Early Cholangiocarcinoma Detection With Magnetic Resonance Imaging Versus Ultrasound in Primary Sclerosing Cholangitis

BACKGROUND AND AIMS

Early detection of perihilar cholangiocarcinoma (CCA) among patients with primary sclerosing cholangitis (PSC) is important to identify more people eligible for curative therapy. While many recommend CCA screening, there are divergent opinions and limited data regarding the use of ultrasound or magnetic resonance imaging (MRI) for early CCA detection, and it is unknown whether there is benefit in testing asymptomatic individuals. Our aims were to assess the diagnostic performances and prognostic implications of ultrasound and MRI-based CCA detection.

APPROACH AND RESULTS

This is a multicenter review of 266 adults with PSC (CCA, n = 120) who underwent both an ultrasound and MRI within 3 months. Images were re-examined by radiologists who were blinded to the clinical information. Respectively, MRI had a higher area under the curve compared with ultrasound for CCA detection: 0.87 versus 0.70 for the entire cohort; 0.81 versus 0.59 for asymptomatic individuals; and 0.88 versus 0.71 for those listed for CCA transplant protocol. The absence of symptoms at CCA diagnosis was associated with improved 5-year outcomes including overall survival (82% vs. 46%, log-rank P < 0.01) and recurrence-free survival following liver transplant (89% vs. 65%, log-rank P = 0.04). Among those with asymptomatic CCA, MRI detection (compared with ultrasound) was associated with reduction in both mortality (hazard ratio, 0.10; 95% confidence interval, 0.01-0.96) and CCA progression after transplant listing (hazard ratio, 0.10; 95% confidence interval, 0.01-0.90). These benefits continued among patients who had annual monitoring and PSC for more than 1 year before CCA was diagnosed.

CONCLUSIONS

MRI is superior to ultrasound for the detection of early-stage CCA in patients with PSC. Identification of CCA before the onset of symptoms with MRI is associated with improved outcomes.

Growth kinetic models for phenol biodegradation in a batch culture of Pseudomonas putida

Biodegradation of phenol with pure culture of Pseudomonas putida was investigated. P. putida (PTCC 1694) was grown in facultative anaerobic condition at 27 degrees C and media pH value of 7. The effect of initial phenol concentration on the biodegradation rate was studied. The initial concentrations of phenol varied from 300 to 1000 mg/l. Experiments were performed for the duration of seven days while daily samples were withdrawn. The initial rate of biodegradation of phenol increased with initial concentration of 300-500 mg/l. Further increase in phenol concentration resulted in a slight decrease in the rate of biodegradation due to phenol inhibition. It was observed that by increasing the concentration of phenol, the lag phase was prolonged. Phenol is known to be an inhibitory substrate, thus Monod, Haldane and logistic kinetic models were applied to evaluate the growth kinetic parameters. The Monod model was unable to present the growth parameters over the defined concentration range. However, Haldane and logistic models perfectly fitted with the experimental data. The yield coefficients for the growth on phenol at concentrations of 300, 500, 700 and 1000 mg/l were 0.177, 0.062, 0.035 and 0.012 mg/mg, respectively.

Comparison of liver stiffness measurement with MRE and liver and spleen volumetry for prediction of disease severity and hepatic decompensation in patients with primary sclerosing cholangitis

PURPOSE

To compare liver stiffness measurement (LSM) with magnetic resonance elastography (MRE) and liver and spleen volumetry for prediction of disease severity and hepatic decompensation in primary sclerosing cholangitis (PSC).

METHODS

This retrospective study was approved by the institutional review board. Magnetic resonance imaging (MRI) and MRE studies were reviewed, and mean LSM of entire liver, right lobe and left lobe, total liver, right lobe, left lobe, caudate lobe, and spleen volumes were calculated. Qualitative evaluation of lobar atrophy or hypertrophy and presence of macronodular regeneration (MNR) was recorded. Statistical analysis was performed to evaluate correlations between LSM, volumetry measurements, and Mayo risk score. Univariate and multivariate analyses were performed to predict hepatic decompensation.

RESULTS

A total of 266 patients with PSC were included in the study. Lobar stiffness measures were higher in the presence of relative lobe atrophy. Mean LSM was higher in the presence of MNR. Significant correlations were observed between mean LSM and volumetry measurements with a fair correlation between LSM and spleen volume (r_s = 0.526, p < 0.0001). Among the measurements, the best correlation was observed between mean LSM and Mayo risk score (r_s = 0.646, p < 0.0001). In the multivariate analyses, mean LSM and Mayo risk score were significantly associated with liver decompensation (hazard ratio, 1.18; 95%CI 1.02-1.36 and hazard ratio, 1.65; 95%CI 1.08-2.53, respectively).

