of liver explant regardless of the etiology of chronic liver disease. With extremes in CT volumetric analysis, actual liver volume tends to be under- or overestimated. For patients with end-stage liver disease, both CT-derived and actual liver volume are greater in cholestatic than in hepatocellular disorders.

Increased hepatic iron deposition resulting from treatment of chronic hepatitis C with ribavirin

Increased levels of hepatic iron may impair the response of patients with chronic hepatitis C to treatment with interferon-alfa, but combination therapy with ribavirin has demonstrated efficacy in the treatment of hepatitis C. When used alone or with interferon-alfa, ribavirin may cause a dose-dependent reversible hemolytic anemia. We compared the extent and cellular localization of iron deposition in liver tissue from biopsy specimens obtained before and after 36 weeks of therapy with ribavirin or placebo for 59 patients with chronic hepatitis C. Paired slides were available for review from 26 ribavirin and 27 placebo recipients. Iron deposition was assessed using coded slides stained with Perls Prussian blue and was semi-quantitated in hepatocytes, Kupffer cells, and areas of fibrosis. The overall iron score fell by 0.96 in the placebo group and increased 1.69 in the ribavirin recipients. Iron was deposited mainly in hepatocytes; the hepatocyte iron score increased from 2.19 to 3.81 in the ribavirin group. The amount of iron staining in Kupffer cells declined in the placebo group and increased slightly in the ribavirin group. Iron changes in areas of fibrosis were minor and did not differ between groups. Increased total hepatic iron deposition occurred during a 9-month course of ribavirin. Ribavirin-associated hemolysis deposits iron preferentially in hepatocytes. This increased deposition of hepatic iron does not seem to affect the biochemical or histologic response to ribavirin therapy but may have implications for hepatocyte susceptibility to future injury.

Successful combined liver-heart transplantation in adults: report of three patients and review of the literature

BACKGROUND

Three patients received liver/heart transplantation, and we report their successful outcome.

METHODS

Two patients had alcoholic cirrhosis and dilated cardiomyopathy; one had cryptogenic liver disease and idiopathic cardiomyopathy.

RESULTS

All patients had evidence of portal hypertension and coagulopathy. The cardiac transplants were performed first. Cardiopulmonary bypass was discontinued in favor of venovenous bypass, and liver transplantation was then performed. All patients developed acute tubular necrosis; two required a brief period of hemodialysis. There was only one episode of acute cellular rejection of the liver. Protocol endomyocardial biopsies in all three patients revealed no evidence of rejection. All patients are currently using low doses of immunosuppressive medications and have normal liver chemistry tests and cardiac function; two patients have mild renal insufficiency.

CONCLUSION

In selected patients with severe cardiac dysfunction and advanced liver disease, liver/heart transplantation can be successfully performed even in the face of portal hypertension and coagulopathy.

Rapidly progressive liver injury and fatal alcoholic hepatitis occurring after liver transplantation in alcoholic patients

Alcohol-related liver disease (ALD) is a common indication for orthotopic liver transplantation (OLT) in adults. Although return to 'heavy drinking' post-OLT is believed to be uncommon, the prevalence and severity of alcohol-related liver injury in such patients is not well characterized. We retrospectively reviewed the records of 68 adult patients who underwent OLT for ALD to determine the incidence of return to heavy drinking and to assess their clinical outcome. Follow-up ranged from 8-99 months (mean 42) post-OLT; 54 patients were followed for > or = 12 months. Ten patients (15%) had evidence of coexisting viral hepatitis (hepatitis C in 9 and hepatitis B in 1) before OLT. Six of 68 patients (8%) returned to heavy drinking post-OLT, and three of those died of alcoholic hepatitis at nine months, 2.5 and 3.5 years after OLT. In two of these three patients, premortem liver biopsy showed histologic features of alcoholic hepatitis in addition to bridging fibrosis or cirrhosis. None of the three patients who died of ALD had coexisting viral hepatitis. Of the 57 patients surviving for > or = 3 months post-OLT, 4 of 8 patients (50%) with steatosis and Mallory bodies in their native livers returned to heavy drinking compared to only 2/49 (4%) without these histologic findings (P<0.05). In conclusion, the incidence of heavy drinking post-OLT was uncommon, however, it was associated with fatal alcoholic hepatitis in 50% of patients. Rapidly progressive alcohol-related liver injury was seen even in the absence of coexisting viral hepatitis. The presence of steatosis and Mallory bodies in the native liver, which suggests recent or ongoing alcohol-related liver injury, predicted a return to heavy drinking post-OLT.

