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Contents Journal of Gastrointestinal and Liver Diseases

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					Volume 20 Number 1 March 2011

                                                                         Contents
Images of the issue
Expulsion of vascular atheroma through aorto-esophageal fistula
       S. Bargiggia, F. Parente, G. Rossi, G. Lorenzi..............................................................................................7
Hanging liver tumor
      K. Pavithran, S. Sudhindran..........................................................................................................................8

Editorial
Gallstones and liver disease: an overview
       D. Conte, M. Fraquelli, M. Giunta, C. B. Conti............................................................................................9

Original Papers
Histological features of gastric cardia in adults: an autopsy study
       Z.M. Stojsic, R.M. Stevanovic, M.M. Stojanovic, A.D. Stanojevic, D.T. Bacetic.........................................13
Silencing of the MMP-3 gene by siRNA transfection in gastric cancer ags cells
        S. Gencer, A. Cebeci, M.B. Irmak-Yazicioglu .............................................................................................19
Are patients with coeliac disease seeking alternative therapies to a gluten-free diet?
       I. Aziz, K.E. Evans, V. Papageorgiou, D.S. Sanders....................................................................................27
Capsule endoscopy in patients with cardiac pacemakers and implantable cardioverter-defibrillators –
a retrospective multicenter investigation
        D. Bandorski, E. Lotterer, D. Hartmann, R. Jakobs, M. Brück, R. Hoeltgen, M. Wieczorek,
        A. Brock, T. de Rossi, M. Keuchel................................................................................................................33
The safety of endoscopic ultrasonography-guided drainage of pancreatic fluid collections without
fluoroscopic control: a single tertiary center experience
        A. Seicean, R. Stan-Iuga, R. Badea, M. Tantau, T. Mocan, R. Seicean, C. Iancu, O. Pascu.......................39
Initial high dose of lamivudine delays the appearance of viral resistance in chronic hepatitis B patients
         F. Torre, E.G. Giannini, M. Basso, V. Fazio, V. Savarino, A. Picciotto.....................................................47
How severe is chronic hepatitis with HCV genotype 1b? A study of 1,220 cases on the waiting list
for antiviral therapy in Romania
        O. Pascu, L. Gheorghe, M. Voiculescu, E. Ceausu, B. Mateescu................................................................51
A new and simple algorithm for the noninvasive assessment of esophageal varices in cirrhotic
patients using serum fibrosis markers and transient elastography
        H. Stefanescu, M. Grigorescu, M. Lupsor, A. Maniu, D. Crisan, B. Procopet, D. Feier,
        R. Badea.......................................................................................................................................................57
Characteristics and treatment strategy of hepatic angiomyolipoma: a series of 94 patients collected
from four institutions
       Z.-G. Chang, J.-M. Zhang, J.-Q. Ying, Y.-P. Ge..........................................................................................65

Review
The infectious complications of interventional radiology based procedures in gastroenterology
and hepatology
       D.F. Halpenny, W.C. Torreggiani ..............................................................................................................71
Case Reports
Hepatotoxicity by bosentan in a patient with portopulmonary hypertension: a case-report and
review of the literature
       C. Eriksson, A. Gustavsson, T. Kronvall, C. Tysk........................................................................................77
Non-secretory multiple myeloma relapsing as extramedullary liver plasmacytomas
       R. Lopes da Silva, A. Monteiro, J. Veiga.....................................................................................................81
Successful endoscopic treatment of an unusual cause of lower gastrointestinal bleeding using the
OVESCO system
       M.H. Strain, D.M. Chisevescu, S. Potopea..................................................................................................85
Endoscopic submucosal dissection of superficial digestive tumors after evaluation through
magnification chromoendoscopy and endoscopic ultrasound with miniprobes. Report of three cases
       M. Tantau, A.Tantau, O. Mosteanu, T. Pop, G. Mester, O. Pascu..............................................................89
Herpes simplex virus hepatitis - it’s high time we consider empiric treatment
       U. Navaneethan, E. Lancaster, P.G.K. Venkatesh, J. Wang, G.W. Neff......................................................93

