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

AIM:To study the outcomes of primary sclerosing cholangitis(PSC) patients with ulcerative colitis(UC) undergoing colectomy.METHODS: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.RESULTS: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).CONCLUSION:One third of patients with PSC and UCundergoing 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.

Use of Acellular Fish Skin for Dura Repair in an Ovine Model: A Pilot Study

Recently the use of biologic materials as dura mater repair patches has been increasing. The purpose of this study is to assess the basis for efficacy and safety of using a novel fish derived acellular dermis (Kerecis Omega3 DuraTM). In an ovine model a craniotomy under general anaesthesia was performed. A defect was produced in the dural covering of approximately 1 × 2 cm and closed with an onlay technique, with Kerecis Omega3 Dura. The bone defect was covered with the bony flap and the overlying tissues closed in layers. At 2, 5, 8 and 11 weeks the sheep underwent MRI scanning followed by euthanasia, necropsy and histological assessment. MRI images taken at 2, 5, 8 and 11 weeks showed initially moderate inflammatory response, which diminished over time, and at 11 weeks no evidence of inflammation existed. There was evidence of cerebrospinal fluid leakage at no time point. Necropsy revealed some adhesions at 5 and 8 weeks, in particular at 5 weeks, but at 11 weeks there were no adhesions found. From 2 - 11 weeks, there was evidence of initially an inflammatory reaction followed by neodura formation at the defect site through cellular ingrowth and remodeling of the acellular fish skin. Histology showed a histiocytic foreign body reaction initially that subsided over time. As early as 8 weeks there was evidence of neodura formation and by 11 weeks there was a minimal inflammatory response with an intact neodura formed. In this pilot study the Kerecis Omega3 Dura patches performed in a safe and efficacious manner. This new material needs to be fully assessed and compared with other products that are currently on the market in a larger scale animal study.

NAFLD fibrosis score:A prognostic predictor for mortality and liver complications among NAFLD patients

AIM:To study whether the severity of liver fibrosis estimated by the nonalcoholic fatty liver disease(NAFLD) fibrosis score can predict all-cause mortality,cardiac complications,and/or liver complications of patients with NAFLD over long-term follow-up.METHODS:A cohort of well-characterized patients with NAFLD diagnosed during the period of 1980-2000 was identified through the Rochester Epidemiology Project.The NAFLD fibrosis score(NFS) was used to separate NAFLD patients with and without advanced liver fibrosis.We used the NFS score to classify the probability of fibrosis as <-1.5 for low probability,>-1.5 to < 0.67 for intermediate probability,and > 0.67 for high probability.Primary endpoints included allcause death and cardiovascular-and/or liver-related mortality.From the 479 patients with NAFLD assessed,302 patients(63%) greater than 18 years old were included.All patients were followed,and medical charts were reviewed until August 31,2009 or the date when the first primary endpoint occurred.By using a standardized case record form,we recorded a detailed history and physical examination and the use of statins and metformin during the follow-up period.RESULTS:A total of 302/479(63%) NAFLD patients(mean age:47 ± 13 year) were included with a followup period of 12.0 ± 3.9 year.A low probability of advanced fibrosis(NFS <-1.5 at baseline) was found in 181 patients(60%),while an intermediate or high probability of advanced fibrosis(NSF >-1.5) was found in 121 patients(40%).At the end of the follow-up period,55 patients(18%) developed primary endpoints.A total of 39 patients(13%) died during the follow-up.The leading causes of death were non-hepatic malignancy(n = 13/39;33.3%),coronary heart disease(CHD)(n = 8/39;20.5%),and liver-related mortality(n = 5/39;12.8%).Thirty patients had new-onset CHD,whereas 8 of 30 patients(27%) died from CHD-related causes during the follow-up.In a multivariate analysis,a higher NFS at baseline and the presence of new-onset CHD were significantly predictive of death(OR = 2.6 and 9.2,respectively;P < 0.0001).Our study showed a significant,graded relationship between the NFS,as classified into 3 subgroups(low,intermediate and high probability of liver fibrosis),and the occurrence of primary endpoints.The use of metformin or simvastatin for at least 3 mo during the follow-up was associated with fewer deaths in patients with NAFLD(OR = 0.2 and 0.03,respectively;P < 0.05).Additionally,the rate of annual NFS change in patients with an intermediate or high probability of advanced liver fibrosis was significantly lower than those patients with a low probability of advanced liver fibrosis(0.06 vs 0.09,P = 0.004).The annual NFS change in patients who died was significantly higher than those in patients who survived(0.14 vs 0.07,P = 0.03).At the end of the follow-up,we classified the patients into 3 subgroups according to the progression pattern of liver fibrosis by comparing the NFS at baseline to the NFS at the end of the followup period.Most patients were in the stable-fibrosis(60%) and progressive-fibrosis(37%) groups,whereas only 3% were in the regressive fibrosis.CONCLUSION:A higher NAFLD fibrosis score at baseline and a new onset of CHD were significantly predictive of death in patients with NAFLD.

大血管的血管炎导致重度淤胆型肝炎:两例报告

Giant cell arteritis(GCA)is a vasculitis of medium and large sized vessels that occurs most often in people>50 years of age with associated symptoms of fever,weight loss,headache and jaw claudication.Polymyalgia rheumatica(PMR),which is characterized by aching and stiffness in the shoulders,hip girdle,neck and torso,is intimately associated with GCA,and evidence suggests that GCA and PMR are two phases of the same disease.The occurrence of liver enzyme abnormalities in either of these conditions is rare.Furthermore,as these conditions occur most commonly in the elderly population who may be subject to polypharmacy,patients with elevated aminotransferases due to underlying GCA/PMR may mistakenly have their abnormal liver function tests attributed to drug-induced liver injury.Given the potential complications of these diseases if left untreated,including ischemic stroke and blindness,early recognition and treatment are critical.We report two patients who developed severe cholestatic liver enzyme elevation,which had been initially attributed to drug toxicity,but was ultimately caused by large vessel vasculitis,specifically GCA and PMR.