Recurring fibro-obliterative venopathy in liver allografts

Recurrent diseases in liver allografts are not uncommon. These occur most frequently in those transplanted for viral hepatitis B and C. We report an unusual case of recurrent process in two consecutive liver allografts received by a 37-year-old woman, who previously had an unremarkable past medical history but developed a rapidly progressive cholestatic liver failure. Histopathologic examination of the native liver showed fibroocclusive lesions of both terminal hepatic venules and portal vein branches. The exuberant fibroobliterative process created dense fibrosis with whorled appearance, and broad fibrous septa connecting adjacent central areas, and sometimes bridging portal to central areas. Dense portal fibrosis resulted in compression atrophy and loss of bile ducts. The first allograft, which failed within 3 months, showed histopathologic findings similar to that of the native liver. A liver biopsy that was performed 20 months after the second liver transplant again showed similar histopathology. The histopathologic features and clinical presentation of this patient suggest an unusual form of recurring progressive fibroobliterative venopathy causing liver failure.

Absence of hepatitis G virus within liver tissue of patients undergoing liver transplantation for cryptogenic cirrhosis

BACKGROUND

Epidemiological studies have detected up to a 9% incidence of hepatitis G (HGV)-RNA in patients with acute and chronic liver disease of unknown etiology. We sought to clarify the role of HGV as a causative agent in cryptogenic cirrhosis by analyzing archival liver tissue for HGV-RNA in patients undergoing orthotopic liver transplantation.

METHODS

Using a computer database, we identified 54 patients who underwent orthotopic liver transplantation for cryptogenic cirrhosis. After using rigorous serologic and histopathologic screening guidelines, 20 patients were studied, 7 of whom had concurrent hepatocellular carcinoma (HCC). RNA was extracted from archival paraffin-embedded liver tissue; HGV sequences were amplified by nested reverse transcription-polymerase chain reaction using primers designed from the 5' noncoding region.

RESULTS

HGV-RNA was absent from all 20 liver specimens, including those 7 with HCC. Beta-actin RNA, used as a positive control for cellular RNA, was isolated from all 20 liver specimens, including the 7 with HCC.

CONCLUSIONS

Utilizing a highly sensitive reverse transcription-polymerase chain reaction assay for HGV-RNA, we were unable to detect HGV-RNA within the livers of patients with cryptogenic cirrhosis or in the HCC arising within them. This lends further evidence to HGV infection not being a cause of cryptogenic cirrhosis and not being associated with the development of HCC in cryptogenic cirrhosis.

High-resolution endoluminal sonography assessment of the hematocystic spots of esophageal varices

BACKGROUND

Many variables are associated with an increased potential for esophageal variceal rupture, especially the presence of hematocystic spots and other red signs on upper endoscopy. The etiology of hematocystic spots is unknown. High-resolution endoluminal sonography has been shown to be an accurate and sensitive imaging modality for detection, as well as the qualitative and quantitative assessment of esophageal varices. Because the high-resolution endoluminal sonography transducer permits detailed resolution of submucosal structures thereby allowing more precise examination of the actual wall of the varix, we sought to image variceal hematocystic spots in an effort to better define their anatomy.

METHODS

Simultaneous upper endoscopy and high-resolution endoluminal sonography were performed in 68 patients with cirrhosis. Endoscopy was performed as part of screening for varices during evaluation for liver transplantation or in patients with previous presumed variceal bleeding. On endoscopy and high-resolution endoluminal sonography, two independent reviewers identified the same 10 patients having esophageal varices with hematocystic spots. The patients who had bled from their varices had not received prior endoscopic treatment.

RESULTS

Hematocystic spots as seen with high-resolution endoluminal sonography imaging appeared as saccular aneurysm like projections on the variceal surface in 6 of 10 patients. Four of six patients would later have recurrent bleeding; two of these patients were again noted to have hematocystic spots on endoscopy with a similar corresponding high-resolution endoluminal sonography appearance. Patients without hematocystic spots did not have similar high-resolution endoluminal sonography imaging.