Letters
Laparoscopic greater curvature plication - a new and safe bariatric procedure
      C. Puia, V. Puia...........................................................................................................................................97
Multiple complicated gallbladder disease
       V. Zimmer, J. Raedle, R. Grobholz, A. Massmann, M.K. Schilling, F. Lammert........................................98
Fluindione: a francophone oral anticoagulant drug utilized in liver transplant recipients for
Budd-Chiari syndrome
       F. Panaro, H. Bouyabrine, M. Hamoui, P. Wolf, F. Navarro.....................................................................99
Clinical penetrance of C282Y homozygous HFE hemochromatosis in a western Romanian population
        A.M. Neghina, A. Anghel, I. Sporea, A. Popescu.......................................................................................100
Face to face with Crohn’s disease: two cases when infliximab works as the best cosmetics
        K. Farkas, P. Miheller, Z. Szepes, D. Lippai, T. Wittmann, T. Molnar.....................................................101
Perspective on routine rectal retroflexion during screening colonoscopy; a survey of American
gastroenterologists
       W.E. Mattar, A.S. Kumar, K.W. Olden......................................................................................................102

Calendar of Events.............................................................................................................................................104
Guidance for Authors........................................................................................................................................106

Correction..............................................................................................................................................................110
Histological Features of Gastric Cardia in Adults: an Autopsy
Study
Zorica M. Stojsic1, Radmila M. Stevanovic1, Martina M. Stojanovic1, Aleksandar D. Stanojevic2, Dragoljub T. Bacetic1

1) Institute of Pathology, School of Medicine; 2) Institute of Forensic Medicine, School of Medicine, University of Belgrade,
Belgrade, Serbia


   Abstract
    Background & Aims. The existence, histology and origin of gastric cardiac mucosa are controversial. The aim of the
present study was to determine the existence, histological characteristics and length of cardiac mucosa and to correlate these
features with the patients’ age and the presence of inflammation in the gastric cardia and/or esophagus. Methods. The cardiac
mucosa within the whole esophagogastric junction was histologically analyzed in 38 consecutive autopsy specimens and
measured in 24 cases. Results. The cardiac mucosa was identified in all specimens from all cases, with a mean length of 6.7
mm, range 0.927-19.5 mm. In the majority of cases, the length of cardiac mucosa was less than 10 mm (87.5%) and greater
than 5 mm (71%). Cardiac mucosa was composed of a combination of pure mucous glands and mucous glands with parietal
cells in 74% of cases, and only of mucous glands with parietal cells in 26% of cases. Carditis was recorded in 23.7% cases
and reflux esophagitis in 15.8%. The length of cardiac mucosa was not significantly different between cases with and without
carditis (p>0.05), between those with and without esophagitis (p>0.05), and between age groups older and younger than 60
years (p>0.05). Conclusion. In the adult population, a short histological segment of gastric cardia was consistently present as
a normal histological structure. The type, length and circumferential presence of cardiac mucosa were not significantly
associated with carditis, esophagitis or age.
    Key words
    Cardiac mucosa - gastric cardia - esophagogastric junction - histology.
Silencing of the MMP-3 Gene by siRNA Transfection in Gastric
Cancer AGS Cells
Salih Gencer1 , Anıl Cebeci2, Meliha Burcu Irmak-Yazicioglu 1*,2

1) Department of Genetics and Bioengineering, Faculty of Engineering, and Department of Biology, Faculty of Arts and
Sciences, Fatih University, Buyukcekmece; 2) Department of Molecular Biology and Genetics, Faculty of Arts and Sciences,
Halic University, Kaptanpasa, Okmeydani, Istanbul, Turkey. 1*) Previous Address: Department of Biology, Faculty of Arts
and Science, Fatih University, Buyukcekmece, Istanbul, Turkey


