Obeticholic Acid Decreases Intestinal Content of Enterococcus in Rats With Cirrhosis and Ascites.

The intestinal microbiome and bacterial translocation (BT), the passage of microorganisms from the gut lumen to mesenteric lymph nodes and other extra-intestinal sites, are main mechanisms implicated in liver injury and further decompensation in patients with cirrhosis. We hypothesized that obeticholic acid (OCA), a semisynthetic bile acid, would change the microbiome composition and reduce bacterial translocation in experimental cirrhosis. Rats with cirrhosis induced by carbon tetrachloride inhalation (a nonseptic model) with ascites present for at least 7 days were randomized to receive a 14-day course of OCA at a dose of 5 mg/kg/day (n = 34) or placebo (n = 34). Stool was collected at days 1 (randomization), 8, and 14 (sacrifice) for analysis of intestinal microbiome using the V4 hypervariable region of the bacterial 16S gene amplified by polymerase chain reaction. Bacteriological cultures of mesenteric lymph nodes, blood, and ascites were performed at end of study. Twenty-four animals in each group reached the end of study. Compared with placebo, rats treated with OCA had decreased relative abundance of Enterococcus in both ileum content (P = 0.02) and in stool (P < 0.001). BT from pathogenic bacteria was not different between groups. At end of treatment, rats on OCA had a significantly lower aspartate aminotransferase (AST) (266 vs. 369 IU/L; P < 0.01) and higher serum albumin (0.9 vs. 0.7 g/dL; P < 0.01) than rats on placebo. Conclusion: Although OCA did not appear to reduce BT by pathogenic bacteria, the reduction in intestinal content of Enterococcus, which has been associated with hepatocyte death, in OCA-treated animals is consistent with our observed improvements in AST and in liver function, as evidenced by higher serum albumin.

Acute kidney injury, but not sepsis, is associated with higher procedure-related bleeding in patients with decompensated cirrhosis.

BACKGROUND: Bleeding after low-risk invasive procedures can be life-threatening or can lead to further complications in decompensated cirrhosis patients. In unstratified cohorts of hospitalized patients with cirrhosis, the rate of procedure-related bleeding is low despite abnormal coagulation parameters. Our objective was to identify patients with decompensated cirrhosis at a high risk of developing procedure-related bleeding in whom the value of pre-procedure transfusions could be assessed. METHODS: Hospitalized patients with cirrhosis who developed post-paracentesis hemoperitoneum confirmed by CT scan, from the period of January 2012 to August 2016, constituted the study group. They were compared to patients hospitalized in the same period in whom post-paracentesis hemoperitoneum was suspected but ruled out by CT scan. A retrospective chart review was conducted to determine specifics of the adverse event, patient characteristics and risk factors for bleeding. RESULTS: On multivariate analysis, acute kidney injury prior to paracentesis was the only independent predictor of post-paracentesis hemoperitoneum (OR 4.3, 95% CI 1.3-13.5, P = .01), independent of MELD score, large volume paracentesis, sepsis, platelets, INR and haemoglobin levels. CONCLUSIONS: Infection/sepsis is generally considered predictive of bleeding in cirrhosis. Our study suggests that acute kidney injury, and not sepsis, is the most important predictor of post-procedure bleeding in patients with decompensated cirrhosis. Although end-stage renal disease is a known cause of bleeding in non-cirrhotic patients, there are no studies establishing acute kidney injury as a risk factor for post-procedure bleeding in cirrhosis. Future studies investigating blood product transfusion needs in cirrhosis prior to procedures should carefully look at patients with acute kidney injury.

Systemic Mastocytosis Complicated by Non-Cirrhotic Portal Hypertension and Variceal Bleeding.

Systemic mastocytosis is a myeloproliferative disorder characterized by extracutaneous involvement of at least one organ. Although rare, infiltration of inflammatory mast cells within the portal vein may lead to obstruction of the sinusoids resulting in non-cirrhotic portal hypertension. We present a patient with known history of systemic mastocytosis with bone marrow involvement presenting with new-onset esophageal variceal bleeding. Although systemic mastocytosis is uncommon, the subsequent development of hepatic involvement and non-cirrhotic portal hypertension are discussed. Further highlighted is a lack of organization guidelines and the potential for gastrointestinal and hepatic screening of mastocytosis patients with known extracutaneous involvement.