CONCLUSION

Aneurysm-like projections in the wall of varices may represent focal weaknesses of the variceal wall and thus play a role in the pathophysiology of esophageal variceal rupture. The present findings may help to explain why there is an increased risk of variceal hemorrhage associated with the presence of hematocystic spots on esophageal varices.

Fulminant hepatic failure secondary to malignant melanoma: case report and review of the literature

Malignant melanoma has a propensity to metastasize widely to many organs, involving the liver in up to one-third of cases. Fulminant hepatic failure is an unusual presentation of hepatic neoplasms, whether primary or metastatic. We describe a case of malignant melanoma with liver metastases that rapidly progressed to fulminant hepatic failure and death. Striking elevations of liver tests, particularly lactate dehydrogenase, were seen. Liver biopsy showed diffuse intrasinusoidal infiltration with melanoma cells. In patients with malignant melanoma, raised serum lactate dehydrogenase levels may suggest hepatic involvement, with extreme elevations possibly predictive of liver failure.

Hereditary hemochromatosis in liver transplantation

A candidate gene, HFE, was recently described in patients with hereditary hemochromatosis (HH) and found to contain a missense mutation leading to a cysteine to tyrosine substitution (C282Y). A second mutation, H63D, was also found in the gene. This study was undertaken to determine the HFE genotype in liver transplant recipients clinically diagnosed with HH and those incidentally found to have increased iron deposition in their explanted livers and to evaluate whether biochemical or histological hepatic iron indices (HIIs) correlated with homozygosity for the C282Y mutation. We identified 15 patients clinically diagnosed with various liver disorders other than HH who had increased liver iron deposits among 918 adult patients who underwent liver transplantation from 1988 to 1995. Four additional patients were clinically diagnosed as having HH. Archival explant liver tissue was evaluated for the histological HII according to the method of Deugnier et al, in which an index greater than 0.15 suggests homozygosity for HH. The HII was computed according to established methods, with a value greater than 1.9 suggesting homozygosity for HH. A portion of liver tissue was subjected to DNA genotyping using polymerase chain reaction-amplified products. Two of 4 patients with clinically suspected HH were homozygous for C282Y, and 2 patients had neither mutation. One of the 15 patients not suspected to have HH was a C282Y homozygote, 1 was a C282Y heterozygote, 6 were H63D heterozygotes, and 7 had neither mutation. The histological HII was consistent with HH in 13 patients, whereas the HII was consistent with HH in 6 patients. Thus, in patients with end-stage liver disease, despite fulfilling the established clinical criteria for HH using biochemical and histological parameters, only a minority of patients were homozygous for the C282Y mutation. Hepatic iron overload may result from other causes, and in end-stage liver disease, an elevated HII may not accurately predict HH. Other factors that either control or lead to iron absorption may explain iron overload in these patients.

Night blindness secondary to vitamin A deficiency in a patient with bile duct strictures after liver transplantation

Vitamin A deficiency and resulting night blindness have previously been reported in patients with chronic liver disease before undergoing liver transplantation. Because early identification of patients with vitamin A deficiency can lead to the relief of symptoms and the prevention of irreversible retinal degeneration, vitamin A deficiency should always be considered in the differential diagnosis of visual disturbances in patients with liver disease. We describe a case of night blindness due to vitamin A deficiency resulting from bile duct strictures in a post-orthotopic liver transplant patient and its successful resolution with vitamin A supplementation.

In vivo comparison of esophageal varices at and above the diaphragmatic high pressure zone using high resolution endoluminal sonography

Our objective in this study was to use high resolution endoluminal sonography to compare the size of esophageal varices within 5 cm of and at the esophageal high pressure zone. We carried out the study in 36 patients with endoscopically proven esophageal varices. A 20-MHz 6.2F ultrasound catheter was passed through a 34F endoscope and used to image esophageal varices as it was slowly withdrawn through the high pressure zone (the level at which the diaphragm was imaged) and into the body of the esophagus approximately 5 cm above the high pressure zone. All images were captured on videotape and reviewed by one of the investigators. The mean, total, and percent cross-sectional surface areas occupied by varices were calculated and then compared within 5 cm and at the esophageal high pressure zone. Six of 36 (17%) patients had no varices imaged at the high pressure zone but did have varices imaged in the distal esophagus. The mean cross-sectional surface area per varix at the high pressure zone (0.036+/-0.006 cm2) was significantly less (p < or = 0.0001) than the mean cross-sectional area per varix 5 cm above the high pressure zone (0.142+/-0.018 cm2). The average total cross-sectional surface area occupied by varices at the high pressure zone (0.137+/-0.034 cm2) was significantly less (p < 0.0001) than the average cross-sectional surface area occupied by varices 5 cm above the high pressure zone (0.672+/-0.080 cm2). The mean percent esophageal wall cross-sectional surface area occupied by varices at the high pressure zone (16%) was significantly less (p < or = 0.0001) than 5 cm above the high pressure zone (49%). We conclude that the mean, total, and percent cross-sectional surface areas of esophageal varices at the high pressure zone are significantly less than those 5 cm above the high pressure zone.