   Abstract
    Background. The gastric epithelium is continuously exposed to toxic reactive oxygen species and matrix
metalloproteinases (MMPs) are the enzymes known for their roles in the invasion of tumor cells. Here, we report the
suppression of matrix metalloproteinase 3 (MMP-3) in gastric cancer cell line AGS by small interfering RNA (siRNA)
transfection and its potential role in gastric cancers. Methods. Oxidative stress in the cell lines was assessed following H2O2
exposure using an oxidative stress marker, 2,7-dichlorofluorescein diacetate (DCFDA). Transfection of cells with small
interfering RNA specific to MMP-3, Transwell invasion assay, quantitative reverse transcriptase polymerase chain reaction
analysis, and over-expression of MMP-3 were used to determine the potential role of MMP-3 gene in gastric cancers.
Results. The silencing of the MMP-3 gene resulted in a decrease of invading AGS while the over-expression of it caused an
increase in the invading cells compared to the untreated control cells. Moreover, it also caused a 4.1 fold increase in matrix
metalloproteinase 10 (MMP-10) and a 7.4 fold decrease in matrix metalloproteinase 15 (MMP-15) mRNA expression levels.
Conclusions. Our results show that the silencing of the MMP-3 gene decreases the number of invading AGS cells and
additionally, affects the expressions of MMP-10 and MMP-15, suggesting that targeting the MMP-3 gene in gastric cancers
might be a therapeutic approach due to its effects on the invasion of AGS cells and the expression of the MMP-15 gene.
    Key words
    Gastric cancer - AGS - invasion - MMP-3 - siRNA.
Are Patients with Coeliac Disease Seeking Alternative Therapies
to a Gluten-free Diet?
Imran Aziz, Kate E Evans, Vasiliki Papageorgiou, David S Sanders
Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK




   Abstract
    Background & Aims: The cornerstone of treatment for coeliac disease is a gluten-free diet (GFD). However, adherence
to a GFD is variable. Recently investigators have been reporting their preliminary findings using novel therapies. In addition,
there is a growing interest in the use of complementary or alternative medicine (CAM) in gastrointestinal illnesses. These
observations suggest that patients with coeliac disease may be dissatisfied with a GFD and possibly are seeking/using
alternative therapies for their disease. Our aim was to assess the satisfaction levels of adults with coeliac disease towards a
GFD, their use of oral CAM and views regarding novel therapies. Methods: 310 patients with coeliac disease completed a
questionnaire survey while attending their out-patient appointment. The control group comprised 477 individuals. Results:
Over 40% of patients with coeliac disease were dissatisfied with a GFD. The frequency of CAM use in patients with coeliac
disease was 21.6% (67/310) vs 27% in the control group (129/477), p=0.09. All patients expressed an interest in novel
therapies, with a vaccine being the first choice in 42% of patients, 35% and 23% for anti- zonulin and peptidases,
respectively. Universally, patients placed genetically modified wheat as the lowest preference. Conclusions: A large
proportion of patients with coeliac disease are dissatisfied with a GFD. Coeliac patients are not taking CAM any more than
controls, suggesting they do not view CAM as an alternative to a GFD. However, all the patients in this survey were keen to
consider novel therapies, with a vaccine being the most preferred option.
    Key words
    Complementary medicine - alternative medicine - coeliac disease - gluten free diet.
Capsule Endoscopy in Patients with Cardiac Pacemakers and
Implantable Cardioverter-Defibrillators – a Retrospective
Multicenter Investigation
Dirk Bandorski1, Erich Lotterer2, Dirk Hartmann3, Ralf Jakobs3, Martin Brück4, Reinhard Hoeltgen5, Marcus Wieczorek5,
Alexander Brock2, Thomas de Rossi6, Martin Keuchel7
1) Universität Gießen; 2) Klinikum Wetzlar, Medizinische Klinik 2; 3) Klinikum Ludwigshafen, Medizinische Klinik C; 4)
Klinikum Wetzlar, Medizinische Klinik 1; 5) Herzzentrum Duisburg, Medizinische Klinik III; 6) Universitätsklinikum
Erlangen, Medizinische Klinik 1; 7) Bethesda Krankenhaus, Bergedorf, Germany