CONCLUSION

LSM with MRE performs significantly better than liver and spleen volumes for prediction of both disease severity and hepatic decompensation.

Effects of Clarithromycin-Containing Quadruple Therapy on Helicobacter Pylori Eradication after Nitroimidazole-Containing Quadruple Therapy Failure

BACKGROUND

Several large clinical trials and meta-analyses have shown about 20% failure to eradicate Helicobacter pylori (H.pylori), necessitating investigations for second-line treatments. The aim of this study was to evaluate the effects of clarithromycin-containing quadruple regimen after nitroimidazole-containing quadruple therapy failure.

METHODS

Thirty two patients who had failed 10-day H.pylori treatment with omeprazole, amoxicillin, bismuth subcitrate, and metronidazole (OABM) regimen and 31 patients who had failed 10-day treatment with omeprazole, amoxicillin, bismuth subcitrate, and furazolidone (OAMF) regimen entered the study. They all received omeprazole (20 mg), amoxicillin (1 gr), bismuth subcitrate (240 mg) and clarithromycin (500 mg) twice a day for 10 days. Eight weeks after treatment, H. pylori eradication was assessed by ¹⁴C-urea breath test.

RESULTS

Totally 61 patients completed the study. According to intention to treat (ITT) analysis, eradication rates by second-line OABC regimen were 84.37% (95% CI= 71.7–96.9%) in OABM group and 77.41% (95% CI= 62.71–92.11%) in OABF group (p=0.756). Per-protocol (pp) eradication rates were 87.09% (95% CI= 75.2–98.8%) and 82.75% (95% CI= 79.4–96%), respectively (p=0.638). Also the cumulative eradication rates by OABC regimen were 80.9% (95% CI= 71.2–90.6%) and 85% (95% CI= 75.9–94%) according to ITT and PP analyses, respectively. Severe side effects were reported in 3.1% of the patients.

CONCLUSION

Regarding ideal eradication rate (>80%) and very low adverse effects, it seems that clarithromycin-containing quadruple therapy can be an encouraging regimen after nitroimidazole-containing regimen failure.

Comparative Performance of Quantitative and Qualitative Magnetic Resonance Imaging Metrics in Primary Sclerosing Cholangitis

Background and Aims

Several quantitative and qualitative magnetic resonance imaging (MRI) metrics have been reported to predict outcomes among those with primary sclerosing cholangitis (PSC). We aimed to compare the reproducibility and prognostic performances of MRI biomarkers and examine if combining these measurements adds value.

Methods

We performed a retrospective review of 388 patients with PSC who underwent a magnetic resonance elastography and magnetic resonance cholangiopancreatography. Liver stiffness (LS) was determined by validated automated software, whereas spleen volume was calculated by semiautomated software, and radiologists manually determined the ANALI scores. The primary endpoint was hepatic decompensation.

Results

LS and spleen volume values had perfect and near-perfect agreement (intraclass correlation coefficient of 1.00 and 0.9996, respectively), whereas ANALI with and without gadolinium had a moderate inter-rater agreement between 3 radiologists (kappa = 0.42-0.54 and 0.46-0.57, respectively). As a continuous variable, LS alone was the best predictor of hepatic decompensation (concordance score = 0.90; 95% confidence interval, 0.87-0.93). A quantitative-only MRI model [LS (>4.70 kPa = 2 or ≤4.70 kPa = 0) + spleen volume (>600 mm3 = 1 or ≤600 mm3 = 0)] had the optimal reproducibility and performance (concordance score = 0.85; 95% confidence interval = 0.80-0.89) and enabled patient risk stratification by estimating the 5-year incidence of hepatic decompensation: 7.49%, 44.50%, 70.00%, and 91.30% (score 0-3).

Conclusion

Quantitative MRI markers of fibrosis and portal hypertension generated by automated and semiautomated software are highly reproducible. LS is the single best imaging predictor of hepatic decompensation. However, a quantitative MRI score using LS and spleen volume is well suited to risk stratify those with PSC.

Dynamic Prediction of Advanced Colorectal Neoplasia in Inflammatory Bowel Disease

BACKGROUND & AIMS

Colonoscopic surveillance is recommended in patients with colonic inflammatory bowel disease (IBD) given their increased risk of colorectal cancer (CRC). We aimed to develop and validate a dynamic prediction model for the occurrence of advanced colorectal neoplasia (aCRN, including high-grade dysplasia and CRC) in IBD.

