Pump provides liver disease relief


pump diagram
The rechargeable pump sits underneath the skin and can be switched off at night

Patients at the Royal Free Hospital in London are testing a device that provides relief from a common side-effect of liver disease.

The pump siphons off excess fluid that can build up in the abdomen after liver failure and diverts it to the bladder so it can be urinated out.

A liver transplant may be the only option for patients with cirrhosis.

Doctors say the pump could buy time and may even allow the liver to recover, avoiding the need for a transplant.

“Start Quote

It can improve quality of life for patients and keep them out of hospital for longer”

Prof Rajiv Jalan

So far eight patients at the Royal Free have had one fitted.

The Alphapump sits beneath the skin of the abdomen and is connected to two small tubes that do the siphoning.

Ascites

When patients have cirrhosis, the liver and kidneys stop working properly and fluid, known as ascites, can accumulate.

Litres of fluid can gather inside the abdominal cavity, making the patient appear pregnant as well as being painful.

Patients may have to make weekly or monthly trips to hospital to have the fluid drained.

Rajiv Jalan, professor of hepatology at University College London’s institute for liver and digestive health at the Royal Free, is the doctor running the trial.

He said: “With cirrhosis, patients can accumulate litres and litres of fluid. They might need to come to hospital fortnightly to have up to 20 litres drained from their tummy.

“The pump can avoid this by draining about 15 millilitres every 15 minutes. It means they’ll pass a little bit more urine but they can turn the pump off at night.

“It can improve quality of life for patients and keep them out of hospital for longer.”

Cecal Volvulus Presenting as Epigastric Swelling and Mimicking Gastric Volvulus.


Caecal volvulus is the second most common volvulus involving the large bowel, following sigmoid volvulus. It usually manifests as closed-loop obstruction and patient usually presents with early gangrene and perforation. It is unusual for caecal volvulus to present as an epigastric swelling. We report a case of caecal volvulus in a 90-year-old patient who presented with an epigastric swelling.Case ReportA 90-year-old man presented to surgical emergency with complaints of progressive abdominal distension, obstipation and pain for 3 days; he had no associated comorbid conditions. On examination, the patient was dehydrated and had tachycardia. The supra-umbilical half of the abdomen was distended and associated with tenderness and guarding. X-rays findings were of multiple air fluid levels with a large air filled viscus occupying the upper abdomen (Figure 1).Computer tomography (CT) at the level of L2 also showed a large air filled viscus. On exploration, large bowel popped into the operative field as soon as the peritoneal cavity was opened (Figure 2).It included the cecum and ascending colon which were grossly distended, reaching upto 14 cm in diameter, rotated on the longitudinal axis clockwise and lying in the upper abdomen. There were signs of rupture of the tenia coli and impending perforation. The patient underwent derotation of the gut with right hemicolectomy and ileo-transverse anastomosis. Postoperative period was uneventful and patient was discharged in a stable condition and is healthy on follow up.

Discussion

The term volvulus is derived from the Latin word volvere (“to twist”.) Cecal volvulus is the second most common site of colonic volvulus after the sigmoid colon. It is regarded as a misnomer because, in most patients, the torsion is located in the ascending colon. Cecal volvulus is essentially a closed-loop obstruction that may lead to vascular compromise with consequent gangrene and perforation. It is a disease of the elderly, predominately affecting women.[1]

Cecal volvulus is responsible for 10%-15% of all cases of large-bowel obstruction; the most common site of large-bowel torsion being the sigmoid colon (80%), followed by the cecum (15%), the transverse colon (3%), and the splenic flexure (2%).[2] People with incomplete intestinal rotation generally have inadequate right colon fixation which is associated with clockwise torsion of the cecum, terminal ileum, and ascending colon. Based on autopsy reports, sufficient cecal mobility for volvulus and bascule formation is found in 11% and 25% of adults, respectively.[3] Prior abdominal surgery with colonic mobilization, recent surgical manipulation, adhesion formation, congenital bands, distal colonic obstruction, pregnancy, pelvic masses, extreme exertion, and hyperperistalsis have all been implicated as causative.[4]

