BACKGROUND Esophageal varices are a result of progressive liver disease and portal hypertension. Treatment can be performed with band ligation versus nonselective beta blockers depending on the size of varices, abilit...BACKGROUND Esophageal varices are a result of progressive liver disease and portal hypertension. Treatment can be performed with band ligation versus nonselective beta blockers depending on the size of varices, ability to tolerate medications and history of variceal bleeding. Band ligation is an effective intervention with rare but serious complications including bleeding, ulcers and rarely obstruction. Few cases of esophageal obstruction and necrosis caused by banding have been reported, each with varied management from conservative treatment to band removal.CASE SUMMARY An 89 years old woman with a past medical history of nonalcoholic steatohepatitis cirrhosis presented to the hospital with an inability to swallow one day after screening esophagogastroduodenoscopy where band ligation of esophageal varices was performed for primary prophylaxis. The patient was not able to tolerate her oral secretions. Initial blood work revealed a Model of End Organ Liver Disease score of 7. She was treated with sublingual nitroglycerin for esophageal spasm, a known complication after esophageal banding. When she failed to improve, esophagogastroduodenoscopy was performed and revealed the mucosa surrounding the banded varix was necrosed and blocking the lumen of the esophagus. The band was purposefully dislodged, revealing distal ulceration and stricturing. Within 72 h after band removal, she was tolerating an oral diet. Endoscopy performed 2 wk later revealed an intrinsic stenosis,measuring 8 mm in diameter by 1 cm in length, which was dilated.CONCLUSION Esophageal obstruction is a complication of variceal banding that should be considered in patients with inability to tolerate oral diet after banding.展开更多
AIM To determine the readmission rate, its reasons, predictors, and cost of 30-d readmission in patients with cirrhosis and ascites.METHODS A retrospective analysis of the nationwide readmission database(NRD) was perf...AIM To determine the readmission rate, its reasons, predictors, and cost of 30-d readmission in patients with cirrhosis and ascites.METHODS A retrospective analysis of the nationwide readmission database(NRD) was performed during the calendar year 2013. All adults cirrhotics with a diagnosis of ascites,spontaneous bacterial peritonitis, or hepatic encephalopathy were identified by ICD-9 codes. Multivariate analysis was performed to assess predictors of 30-d readmission and cost of readmission.RESULTS Of the 59597 patients included in this study, 18319(31%) were readmitted within 30 d. Majority(58%) of readmissions were for liver related reasons. Paracentesis was performed in 29832(50%) patients on index admission. Independent predictors of 30-d readmission included age < 40(OR: 1.39; CI: 1.19-1.64), age 40-64(OR: 1.19; CI: 1.09-1.30), Medicaid(OR: 1.21; CI: 1.04-1.41) and Medicare coverage(OR: 1.13; CI: 1.02-1.26), > 3 Elixhauser comorbidity(OR: 1.13; CI: 1.05-1.22), nonalcoholic cirrhosis(OR: 1.16; CI: 1.10-1.23), paracentesis on index admission(OR: 1.28; CI: 1.21-1.36) and having hepatocellular carcinoma(OR: 1.21; CI: 1.05; 1.39). Cost of index admission was similar in patients readmitted and not readmitted(P-value: 0.34); however cost of care was significantly more on 30 d readmission($30959 ± 762) as compared to index admission($12403 ± 378), P-value: < 0.001.CONCLUSION Cirrhotic patients with ascites have a 33% chance of readmission within 30-d. Younger patients, with public insurance, nonalcoholic cirrhosis and increased comorbidity who underwent paracentesis are at increased risk of readmission. Risk factors for unplanned readmission should be targeted given these patients have higher healthcare utilization.展开更多