Clinical course and management of inflammatory bowel disease after liver transplantation

BACKGROUND

Previous reports investigating the clinical course and management of inflammatory bowel disease (IBD) after orthotopic liver transplant (OLT) have revealed conflicting results.

METHODS

To determine the natural history and course of therapy for liver transplant patients with IBD, we reviewed the records of 35 patients, who underwent OLT between 1985 and 1996 and who had a history of either IBD (29 patients) or primary sclerosing cholangitis (PSC) without evidence of IBD before OLT (6 patients). Of 29 patients with IBD before OLT, 25 had a history of ulcerative colitis (UC) and 4 had Crohn's disease. Six patients had undergone total colectomy, one subtotal colectomy, and three partial colectomy before OLT. Mean follow-up after OLT was 37+/-6.4 months. Immunosuppression included cyclosporine, prednisone, and azathioprine in 34 patients and tacrolimus and prednisone in 1 patient.

RESULTS

After OLT, 17 patients (49%) had quiescent disease and were receiving no additional medications other than standard immunosuppression to prevent organ rejection. Five patients (14%) had mild flares controlled with initiation of 5'-aminosalicylates (5'-ASA), and two patients (6%) required an increase in oral prednisone. Only one patient with PSC, without evidence of IBD before OLT, developed IBD after OLT. No patients required intravenous steroids or surgical intervention for active IBD.

CONCLUSIONS

(1) Standard postOLT immunosuppressive agents in patients undergoing OLT with IBD were able to adequately control disease activity after OLT in the majority of patients. (2) IBD flares after OLT were generally well controlled with aminosalicylates or oral steroids. (3) Aminosalicylates were helpful in the clinical management of IBD, even when patients were taking standard doses of steroids, azathioprine, and cyclosporine.

Use of botulinum toxin in the treatment of achalasia

Achalasia is a chronic esophageal motor disorder characterized by failure of the lower esophageal sphincter (LES) to relax during swallowing, aperistalsis of the esophageal body, and, often, an elevated resting LES pressure. Pneumatic dilation and Heller cardiomyotomy have been the time-honored, accepted treatments, but each may carry significant morbidity. Recently, intrasphincteric injection of botulinum toxin has been shown to be an effective treatment for achalasia, probably by reducing the excitatory cholinergic tone of the LES. Subjective and objective improvement have been reported in many patients with few reported adverse reactions. Clinical improvement generally lasts 2-6 months with patients often requiring repeat treatment. Although studies directly comparing botulinum toxin injection with pneumatic dilation and surgical myotomy are needed, botulinum toxin injection has rapidly become another therapeutic option in the treatment of achalasia.

Adult presentation of Caroli's syndrome treated with orthotopic liver transplantation

When Caroli's disease, defined as a congenital dilation and ectasia of segmental intrahepatic bile ducts in the absence of other histological abnormalities, is associated with periportal fibrosis, it is termed Caroli's syndrome. We describe the case of a 35-yr-old woman with Caroli's syndrome without clinical manifestation of portal hypertension despite diffuse involvement of the liver who was successfully treated with orthotopic liver transplantation after recurrent nearly fatal episodes of cholangitis.

High-resolution endoluminal sonography is a sensitive modality for the identification of Barrett's metaplasia

BACKGROUND

The "gold standard" and only accurate method for diagnosing Barrett's esophagus is by esophagogastroduodenoscopy with biopsy. We evaluated the ability of high-resolution endoluminal sonography (HRES) to detect the mucosal changes in Barrett's esophagus.