The usual presentation is acute obstruction with progression to cecal gangrene and perforation. There is an associated distension of the abdomen, usually in the lower part. In contrast gastric volvulus presents as epigastric pain, upper abdominal distension and enderness. The diagnosis is based on the combination of clinical presentation, plain abdominal x-ray and barium enema. In gastric volvulus the Borchardt’s triad of pain, retching, and the inability to pass a nasogastric tube is diagnostic and reportedly occurs in 70% of cases.[6] This triad was absent in the present case. X-ray findings of cecal volvulus differ from gastric volvulus in its location being in the right lower abdomen rather than the epigastrium or the thorax.[7] CT is widely replacing barium contrast imaging as the preferred imaging modality for the diagnosis of volvulus. However in this case it was unable to identify the segment of bowel involved in the volvulus.

Early diagnosis is essential to reduce the substantial morbidity and mortality. The treatment is essentially surgical. Five surgical procedures have been used in the treatment of cecal volvulus: detorsion alone, cecopexy, cecostomy, both cecopexy and cecostomy, and resection. There are reports of decompression of cecal volvulus using a colonoscope or decompression tube and this modality of treatment can be given a chance.[8] The recurrence rate for detorsion alone was 13%, which is the same recurrence rate as for cecopexy.[9] Cecostomy had a recurrence rate of 1%, but there is a high incidence of wound infection, limiting the use of this procedure mainly in moribund patients. Resection eliminates the risk of recurrence entirely and is the procedure of choice in stable patients.

Key Points

  • Caecal volvulus is an uncommon cause of largebowel obstruction, which is commonly associated with gangrene and perforation.
  • A high degree to suspicion is required to diagnose this condition early.
  • Surgical management remains the treatment of choice in this condition.

References

  1. Rabinovici R, Simansky DA, Kaplan O, Kaplan O, Mavor E. Cecal volvulus. Dis Colon Rectum. 1990;33:765–69.
  2. Rogers RL, Harford FJ: Mobile cecum syndrome. Dis Colon Rect. 1984;27:399-402.
  3. Wolfer JA, Beaton LE, Anson BJ. Volvulus of the cecum. Anatomical factors in its etiology: report of case. Surg Gynecol Obstet. 1942;74:882-94.
  4. Margolin DA, Whitlow CB. The pathogenesis and etiology of colonic volvulus. Semin Colon Rectal Surg. 1999;10:129-138.
  5. Madiba TE, Thomson SR. The management of cecal volvulus. Dis Colon Rectum. 2002;45:264-67.
  6. Dibra A, Rulli F, Kaçi M, Çeliku E, Draçini X. Acute right intrathoracic gastric volvulus. A rare surgical emergency. Ann Ital Chir. 2013;84:205-07.
  7. Carter R, Brewer LA 3rd, Hinshaw DB. Acute gastric volvulus. A study of 25 cases. Am J Surg. Jul 1980;140(1):99-106.
  8. Janardhanan R, Bowman D, Brodmerkel GJ Jr, Agrawal RM, Gregory DH, Ashok PS. Cecal volvulus: decompression and detorsion with a colonoscopically placed drainage tube. Am J Gastroenterol. September 1987;82(9):912-14.
  9. Tejler G, Jiborn H. Volvulus of the cecum. Report of 26 cases and review of the literature. Dis Colon Rect. 1988;31:445-49.

A randomized, open-label study of sirolimus versus cyclosporine in primary de novo renal allograft recipients. .


Despite a decreased incidence of acute rejection and early renal allograft loss due to calcineurin inhibitors (CNIs) in transplant recipients, nephrotoxicity associated with long-term CNI use remains an important issue. This study evaluated whether a CNI-free regimen, including sirolimus, mycophenolate mofetil, corticosteroids, and anti-interleukin-2 receptor antibody induction, results in improved long-term renal function.

