Medically Refractory IBD in a Patient with CVID Responsive to Tofacitinib: A Case Report

Background & Aims: The risk of laparoscopic surgery in cirrhotics remains unclear. We report on outcome and safety of open versus laparoscopic surgery in cirrhotics.

Methods: Retrospective review of cirrhotics undergoing abdominal or pelvic surgery at a university hospital from 2000 to 2010. Pre-, intra-, and post-operative data was collected. Open and laparoscopic patients were compared for post-operative outcomes including minor and major complications, hepatic decompensation, and mortality. Patients were stratified by Child-Pugh and MELD scores, and emergent vs. elective surgery. 164 total patients were identified (131 open and 31 laparoscopic).

Results: There was significantly more intra-operative blood loss (p<0.001) and minor complications (p=0.043) in the open group, but no other significant differences between the laparoscopic and open patients. All 5 deaths occurred in open patients (p=0.58). Increasing Child and MELD scores were predictive of adverse events. Overall complications, hepatic decompensation (p=0.015) and death (p<0.022) were more common in open emergent compared to open elective cases. In open emergent Child C patients, 100% had major complications and hepatic decompensation and 67% died. Of emergent open MELD>20 patients, 100% had major complications, 67% had hepatic decompensation, and 33% died.

Conclusion: Open and laparoscopic surgical approaches for cirrhotics yielded similar safety and outcomes. Child and MELD scores were predictive of adverse outcomes. Emergent cases were more likely to have complications than elective cases. Further studies including larger numbers of emergent laparoscopic patients are needed to better ascertain the risk of laparoscopy in cirrhotics.

Cannabinoid hyperemesis syndrome (CHS) is a condition observed in patients with chronic use of cannabis. It is characterized with GI symptoms including nausea, vomiting, abdominal pain and diarrhea. The patients tend to be chronic abusers for several years and experience these symptoms in a cyclical manner similar to the cyclical vomiting syndrome. They find relief after taking hot baths, a pathognomonic feature of CHS. We hereby describe 3 cases who presented with clinical features consistent with CHS. Cannabis acts through CB1 and CB2 receptors located in brain and gastrointestinal tract, respectively. There are no standard therapeutic measures available for management of CHS. We propose the idea of using short-acting cannabinoids including dronabinol. Also review of literature suggests treatments with drugs including clonidine, lorazepam and risperidone. Recent endeavors on legalization of recreational cannabis use have initiated several debates and we should be mindful of CHS as one of its long-term complications.

Present study was designed to characterize the postjunctional muscarinic acetylcholine receptor mediating contraction of the chicken proventriculus by using muscarinic receptor agonists and antagonists. Muscarinic agonists caused concentration-dependent contraction. The ranking order of pEC50 values were muscarine > arecaidine propargyl ester > oxotremorine M > carbachol > methacholine > arecoline > acetylcholine > bethanechol = McN-A343 = pilocarpine. The responses to carbachol were competitively antagonized by AF-DX116 (pKb =5.9), AF-DX384 (6.84), 4-DAMP (8.79), methoctramine (5.81), pirenzepine (6.78), p-F-HHSID (7.41), atropine (8.43),tropicamide (6.91), himbacine (7.01), AQ-RA741 (6.6) and dimethindene (6.73). The correlation of pKb of the chicken proventriculus with that of the mammalian M3 receptor was the highest among five muscarinic receptors. The proventriculus membrane contained a single class of [3 H]-quinuclidinyl benzilate binding sites. pKi values of the antagonists in a binding displacement study correlated with that of the M3 subtype. Pertussis toxin(100µg/kg, i.p. for 72h) significantly decreased the contraction induced by a low concentration of carbachol. In 4-DAMP mustard and AF-DX116-pretreated muscle strips, AF-DX116 shifted the concentration-response curve for oxotremorine M to the right in the presence of 5-hydroxytryptamine and forskolin. The pKb value (6.22) was significantly higher than that obtained in the normal condition (5.78). Isoproterenol increased cyclic AMP, and carbachol significantly decreased the isoproterenol-induced increase in cyclic AMP. The results indicated that a muscarinic agonist mainly acts on the M3 receptor to cause contraction of the chicken proventriculus but the possible involvement of M2 /M4 receptors cannot be excluded as demonstrated in mammalian gastrointestinal tract.