   Abstract
    Background & Aims. Capsule endoscopy (CE) is an established tool for the investigation of the small intestine. The
Food and Drug Administration, Given Imaging and Olympus have not recommended the use of capsule endoscopy in patients
with cardiac pacemakers and implantable cardioverter defibrillators (ICDs). The aim of this retrospective study was to
investigate the safety of capsule endoscopy systems (Given Imaging and Olympus) when applied in patients with different
types of pacemakers/ICDs in vivo. Methods. A standardized questionnaire was sent to high volume centers in Germany and
in Austria. The questionnaire covered the age and gender of the examined patients, indication of CE, brand and type of CE,
brand and model of pacemaker/ICD, check of the devices before and after CE, monitoring during CE, possible interference
between CE and cardiac pacemakers/ICDs and possible adverse events during CE. Results. Data from 62 patients were
retrieved for this study. Capsules used were Given Imaging (n=58; M2A, M2Aplus, PillCam SB2), Olympus EndoCapsule
(n=3), Given PillCam Colon (n=1). The collective included patients with pacemakers/ICDS from seven brands (Biotronik,
Medtronic, St. Jude Medical, Guidant, Boston Scientific, Ela Sorin, Vitatron) with a total of 19/8 (pacemaker/ICD) different
types. In two patients interference between capsule endoscopy and telemetry (loss of images/gaps in video) was recorded.
None of the cardiac pacemakers or ICDs was impaired in function. No clinically evident event was observed in any of these
patients. Conclusions. Clinical use of these CE types is safe in patients with cardiac pacemakers and ICDs. Interference can
occur between CE and ECG-telemetry leading to loss of images or impaired quality of video.
    Key words
    Capsule endoscopy - cardiac pacemakers - implantable cardioverter defibrillators - safety.
The Safety of Endoscopic Ultrasonography-Guided Drainage of
Pancreatic Fluid Collections Without Fluoroscopic Control: a
Single Tertiary Center Experience
Andrada Seicean1, Roxana Stan-Iuga1, Radu Badea1, Marcel Tantau1, Teodora Mocan2, Radu Seicean3, Cornel Iancu4, Oliviu
Pascu1

1) Third Medical Clinic; 2) Department of Physiology; 3) First Surgical Clinic; 4) Third Surgical Clinic, University of
Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania


   Abstract
    Background: Endoscopic ultrasonography (EUS) is preferred for guiding drainage of pancreatic fluid collections, with a
success rate exceeding 90% when fluoroscopy is used. When fluoroscopy cannot be used, drainage can still be performed,
but no data regarding the safety of such a procedure have yet been published. Aim: To establish the safety of EUS-guided
drainage without fluoroscopic control and to identify criteria for the selection of suitable patients. Methods: The pancreatic
fluid collections considered suitable for EUS-guided drainage were >5 cm in diameter, symptomatic, without ductal
communication. We attempted EUS-guided drainage of PC prospectively in 24 patients: 9 with abscesses and 15 with
pseudocysts. Results: Drainage was successful in 20 cases (83.3%), with complete resolution after a median 18 months’
follow-up. EUS-guided drainage failed in four patients (16.7%): one in the abscess group due to symptomatic
pneumoperitoneum and three in the pseudocyst group due to thick wall. Drainage failure was associated with a diameter <6
cm and wall thickness >2 mm and was considered to be due to the sliding of the cystotome on the pseudocyst wall. During
follow-up there was one procedure unrelated death (4.1%) and no pancreatic fluid collections relapses. Conclusions:
Fluoroscopic control represents a helpful tool, but it is not always necessary for EUS-guided drainage of pancreatic fluid
collections. EUS-guided drainage is possible, efficient and safe without fluoroscopy in selected pancreatic fluid collections
with a diameter larger than 6 cm and a thin wall. Collections with a thick wall should be drained under fluoroscopy or
referred directly for surgery.
    Keywords
    EUS drainage fluid collection - pseudocyst - abscesses - treatment - pancreas.
Initial High Dose of Lamivudine Delays the Appearance of Viral
Resistance in Chronic Hepatitis B Patients
Francesco Torre, Edoardo G. Giannini, Monica Basso, Valentina Fazio, Vincenzo Savarino, Antonino Picciotto
Department of Internal Medicine, University of Genoa, Genoa, Italy