METHODS: This open-label, randomized, parallel group, comparative study in primary de novo renal transplant recipients was planned for 48 months but terminated early because of high acute rejection rates in the sirolimus arm.
RESULTS: Enrollment was stopped after approximately 12 months, with 475 transplanted patients randomized (2:1) to sirolimus (n=314) or cyclosporine A (CsA) treatment (n=161). Mean length of follow-up after transplantation was 190 days; this article focuses on available data through 6 months. Mean+/-SD on-therapy Nankivell-calculated glomerular filtration rate was not significantly different between the sirolimus (69.1+/-18.7 mL/min) and CsA (66.0+/-15.2 mL/min) treatment groups. Occurrence and length of delayed graft function was not significantly different between groups. Patients in the sirolimus group experienced numerically lower survival rates (96.9% vs. 99.4%; P=0.14), with nine deaths reported with sirolimus and one with CsA; higher rates of biopsy-confirmed acute rejection (21.4% vs. 6.1%; P<0.001); and higher rates of discontinuations due to adverse events (17.4% vs. 6.8%; P=0.001).
CONCLUSION: A sirolimus-based, CNI-free immunosuppressive regimen, when used with mycophenolate mofetil, corticosteroids, and anti-interleukin-2 receptor antibody induction, was associated with high rates of biopsy-confirmed acute rejection compared with CsA-based immunosuppression and is not recommended.

Source: Transplantation.

 

Mortality and causes of death in Crohn`s disease: results from 20 years of follow-up in the IBSEN study.

Population-based studies have shown a slightly decreased life expectancy in patients with Crohn`s disease (CD). The primary aim of the present study was to evaluate mortality and causes of death 20 years after the diagnosis in a well defined population-based cohort of CD patients in Norway.
DESIGN: The Inflammatory Bowel South-Eastern Norway study has prospectively followed all patients diagnosed with CD in the period between 1 January 1990 and 31 December 1993 in four geographically well-defined areas. All patients (n=237) were age and sex matched with 25 persons from the same county selected at random from the general population. Data on death and causes of deaths were collected from the Norwegian Causes of Death Register. All causes and cause-specific mortality (gastrointestinal cancer, cancer and heart disease) were modelled with Cox regression model stratified by matched sets. Results are expressed as HRs with 95% CIs.
RESULTS: There was no significant difference between CD patients and controls in overall mortality (HR=1.35, 95% CI 0.94 to 1.94, p=0.10). Furthermore, there were no marked differences in deaths from gastrointestinal cancer, other cancers or cardiovascular diseases in the CD group compared with the controls. In the CD group, 13.9% had died compared with 12.7% in the control group (p=0.578).
CONCLUSIONS: In our population-based inception cohort followed for 20 years, there was no increased mortality or more deaths from cancer compared with the general population.

Source: Gut

Dysphagia in a young woman.


A 31-year-old woman presented to our clinic with a history of intermittent dysphagia to both solid and liquid food for several years. Her dysphagia increased in severity, and in recent months, was accompanied by frequent postprandial chest tightness, and vomiting. Physical examination and routine laboratory workup showed no obvious abnormalities. Oesophagogastroduodenoscopy ,showed an elongated pouch with a blind end originating from the mid-oesophagus. A demarcation was clearly seen between the epithelium in the pouch and the normal oesophageal mucosa. Upper gastrointestinal series .showed an 8·4×2·8 cm pouch stemming from the thoracic oesophagus. The tubular structure’s blind end did not connect with the distal oesophagus, suggesting an incomplete duplication of the oesophagus. CT of chest () also showed a tube-like lesion with internal air-fluid level. Video-assisted thoracic surgery was done to remove the duplication, resulting in improvement of her symptoms.

esopha

Oesophageal duplication is a rare congenital malformation and occurs in about one in 8200 livebirths. It can be categorised into cystic or tubular forms, with the cystic type accounting for nearly 90—95% of cases. Oesophageal duplication can cause recurrent dysphagia, hoarseness, vomiting, respiratory distress or even haematemesis. Most duplications are detected before 2 years of age; 25—35% of the duplications were first identified during adulthood. Surgical resections should be considered in symptomatic patients, and close follow-up is recommended for the asymptomatic individuals because malignancy can develop from the pouch.

