Medical Specialties Commons^™

Self Expanding Metal Stents (Sems) For Management Of Peri-Pancreatic Fluid Collections (Pfc): A Single Center Experience, Whitney E. Jackson, Jason Korenblit, Vaibhav Mehendiratta, Jason Lewis, Ali A. Siddiqui, Thomas E. Kowalski, David E. Loren

Division of Internal Medicine Faculty Papers & Presentations

Background

Endoscopic management of peri-pancreatic fluid collections (PFC) with or without organizing necrosis has been shown to decrease morbidity and mortality compared to early surgical management. Plastic stents are often used for transmural drainage, although the use of self-expanding metal stents (SEMS) has been reported. Theoretical benefits of SEMS include a large diameter for drainage and facilitation of endoscopic necrosectomy. We report a single-center experience to evaluate the efficacy and safety of SEMS for management of PFC.

Methods

A single-center retrospective review was performed of patients undergoing endoscopic management of PFC using SEMS from January through November 2011. Electronic database …

Predicting Native Papilla Biliary Cannulation Success Using A Multinational Ercp Quality Network, Chunyan Peng

MUSC Theses and Dissertations

Background and Objective: Success in achieving deep biliary cannulation success in native papillae is an accepted measure of competence in ERCP training and practice. This study aimed to determine the factors associated with native papilla deep biliary cannulation success, with and without precut sphincterotomy. Methods: A retrospective analysis was conducted in a prospectively collected database. The main outcome was deep biliary cannulation success, with and without precut facilitating access, in non-operated papillae. Multilevel random fixed effect multivariate model was used to control for doctor factor. Results: 13018 ERCPs were performed by 85 endoscopists between March 2007, and May 2011. Conventional …

Idiopathic Adult Ileoileal And Ileocolic Intussusception In Situs Inversus Totalis: A Rare Coincidence, Nazish Butt, Syed H Shah, Abdul R. Alvi, Saba Hassan

Section of Gastroenterology

Situs inversus totalis is a rare autosomal recessive congenital anomaly that is characterized by mirror image anatomy of the abdominal and thoracic organs. We report a case of a 28-year-old male with situs inversus totalis, who developed an idiopathic ileoileal and ileocolic intussusception, which was diagnosed on computed tomography scan. Patient underwent successfully ileal resection and side-to-side functional anastomosis of ileum 12 cms from ileocecal junction. Postoperative course was uneventful. To the best of our knowledge, this is the first case of idiopathic adult intussusception with situs inversus totalis in the literature.

Prevalence Of Non Helicobacter Pylori Species In Patients Presenting With Dyspepsia., Javed Yakoob, Z Abbas, Rustam Khan, Chagufta Naz, Zubair Ahmad, Muhammad Islam, Safia Awan, Fatima Jafri, Wasim Jafri

Section of Gastroenterology

BACKGROUND:

Helicobacter species associated with human infection include Helicobacter pylori, Helicobacter heilmannii and Helicobacter felis among others. In this study we determined the prevalence of H. pylori and non-Helicobacter pylori organisms H. felis and H. heilmannii and analyzed the association between coinfection with these organisms and gastric pathology in patients presenting with dyspepsia. Biopsy specimens were obtained from patients with dyspepsia on esophagogastroduodenoscopy (EGD) for rapid urease test, histology and PCR examination for Helicobacter genus specific 16S rDNA, H. pylori phosphoglucosamine mutase (glmM) and urease B (ureB) gene of H. heilmannii and H. felis. Sequencing of PCR products of H. …

The Effect On Colon Visualization During Colonoscopy Of The Addition Of Simethicone To Polyethylene Glycol-Electrolyte Solution: A Randomized Single-Blind Study., Rebecca Matro, Keegan Tupchong, Constantine Daskalakis, Victoria Gordon, Leo Katz, David Kastenberg

Division of Gastroenterology and Hepatology Faculty Papers

OBJECTIVES: Colonic bubbles associated with polyethylene glycol-electrolyte solution (PEG-ELS) are common and obscure mucosal visualization. This study aimed to determine whether adding simethicone decreases the incidence of bubbles.

