Cholangiocarcinoma (CCA) is a dreaded complication of primary sclerosing cholangitis (PSC); however, marked variability in the incidence of CCA in PSC is reported. Furthermore, limited information ...exists on risk factors for the development of CCA in PSC. The aim of this study was to determine the incidence of CCA in patients with PSC and to evaluate baseline risk factors for the later development of CCA. From a previous study of the natural history of PSC, we identified 161 patients with PSC who did not have CCA at study entry. Patients were followed until a diagnosis of CCA was established, liver transplantation was performed, or death occurred. Patients were followed for a median of 11.5 yr (interquartile range 4.0-16.1 yr). Fifty-nine patients (36.6%) died, 50 patients (31.1%) underwent liver transplantation, and 11 patients (6.8%) developed CCA. The rate of CCA developing was approximately 0.6% per year. Compared to the incidence rates of CCA in the general population, the relative risk of CCA in PSC was significantly increased (RR = 1,560; 95%CI = 780, 2,793; p < 0.0001). On univariate analysis, a history of variceal bleeding (p < 0.001), proctocolectomy (p= 0.01), and lack of symptoms (p= 0.02) were significant risk factors for CCA with the Mayo Risk Score being marginally significant (p= 0.051). Multivariate analysis determined only variceal bleeding to be a significant risk factor for CCA (RR 24.2; 95%CI: 3.3-67.1). No association was found between the duration of PSC and the incidence of CCA. In conclusion, approximately 7% of PSC patients later developed CCA over a mean follow-up of 11.5 yr, which is dramatically higher than the rates in the general population. Variceal bleeding is a major risk factor for the later development of CCA.
Objectives
Crohn's disease of the esophagus is rare. We sought to determine the clinical features and outcome of patients with esophageal Crohn's disease seen at our institution.
Methods
Patients ...with esophageal Crohn's disease evaluated at Mayo Clinic Rochester between 1976 and 1998 were identified.
Results
Twenty patients (0.2%) with esophageal involvement were identified. Median age at diagnosis was 31 years (range, 7–77 years). Eleven patients (55%) were female. Extraesophageal Crohn's disease preceded or was found at the same time as the diagnosis of esophageal Crohn's in all cases. Sixteen patients (80%) had symptoms referable to the esophagus. Endoscopic findings included ulcers in 17 (85%), erythema or erosions in 8 (40%), and strictures in 4 patients (20%). One patient had a fistula. The most common histological findings were active chronic inflammation (75%) and ulcer (30%). No granulomata were identified. Approximately one‐half of our patients improved with first‐line therapy. Eleven patients (55%) received immune modifier therapy. Six showed significant improvement on azathioprine, 6‐mercaptopurine, or cyclosporine. Esophageal dilatation was required in six patients, and three patients required surgery.
Conclusion
Esophageal Crohn's disease may be underdiagnosed. Patients with Crohn's disease complaining of esophageal symptoms should undergo upper endoscopy with biopsies, and the diagnosis of esophageal Crohn's disease should be entertained if aphthous or deep ulcers or strictures are present. Immune modifier therapy should be considered for steroid‐dependent and steroid‐resistant cases.
Gastrointestinal basidiobolomycosis (GIB) is an unusual fungal infection that is rarely reported in the medical literature. From April 1994 through May 1999, 7 cases of GIB occurred in Arizona, 4 ...from December 1998 through May 1999. We reviewed the clinical characteristics of the patients and conducted a case-control study to generate hypotheses about potential risk factors. All patients had histopathologic signs characteristic of basidiobolomycosis. Five patients were male (median age, 52 years; range, 37-59 years) and had a history of diabetes mellitus (in 3 patients), peptic ulcer disease (in 2), or pica (in 1). All patients underwent partial or complete surgical resection of the infected portions of their gastrointestinal tracts, and all received itraconazole postoperatively for a median of 10 months (range, 3-19 months). Potential risk factors included prior ranitidine use and longer residence in Arizona. GIB is a newly emerging infection that causes substantial morbidity and diagnostic confusion. Further studies are needed to better define its risk factors and treatment.