METHODS

Seventeen patients with documented Barrett's and 12 normal controls underwent endoscopy with HRES examination using a 20 MHz ultrasound transducer to evaluate for mucosal changes. HRES examinations were videotaped then reviewed by an unblinded investigator to identify criteria possibly diagnostic of Barrett's and then by a blinded investigator to test the validity of these criteria. Barrett's was diagnosed by HRES if the second hypoechoic layer appeared thicker than the first hyperechoic layer of the mucosa. Normal mucosa was defined as having a pencil-thin second hypoechoic layer on HRES. Measurements of the second hypoechoic layer were made using a computer and compared in patients with Barrett's and patients with normal esophagus.

RESULTS

All 17 patients with Barrett's were correctly identified by HRES (sensitivity 100%). Ten of 12 controls were correctly identified as normal (specificity 86%). There was good correlation between HRES and pathologic diagnoses (r 0.86). The second hypoechoic layer was significantly thicker in Barrett's patients than in normal controls (p < .001).

CONCLUSIONS

HRES is a sensitive new method for identifying Barrett's esophagus. However, dysplasia could not be identified by HRES in this study.

Fatal fungemia resulting from an infected transjugular intrahepatic portosystemic shunt stent

Placement of a transjugular intrahepatic portosystemic shunt is a well accepted treatment in the management of gastroesophageal variceal bleeding. Although morbidity and mortality associated with the use of transjugular intrahepatic portosystemic shunts have dramatically decreased, complications still occur. We report a case of fatal fungemia resulting from an infected transjugular intrahepatic portosystemic shunt stent.

Thiamine status in patients receiving long-term home parenteral nutrition

OBJECTIVES

Clinical thiamine deficiency can occur in patients receiving total parenteral nutrition (TPN) without thiamine supplementation. Because considerable breakdown of thiamine may occur in the presence of bisulfite-containing amino acid solutions, subclinical thiamine deficiency may develop with the use of these solutions, even with appropriate thiamine supplementation. The current American Medical Association-Food and Drug Administration approved injectable multivitamin formula contains 3 mg of thiamine. This study was undertaken to determine whether this quantity of thiamine is sufficient to avoid clinical thiamine deficiency in long-term home TPN patients with negligible oral thiamine absorption and in the presence of bisulfite-containing amino acid solutions.

METHODS

Twenty-four long-term home TPN patients with oral caloric intakes below the norm were evaluated. Seventeen patients suffered from short bowel syndrome or radiation enteritis, and another three had draining gastrostomies that precluded all intestinal absorption. The duration of TPN therapy ranged between 1 and 164 months. Thiamine status was assessed by assaying thiamine pyrophosphate, transketolase activity, and blood thiamine levels.

RESULTS

All thiamine pyrophosphate and erythrocyte transketolase activity levels were within the normal range.

CONCLUSIONS

This study demonstrates that the currently recommended 3 mg of thiamine hydrochloride added to TPN solutions is adequate to maintain normal thiamine status. This should prevent the development of thiamine deficiency even in patients with compromised intestinal thiamine absorption, and in the presence of bisulfite-containing amino acid solutions.

Treatment of symptomatic nonachalasia esophageal motor disorders with botulinum toxin injection at the lower esophageal sphincter

The purpose of this study was to determine if botulinum toxin injection at the lower esophageal sphincter improves symptoms in patients with nonachalasia spastic esophageal motility disorders. Fifteen patients with nonachalasia spastic esophageal motility disorders (diffuse esophageal spasm, nonspecific esophageal motility disorders, and lower esophageal sphincter dysfunction) unresponsive to medical therapy underwent endoscopic injection of botulinum toxin at the level of the gastroesophageal junction. Symptoms were scored (0 = no symptoms, 1 = mild, 2 = moderate, 3 = severe and 4 = very severe) before treatment, at seven days and every 30 days after treatment. There was significant improvement in chest pain, dysphagia, and regurgitation at 7,30,60 and 90 days after treatment. At one month after treatment, 11 of 15 (73%) patients had a good or excellent response to treatment. At the last patient interview (mean follow-up of 10.6 months), five (33%) patients continued to have a good to excellent response, whereas 10 (67%) underwent subsequent treatment with repeat botulinum toxin, pneumatic dilation, or bougienage. We conclude that botulinum toxin injection at the gastroesophageal junction leads to significant symptom improvement in patients with nonachalasia esophageal motility disorders. These results suggest that botulinum toxin may be an effective treatment option in some of these patients not responsive to conventional medical therapy.

