Outcome of patients with primary sclerosing cholangitis and ulcerative colitis undergoing colectomy.

To access publisher's full text version of this article, please click on the hyperlink in Additional Links field or click on the hyperlink at the top of the page marked Files. This article is open access.To study the outcomes of primary sclerosing cholangitis (PSC) patients with ulcerative colitis (UC) undergoing colectomy.We identified 193 patients with PSC and UC undergoing colectomy at the Mayo Clinic (Rochester, MN, United States), between January 1, 1995 and December 31, 2008 using a computerized record system. Eighty-nine patients were excluded due to unclear diagnosis, liver transplantation prior to colectomy, age less than 18 years, inadequate follow-up data or known cases of cholangiocarcinoma. We retrospectively reviewed data from patient medical records. Clinical information, date of colectomy, preoperative and follow-up liver tests and pathological findings of the colon were reviewed. The Mayo risk score at baseline was calculated to obtain survival estimates for up to 4 years of follow-up. The primary endpoint was defined by the presence of all-cause mortality and/or liver decompensation requiring liver transplantation. All patients who did not have a clinical note on December 31, 2008 were considered as patients with an incomplete follow-up unless they reached a study endpoint (death or underwent liver transplantation) prior to that date. The study was approved by the Institutional Review Boards of the Mayo Clinic.Of the 2441 patients with PSC observed in this period, 104 patients (4.3%) had UC and underwent colectomy and were included. The median age was 43.2 years, and 67% were male. The leading indications for colectomy were severe colonic inflammation (49%), the presence of colonic dysplasia during routine surveillance (42%) and bowel perforation (3%). Twenty-six patients were lost to follow-up after a median duration of 3.9 years. The remaining 78 patients included 52 patients (66.7%) who were followed for a median duration of 5.5 years and 26 patients (33.3%) who developed primary endpoints including death (n = 13) or underwent liver transplantation (n = 13) with a median follow up of 2.6 years. For the secondary endpoint, the liver complications within 1 mo following the colectomy were found in 9 patients (8.6%) and included worsening liver tests (n = 3), liver failure requiring liver transplantation (n = 2), acute cholangitis (n = 3) and right hepatic vein thrombosis with hepatic infarct (n = 1). A multivariate logistic analysis demonstrated that only lower platelet count and lower albumin level preoperatively were significantly associated with more primary endpoints (OR = 0.99 and 0.05 respectively).One third of patients with PSC and UC undergoing colectomy died or underwent liver transplantation within 2.6 years. PSC patients with lower platelet counts and lower albumin levels were significantly more likely to have a poorer outcome

Emerging advances in the pharmacologic treatment of nonalcoholic steatohepatitis and related cirrhosis

The prevalence of nonalcoholic fatty liver disease (NAFLD) is rapidly growing throughout the world. Nonalcoholic steatohepatitis (NASH), the progressive form of NAFLD, is likely to become the leading cause of cirrhosis and etiology for liver transplantation in future decades in the Western World. Most patients with NAFLD have some components of metabolic syndrome, including obesity, insulin resistance, dyslipidemia, and hypertension. NAFLD encompasses a wide spectrum of liver damage, ranging from simple steatosis to NASH, that can progress to advanced liver disease, as well as hepatocellular carcinoma. Unfortunately, the options for the pharmacological treatment of NASH are still very limited. Nonetheless, several classes of therapies have shown promise, and are currently being evaluated in large phase 2b and phase 3 trials, creating some hope that selected agents will be approved in the coming years. As NASH is a heterogeneous disease, multiple mechanistic pathways are being targeted to achieve optimal treatment response. Combination therapy is also on the horizon, where 2 or more drugs targeting different mechanistic pathways are being used to boost the clinical response. In this review, we first present the current concept of the pathophysiology of NASH, focusing on the pathways currently targeted in clinical trials. We then present the pharmacological agents that are being evaluated in phase IIb of clinical development and beyond, using histological outcomes, and finally we present preliminary results from the combination trials that have already been initiated

