Faculty Bibliography

GOAL: The purpose of this study was to assess the effect of decreased colonoscopy reimbursement on gastroenterologist practice behavior, including time to retirement and procedure volume. BACKGROUND: In 2015, the Centers for Medicare and Medicaid Services proposed reductions in colonoscopy reimbursements. With new initiatives for increased colorectal cancer screening, it is crucial to understand how reimbursement changes could affect these efforts. STUDY: Randomly selected respondents from the American College of Gastroenterology membership database were surveyed on incremental changes in practice behavior if colonoscopy reimbursement were to decrease by 10, 20, 30, or 40 %. Data were analyzed using both Pearson's Chi-square and analysis of variance. RESULTS: Two thousand and nine gastroenterologists received the survey with a 16.3 % response rate. Procedure volume significantly decreased with degree of reimbursement reductions (p < 0.001). With a 10 % decrease, 72 % of respondents reported no change in the number of colonoscopies performed. With a 20 % decrease, 39 % would decrease their procedure volume, while 21 % of respondents would increase their procedure volume. With a 30 and 40 % decrease, procedure volume decreased by 48 and 50 %, respectively. In terms of retirement, current plans predict a cumulative retirement rate of 29.4 % at 10 years. More than 42 % of respondents plan to retire after 2030. In the 2014-2023 retirement subgroup (N = 74 responses), there was a significant hastening of retirement year at 20 % (p = 0.016), 30 % (p < 0.001), and 40 % (p < 0.001) reimbursement reductions as compared to baseline responses. CONCLUSION: Decreasing colonoscopy reimbursements may have a significant effect on the effective gastroenterology work force.

Autoimmune phenomena are common in patients with chronic hepatitis C. Management of chronic hepatitis C/autoimmune hepatitis syndrome has until recently been problematic due to the adverse effects of interferon on autoimmune processes and immunosuppression on viral replication. In this report we describe 3 patients with chronic hepatitis C/autoimmune hepatitis overlap syndrome who responded rapidly to direct acting anti-viral therapy. The resolution of the autoimmune process supports a direct viral role in its pathophysiology.

This case report describes the periodontal management of a patient with end-stage liver disease undergoing liver transplantation. In the first part of this article, all medical and dental findings are reported to elaborate adequate diagnoses. A patient-specific treatment plan was structured given the challenging periodontal and systemic scenarios. The second part describes the periodontal therapy delivered in close interaction with the referring physicians. Last, the article reviews current principles and protocols in managing these patients.

Learning Objectives: 1. Describe anatomic and physiologic aspects of creating left hepatic vein (LHV) to left portal vein (LPV) transjugular intrahepatic portosystemic shunts (TIPS). 2. Illustrate through a series of 15 cases the technical aspects unique to left-sided TIPS. 3. Understand outcomes of left-to-left TIPS creation for refractory ascites and variceal bleeding, compared with right and middle hepatic vein and right portal vein TIPS Background: TIPS creation is a primary treatment for complications of portal hypertension. Classically, the shunt is created between the right hepatic and right portal veins, owing to the relatively larger size of the right hepatic lobe that would theoretically increase safety and the potential for accessing one of multiple portal venous branches. LHV to LPV TIPS is much less frequently done, though preliminary studies have suggested possibly increased safety. In addition, there may be specific indications for left to left TIPS, most of which are anatomic in nature Clinical Findings/Procedure Details: Fifteen patients underwent successful LHV to LPV TIPS creation at a single institution from 11/2011 to 12/2014. Through a series of examples, the anatomy of left-to-left TIPS creation will be reviewed: left-sided TIPS tend to be shorter and less angulated compared with right-sided TIPS. Given the shorter trajectory, use of a pediatric needle for access may be considered. Patient outcomes regarding control of ascites and bleeding will be reviewed. Only 2 of 15 patients (13%) required a revision with angioplasty or further stent placement over 6 months. All of the patients were alive at 1 month post-TIPS. Conclusions: Left hepatic to left portal vein TIPS creation is safe and provides comparable outcomes compared with right-sided TIPS. Future controlled trials in centers frequently performing TIPS creation could clarify which approach is optimal. However, familiarity with the technical aspects of left-sided TIPS creation is essential as many patients have anatomy unfavorable for right-sided TIPS