METHODS: Prospective, single-blind, randomized comparison of split dose PEG-ELS vs. PEG-ELS+simethicone (PEG-S) for outpatient colonoscopy. Bubble severity for colonic segments was assessed on withdrawal as A=no/minimal bubbles, B=moderate bubbles/interfere with detecting 5 mm polyp, C=severe bubbles/interfere with detecting 10 mm polyp. Primary end point was Grade B or C bubbles in any colon segment. Secondary end points were cleansing quality, incidence and severity of side effects, and polyp detection.

RESULTS: One hundred …

Boerhaave's Syndrome As A First Presentation Of Eosinophilic Esophagitis, Whitney E. Jackson, Vaibhav Mehendiratta, Juan P. Palazzo, Anthony J. Dimarino, Sidney Cohen

Division of Internal Medicine Faculty Papers & Presentations

Purpose: Prior studies have reported esophageal rupture following endoscopy or bolus impaction in eosinophilic esophagitis. The purpose of this study is to examine the frequency and characteristics of spontaneous rupture (Boerhaave's Syndrome) associated with vomiting S-435 AGA Abstracts in eosinophilic esophagitis.

Methods: A retrospective search of inpatient and outpatient records was conducted for the diagnoses "Boerhaave's", "eosinophilic esophagitis", and "esophageal rupture" from January 2001 to January 2011 within the gastroenterology division at an urban tertiary care hospital. For each subject identified, medical records, endoscopy reports, biopsy reports and radiographic studies were reviewed. A faculty member of the Department of Pathology …

Extent Of Liver Inflammation In Predicting Response To Interferon Alpha & Ribavirin In Chronic Hepatitis C Patients: A Cohort Study, Shirin Mirza, Amna Rehana Siddiqui, Saeed Hamid, Muhammad Umar, Shaheena Bashir

Community Health Sciences

Background: Liver inflammation due to HCV infection leads to fibrosis, which is an independent predictor of treatment response to interferon therapy in Chronic Hepatitis C (CHC) patients. This relationship has not been studied for liver inflammation on pretreatment liver biopsy and End of Treatment Response (ETR). ALT is a less invasive test than liver biopsy for measuring liver inflammation. Aim of this study was to compare ETR to Interferon alpha (recombinant Interferon) & Ribavirin in CHC patients having higher and lower grades of liver inflammation and to determine the diagnostic accuracy of pretreatment ALT for grades of liver inflammation.Methods: A …

Interferon Alpha For Chronic Hepatitis D, Zaigham Abbas, Muhammad Arsalan Khan, Mohammad Salih, Wasim Jafri

Department of Medicine

Background:

Hepatitis D virus is a small defective RNA virus that requires the presence of hepatitis B virus infection to infect a person. Hepatitis D is a difficult-to-treat infection. Several clinical trials have been published on the efficacy of interferon alpha for hepatitis D virus (HDV) infection. However, there are few randomised trials evaluating the effects of interferon alpha, and it is difficult to judge any benefit of this intervention from the individual trials.

Objectives:

To evaluate the beneficial and harmful effects of interferon alpha for Patients with chronic hepatitis D.

Search methods:

We identified relevant for the review randomised …

Disparate Degrees Of Hypervariable Loop Flexibility Control T Cell Receptor Cross-Reactivity, Specificity, And Binding Mechanism, Daniel R. Scott, Oleg Y. Borbulevych, Kurt H. Piepenbrink, Steven A. Corcelli, Brian M. Baker

Food for Health: Publications

αβ T cell receptors recognize multiple antigenic peptides bound and presented by major histocompatibility complex molecules. TCR cross-reactivity has been attributed in part to flexibility of the complementarity-determining region loops, yet there have been limited direct studies of loop dynamics to determine the extent of its role. Here we studied the flexibility of the binding loops of the αβ TCR A6 utilizing crystallographic, spectroscopic, and computational methods. A significant role for flexibility in binding and cross-reactivity was indicated only for the CDR3α and CDR3β hypervariable loops. Examination of the energy landscapes of these two loops indicated that CDR3β possesses a …