AIM To determine if racial disparities continue to exist in the treatment of hepatocellular carcinoma(HCC).METHODS A retrospective database analysis using the Nationwide Inpatient Sample was performed including patien...AIM To determine if racial disparities continue to exist in the treatment of hepatocellular carcinoma(HCC).METHODS A retrospective database analysis using the Nationwide Inpatient Sample was performed including patients with a primary diagnosis of HCC. Univariate and multivariate analyses were utilized to determine racial disparities in liver decompensation, treatment, inpatient mortality, and metastatic disease.RESULTS A total of 62604 patients with HCC were included consisting of 32428 Caucasian, 9726 African-American, 8988 Hispanic, and 11462 patients of other races. Caucasian patients were more likely to undergo curative therapies of liver transplant(OR: 2.66, 95%CI: 1.92-3.68), resection(OR: 1.82, 95%CI: 1.48-2.23), and ablation(OR: 1.77, 95%CI: 1.36-2.30) than African-American patients. Hispanic patients were more likely to undergo transplant(OR: 2.18, 95%CI: 1.40-3.39) and ablation(OR: 1.46, 95%CI:1.05-2.03) than African-American patients. Patients of other races were more likely to receive a liver transplant(OR: 2.41, 95%CI: 1.62-3.61), resection(OR: 1.79 95%CI: 1.39-2.32), and ablation(OR: 2.03, 95%CI: 1.47-2.80) than African-American patients. There are no differences in the rates of transarterial chemoembolization between races.CONCLUSION Racial disparities in HCC treatment exist despite emphasis to support equality in healthcare. African-American patients are less likely to undergo curative treatments for HCC.展开更多
BACKGROUND Cystic fibrosis transmembrane conductance regulator(CFTR)modulators significantly improve pulmonary function in patients with cystic fibrosis(CF)but the effect on hepatobiliary outcomes remains unknown.We h...BACKGROUND Cystic fibrosis transmembrane conductance regulator(CFTR)modulators significantly improve pulmonary function in patients with cystic fibrosis(CF)but the effect on hepatobiliary outcomes remains unknown.We hypothesized that CF patients on CFTR modulators would have a decreased incidence of cirrhosis compared to patients not on CFTR modulators or on ursodiol.AIM To investigate the effect of CFTR modulators on the development of cirrhosis in patients with CF.METHODS A retrospective analysis was performed using Truven MarketScan from January 2012 through December 2017 including all patients with a diagnosis of CF.Patients were excluded if they underwent a liver transplantation or if they had other etiologies of liver disease including viral hepatitis or alcohol use.Subjects were grouped by use of CFTR modulators,ursodiol,dual therapy,or no therapy.The primary outcome was development of cirrhosis.Kaplan-Meier curves estimated the incidence of cirrhosis and log-rank tests compared incidence curves between treatment groups.RESULTS A total of 7201 patients were included,of which 955(12.6%)used a CFTR modulator,529(7.0%)used ursodiol,105(1.4%)used combination therapy,and 5612(74.3%)used neither therapy.The incidence of cirrhosis was 0.1%at 1 year and 0.7%at 4 years in untreated patients,5.9%and 10.1%in the Ursodiol group,and 1.0%and 1.0%in patients who received both therapies.No patient treated with CFTR modulators alone developed cirrhosis.Patients on CFTR modulators alone had lower cirrhosis incidence than untreated patients(P=0.05),patients on Ursodiol(P<0.001),and patients on dual therapy(P=0.003).The highest incidence of cirrhosis was found among patients treated with Ursodiol alone,compared to untreated patients(P<0.001)or patients on Ursodiol and CFTR modulators(P=0.01).CONCLUSION CFTR modulators are associated with a reduction in the incidence of cirrhosis compared to other therapies in patients with CF.展开更多
BACKGROUND Symptomatic biliary and gallbladder disorders are common in adults with cystic fibrosis(CF)and the prevalence may rise with increasing CF transmembrane conductance regulator modulator use.Cholecystectomy ma...BACKGROUND Symptomatic biliary and gallbladder disorders are common in adults with cystic fibrosis(CF)and the prevalence may rise with increasing CF transmembrane conductance regulator modulator use.Cholecystectomy may be considered,but the outcomes of cholecystectomy are not well described among modern patients with CF.AIM To determine the risk profile of inpatient cholecystectomy in patients with CF.METHODS The Nationwide Inpatient Sample was queried from 2002 until 2014 to investigate outcomes of cholecystectomy among hospitalized adults with CF compared to controls without CF.A propensity weighted sample was selected that closely matched patient demographics,patient’s individual comorbidities,and hospital characteristics.The propensity weighted sample was used to compare outcomes among patients who underwent laparoscopic cholecystectomy.Hospital outcomes of open and laparoscopic cholecystectomy were compared among adults with