Background: Certain nutritional and herbal supplements may have potential hepatotoxic effects. With increasing use of these supplements in the general population, supplements-induced liver injury (SILI) has become a common problem clinically. However, there is not much data about the clinical and pathologic features of SILI, and pathological characteristics of SILI have not been defined. Design: All liver biopsy cases with diagnoses of hepatitis or liver injury were reviewed from our pathology database from 2014-2015. The cases of SILI were confirmed by pathological and clinical correlation. Pre-biopsy liver function tests (LFTs) were collected from the electronic medical record system. The H&E and Trichrome stain slides were re-assessed for pathologic changes. The morphologic patterns of liver injury, including bile duct injury, portal inflammation, interface hepatitis, lobular inflammation, fibrosis, presence of granulomas, and plasma cell and eosinophil infiltrates were recorded and analyzed. Results: Total 17 cases of SILI were identified from 323 liver biopsy cases of hepatitis and liver injury. Two of 17 patients with SILI developed acute fulminant hepatic failure and succumbed to the illness. The hepatotoxic nutritional/herbal supplements identified included boswellic acid, carnosyn beta-alanine, whey protein, maca extract, rhodiola, holy basil, creatine, and some unspecified tea and anti-itching supplements. Histologically, the major pattern of liver injury was combined bile duct damage and hepatitis, and the majority of cases showed significant cholestasis. Fibrosis ranged from mild portal fibrosis to cirrhosis. No granulomas were identified. Plasma cells were rare to minimal in all cases, while eosinophils ranged from none up to 12 per high power field. Serologically, the mean values of alanine transaminase, aspartate transaminase, alkaline phosphatase, and total bilirubin were 625 U/L, 447 U/L, 241 U/L, and 12 mg/d, respectively. Conclusions: Nutritional and herbal supplements have become a common cause of drug induced liver injury that may be under recognized. Histologically, the pattern of SILI in this study is the combination of bile duct and hepatocytic damage, ranging from mild disease to fulminant hepatitis. Significant elevation of LFTs, in combination with mixed pattern of liver injury should trigger the consideration of SILI

Thrombocytopenia is the most common hematological abnormality encountered in patients with chronic liver disease (CLD). In addition to being an indicator of advanced disease and poor prognosis, it frequently prevents crucial interventions. Historically, thrombocytopenia has been attributed to hypersplenism, which is the increased pooling of platelets in a spleen enlarged by congestive splenomegaly secondary to portal hypertension. Over the past decade, however, there have been significant advances in the understanding of thrombopoiesis, which, in turn, has led to an improved understanding of thrombocytopenia in cirrhosis. Multiple factors contribute to the development of thrombocytopenia and these can broadly be divided into those that cause decreased production, splenic sequestration, and increased destruction. Depressed thrombopoietin levels in CLD, together with direct bone marrow suppression, result in a reduced rate of platelet production. Thrombopoietin regulates both platelet production and maturation and is impaired in CLD. Bone marrow suppression can be caused by viruses, alcohol, iron overload, and medications. Splenic sequestration results from hypersplenism. The increased rate of platelet destruction in cirrhosis also occurs through a number of pathways: increased shear stress, increased fibrinolysis, bacterial translocation, and infection result in an increased rate of platelet aggregation, while autoimmune disease and raised titers of antiplatelet immunoglobulin result in the immunologic destruction of platelets. An in-depth understanding of the complex pathophysiology of the thrombocytopenia of CLD is crucial when considering treatment strategies. This review outlines the recent advances in our understanding of thrombocytopenia in cirrhosis and CLD.