Capnographic Monitoring of Moderate Sedation During Low-Risk Screening Colonoscopy Does Not Improve Safety or Patient Satisfaction: A Prospective Cohort Study.

OBJECTIVES: Appropriate monitoring during sedation has been recognized as vital to patient safety in procedures outside of the operating room. Capnography can identify hypoventilation prior to hypoxemia; however, it is not clear whether the addition of capnography improves safety or is cost effective during routine colonoscopy, a high volume, low-risk procedure. Our aim was to evaluate the value of EtCO2 monitoring during colonoscopy with moderate sedation. METHODS: We conducted a prospective study of sedation safety and patient satisfaction before and after the introduction of EtCO2 monitoring during outpatient colonoscopy with midazolam and fentanyl using the validated PROcedural Sedation Assessment Survey (PROSAS). Complications of sedation and PROSAS scores were compared among colonoscopies with and without capnography. RESULTS: A total of 966 patients participated in our study, 465 in the pre-EtCO2 group and 501 in the EtCO2 group. On multivariate analysis, patients and nurses reported higher levels of procedural discomfort after adoption of capnography (1.71 vs. 1.00, P<0.001). No serious adverse events were seen, and minor sedation-related adverse events occurred with similar frequency in both groups (8.2% pre-EtCO2 vs. 11.2% EtCO2, P=0.115). The cost of implementing EtCO2 in our unit was $40,169.95 and added $11.68 per case. CONCLUSIONS: Colonoscopy with moderate sedation is a low-risk procedure, and the addition of EtCO2 did not improve safety or patient satisfaction but did increase cost. These data suggest that routine capnography in this setting may not be cost effective and that EtCO2 might be reserved for patients at higher risk of adverse events.

Risk Factors and Outcomes of Reversal Agent Use in Moderate Sedation During Endoscopy and Colonoscopy.

BACKGROUND: Moderate sedation has been standard for noninvasive gastrointestinal procedures for decades yet there are limited data on reversal agent use and outcomes associated with need for reversal of sedation. AIM: To determine prevalence and clinical significance of reversal agent use during endoscopies and colonoscopies. METHODS: Individuals with adverse events requiring naloxone and/or flumazenil during endoscopy or colonoscopy from 2008 to 2013 were identified. A control group was obtained by random selection of patients matched by procedure type and date. Prevalence of reversal agent use and statistical comparison of patient demographics and risk factors against controls were determined. RESULTS: Prevalence of reversal agent use was 0.03% [95% confidence interval (CI), 0.02-0.04]. Events triggering reversal use were oxygen desaturation (64.4%), respiration changes (24.4%), hypotension (8.9%), and bradycardia (6.7%). Two patients required escalation of care and the majority of patients were stabilized and discharged home. Compared with the control group, the reversal group was older (61±1.8 vs. 55±1.6, P=0.01), mostly female (82% vs. 50%, P<0.01), and had lower body mass index (24±0.8 vs. 27±0.7, P=0.03) but received similar dosages of sedation. When adjusted for age, race, sex, and body mass index, the odds of reversal agent patients having a higher ASA score than controls was 4.7 (95% CI, 1.7-13.1), and the odds of having a higher Mallampati score than controls was 5.0 (95% CI, 2.1-11.7) with P<0.01. CONCLUSIONS: Prevalence of reversal agent use during moderate sedation is low and outcomes are generally good. Several clinically relevant risk factors for reversal agent use were found suggesting that certain groups may benefit from closer monitoring.

Complementary and Alternative Medicine Use Is Prevalent Among Patients with Gastrointestinal Diseases.