Haemobilia: A Rare Cause Of Gastrointestinal Bleeding, L. Kamani, S. M. Faisal Mosharraf, Tanveer-Ul-Haq, Hasnain Ali Shah

Section of Gastroenterology

Iatrogenic injury to hepatic duct leading to pseudoaneurysm and haemobilia can occur following laparoscopic cholecystectomy. We report a case of a 60 years old man presenting with haematemesis found to have pseudoaneurysm of accessory hepatic artery 4 months after laparoscopic cholecystectomy. Diagnosis was made by computed tomography (CT) scan followed by celiac and mesenteric artery angiogram. The bleeding was successfully treated with coil embolization.

Autoimmune Enteropathy With A Cd8+ Cd7- T-Cell Small Bowel Intraepithelial Lymphocytosis: Case Report And Literature Review, Shrinivas Bishu, Violeta Arsenescu, Eun Y. Lee, H. David Vargas, Willem J. S. De Villiers, Razvan Arsenescu

Surgery Faculty Publications

Background

Adult onset autoimmune enteropathy (AIE) is a rare condition characterized by diarrhea refractory to dietary therapy diagnosed in patients with evidence of autoimmune conditions. Auto-antibodies to gut epithelial cells and other tissues are commonly demonstrated. Despite increasing awareness, the pathogenesis, histologic, immunologic and clinical features of AIE remain uncertain. There remains controversy regarding the diagnostic criteria, the frequency and types of auto-antibodies and associated autoimmune conditions, and the extent and types of histologic and immunologic abnormalities. CD4+ T-cells are thought to at least responsible for this condition; whether other cell types, including B- and other T-cell subsets are involved, …

Small Intestinal Bacterial Overgrowth And Lactose Intolerance Contribute To Irritable Bowel Syndrome Symptomatology In Pakistan, Javed Yakoob, Zaigham Abbas, Rustam Khan, Saeed Hamid, Safia Awan, Wasim Jafri

Department of Medicine

Background /Aim: The symptoms of irritable bowel syndrome resemble those of small intestinal bacterial overgrowth (SIBO). The aim of this study was to determine the frequency of SIBO and lactose intolerance (LI) occurrence in Patients with diarrhea-predominant irritable bowel syndrome (IBS-D) according to Rome III criteria.

PatientS and Methods: In this retrospective case-control study, Patients over 18 years of age with altered bowel habit, bloating, and Patients who had lactose Hydrogen breath test (H 2 BT) done were included. The "cases" were defined as Patients who fulfill Rome III criteria for IBS-D, while "controls" were those having chronic nonspecific diarrhea …

Efficacy Of L-Ornithine-L-Aspartate As An Adjuvant Therapy In Cirrhotic Patients With Hepatic Encephalopathy, Shahab Abid, Wasim Jafri, Khalid Mumtaz, Muhammad Islam, Zaigham Abbas, Hasnain Ali Shah, Saeed Hamid

Section of Gastroenterology

OBJECTIVE: To evaluate the efficacy of L-ornithine-L-aspartate (LOLA) as an adjuvant therapy in cirrhotic patients with hepatic encephalopathy (HE).

STUDY DESIGN: Randomized placebo controlled study.

PLACE AND DURATION OF STUDY: The Aga Khan University Hospital, Karachi in the year 2003-2004.

METHODOLOGY: Patients with HE were randomized to receive LOLA or placebo medicine as an adjuvant to treatment of HE. Number connection test-A (NCT-A), ammonia level, clinical grade of HE and duration of hospitalization were assessed.