   Abstract
    Background: The lamivudine dosage used for treatment of patients with hepatitis B virus (HBV) chronic liver disease is
one-third of the dose used in patients infected with human immunodeficiency virus. Moreover, lamivudine therapy is
hampered by the early and high rate of drug-resistance. Aim: To assess the effect of an initial high dose of lamivudine on the
rate and temporal incidence of the development of resistance to treatment. Methods: We retrospectively studied 62 patients
(49 males; median age 54 years) with chronic HBV-related liver disease who were treated with lamivudine and who had at
least 1-year on-treatment follow-up. Patients were subdivided according to the lamivudine dosage: 25 patients were treated
with lamivudine 300mg qd for two weeks, then shifted to 100mg qd (high-dose group) and 37 patients were treated with the
standard dose of 100mg qd (standard-dose group). Results: Median treatment duration was 45 months. As far as baseline
HBV-DNA, HBeAg status, stage of disease, and previous interferon treatment are concerned there were no differences
between groups. Viral resistance was detected in 43 patients (69%) after a median of 27 months (range: 6-72) with no
significant difference between groups (high-dose, 60% versus standard-dose, 76%). Appearance of viral resistance was
significantly delayed in the high-dose group (p=0.0274). Conclusions: This study has shown that an initial high dose of
lamivudine is able to delay the appearance of viral resistance in patients with chronic HBV infection, thus suggesting that the
genetic barrier of lamivudine could be dose-dependent.
    Key words
    Lamivudine - chronic hepatitis B - resistance.
How Severe Is Chronic Hepatitis with HCV Genotype 1b?
A Study of 1,220 Cases on the Waiting List for Antiviral Therapy
in Romania
Oliviu Pascu1, Liana Gheorghe2, Mihai Voiculescu2, Emanoil Ceausu3, Bogdan Mateescu3

1) Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca; 2) Fundeni Clinical Institute; 3) Victor Babes
Hospital; 4) Colentina Clinical Hospital, Bucharest, Romania


   Abstract
    Introduction. Chronic HCV infection represents a public health problem in Romania, with a prevalence of 3.23-4.56%,
and more than 5,000 patients on the waiting lists for antiviral therapy. Aim: To perform an evaluation of the severity of
chronic HCV infection genotype 1b, and a quantification of patients with a low viral load, in order to quantify the number of
patients who may be considered for shortened treatment duration. Material: Histological assessment and viral load were
performed in 1,220 consecutive patients from the waiting list for antiviral therapy in 2009. The severity of chronic hepatitis
was assessed by histological evaluation (the necrotic-inflammatory index - Metavir and the fibrosis score - Metavir). Viral
load was measured by PCR and 400,000UI/ml and 600,000UI/ml were defined as thresholds for low versus high viral load
We assessed the influence of age, sex, and viral load on necro-inflammatory activity and fibrosis. Results: The mean age of
the patients included was 48 ±10.69 years and females predominated (58%). Many of them (60%) were in stage F3, with a
high potential for disease progression in the next 10 years (necro-inflammatory activity was moderate to severe in over 90%).
Almost half of the patients had low viral load, below 600,000 copies/ml. The viral load was significantly associated with the
age (p< 0.001) and sex (p< 0.001) of the patients. Conclusion: Chronic HCV hepatitis in patients on the waiting lists for
antiviral therapy in Romania has a high severity with important predictable consequences on the duration of life,
complications and treatment costs. The strategy of shortening the duration of treatment would be beneficial for almost 50%
of the patients.
    Key words
    Chronic hepatitis C - HCV genotype 1b - viral load - severity - histological scores.
A New and Simple Algorithm for the Noninvasive Assessment of
Esophageal Varices in Cirrhotic Patients Using Serum Fibrosis
Markers and Transient Elastography
Horia Stefanescu1,2, Mircea Grigorescu1, Monica Lupsor2, Anca Maniu2, Dana Crisan1, Bogdan Procopet1, Diana Feier2,
Radu Badea2