CF.RESULTS A total of 1239 inpatient cholecystectomies were performed in patients with CF,of which 78.6%were performed laparoscopically.Mortality was<0.81%,similar to those without CF(P=0.719).In the propensity weighted analysis of laparoscopic cholecystectomy,there was no difference in mortality,or pulmonary or surgical complications between patients with CF and controls.After adjusting for significant covariates among patients with CF,open cholecystectomy was independently associated with a 4.8 d longer length of stay(P=0.018)and an$18449 increase in hospital costs(P=0.005)compared to laparoscopic cholecystectomy.CONCLUSION Patients with CF have a very low mortality after cholecystectomy that is similar to the general population.Among patients with CF,laparoscopic approach reduces resource utilization and minimizes post-operative complications.展开更多
BACKGROUND Accurate detection of gastric antral vascular ectasia(GAVE)is critical for proper management of cirrhosis-related gastrointestinal bleeding.However,endoscopic diagnosis of GAVE can be challenging when GAVE ...BACKGROUND Accurate detection of gastric antral vascular ectasia(GAVE)is critical for proper management of cirrhosis-related gastrointestinal bleeding.However,endoscopic diagnosis of GAVE can be challenging when GAVE overlaps with severe portal hypertensive gastropathy(PHG).AIM To determine the added diagnostic value of virtual chromoendoscopy to high definition white light for real-time endoscopic diagnosis of GAVE and PHG.METHODS We developed an I-scan virtual chromoendoscopy criteria for diagnosis of GAVE and PHG.We tested our criteria in a cross-sectional cohort of cirrhotic adults with GAVE and PHG when high-definition white light endoscopy(HDWLE)diagnosis was in doubt.We then compared the accuracy of I-scan vs HDWLE alone to histology.RESULTS Twenty-three patients were included in this study(65.2%Caucasians and 60.9%males).Chronic hepatitis C was the predominant cause of cirrhosis(43.5%)and seven adults(30.4%)had confirmed GAVE on histology.I-scan had higher sensitivity(100%vs 85.7%)and specificity(75%vs 62.5%)in diagnosing GAVE compared to HDWLE.This translates into a higher,albeit not statistically significant,accuracy of I-scan in detecting GAVE compared to HDWLE alone(82%vs 70%).I-scan was less likely to lead to an accurate diagnosis of GAVE in patients on dialysis(P<0.05)and in patients with elevated creatinine(P<0.05).Iscan had similar accuracy to HDWLE in detecting PHG.CONCLUSION This pilot work supports that virtual chromoendoscopy may obviate the need for biopsies when the presence of GAVE is in doubt.Larger studies are needed to assess the impact of virtual chromoendoscopy on success of endoscopic therapy for GAVE.展开更多
文摘BACKGROUND Esophageal varices are a result of progressive liver disease and portal hypertension. Treatment can be performed with band ligation versus nonselective beta blockers depending on the size of varices, ability to tolerate medications and history of variceal bleeding. Band ligation is an effective intervention with rare but serious complications including bleeding, ulcers and rarely obstruction. Few cases of esophageal obstruction and necrosis caused by banding have been reported, each with varied management from conservative treatment to band removal.CASE SUMMARY An 89 years old woman with a past medical history of nonalcoholic steatohepatitis cirrhosis presented to the hospital with an inability to swallow one day after screening esophagogastroduodenoscopy where band ligation of esophageal varices was performed for primary prophylaxis. The patient was not able to tolerate her oral secretions. Initial blood work revealed a Model of End Organ Liver Disease score of 7. She was treated with sublingual nitroglycerin for esophageal spasm, a known complication after esophageal banding. When she failed to improve, esophagogastroduodenoscopy was performed and revealed the mucosa surrounding the banded varix was necrosed and blocking the lumen of the esophagus. The band was purposefully dislodged, revealing distal ulceration and stricturing. Within 72 h after band removal, she was tolerating an oral diet. Endoscopy performed 2 wk later revealed an intrinsic stenosis,measuring 8 mm in diameter by 1 cm in length, which was dilated.CONCLUSION Esophageal obstruction is a complication of variceal banding that should be considered in patients with inability to tolerate oral diet after banding.