Source: Lancet

 

Antireflux Surgery in Patients With Chronic Cough and Abnormal Proximal Exposure as Measured by Hypopharyngeal Multichannel Intraluminal Impedance.


Importance  Chronic cough is a laryngeal symptom that can be caused by gastroesophageal reflux disease; however, treatment outcome has been difficult to predict because of the lack of an objective testing modality that accurately detects reflux-related cough.

Objective  To define the patterns of reflux and assess the outcome of antireflux surgery (ARS) in patients with chronic cough who were selected using hypopharyngeal multichannel intraluminal impedance (HMII).

Design  Review of prospectively collected data.

Setting  Tertiary care university hospital.

Participants  Patients with chronic cough, which was defined as persistent cough (≥8 weeks) of unknown cause.

Interventions  Hypopharyngeal multichannel intraluminal impedance with a specialized catheter to detect laryngopharyngeal reflux and high-esophageal reflux (reflux 2 cm distal to the upper esophageal sphincter) and ARS.

Main Outcomes and Measures  Abnormal proximal exposure was defined as laryngopharyngeal reflux occurring 1 or more times per day and/or high-esophageal reflux occurring 5 or more times per day. The outcomes of ARS included symptomatic improvement.

Results  From October 2009 to June 2011, a total of 314 symptomatic patients underwent HMII. Of this population, 49 patients (15 men, 34 women; median age, 57 years) were identified as having chronic cough. Of the 49 participants, 23 of 44 patients (52%) had objective findings of gastroesophageal reflux disease, such as esophagitis. Abnormal proximal exposure was discovered in 36 of the 49 patients (73%). Of 16 patients with abnormal proximal exposure who subsequently underwent ARS, 13 patients (81%) had resolution of cough and 3 patients (19%) had significant improvement at a median follow-up of 4.6 months (range, 0.5-13 months).

Conclusions and Relevance  A highly selective group of patients with idiopathic chronic cough may have abnormal proximal exposure to gastroesophageal reflux documented by HMII that would have not been detected with conventional pH testing. Thus, HMII is likely to improve the sensitivity of laryngopharyngeal reflux diagnosis and better elucidate those who will respond to antireflux surgery.

 

Source: JAMA

 

 

 

An Unusual Inflammatory Hepatic Lesion.


A 26-year-old man was admitted to our institution for a fever (temperature, 39°C) and abdominal pain on the right side of his hypochondrium. He complained of nausea, vomiting, and asthenia as well. His medical history was significant for pharyngitis associated with scarlet fever that he had a month before; the pharyngitis was treated by his general practitioner with clarithromycin (500 mg twice daily for a week). No throat culture or rapid antigen test for group A streptococci was performed at that time. On physical examination, he presented with mild right upper abdominal quadrant tenderness. He met all the criteria for systemic inflammatory response syndrome, and his blood tests showed a marked increase in inflammatory markers. Blood and urine cultures were obtained, and the results were negative.

case

Empirical antibiotic therapy with ampicillin sodium/sulbactam sodium was started. His chest radiograph was normal. An abdominal ultrasonographic examination revealed a 6-cm, solid, inhomogeneous mass in liver segment 6. A contrast-enhanced computed tomographic scan of the abdomen (Figure 1) showed that the lesion was hypodense with numerous septa without contrast enhancement. Magnetic resonance imaging (Figure 2) evidenced a mixed solid-liquid lesion, with some septa delimiting large areas of necrosis. The results of a serological detection test for echinococcosis were negative. His carcinoembryonic antigen, carbohydrate antigen 19-9, and α1-fetoprotein blood levels were normal. Serological markers for hepatitis B virus, hepatitis C virus, and human immunodeficiency virus were negative. A study of leukocyte populations and immunoglobulin electrophoresis did not reveal any disorder of the immune system.