Use of high-resolution endoluminal sonography to measure the radius and wall thickness of esophageal varices

BACKGROUND

Measurement of variceal wall tension theoretically provides the most accurate method of predicting future variceal bleeding. Using high-resolution endoluminal sonography in 45 patients with known portal hypertension, we measured and correlated the two previously unmeasured variables involved in the calculation of variceal wall tension (radius and wall thickness) by the Laplace equation.

METHODS

A 20 MHz 6.2F ultrasound transducer was used to image esophageal varices during standard esophagoscopy. All images were captured on videotape and later reviewed by two blinded investigators. Outer and inner variceal wall circumferences were measured at a cross section of each varix. The radius of each varix and the variceal wall thickness were calculated. The radius of each varix was then correlated with its wall thickness. The interobserver and intraobserver variabilities were measured.

RESULTS

The mean variceal radius was .86 +/- .34 cm for the inner radius and 1.48 +/- .41 cm for the outer radius; mean variceal wall thickness was .099 +/- 0.037 cm. Intraobserver and interobserver correlation for the radius was r = .98 and r = .97, respectively. The intraobserver and interobserver correlations for the wall thickness were r = .92 and r = .91, respectively. Variceal radius did not correlate with the wall thickness of the varix.

CONCLUSIONS

High-resolution endoluminal sonography provides a method for the accurate measurement of esophageal variceal radius and wall thickness. Variceal radius does not correlate with variceal wall thickness, implying that variceal wall tension cannot be accurately estimated by measurement of variceal size alone. Combining these data with measurements of variceal pressure should allow for the direct determination of wall tension and, subsequently, identification of patients at risk for variceal bleeding.

Comparison of high-resolution endoluminal sonography to video endoscopy in the detection and evaluation of esophageal varices

High-resolution endoluminal sonography (HRES) was used to image and measure esophageal varices in control subjects and patients with portal hypertension and compared with endoscopic findings. Nine control patients and 68 patients with known cirrhosis or noncirrhotic portal hypertension underwent videotaped HRES and videotaped esophagoscopy (EGD). Two blinded investigators reviewed the videotapes to determine the presence and size of the largest esophageal varix in each patient. The largest varix by HRES was measured with the esophagus at rest at a point where the varix appeared most circular. The largest varix seen on EGD was graded on a 5-point scale. All nine of the control patients were correctly identified by both EGD and HRES as grade I (no varices). Eight of the 10 patients with no varices seen on EGD had varices identified by HRES. The interobserver correlation for HRES was r = .88 and for EGD was r = .79. The correlation between EGD and HRES was r = .50. High resolution endoluminal sonography allows quantitative measurement of variceal size, is a more sensitive and reproducible imaging modality than esophagoscopy for the detection and sizing of esophageal varices. There is poor correlation between monographic measurement and endoscopic grading of esophageal varices. Assessment of esophageal variceal presence and the measurement of variceal size by high resolution endoluminal sonography is an accurate, reproducible method of determining the size of esophageal varices.

Symptomatic improvement in achalasia after botulinum toxin injection of the lower esophageal sphincter

OBJECTIVES

The aim of this study was to assess the long term clinical outcome of patients with achalasia after treatment with botulinum toxin.

METHODS

Sixty five patients with achalasia (60 idiopathic, five secondary) were treated with injection of botulinum toxin at the gastroesophageal junction. Dysphagia, chest pain, and regurgitation were scored (0 = no symptoms, 1 = mild, 2 = moderate, 3 = severe, 4 = very severe), with the sum representing the total symptom score, at 0, 7, 30, 120, 240, and 365 days posttreatment. Responders were defined as patients with a 50% decrease in total symptom score at 1 month posttreatment.

RESULTS

The 60 patients with idiopathic achalasia had significant improvement in symptoms of dysphagia, chest pain, and regurgitation at 1 and 4 wk posttreatment. At 1 month posttreatment, 42 of 60 patients (70%) were classified as responders. Of 33 patients with at least 1 yr follow-up, 36% continued to have a good or excellent response, whereas 39% underwent a subsequent treatment with botulinum toxin, pneumatic dilation, or myotomy. When symptoms recurred after an initial response, patients responded to a second injection of botulinum toxin in six of seven cases. In four of five patients with secondary achalasia, there was no response to botulinum toxin.