Transmission of hepatitis B infection has been reported in liver transplant recipients whose donor livers were negative for hepatitis B surface antigen (HBsAg) and positive for antibody to hepatitis ...B core antigen (anti-HBc). These infections usually have a mild clinical course and no adverse effects on survival. However, the outcome of liver transplant recipients with serologic evidence of past infection to hepatitis B virus (HBV) is unknown. The prevalence of HBV DNA positivity by polymerase chain reaction (PCR) pretransplantation in HBsAg-negative, anti-HBc-positive people is reported to be 0% to 32%. To assess the prevalence of HBV DNA in pretransplantation serum and liver tissue and to determine the clinical outcome of HBsAg-negative, anti-HBc-positive recipients, we retrospectively reviewed the first 693 orthotopic liver transplantations performed at Mayo Clinic between March 19, 1985, and May 25, 1996. Pretransplantation specimens of frozen serum and liver tissue were available for HBV DNA by PCR for 35 of 56 HBsAg-negative, anti-HBc-positive recipients. Twenty-two recipients had positive serologic findings for anti-HBc alone, and 13 were positive for anti-HBc and antibody to HBsAg (anti-HBs). Pretransplantation prevalence of HBV DNA in HBsAg-negative, anti-HBc-positive recipients was 6% (serum) to 29% (liver). Of those recipients whose liver was HBV DNA-positive pretransplantation, 40% also had evidence of HBV DNA in posttransplantation liver biopsy specimens, and this finding was more common in patients co-infected with hepatitis C. None of the recipients became antigenemic (HBsAg-positive) or developed clinical hepatitis B posttransplantation. Thus, prophylactic intervention (eg, antiviral or antinucleoside analog therapy is not warranted after liver transplantation in HBsAg-negative, anti-HBc-positive recipients. In our experience, infected donor livers are the most common source of de novo posttransplantation hepatitis B infection in transplant recipients.
Transmission of hepatitis B infection has been reported in liver transplant recipients whose donor livers were negative for hepatitis B surface antigen (HBsAg) and positive for antibody to hepatitis ...B core antigen (anti‐HBc). These infections usually have a mild clinical course and no adverse effects on survival. However, the outcome of liver transplant recipients with serologic evidence of past infection to hepatitis B virus (HBV) is unknown. The prevalence of HBV DNA positivity by polymerase chain reaction (PCR) pretransplantation in HBsAg‐negative, anti‐HBc‐positive people is reported to be 0% to 32%. To assess the prevalence of HBV DNA in pretransplantation serum and liver tissue and to determine the clinical outcome of HBsAg‐negative, anti‐HBc‐positive recipients, we retrospectively reviewed the first 693 orthotopic liver transplantations performed at Mayo Clinic between March 19, 1985, and May 25, 1996. Pretransplantation specimens of frozen serum and liver tissue were available for HBV DNA by PCR for 35 of 56 HBsAg‐negative, anti‐HBc‐positive recipients. Twenty‐two recipients had positive serologic findings for anti‐HBc alone, and 13 were positive for anti‐HBc and antibody to HBsAg (anti‐HBs). Pretransplantation prevalence of HBV DNA in HBsAg‐negative, anti‐HBc‐positive recipients was 6% (serum) to 29% (liver). Of those recipients whose liver was HBV DNA‐positive pretransplantation, 40% also had evidence of HBV DNA in posttransplantation liver biopsy specimens, and this finding was more common in patients co‐infected with hepatitis C. None of the recipients became antigenemic (HBsAg‐positive) or developed clinical hepatitis B posttransplantation. Thus, prophylactic intervention (eg, antiviral or antinucleoside analog therapy) is not warranted after liver transplantation in HBsAg‐negative, anti‐HBc‐positive recipients. In our experience, infected donor livers are the most common source of de novo posttransplantation hepatitis B infection in transplant recipients.
To assess the incidence, clinical features, and management of endoscopic colon perforations in a large number of patients at a major medical teaching center.
A retrospective review of medical records ...of all patients with colon perforations from endoscopy over a 10-yr period.