1) Hepatology Department; 2) Medical Imaging Department, 3rd Medical Clinic, “Iuliu Hatieganu” University of Medicine
and Pharmacy, Cluj-Napoca, Romania


   Abstract
    Background and aim: Noninvasive serum liver fibrosis markers and liver stiffness could be used as predictors of
esophageal varices in cirrhotic patients because portal hypertension is related to liver fibrosis. The aim of this study was to
compare the performance of common serum fibrosis scores and transient elastography in diagnosing esophageal varices and
to propose a new algorithm for predicting large varices. Methods: 231 consecutive cirrhotic patients (58.4% males, mean age
55.9 years) were enrolled. Routine biological tests were performed, so that APRI, FIB-4, Forns Index and Lok Score could
be calculated. All patients underwent transient elastography and eso-gastroscopy. The diagnostic performance of the methods
was assessed using sensitivity, specificity, positive predictive value, negative predictive value, accuracy, likelihood ratios and
receiver operating characteristic curves. Results: The Lok Score was the best among all the serum scores for diagnosing the
varices. For a value higher than 0.8, it had a 45.5% positive predictive value, 86.4% negative predictive value and 67.72%
diagnostic accuracy for prediction of large varices. For liver stiffness higher than 30.8KPa, the positive predictive value was
47.3%, negative predictive value 81% and diagnostic accuracy 68.32%. Using both tests simultaneously, the presence of
large varices was predicted with a diagnostic accuracy of 78.12%, obtaining an increment in NPV and -LR up to 93.67% and
0.21, respectively. Conclusion: The Lok Score is a good predictor for excluding the presence of large varices in cirrhotic
patients, similarly with liver stiffness. The two methods can be successfully combined into a noninvasive algorithm for the
assessment of esophageal varices in cirrhotic patients.
    Keywords
    Transient elastography - serum fibrosis scores - noninvasive - liver cirrhosis - esophageal varices.
Characteristics and Treatment Strategy of Hepatic
Angiomyolipoma: a Series of 94 Patients Collected from Four
Institutions
Zhi-Gang Chang1, Jin-Ming Zhang2, Jiao-Qian Ying3, Yu-Ping Ge4

1) Department of General Surgery, Beijing Hospital; 2) Department of Surgery, Eastern Hepatobiliary Surgery Hospital,
Second Military Medical University, Shanghai; 3) Department of Emergency, China-Japan Friendship Hospital, East
Yinghua Road, He Pingli, Chao Yang District, Beijing; 4) Department of Internal Medicine, Peking Union Medical College
Hospital, Beijing, P.R. China


   Abstract
    Aim. To report on a Chinese multicenter series of hepatic angiomyolipoma (HAML) patients and to study the
characteristics and the treatment strategy of the disease. Method. Data of 94 patients diagnosed with HAML from four
institutions of China between December 1997 and January 2008 were reviewed retrospectively. Immunohistochemical assays
were performed on the surgical specimens and follow up studies were done in all the patients. Results. 52 of 94 patients
(55.3%) showed no significant clinical symptoms. There were no specific findings on laboratory examinations. The correct
preoperative diagnostic rate of ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI) was
0% (0/94), 15.7% (11/70) and 22.7% (10/44), respectively. Regarding the treatment, 93 patients had a hepatectomy and 1
patient was treated by radiofrequency ablation. The postoperative pathology showed HAML in all the patients: 69 patients
were studied with HMB-45 staining by immunohistochemistry and the positive rate was 100% . The postoperative follow-up
rate was 91.5% (86/94), no sign of recurrence or metastasis was observed during the follow-up period. Conclusion. This is
the largest HAML series reported in the literature. There are no specific signs and symptoms in HAML patients; the
preoperative imaging diagnosis (including CT, MRI) is insensitive. The common pathological features include the basic
histological components and expression of HMB-45. Conservative treatment is not suggested; surgical resection should be
considered as a treatment choice for HAML.
    Keywords
    Hepatic angiomyolipoma - HMB-45 - diagnosis - surgical treatment.
The Infectious Complications of Interventional Radiology Based
Procedures in Gastroenterology and Hepatology
Darragh F Halpenny, William C Torreggiani
Adelaide and Meath Hospitals incorporating the National Children’s Hospital, Tallaght, Dublin, Ireland