Source: JAMA

Spleen Stiffness in Patients With Cirrhosis in Predicting Esophageal Varices.


OBJECTIVES:

 

Screening for esophageal varices (EV) is recommended in patients with cirrhosis. Noninvasive tests had shown varying sensitivity (Se) and specificity (Sp) for predicting EV. Splenomegaly is a common finding in liver cirrhosis because of portal and splenic congestion. These changes can be quantified by transient elastography; hence, the aim of this study was to investigate the utility of spleen stiffness (SS) in evaluating EV in comparison with other noninvasive tests.

METHODS:

 

We measured SS and liver stiffness (LS) by using FibroScan in 200 consecutive cirrhotic patients who met the inclusion criteria. Patients were also assessed by hepatic venous pressure gradient (HVPG), upper gastrointestinal endoscopy, LS–spleen diameter to platelet ratio score (LSPS), and platelet count to spleen diameter ratio (PSR).

RESULTS:

 

Of 200 patients enrolled, 174 patients had valid LS and SS measurement, and 124 (71%) patients had EV (small, n=46 and largen=78). There was a significant difference in median LS (51.4 vs. 23.9kPa,P=0.001), SS (54 vs. 32kPa, P=0.001), LSPS (6.1 vs. 2.5, P=0.001), and PSR (812 vs. 1,165, P=0.001) between patients with EV and those without EV. LS ≥27.3kPa had an Se of 91%, Sp of 72%, positive predictive value (PPV) of 89%, negative predictive value (NPV) of 76%, and a diagnostic accuracy of 86% in predicting EV. LSPS ≥3.09 had Se and Sp of 89% and 76%, respectively, and a PSR cutoff value of 909 or less had Se of 64%, Sp of 76%, and diagnostic accuracy of 68% in predicting EV. SS ≥40.8kPa had Se (94%), Sp (76%), PPV (91%), NPV (84%), and diagnostic accuracy of 86%for predicting EV. SS was significantly higher in patients who had large varices (56 vs. 49kPa, P=0.001) and variceal bleed (58 vs. 50.2kPa,P=0.001). Combining LS+SS (27.3+40.8kPa) had Se of 90%, Sp 90%, PPV 96%, NPV 79%, and a diagnostic accuracy of 90%. HVPG (n=52) showed significant correlation with SS (r=0.433, P=0.001), LSPS (r=0.335, P=0.01), and PSR (r=−0.270, P=0.05), but not with LS (r=0.178, P=0.20).

CONCLUSIONS:

 

Measurement of SS can be used for noninvasive assessment of EV and can differentiate large vs. small varices and nonbleeder vs. bleeder.

 

Source: http://www.nature.com

 

youe�tk�&� �t� plement, it’s a good idea to check the FDA website periodically for updates.

 

Source: Mayo clinic

 

 

white�pn�t� X1� font-size:9.0pt;font-family:”Arial”,”sans-serif”;color:#666666′>And, I’ll tell you right now, after this last year, leaving Waiheke Island, going to Hawaii (as detailed in Going Out On A Limb), well… I feel freer, happier, more peaceful and more my true self than I ever have in 35 years and I categorically COULD NOT have done it if I had not reached out for support.

 

So, I implore you, if you are someone who is afraid to reach out for support, please… for the love of all things… swallow your fears, your negative self-talk, your pride or whatever is keeping you stuck and please, please put your freaking hand up! The Universe will deliver what you need if you will only step up to help yourself. People will materialise to support you. Information will find its way to you when you move forward to open your arms to receive it. You will find help in the most unlikely of places if you are willing to step outside your comfort zone. Do not judge how things may have gone before… perhaps once before you reached out and you didn’t get the response and support you needed. The past is gone and it has no bearing now. Life is short, don’t waste one second of it when the support you need lies all around you, beckoning you to call upon it.

 

Transcatheter Arterial Catheter Embolization for Hepatocellular Cancer.


 

TACE, plus radiofrequency ablation, was superior to RFA alone in patients with liver-confined disease.