A total of 10,486 colonoscopies were performed over a 10-yr period. There were 20 (0.19%) perforations and two (0.019%) deaths related to colonoscopy and two perforations with no deaths in 49,501 sigmoidoscopies (0.004%). The majority of perforations (65%) occurred in the sigmoid colon. The mean age of the patients was 72 yr (range, 48-87 yr). Multivariate analysis using gender and age showed that female gender was an independent predictor of a higher risk of perforation (p < 0.05). Electrocautery injury (36%) and mechanical injury (32%) from the tip and shaft of the endoscope were the major causes for perforation. Most patients (91%) presented within 48 h of endoscopy. Nine patients (47%) required a surgical resection with primary anastomosis; seven (37%) required a simple closure. The average hospital length of stay was 7.7 +/- 2.8 days. Although trainee endoscopists were involved in only 20% of the colonoscopies performed, eight (40%) perforations occurred while the training fellow was involved in the case. However, this increased risk of perforation with a training fellow was not statistically significant (p = 0.625).
Colonoscopy can result in significant morbidity and carries a small risk of death. Sigmoidoscopy has lower risk. The following situations may represent increased risk to colonoscopy patients: unusual difficulty in traversing the sigmoid colon; difficult examinations in female patients, and difficult examinations performed by trainee physicians.
Background: The optimum choice of dilator (rigid vs. balloon) for benign esophageal strictures has not been well studied. The aim of this study was to compare the immediate relief of dysphagia and ...the incidence of repeat dilatation within the first year with the use of either a rigid (Savary) dilator or balloon dilator for benign lower esophageal strictures.
Methods: Patients with dysphagia found to have benign esophageal strictures during endoscopy were randomized to undergo dilation with a rigid (Savary) or a balloon dilator (Microvasive or Bard). The 1-year incidence of repeat dilatation was estimated by the Kaplan-Meier method.
Results: A total of 251 subjects were stratified at entry according to the type of stricture (peptic vs. Schatzki ring) and severity of stricture (mild vs. moderate/severe) and then randomized to either a Savary (n = 88), Microvasive (n = 81), or Bard (n = 82) dilator. There were no significant differences between the rigid dilator or the two balloons with regard to immediate relief of dysphagia or the need for repeat dilatation at one year. Patients with moderate/severe strictures required repeat dilatation at one year twice as often as those with mild strictures. There were no significant complications reported in these patients.
Conclusions: Both rigid and balloon dilators are equally effective and safe in the treatment of benign lower esophageal strictures caused by acid reflux and Schatzki rings. (Gastrointest Endosc 1999;50:13-7.)
Protein-calorie malnutrition, best measured by body cell mass (BCM) depletion, has been associated with adverse outcomes in patients with end-stage liver disease. We prospectively measured BCM and ...multiple standard nutritional parameters in patients with end-stage liver disease to determine which, if any, of the traditionally measured nutritional parameters correlate with BCM. A detailed nutritional assessment, including BCM analysis, subjective global assessment, anthropometry, handgrip dynamometry, laboratory tests, and body composition measured by dual-energy X-ray absorptiometry was performed in 69 sequential patients awaiting liver transplantation. The frequency of abnormalities of specific parameters of nutritional status varied between 19% and 99%. Most of the commonly measured parameters of nutritional status correlated poorly with BCM. Patients with depleted BCM (lowest quartile for sex) had midarm circumference (P < .01), arm-muscle circumference (P < .001), handgrip strength (P < .001), blood urea nitrogen (P < .01), and creatinine (P < .01) values less than those for patients with greater BCM (highest 3 quartiles for sex). In multivariate analysis, arm-muscle circumference and handgrip strength were the best predictors of BCM. The combined criteria of handgrip strength less than 30 kg and arm-muscle circumference less than 23 cm have a sensitivity of 94% and a negative predictive value of 97% in identifying patients with depleted BCM. Although abnormalities of nutritional parameters are highly prevalent among patients with end-stage liver disease, most parameters of nutritional status do not correlate with BCM. In patients with end-stage liver disease, arm-muscle circumference and handgrip strength are the most sensitive markers of BCM depletion. (Liver Transpl 2000;6:575-581.)
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