CONCLUSIONS

Botulinum toxin injection at the gastroesophageal junction significantly improved symptoms in 70% of patients with idiopathic achalasia at 1 month. Recurrent symptoms responded to repeat botulinum toxin treatment in initially responsive patients. In contrast, most patients with secondary achalasia did not improve after botulinum toxin injection.

Use of high-resolution endoscopic ultrasonography to assess esophageal wall damage after pneumatic dilation and botulinum toxin injection to treat achalasia

OBJECTIVE

The purpose of this study was to utilize high-resolution endoscopic ultrasonography to assess esophageal wall damage in patients with achalasia treated by either pneumatic dilation or botulinum toxin injection and to compare their symptomatic response.

METHODS

Twenty-nine patients were treated with pneumatic dilation (11) or botulinum toxin injection (18) in a nonrandomized, controlled manner. An achalasia balloon dilator inflated at the gastroesophageal junction was used for dilation. Botulinum toxin was injected during endoscopy into the gastroesophageal junction. Endoscopic ultrasonography was performed at the level of the diaphragm before, immediately after, and 24 hours after treatment. Symptoms were assessed before and 7, 30, 60, and 90 days after therapy.

RESULTS

The mucosal-submucosal thickness increased significantly immediately after pneumatic dilation, but normalized by 24 hours. No significant change in mucosal-submucosal thickness occurred after botulinum toxin injection. No significant alteration in muscularis propria thickness was observed after either procedure. Dysphagia and regurgitation improved significantly at 7, 30, 60, and 90 days after both procedures.

CONCLUSIONS

Pneumatic dilation produced transient thickening of the mucosa-submucosa, but no thickening or breaks in the muscularis propria. This transient wall damage suggestive of edema was not seen after botulinum toxin injection. Over a 3-month period, botulinum toxin was equivalent to pneumatic dilation in relieving dysphagia and regurgitation in patients with achalasia.

Comparative killing kinetics of methicillin-resistant Staphylococcus aureus by bacitracin or mupirocin

The in vitro activities of bacitracin and mupirocin were compared for seven different strains of methicillin-resistant Staphylococcus aureus. Six of seven strains showed bacitracin minimum inhibitory concentrations (MICs) of 0.5 to 1.0 units/mL, and all seven had mupirocin MICs of 0.5 to 2 micrograms/mL. Time-kill studies revealed 2.6- to 4.5-log reduction in 24 hours with strains susceptible to bacitracin (4 units/mL) and 0 to 2.2 reduction with mupirocin (16 micrograms/mL). Bacitracin should be considered further for in vivo studies because of enhanced bacteriocidal effect and lower cost.

High-resolution endoluminal sonography in achalasia

BACKGROUND

Imaging of the lower esophageal sphincter in patients with achalasia using 7.5 and 12 MHz ultrasound transducers has shown variable results.

METHODS

A 20 MHz radial ultrasound transducer was used to quantitatively compare the lower esophageal sphincter in patients with achalasia to that of normal volunteers. The transducer, housed in a 6.2F catheter, was placed at the level of the lower esophageal sphincter in 29 patients with achalasia and 19 normal subjects. Videotaped images from the lower esophageal sphincter were digitized and the width of the circular smooth muscle, longitudinal smooth muscle, and total muscularis propria were measured. A mean width for each muscle layer was calculated.

RESULTS

All muscle layers were found to be significantly thickened at the lower esophageal sphincter in patients with achalasia when compared with those in normal subjects: circular smooth muscle (0.206 cm +/- 0.137 cm vs 0.124 cm +/- 0.038 cm, p < 0.017); longitudinal smooth muscle (0.128 cm +/- 0.077 cm vs 0.088 cm +/- 0.028 cm, p < .041); and total muscle thickness (0.317 +/- 0.180 cm vs 0.224 cm +/- 0.049 cm, p < 0.033).

CONCLUSION

Although high-resolution endoluminal sonography cannot be used to differentiate patients with achalasia from normal controls, this study quantitatively demonstrates that both the mean longitudinal and mean circular smooth muscle layers at the lower esophageal sphincter are wider in patients with achalasia than in a group of normal subjects.