RESULTS: Out of 120 patients, there were 62 males with mean age of 57 11 years. Improvement in HE was higher (n=40, 66.7%) in LOLA …

Mast Cell Activation And Clinical Outcome In Pediatric Cholelithiasis And Biliary Dyskinesia., Craig A. Friesen, Nancy Neilan, James F. Daniel, Kim Radford, Jennifer Verrill Schurman, Ding-You Li, Linda Andre, Shawn D. St Peter, G W. Holcomb Iii

Manuscripts, Articles, Book Chapters and Other Papers

BACKGROUND: The current study was undertaken to determine the degree of activation of gallbladder mucosal mast cells, whether mast cell (MC) density or activation differ between patients with and without a positive clinical response to cholecystectomy, and whether either density or activation correlate with gallbladder emptying.

RESULTS: Fifteen biliary dyskinesia (BD) and 13 symptomatic cholelithiasis (CL) patients undergoing cholecystectomy were prospectively enrolled. Gallbladder wall MC density (by immunohistochemistry) and activation (by electron microscopy) were determined. Clinical response was evaluated 30 days post-cholecystectomy on a 5-point Likert-type scale. A complete or nearly complete clinical response was seen in 100% of CL …

Deletion Of Rb Accelerates Pancreatic Carcinogenesis By Oncogenic Kras And Impairs Senescence In Pre-Malignant Lesions, Catherine Carrière, A. Jesse Gore, Alixanna M. Norris, Jason R. Gunn, Alison Young, Daniel Longnecker, Murray Korc

Dartmouth Scholarship

Rb1 encodes a cell-cycle regulator that is functionally disrupted in most human cancers. Pancreatic ductal adenocarcinomas (PDACs) have a high frequency of mutations in KRAS and INK4A/CDKN2A that might allow cells to bypass the regulatory actions of retinoblastoma (RB). To determine the role of loss of RB function in PDAC progression, we investigated the effects of Rb disruption during pancreatic malignant transformation initiated by oncogenic Kras.We generated mice with pancreas-specific disruption of Rb, in the absence or presence of oncogenic Kras, to examine the role of RB in pancreatic carcinogenesis.

45 25 Gram Versus 50 Gram Of 25% Albumin In Preventing Renal Impairment After Large Volume Paracentesis In Cirrhosis.Khali, A. B. Khalid, Mumtaz J Khan, A Ghufran, Syed H Shah, Saeed Hamid, Wasim Jafri

Section of Gastroenterology

No abstract provided.

Early Complications After Biliary Enteric Anastomosis For Benign Diseases: A Retrospective Analysis, Syed Nabeel Zafar, M. R. Khan, Rushna Raza, Muhammad N. Khan, Mahwash Kasi, Ammar Rafiq, Omer H. Jamy

Department of Surgery Docs

Background:Biliary-enteric anastomosis (BEA) is a common surgical procedure performed for the management of biliary obstruction or leakage that results from a variety of benign and malignant diseases. Complications following BEA are not rare. We aimed to determine the incidence and the factors associated with early complications occurring after BEA for benign diseases.

Methods:

We reviewed the medical records of all Patients who underwent BEA for benign diseases at our institution between January 1988 and December 2009. The primary outcome was early post operative complication. Logistic regression analysis was done to identify factors predicting the occurrence of complications.

Results:

Records …

A Conserved Tissue-Specific Homeodomain-Less Isoform Of Meis1 Is Downregulated In Colorectal Cancer., Richard C Crist, Jacquelyn J Roth, Scott A Waldman, Arthur M Buchberg

Department of Microbiology and Immunology Faculty Papers

Colorectal cancer is one of the most common cancers in developed nations and is the result of both environmental and genetic factors. Many of the genetic lesions observed in colorectal cancer alter expression of homeobox genes, which encode homeodomain transcription factors. The MEIS1 homeobox gene is known to be involved in several hematological malignancies and solid tumors and recent evidence suggests that expression of the MEIS1 transcript is altered in colorectal cancer. Despite this potential connection, little is known about the role of the gene in the intestines. We probed murine gastrointestinal tissue samples with an N-terminal Meis1 antibody, revealing …

Primary Provider Beliefs And Practice Patterns Contribute To The Lack Of Hiv/Hcv Coinfected Patients Undergoing Liver Transplantation In The United States, Jonathan M. Fenkel, Md, Victor J. Navarro, Md

Division of Gastroenterology and Hepatology Faculty Papers

Conclusions:

1. The majority of primary providers were ambivalent toward or against LT for HIV/HCV coninfected patients.

2. Half of all respondents were unlikely to refer cirrhotic coinfected patients for LT evaluation.

3. HIV specialists were significantly more likely to believe transplant should be offered, but reported no difference in likelihood of LT referral.