文摘AIM To determine the readmission rate, its reasons, predictors, and cost of 30-d readmission in patients with cirrhosis and ascites.METHODS A retrospective analysis of the nationwide readmission database(NRD) was performed during the calendar year 2013. All adults cirrhotics with a diagnosis of ascites,spontaneous bacterial peritonitis, or hepatic encephalopathy were identified by ICD-9 codes. Multivariate analysis was performed to assess predictors of 30-d readmission and cost of readmission.RESULTS Of the 59597 patients included in this study, 18319(31%) were readmitted within 30 d. Majority(58%) of readmissions were for liver related reasons. Paracentesis was performed in 29832(50%) patients on index admission. Independent predictors of 30-d readmission included age < 40(OR: 1.39; CI: 1.19-1.64), age 40-64(OR: 1.19; CI: 1.09-1.30), Medicaid(OR: 1.21; CI: 1.04-1.41) and Medicare coverage(OR: 1.13; CI: 1.02-1.26), > 3 Elixhauser comorbidity(OR: 1.13; CI: 1.05-1.22), nonalcoholic cirrhosis(OR: 1.16; CI: 1.10-1.23), paracentesis on index admission(OR: 1.28; CI: 1.21-1.36) and having hepatocellular carcinoma(OR: 1.21; CI: 1.05; 1.39). Cost of index admission was similar in patients readmitted and not readmitted(P-value: 0.34); however cost of care was significantly more on 30 d readmission($30959 ± 762) as compared to index admission($12403 ± 378), P-value: < 0.001.CONCLUSION Cirrhotic patients with ascites have a 33% chance of readmission within 30-d. Younger patients, with public insurance, nonalcoholic cirrhosis and increased comorbidity who underwent paracentesis are at increased risk of readmission. Risk factors for unplanned readmission should be targeted given these patients have higher healthcare utilization.
文摘AIM To determine if racial disparities continue to exist in the treatment of hepatocellular carcinoma(HCC).METHODS A retrospective database analysis using the Nationwide Inpatient Sample was performed including patients with a primary diagnosis of HCC. Univariate and multivariate analyses were utilized to determine racial disparities in liver decompensation, treatment, inpatient mortality, and metastatic disease.RESULTS A total of 62604 patients with HCC were included consisting of 32428 Caucasian, 9726 African-American, 8988 Hispanic, and 11462 patients of other races. Caucasian patients were more likely to undergo curative therapies of liver transplant(OR: 2.66, 95%CI: 1.92-3.68), resection(OR: 1.82, 95%CI: 1.48-2.23), and ablation(OR: 1.77, 95%CI: 1.36-2.30) than African-American patients. Hispanic patients were more likely to undergo transplant(OR: 2.18, 95%CI: 1.40-3.39) and ablation(OR: 1.46, 95%CI:1.05-2.03) than African-American patients. Patients of other races were more likely to receive a liver transplant(OR: 2.41, 95%CI: 1.62-3.61), resection(OR: 1.79 95%CI: 1.39-2.32), and ablation(OR: 2.03, 95%CI: 1.47-2.80) than African-American patients. There are no differences in the rates of transarterial chemoembolization between races.CONCLUSION Racial disparities in HCC treatment exist despite emphasis to support equality in healthcare. African-American patients are less likely to undergo curative treatments for HCC.
文摘BACKGROUND Cystic fibrosis transmembrane conductance regulator(CFTR)modulators significantly improve pulmonary function in patients with cystic fibrosis(CF)but the effect on hepatobiliary outcomes remains unknown.We hypothesized that CF patients on CFTR modulators would have a decreased incidence of cirrhosis compared to patients not on CFTR modulators or on ursodiol.AIM To investigate the effect of CFTR modulators on the development of cirrhosis in patients with CF.METHODS A retrospective analysis was performed using Truven MarketScan from January 2012 through December 2017 including all patients with a diagnosis of CF.Patients were excluded if they underwent a liver transplantation or if they had other etiologies of liver disease including viral hepatitis or alcohol use.Subjects were grouped by use of CFTR modulators,ursodiol,dual therapy,or no therapy.The primary outcome was development of cirrhosis.Kaplan-Meier curves estimated the incidence of cirrhosis and log-rank tests compared incidence curves between treatment groups.RESULTS A total of 7201 patients were included,of which 955(12.6%)used a CFTR modulator,529(7.0%)used ursodiol,105(1.4%)used combination therapy,and 5612(74.3%)used neither therapy.The incidence of cirrhosis was 0.1%at 1 year and 0.7%at 4 years in untreated patients,5.9%and 10.1%in the Ursodiol group,and 1.0%and 1.0%in patients who received both therapies.No patient treated with CFTR modulators alone developed cirrhosis.Patients on CFTR modulators alone had lower cirrhosis incidence than untreated patients(P=0.05),patients on Ursodiol(P<0.001),and patients on dual therapy(P=0.003).The highest incidence of cirrhosis was found among patients treated with Ursodiol alone,compared to untreated patients(P<0.001)or patients on Ursodiol and CFTR modulators(P=0.01).CONCLUSION CFTR modulators are associated with a reduction in the incidence of cirrhosis compared to other therapies in patients with CF.