METHODS

We pooled data from 6 existing cohort studies from Canada, The Netherlands, the United Kingdom, and the United States. Patients with IBD and an indication for CRC surveillance were included if they underwent at least 1 follow-up procedure. Exclusion criteria included prior aCRN, prior colectomy, or an unclear indication for surveillance. Predictor variables were selected based on the literature. A dynamic prediction model was developed using a landmarking approach based on Cox proportional hazard modeling. Model performance was assessed with Harrell's concordance-statistic (discrimination) and by calibration curves. Generalizability across surveillance cohorts was evaluated by internal-external cross-validation.

RESULTS

The surveillance cohorts comprised 3731 patients, enrolled and followed-up in the time period from 1973 to 2021, with a median follow-up period of 5.7 years (26,336 patient-years of follow-up evaluation); 146 individuals were diagnosed with aCRN. The model contained 8 predictors, with a cross-validation median concordance statistic of 0.74 and 0.75 for a 5- and 10-year prediction window, respectively. Calibration plots showed good calibration. Internal-external cross-validation results showed medium discrimination and reasonable to good calibration.

CONCLUSIONS

The new prediction model showed good discrimination and calibration, however, generalizability results varied. Future research should focus on formal external validation and relate predicted aCRN risks to surveillance intervals before clinical application.

Osteonecrosis in Inflammatory Bowel Disease: Clinical Features, Risk Factor Analysis, and Outcomes

BACKGROUND

Avascular necrosis (AVN) is a known adverse event associated with corticosteroid (CS) usage. Inflammatory bowel disease (IBD) is often treated with a CS for induction of remission. We sought to describe clinical features and outcomes of IBD patients with AVN.

METHODS

In this retrospective, single-center, case-control study, patients with IBD who had a diagnosis of osteonecrosis, aseptic necrosis, or AVN from 1976 to 2009 were included, and each was matched with up to 2 controls (IBD but no AVN) on age, sex, IBD subtype, geographic area of residence, and date of IBD diagnosis. We abstracted risk factor data from the medical records. Conditional logistic regression was performed accounting for minor differences in age and date of first IBD visit to assess the relationship between putative risk factors and AVN, expressed as odds ratio and 95% confidence interval.

RESULTS

Eighty-five patients were diagnosed with IBD-AVN and were matched with 163 controls. The mean age at AVN diagnosis was 47.5 years. AVN was diagnosed a median of 12.2 years after IBD diagnosis, and the control group was followed for a median of 15 years after IBD diagnosis to ensure that they did not have AVN. Ten percent of patients with AVN did not have any CS exposure. History of arthropathy or estrogen use in Crohn's disease and use of CS, osteoporosis, and history of arthropathy in ulcerative colitis were significantly associated with AVN.

CONCLUSIONS

Most patients with IBD-AVN had multifocal involvement. Most had received CS, but many patients had other risk factors including arthropathy.

Incidence and Outcomes of Home Parenteral Nutrition in Patients With Crohn Disease in Olmsted County, Minnesota

BACKGROUND

We sought to estimate the incidence of home parenteral nutrition (HPN) use in a population-based cohort of patients with Crohn disease (CD), and to assess clinical outcomes and complications associated with HPN.

METHODS

We used the Rochester Epidemiology Project (REP) to identify residents of Olmsted County, who were diagnosed with CD between 1970 and 2011, and required HPN.

RESULTS

Fourteen out of 429 patients (3.3%) with CD received HPN (86% female). Eleven patients (79%) had moderate-severe CD and 12 patients (86%) had fistulizing disease. Thirteen patients (93%) underwent surgery, primarily due to obstruction. Among CD incidence cases, the cumulative incidence of HPN from the date of CD diagnosis was 0% at 1 year, 0.5% at 5 years, 0.8% at 10 years, and 2.4% at 20 years. Indications for HPN included short bowel syndrome in 64%, malnutrition in 29%, and bowel rest in 21%. The median duration of HPN was 2.5 years. There was an average weight gain of 1.2 kg at 6 months, an average weight loss of 1.4 kg at 1 year, and a further weight loss of 2.2 kg at 2 years from the start of HPN. Patients were hospitalized a mean of 5 times after the start of HPN, mainly due to catheter-related bloodstream infections and thrombosis.

CONCLUSIONS

Less than 4% of patients with CD need HPN. Most have moderate to severe disease with short bowel syndrome or malnutrition. Possible reasons for the patients' weight loss could be noncompliance, and increased metabolic needs because of active disease.