4. These findings suggest that primary provider beliefs and self-reported practice patterns may partially explain the paucity of coinfected US liver transplant recipients.

Measures Of Socio-Demographic Factors For Child, Javed Yakoob, Safia Awan

Section of Gastroenterology

No abstract provided.

In-Vivo Ct Dosimetry During Virtual Colonoscopy, Jonathon W. Mueller

Dissertations and Theses (Open Access)

Virtual colonoscopy (VC) is a minimally invasive means for identifying colorectal polyps and colorectal lesions by insufflating a patient’s bowel, applying contrast agent via rectal catheter, and performing multi-detector computed tomography (MDCT) scans. The technique is recommended for colonic health screening by the American Cancer Society but not funded by the Centers for Medicare and Medicaid Services (CMS) partially because of potential risks from radiation exposure. To date, no in‐vivo organ dose measurements have been performed for MDCT scans; thus, the accuracy of any current dose estimates is currently unknown.

In this study, two TLDs were affixed to the inner …

Assessment Of Adherence To Guidelines For Hepatocellular Carcinoma Screening In Hiv/Hcv Coinfected Patients, Jonathan M. Fenkel, Md, Victor J. Navarro, Md

Division of Gastroenterology and Hepatology Faculty Papers

Conclusions:

1. Self-reported adherence with published guidelines for HCC screening is poor among primary providers for HIV/HCV coinfected patients, including HIV specialists and University-based providers.

2. Unnecessary imaging is also frequently ordered on non-cirrhotics, particularly by University-based providers.

3. Improved adherence to guidelines is needed among primary providers as over 50% of HCC's may be missed, and many patients many not be referred for subspecialty GI or Liver care, where screening practices may differ.

Role Of Prostaglandin E2 In The Regulation Of Pancreatic Stellate Cells Hyper Activity Associated With Pancreatic Cancer, Chantale Charo

Dissertations and Theses (Open Access)

Pancreatic cancer is one of the most lethal type of cancer due to its high metastasis rate and resistance to chemotherapy. Pancreatic fibrosis is a constant pathological feature of chronic pancreatitis and the hyperactive stroma associated with pancreatic cancer. Strong evidence supports an important role of cyclooxygenase-2 (COX-2) and COX-2 generated prostaglandin E2 (PGE2) during pancreatic fibrosis. Pancreatic stellate cells (PSC) are the predominant source of extracellular matrix production (ECM), thus being the key players in both diseases. Given this background, the primary objective is to delineate the role of PGE2 on human pancreatic stellate cells (PSC) hyper activation associated …

Factors Predicting The Recurrence Of Spontaneous Bacterial Peritonitis In Patients With Cirrhosis, Sajjad Jamil, Shahid Ahmed, Adil Memon, Sara Masood, Syed H Shah, Saeed Sadiq Hamid, Wasim Jafri

Department of Medicine

Objective: To evaluate the frequency of recurrence of spontaneous bacterial peritonitis (SBP) in patients with end stage liver disease and the factors responsible for it.

Study Design: Descriptive study.

Place and Duration of Study: The Aga Khan University Hospital, Karachi, from November 2008 till November 2009.

Methodology: Patients with cirrhosis who were admitted at AKUH with diagnosis of SBP during the study period were included. Any episode of SBP after resolution of the first index case of SBP within one year was considered as recurrence.