INTRODUCTION: Complementary and alternative medicine (CAM) use is reported to be higher among patients with irritable bowel syndrome and inflammatory bowel disease; however, demographic predictors and reasons for utilization for all GI conditions are less clear. AIM: To determine prevalence, predictors, and reasons for CAM use among all patients attending a gastrointestinal (GI) clinic in a single academic center. METHODS: Adults attending outpatient GI clinics at Beth Israel Deaconess Medical Center completed a questionnaire to assess CAM utilization as well as perceived benefits, harms, and costs of CAM therapy. Fisher's exact test was used to compare statistical differences between CAM and non-CAM users. RESULTS: Survey questionnaires were completed by 269 patients. Prevalence of CAM use was 44 % (95 % CI 38-50). Users were more likely to be female (81 vs. 56 %, p < 0.01) and dissatisfied with conventional treatment (22 vs. 8 %, p < 0.01). There was no significant difference in age, race, education, income, GI diagnosis, and duration of symptoms between the two groups. Users reported "wish to feel generally better" as main reason for utilization, and a majority of patients (62 %) experienced improved GI symptoms. Among patients who did not discuss CAM with their physicians (30 %), they cited physician failure to ask about CAM as the major reason (82 %). CONCLUSION: CAM is prevalent among patients attending a GI clinic, particularly among women and those who are dissatisfied with conventional therapies and "wish to feel better." Greater awareness and understanding of CAM among GI physicians is necessary.

Successful management of latent tuberculosis infection in an underserved community by a student-run free clinic.

The management of latent tuberculosis infection (LTBI) most commonly consists of a nine-month course of isoniazid (INH) therapy and is complicated by low adherence and completion rates. The Latent Tuberculosis Initiative at the HAVEN Free Clinic was developed to provide LTBI treatment to an underserved, high-risk, foreign-born population. We conducted a retrospective chart review to evaluate the program. Of 39 patients enrolled, 26 (67%) successfully completed nine months of INH, eight (21%) discontinued, and five (12%) were lost to follow-up. Patients had a median of nine encounters during the course of treatment and mean self-reported medication adherence was 29/30 pills/month (96%). Median days-of-treatment was 273, 95, and 63 among completion, discontinuation, and lost to follow-up groups, respectively (p < .0001). There was one death in the program, related to a complication of a diagnostic procedure in a patient who had developed INH toxicity. These results are comparable to the most successful published programs (50-65% six-month completion rates), suggesting that student-run clinics serving high-risk populations may contribute to LTBI management and TB control efforts.

Carotid intima-media thickness provides evidence that ascending aortic aneurysm protects against systemic atherosclerosis.

Previous evaluation of total aortic calcium score suggests that mutations promoting ascending aortic aneurysm development may protect against atherosclerosis. However, calcium score is a late indicator of atherosclerosis. We evaluated carotid intima-media thickness (IMT), an earlier marker, to assess the degree of atherosclerosis in ascending aortic aneurysm patients compared to controls. Images of right and left common carotid arteries were obtained in 52 patients with ascending aortic aneurysms and 29 controls using a Sonosite MicroMaxx ultrasound. IMT was measured with Sonosite Sonocalc IMT software, a computer-based algorithm with manual override. Six IMT measurements were obtained for each patient (right and left proximal, mid and distal common carotid artery) by a single observer and averaged. A multiple linear regression analysis was applied to test for an association between aneurysm and IMT. Patients with ascending aortic aneurysms had 0.131-mm lower carotid IMT values than controls (p = 0.0002), independent of risk factors for atherosclerosis (age, BMI, gender, family history, smoking, dyslipidemia, race, diabetes and hypertension). The average IMT was 0.50 ± 0.13 mm for individuals with aneurysm and 0.60 ± 0.11 mm for controls. Age increased the IMT by 0.005 mm per year (p = 0.0003). BMI, male gender, positive family history, dyslipidemia, diabetes and hypertension also increased the IMT, but did not reach statistical significance. This investigation provides further evidence that ascending aortic aneurysm provides protection against the development of atherosclerosis, supporting the hypothesis that proaneurysmal genetic mutations may also be antiatherogenic.