文摘BACKGROUND Symptomatic biliary and gallbladder disorders are common in adults with cystic fibrosis(CF)and the prevalence may rise with increasing CF transmembrane conductance regulator modulator use.Cholecystectomy may be considered,but the outcomes of cholecystectomy are not well described among modern patients with CF.AIM To determine the risk profile of inpatient cholecystectomy in patients with CF.METHODS The Nationwide Inpatient Sample was queried from 2002 until 2014 to investigate outcomes of cholecystectomy among hospitalized adults with CF compared to controls without CF.A propensity weighted sample was selected that closely matched patient demographics,patient’s individual comorbidities,and hospital characteristics.The propensity weighted sample was used to compare outcomes among patients who underwent laparoscopic cholecystectomy.Hospital outcomes of open and laparoscopic cholecystectomy were compared among adults with CF.RESULTS A total of 1239 inpatient cholecystectomies were performed in patients with CF,of which 78.6%were performed laparoscopically.Mortality was<0.81%,similar to those without CF(P=0.719).In the propensity weighted analysis of laparoscopic cholecystectomy,there was no difference in mortality,or pulmonary or surgical complications between patients with CF and controls.After adjusting for significant covariates among patients with CF,open cholecystectomy was independently associated with a 4.8 d longer length of stay(P=0.018)and an$18449 increase in hospital costs(P=0.005)compared to laparoscopic cholecystectomy.CONCLUSION Patients with CF have a very low mortality after cholecystectomy that is similar to the general population.Among patients with CF,laparoscopic approach reduces resource utilization and minimizes post-operative complications.
文摘BACKGROUND Accurate detection of gastric antral vascular ectasia(GAVE)is critical for proper management of cirrhosis-related gastrointestinal bleeding.However,endoscopic diagnosis of GAVE can be challenging when GAVE overlaps with severe portal hypertensive gastropathy(PHG).AIM To determine the added diagnostic value of virtual chromoendoscopy to high definition white light for real-time endoscopic diagnosis of GAVE and PHG.METHODS We developed an I-scan virtual chromoendoscopy criteria for diagnosis of GAVE and PHG.We tested our criteria in a cross-sectional cohort of cirrhotic adults with GAVE and PHG when high-definition white light endoscopy(HDWLE)diagnosis was in doubt.We then compared the accuracy of I-scan vs HDWLE alone to histology.RESULTS Twenty-three patients were included in this study(65.2%Caucasians and 60.9%males).Chronic hepatitis C was the predominant cause of cirrhosis(43.5%)and seven adults(30.4%)had confirmed GAVE on histology.I-scan had higher sensitivity(100%vs 85.7%)and specificity(75%vs 62.5%)in diagnosing GAVE compared to HDWLE.This translates into a higher,albeit not statistically significant,accuracy of I-scan in detecting GAVE compared to HDWLE alone(82%vs 70%).I-scan was less likely to lead to an accurate diagnosis of GAVE in patients on dialysis(P<0.05)and in patients with elevated creatinine(P<0.05).Iscan had similar accuracy to HDWLE in detecting PHG.CONCLUSION This pilot work supports that virtual chromoendoscopy may obviate the need for biopsies when the presence of GAVE is in doubt.Larger studies are needed to assess the impact of virtual chromoendoscopy on success of endoscopic therapy for GAVE.
