Eosinophilic cholangitis: A case report of diagnostically challenging eosinophilic infiltrative biliary obstruction.

BACKGROUND: Evaluation of biliary strictures primarily focuses on ruling out malignancy in older age groups. With endoscopic tools such as endoscopic ultrasound (EUS) and cholangioscopy, improved biliary visualization has enhanced the investigation of intraluminal biliary lesions and provided modalities for targeted biopsies. Benign biliary strictures, however, may pose a diagnostic dilemma. CASE SUMMARY: A 71-year-old female with past medial history of hypothyroidism presenting for abnormal biliary imaging. Patient's previous evaluation was concerning for common bile duct dilation with cholelithiasis, for which she underwent a cholecystectomy. Due to persistent symptoms and worsening liver function tests, she presented to our institution for further workup. Subsequently, the patient underwent an EUS and multiple ERCP's with cholangioscopy; biliary biopsies revealed no evidence of malignancy but concerning for prominent eosinophilic infiltration. After further review of multiple pathology specimens and the benign clinical course, we diagnosed the patient with eosinophilic cholangitis. CONCLUSION: Eosinophilic cholangitis is a rare disease and can present as a challenging case diagnostically. This case raises the potential utility of quantitative eosinophilic infiltration reporting in creating an objective diagnostic metric for eosinophilic cholangitis.

Reply to critique of "A randomized trial of the effects of the no-carrageenan diet on ulcerative colitis disease activity".

This article is an invited response to a critique by industry of our published study about the impact of carrageenan supplement on the interval to relapse in ulcerative colitis patients on a no-carrageenan diet.

A randomized trial of the effects of the no-carrageenan diet on ulcerative colitis disease activity.

BACKGROUND: Carrageenan is a very common food additive in Western diets, but predictably causes inflammation in thousands of cell-based and animal experiments. OBJECTIVE: To assess the impact of carrageenan exposure on the interval to relapse in patients with ulcerative colitis in remission. METHODS: A randomized, double-blind, placebo-controlled, multicenter, clinical trial was conducted to assess if patients with ulcerative colitis in remission would have a longer interval to relapse if they followed a diet with no carrageenan. All participants were instructed in the no-carrageenan diet and were randomized to either placebo capsules or carrageenan-containing capsules. The carrageenan in the capsules was less than the average daily carrageenan intake from the diet. Relapse was defined as an increase of two or more points on the Simple Clinical Colitis Activity Index (SCCAI) and intensification of treatment for ulcerative colitis. Participants were followed by telephone calls every two weeks until relapse or one year of participation. The occurrence of relapse and inflammatory biomarkers were compared between the two groups. RESULTS: Twelve patients completed study questionnaires. Three patients who received carrageenan-containing capsules relapsed, and none of the patients who received placebo-containing capsules relapsed (p = 0.046, log-rank test). Laboratory tests showed increases in Interleukin-6 (p = 0.02, paired t-test, two-tailed) and fecal calprotectin (p = 0.06; paired t-test, two-tailed) between the beginning and the end of study participation in the carrageenan-exposed group, but not in the placebo-group. CONCLUSION: Carrageenan intake contributed to earlier relapse in patients with ulcerative colitis in remission. Restriction of dietary carrageenan may benefit patients with ulcerative colitis.

Performance Feedback Improves Compliance With Quality Measures.

Cirrhotic complications portend high morbidity and mortality and burden the health care system. Established quality measures in management of cirrhotics include screening for esophageal varices (EV), screening for hepatocellular carcinoma (HCC), and hepatitis A and B immunization. A retrospective review was conducted to identify adherence to cirrhosis. Baseline rates were shared with providers. Compliance with quality measures was measured prospectively at 1-month, 2-month, 1-year, and 3-year follow-up after provision of performance feedback. Baseline HCC rate was 60%, EV was 68%, and hepatitis A and B immunization was 51% and 47%, respectively. After performance feedback, HCC, EV, and hepatitis A and B vaccination rates improved to rates ranging from 92% to 100% and remained statistically significant after 3 years. Provider feedback, a simple intervention, achieved significant improvement in compliance with quality measures for management of cirrhotics. This improvement in adherence to quality measures was sustainable over a 3-year time period.