Ulcerative Colitis (UC) is a mucosal disease that usually involves the rectum and extends proximally to involve all or part of the colon. Main causes are gut microbiota, dysregulation of the host’s immune system, genetic susceptibility and environmental factors. Active disease can be associated with a rise in acute phase reactants [C - reactive protein (CRP)], platelet count and Erythrocyte Sedimentation Rate (ESR) and a decrease in hemoglobin. Colonoscopy is used to assess disease activity and is often performed before treatment. In this case, recurrence UC was observed and it was treated with suitable therapy but some drug interactions like metronidizole additive effect with ofloxacin results in ST-T elevation and adverse effects like abdominal pain, burning pain in midsternal area radiating to epigastric region [Calcium+Vitamin-D] were seen. Those are monitored by the alternative therapy like dose management and drug alterations.

Fatty liver is defined as an accumulation of fat, mainly Triacylglycerol (TAG) in liver. Fatty liver in dairy cows is categorized into mild, moderate and severe fatty liver. Obesity in pregnant cow is crucial etiological factor for postpartal development of fatty liver. Namely, obese cows have a greater decrease in feed intake during the period around parturition and, therefore, have a more severe negative energy balance during early lactation which leads to increased lipolysis of adipose tissue. Non Esterified Fatty Acids (NEFA), released from the stored TAG in the adipose tissue, are readily taken up by liver. The excess of NEFA may be converted to TAG and deposit in liver. Liver biopsy is the only reliable method for the detection of fatty liver, especially for the determination of its severity through the estimation of total lipids and TAG. Ecography may be considered as noninvasive, on-farm method for diagnosis of fatty liver which is not commonly used do to the not widely achievable equipment. Since some metabolic and endocrine parameters are significantly correlated with fatty liver degree, they may be used as diagnostic indicators of fatty liver. The significance of those indicators for diagnosis of fatty liver is present in this review. Additionally, indicators that may be used for prediction of fatty liver are explained. Specially attention was given to glucose, NEFA, BHBA, liver enzymes, total bilirubin, total protein, albumin and urea as well as some hormones involved in lipid metabolism. Achievements of novel methods, like genomic and proteomic profiling of biological fluids of diseased cows, in providing tools for diagnosis and prognosis of this metabolic disease are presented.

The treatment of primary gastric lymphoma is evolving in post-rituximab era. The role of Helicobacter pyroli eradication alone can cure not only Mucosa-Associated Lymphoepithelial Tumor (MALT) but also some of diffuse large B cell lymphoma with or without MALT component. The efficacy of rituximab containing chemotherapy is so effective that the role of surgery is overshadowed. There are many studies, although most of them were retrospective trials, however it highlights the current mainstay of immune-chemotherapy provided an outstanding long term survival more than 80-90%.H pylori In real world there are substantial patients may receive surgery first, yet still needs post-operative adjuvant chemotherapy for some of them has a risk of relapse of lymphoma. And recent studies showed there’s no statistical difference between the two modalities. The main reason for patients proceeded to surgery as primary treatment is the gastroenterologist preference and showed no difference in terms of progression free survival and overall survival. The rituximab was introduced to lymphoma treatment since 1999, and demonstrated a superior long term survival in diffuse large B cell lymphoma for R-CHOP relatively to CHOP regimen. The highly effective treatment made PGL being easily curable disease; furthermore there are new insights of why and how the antibiotic therapy as exclusive treatment for limited disease will be a mainstay in treating this malignancy. We make a proposal how to treat the primary gastric lymphoma and MALT, and highlight the changing treatment modalities with regards to the integration of Helicobacter pyroli eradication to conventional chemotherapy as well as the complimentary role of surgery and radiotherapy.

Aims: The aim of this study was to demonstrate epidemiological, clinical and endoscopic characteristics of acute Upper Gi Bleeding (UGIB) with a focus on Peptic Ulcer Bleeding (PUB).