For patients with liver-limited, nonresectable hepatocellular cancer (HCC), treatment options include alcohol injection, radiofrequency ablation (RFA), and transcatheter arterial catheter embolization (TACE), with or without chemotherapy. However, the optimal therapy has not been clearly defined.

Now, Chinese investigators have conducted a single-institution, randomized trial to compare RFA, with or without TACE, in HCC patients with a solitary liver lesion ≤7 cm in size (or ≤3 lesions, each ≤3 cm in size), Child’s Pugh A or B liver disease, and no evidence of hepatic or portal venous invasion. All patients received RFA (up to 3 applications per session; an additional session was permitted if imaging indicated persistent viable tumor). For patients who received RFA plus TACE, hepatic artery infusion chemotherapy with carboplatin (300 mg) was followed by embolization with lipiodol (5 mL), epirubicin (50 mg), and mitomycin (8 mg) followed within 2 weeks by RFA. Of the nearly 2300 patients screened, 189 were treated. Most were male (89%) and positive for hepatitis B surface antigen (89%), and most had Child’s Pugh A liver disease (95%) and a solitary liver lesion (68%).

Recurrence rates trended lower with TACE plus RFA compared with RFA alone (35.1% and 54.7%, respectively). Overall survival (OS; the primary endpoint) was significantly better with TACE plus RFA (hazard ratio, 0.525; P=0.002; 4-year OS rates, 61.8% vs. 45.0%). Recurrence-free survival (RFS) was also significantly better with TACE plus RFA (HR 0.575; P=0.009; 4-year RFS rates, 54.8% vs. 38.9%). Complication rates were similar in the two therapy arms.

Comment: These results support the combination of RFA and chemoembolization for selected patients with liver-confined HCC. Issues remaining to be resolved include the role of chemotherapy added to embolization compared with embolization alone. The large degree of patient exclusion after screening, the relatively small number of patients treated, and the conduction of the trial at a single institution call into question the extent to which the findings can be generalized.

Source: Journal Watch Oncology and Hematology

Is Helicobacter pylori Eradication Sufficient for Bleeding Ulcers?


A prospective study suggests that peptic ulcer rebleeding is very unusual after H. pylori eradication and that maintenance antiulcer therapy may not be needed.

Helicobacter pylori infection is associated with peptic ulcer disease, and eradication of the infection reduces ulcer recurrence. The need for maintenance acid-reduction therapy in this setting is controversial.

To explore this issue, investigators at 10 university hospitals in Spain prospectively studied 1000 patients with endoscopically documented bleeding peptic ulcers and H. pylori infection. Participants were treated until eradication of the infection was confirmed by breath test. Thereafter, they received no acid-reduction therapy and were told not to take aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs). They returned at 1-year intervals for a clinical examination and a breath test for H. pylori. If signs or symptoms of upper gastrointestinal bleeding occurred, urgent endoscopy was performed.

All participants were followed for at least 12 months (total, 3253 patient-years of follow-up). Recurrence of peptic ulcer bleeding was rare, occurring in three participants during year 1 and two during year 2. All five cases of rebleeding involved either H. pylori reinfection or NSAID use. The cumulative incidence of rebleeding was 0.5% (95% confidence interval, 0.16%–1.16%) overall and 0.15% (95% CI, 0.05%–0.36%) per patient-year of follow-up.

Comment: These findings provide excellent evidence that H. pylori eradication is sufficient therapy for peptic ulcer patients — even if they had bleeding — in the absence of other causes for ulcers. Forty-one percent of the patients in this study had previously used NSAIDs or aspirin. Without a control group in which NSAIDs are continued, we cannot assess the effect of H. pylori eradication alone, but if such agents are avoided, H. pylori eradication appears to be definitive ulcer therapy. The real clinical challenge is to keep these patients from taking NSAIDs and identify those at high risk for H. pylori reinfection to determine who should be considered for continued antiulcer therapy.

Source: Journal Watch Gastroenterology