   Abstract
    Background and aims. Many interventional radiology (IR) procedures are used to manage gastroenterological and
hepatobiliary diseases. One of the most common complications of any IR procedure is infection. Methods. Literature
published in English from January 1960 to August 2010 pertaining to the infectious complications of IR in gastroenterology
and hepatology patients was examined by electronic search (Medline and the National Library of Medicine, Embase and the
Cochrane Library). Results. Percutaneous transhepatic cholangiogram (PTC) and biliary drainage, trans-arterial
chemoembolization (TACE), transjugular intrahepatic portosystemic shunting (TIPS), imaged guided drainage of an intra-
abdominal abscess and radiologically inserted gastrostomy (RIG) are the most common IR procedures performed for
gastroenterology and hepatology patients. Procedures such as PTC have a high rate of infection. Infectious complications of
TACE and TIPS are uncommon but when they occur, they can be devastating. RIG procedures are also rarely complicated by
infection and such infections are generally mild. Use of prophylactic antibiotics is recommended for most of the above
procedures. Conclusion. The increased availability of IR based gastrointestinal and hepatobiliary techniques means that their
related infectious complications will inevitably become more common. It is vital that clinicians be aware of the aetiology,
timing and treatment of any potential infections in the peri-procedure period.
    Keywords
    Interventional radiology - infectious complications - antibiotic prophylaxis - gastroenterology - hepatology.
Hepatotoxicity by Bosentan in a Patient with Portopulmonary
Hypertension: a Case-Report and Review of the Literature
Carl Eriksson1, Anders Gustavsson1,3, Thomas Kronvall2, Curt Tysk1,3
1) Department of Medicine, Division of Gastroenterology; 2) Department of Cardiology, Örebro University Hospital; 3)
School of Health and Medical Sciences, Örebro University, Örebro, Sweden



   Abstract
    Bosentan is an endothelin receptor antagonist approved for treatment of pulmonary arterial hypertension. Mild liver
reactions occur in about 10% of treated patients but severe hepatotoxicity is rare. We present clinical data and treatment
outcome of a severe drug induced liver injury due to bosentan in a patient with non-cirrhotic portopulmonary hypertension.
    After 18 months of uncomplicated therapy with bosentan 125 mg b.i.d., the patient developed a severe mixed hepatic
injury. Serum levels of bilirubin were 316 µmol/l (ref. value <20 µmol/l), AST 14 µkat/l (ref. value < 0.9 µkat/l), ALT 10
µkat/l (ref. value < 0.9 µkat/l), ALP 8 µkat/l (ref. value <1.8 µkat/l) and INR 1.8 (ref. value 0.9-1.1). Complete diagnostic
work-up disclosed no other cause of hepatotoxicity. Treatment with prednisolone 40 mg/day in tapering doses was ultimately
added and the patient made a full recovery. Subsequent treatment with sildenafil and ambrisentan for pulmonary arterial
hypertension was well tolerated and liver function tests have remained normal during 12 months’ follow-up. A review of the
literature revealed three other women with severe hepatotoxicity due to bosentan.
    Bosentan may cause severe liver injury, even after long uneventful therapy, and current recommendations on regular
monitoring of liver function tests are reinforced. Ambrisentan may be a therapeutic alternative in patients with pulmonary
arterial hypertension and hepatotoxicity by bosentan.
    Key words
    Portopulmonary hypertension - bosentan - adverse effects - hepatotoxicity.
Non-Secretory Multiple Myeloma Relapsing as Extramedullary
Liver Plasmacytomas
Rodrigo Lopes da Silva, Alexandra Monteiro, Joana Veiga
Serviço de Hematologia, Hospital Santo António dos Capuchos, Lisboa, Portugal