The role of sorafenib in downsizing hepatocellular carcinoma prior to liver transplantation and in treating tumor recurrence

Sorafenib is shown to improve survival in patients with advanced hepatocellular carcinoma (HCC). However, it has as yet not been tested in the liver transplantation (LT) setting. We report a 55-year-old man with multifocal HCC (stage B) related to hepatitis B virus cirrhosis (Child-Pugh B), initially treated with transarterial chemoembolization. After five months, sorafenib was added due to lack of response. This enhanced the downsizing of the tumor and eventually led to a surgically successful LT after 4 months of combined treatment. Sorafenib was re-initiated 15 months post-transplant due to skeletal tumor recurrence and led to patient’s clinical improvement. The patient remains in good clinical condition 3 years after LT. Sorafenib was well tolerated throughout the entire period of administration with no serious or unexpected adverse events. We conclude that sorafenib can be safely used as a bridge to LT and in transplanted patients in case of HCC recurrence

Chronic kidney disease in patients with non-alcoholic fatty liver disease: What the Hepatologist should know?

The association of non-alcoholic fatty liver disease (NAFLD) with several other diseases has gained increased interest during the recent years. Among them, the association with chronic kidney disease (CKD) has emerged as an important one regarding both its prevalence and significance. The early recognition of this association is important for the prognosis of patients with NAFLD and CKD. Apart from early diagnosis, the accurate assessment of renal function is also crucial in the clinical practice of hepatologists. Several methods have been used in the literature for the evaluation of kidney function in patients with NAFLD up to now. In this respect, calculators (or formulas) for the estimation of Glomerular Filtration Rate (eGFR) and Albumin to Creatinine Ratio (ACR) are simple, practical and easily available methods for this purpose. The aim of this review is to report on the epidemiology and pathophysiology of the relationship between NAFLD and CKD and to describe the different methods of kidney function assessment in patients with NAFLD. The collection of all relevant data regarding this association will provide hepatologists with pertinent knowledge on this topic and allow them to use the most accurate methods for the assessment of kidney function in these patients in their clinical practice

Gastrointestinal stromal tumors: a pictorial review

Abstract We describe the pertinent organ-specific clinical manifestations of gastrointestinal stromal tumors (GISTs) as well as the radiological appearances that allow optimal depiction of pathology and diagnosis. Radiologic features of GISTs vary depending on tumor size and organ of origin. They most commonly have an exophytic growth pattern and manifest as dominant masses outside the organ of origin. Intramural and intraluminal masses are less common radiologic manifestations. GISTs may contain areas of hemorrhage, necrosis, or cyst formation that appear as focal areas of low attenuation on computed tomographic images. Most metastases of GISTs involve the liver and peritoneum by hematogenous spread and peritoneal seeding. CT and MRI are considered to be the imaging modality of choice for the detection, staging, surgical planning and follow-up of patients with GIST. A reduction in tumor size, extensive cystic changes, and calcification in primary and metastatic GISTs on CT and MRI indicate disease response to therapy. Radiologists and clinicians must recognize the imaging features of GISTs, detect, characterize the lesions and evaluate the tumor response during specific treatment

Total regression of hepatocellular carcinoma bone metastases, after liver transplantation, with sorafenib-everolimus

Hepatocellular carcinoma (HCC) represents the 5th commonest malignancy worldwide. Liver transplantation consist a radical and most efficient treatment for HCC. Tumor recurrence or metastases after liver transplantation is not uncommon. Hereby is presented a case of a patient transplanted for alcoholic liver disease and HCC and presented with bone metastases a few months later. Treatment with sorafenib and everolimus showed full regression of the metastases. In conclusion, the point of this report is to advertise a single case of total regression of bone lesions due to HCC recurrence, with the combination of mammalian target of rapamycin and sorafenib, along with radiation