Methods: This study included 2198 consecutive patients that were referred to our emergency department due to acute Upper Gi Bleeding (UGIB) from January 2008 to December 2012. All patients under went urgent upper GI endoscopies within 24 hours of admission, and 842 patients diagnosed with PUB were enrolled and prospectively followed.

Results: The cumulative incidence of UIGB was 126/100000 for a 5-year period. Two out of five patients had a bleeding peptic ulcer, of which 440 (52.3%) patients had a bleeding gastric ulcer, 356 (42.3%) had a bleeding duodenal ulcer, 17 (2%) had both bleeding gastric and duodenal ulcers and 29 (3.5%) patients had bleeding ulcers on gastroenteric anastomosis. PUB was more common in men. Average patient age was 65.9 years. The majority of patients with PUB were taking agents that attenuate the cytoprotective function of the gastric and duodenal mucosa (57%).Half of the patients received a red blood cell transfusion, with a median of 2.2 units. Re-bleeding occurred in 77(9.7%) patients and 47 (5.9%) required surgical intervention. The thirty-day morality was 5.2%, and 10% of patients died from uncontrolled bleeding and concomitant diseases.

Conclusion: PUB is the main cause of UGIB, characterized by a significant re-bleeding rate and mortality.

The Hepatorenal Syndrome (HRS) is one of many potential causes of Acute Kidney Injury (AKI) in patients with decompensated liver disease.

HRS is associated with poor prognosis and represents the end-stage of a sequence of reductions in renal perfusion induced by progressively severe hepatic injury.

The pathophysiology of HRS is complex with multiple mechanisms interacting simultaneously, although HRS is primarily characterised by renal vasoconstriction.

A recently revised diagnostic criteria and management algorithm for AKI has been developed for patients with cirrhosis, allowing physicians to commence treatment promptly.

Vasopressor therapy and other general management, such as antibiotic prophylaxis, need to be initiated while patients are assessed for eligibility for transplantation. Liver transplantation remains the treatment of choice for HRS but is limited by organ shortage.

Other management options, such as transjugular intrahepatic portosystemic shunt, renal replacement therapy and molecular absorbent recirculating system, may provide short term benefit for patients not responding medical therapy while awaiting transplantation.

Clinicians need to be aware of the pathophysiology and management principles of HRS to provide quality care for patients with multi-organ failure.

Enteric fistulas are abnormal connections between the gastrointestinal tract and other organs, chest or skin. Fistulas between the gall bladder and the gastrointestinal system are common [1]. Cholecystoduodenal and cholecystocolic fistulas are seen frequently while cholecystogstric ones are rare [2]. In our case, we accidentally discovered a cholecystogastric fistula in a 71 years old male patient with gastric adenocarcinoma in orally and intravenous contrast enhanced abdomen CT.

Background and Aim: There is an increasing concern on Post-Colonoscopy Colorectal Carcinomas (PostCRCs). Little is known about how these figures have evolved over time. We aim to compare the rates of PostCRCs in two periods of time and identify the risk factors.

Methods: Retrospective control-case study in our Endoscopic Unit. We studied two separate intervals (March 2004-September 2011 and October 2011 - December 2016). In both periods of time all patients diagnosed with CRC were identified. Patients with a previous colonoscopy performed 12 to 60 months before were retrieved (cases) and compared with those who did not have a previous procedure (controls).

Results: 712 and 743 patients diagnosed with CRC in both periods of time. 24 patients in the first period (3.6%) and 28 patients in the second one (3.8%) had a previous colonoscopy performed. PostCRCs were mainly located on the right side of the colon (63% vs. 35% p=0.006 and 68% vs. 33% p< 0.001), were smaller in size (3.17 vs.4.46 p< 0.001 and 3.61 vs. 4.44 p=0.086), with a tendency to host a better TNM stage. No differences in sex and age were found.

More than half of PostCRCs (58.3% and 60.7%) were attributed to procedure causes, meanwhile10 PostCRCs in both periods were considered new developed CRCs.

Conclusions: Despite what could be expected, we did not find a decrease in the rate of PostCRCs over time. A combination of preventable as much as biological factors would account for their etiology.