   Abstract
   We report a case of a 58-year-old woman with a true non secretory multiple myeloma of the producer type relapsing after
many lines of therapy including the novel anti-myeloma drugs, which eventually relapsed as extramedullary liver
plasmacytomas manifesting as a fatal acute cholestatic hepatitis. Due to the aggressiveness of this disease, new therapeutic
modalities are necessary.
   Keywords
   Non-secretory multiple myeloma - extramedullary liver plasmacytoma - cholestatic hepatitis.
Successful Endoscopic Treatment of an Unusual Cause of Lower
Gastrointestinal Bleeding Using the OVESCO System
Mihnea H. Strain1, Dorina M. Chisevescu1, Sorin Potopea2

1) Department of Gastroenterology, University of Medicine and Pharmacy „Victor Babes”; 2) Anesthesiolgy and Intensive
Care Unit, Timisoara Emergency County Hospital, Timisoara, Romania


   Abstract
    The great majority of foreign bodies swallowed and entering the stomach are usually passed through the entire
gastrointestinal tract uneventfully. The ones that remain can cause perforation, obstruction or bleeding. The risk of
perforation is increased with long sharp metal objects, animal bones, in subjects with intestinal diseases (Crohn’s disease,
intestinal stenosis), and in patients with adhesions due to prior abdominal surgery. For a long time, toothpick impaction in the
lower gastrointestinal tract has been managed by surgery. Nowadays with the development of endoscopy, a variety of
ingested foreign bodies have been successfully managed by endoscopy. We report the case of a male patient, with a toothpick
impacted in the rectosigmoid junction, which was diagnosed and successfully managed by colonoscopy.
    Key words
    Toothpick - OTSC - endoscopic management - colon
Endoscopic Submucosal Dissection of Superficial Digestive
Tumors after Evaluation Through Magnification
Chromoendoscopy and Endoscopic Ultrasound with Miniprobes.
Report of three cases
Marcel Tantau1, Alina Tantau2, Ofelia Mosteanu1, Teodora Pop1, Gabriela Mester1, Oliviu Pascu1

1)3rd Medical Clinic; 2) 4th medical Clinic, University of Medicine and Pharmacy Cluj Napoca, Romania


   Abstract
    Magnification chromoendoscopy (MCE) and miniprobes are able to select the tumors suitable for curative endoscopic
treatment. Endoscopic submucosal dissection (ESD) is a new endoscopic technique that has a higher complete resection rate
and a very low recurrence rate. We present three cases of superficial epithelial digestive tumors that were first evaluated with
MCE and miniprobes before being treated by ESD. A complete one-fragment resection was performed with no major
complications in all cases.
    Key words
    Magnification chromoendoscopy - endoscopic ultrasound - submucosal dissection - high-grade dysplasia.
Herpes Simplex Virus Hepatitis - It’s High Time We Consider
Empiric Treatment
Udayakumar Navaneethan1,2, Elisha Lancaster1, Preethi GK Venkatesh2, Jiang Wang3, Guy W Neff1

1) Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati; 2) Digestive Disease Institute,
The Cleveland Clinic Foundation, Cleveland; 3) Department of Pathology, University of Cincinnati College of Medicine,
Cincinnati, USA


   Abstract
    Fulminant hepatitis is an uncommon complication of herpes simplex virus infection. Patients at risk, in particular
pregnant women and immunosuppressed patients presenting with fulminant liver failure, receiving delayed acyclovir
intervention may lose significant liver parenchyma prompting the need for liver transplantation. The diagnosis is often not
straight forward due to the lack of specific signs or symptoms, while many patients are diagnosed at autopsy. Although
herpes simplex virus asociated fulminant hepatic failure carries a high mortality risk, early intervention with acyclovir may
prove to be life saving. In fact, acyclovir given in the early stages of fulminant hepatic failure may prevent mortality and
avoid the need for liver transplantation. We report here two pregnant women with fulminant herpes simplex virus hepatitis in
whom a difference of a few hours in the initiation of empirical treatment made a vast difference to their hospital stay. The
above results demonstrate a significant impact to fulminant hepatic failure and should prompt clinicians to consider empiric
acyclovir therapy for at risk patients.
    Key words
    Herpes simplex virus - fulminant hepatic failure - acyclovir - pregnancy.

				
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posted:4/13/2011
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