Results: Out of 238 cirrhotic patients, 157 (66%) had single, while 81 (34%) had recurrent …

Virological And Clinical Characteristics Of Hepatitis Delta Virus In South Asia, Khalid Mumtaz, Umair S. Ahmed, Sadik Memon, Ali Khawaja, Muhammad T. Usmani, Tariq Moatter, Saeed Hamid, Wasim Jafri

Section of Gastroenterology

Background & Aims:There is a paucity of data on the impact of hepatitis D virus (HDV) in Patients with hepatitis B virus (HBV) infection from South Asia. We studied the impact of HDV co-infection on virological and clinical characteristics.

Methods: We collected data of 480 Patients with HBsAg positive and a detectable HBV DNA PCR, who presented to the Aga Khan University, Karachi and Isra University in Hyderabad, Pakistan in the last 5 years. HDV co-infection was diagnosed on the basis of anti-HDV. ALT, HBeAg, HBeAb and HBV DNA PCR quantitative levels were checked in all Patients. We divided …

Regular Post Dinner Walk; Can Be A Useful Lifestyle Modification For Gastroesophageal Reflux, Shahid Karim, Wasim Jafri, Afsheen Faryal, Shahid Majid, Mohammad Salih, Fatima Jafri, Saeed Hamid, Hasnain Ali Shah, Zohaib Nawaz, Usman Tariq

Section of Gastroenterology

OBJECTIVES: To evaluate the correlation of gastroesophageal reflux disease (GERD) symptoms with routine post dinner physical activity and time interval before going to bed, in multiethnic South Asian population.

METHODS: Prospective, cross sectional analytical, multicenter study was conducted from February 2009 to March 2010. Patient's relative sitting in outpatient clinics with no comorbids, nonsmoker and non alcoholic were included. They were asked to fill a validated GERD questionnaire and were also inquired about routine post dinner physical activity (lying, sitting, walking) and dinner-bed time interval. Odds Ratios (OR) and their 95% Confidence Intervals (CI) were estimated using Logistic Regression, with …

Identification And Engineering Of Human Variable Regions That Allow Expression Of Stable Single-Chain T Cell Receptors, David H. Aggen, Adam S. Chervin, Francis K. Insaidoo, Kurt H. Piepenbrink, Brian M. Baker, David M. Kranz

Food for Health: Publications

Single-chain antibody fragments (scFv), consisting of two linked variable regions (V_H and V_L), are a versatile format for engineering and as potential antigen-specific therapeutics. Although the analogous format for T cell receptors (TCRs), consisting of two linked V regions (Vα and Vβ; referred to here as scTv), could provide similar opportunities, all wild-type scTv proteins examined to date are unstable. This obstacle has prevented scTv fragments from being widely used for engineering or therapeutics. To further explore whether some stable human scTv fragments could be expressed, we used a yeast system in which display of properly folded …

Risk Factors Associated With Helicobacter Pylori Infection Treatment Failure In A High Prevalence Area., Javed Yakoob, Wasim Jafri, Z Abbas, Shahab Abid, S Naz, Khan R, A. B. Khalid

Section of Gastroenterology

Triple therapy is commonly used for the treatment of Helicobacter pylori infection. We determined risk factors associated with its failure in compliant patients focusing on H. pylori density, virulence marker and 23S ribosomal RNA (rRNA) point mutations associated with clarithromycin resistance. H. pylori infection was diagnosed by 14C urea breath test (14C UBT) and rapid urease test or histology. Triple therapy with esomeprazole 20 mg b.i.d., amoxicillin 1 g b.i.d. and clarithromycin 500 mg b.i.d. was prescribed for 10 days. 14C UBT was repeated 4 weeks after treatment. In total, 111 patients [69 (62%) males] with a mean age of …

Size Or The Number Of Portal Tracts: Which Matters In A Liver Biopsy Core In Chronic Hepatitis C?, Om Parkash, Khalid Mumtaz, Zubair Ahmed, Saeed Hamid, Fatima Jafri, Wasim Jafri

Section of Gastroenterology

Liver biopsy has an important role in staging of fibrosis (SoF) and grading of inflammation (GoI) in chronic hepatitis C (CHC) patients. The effect of size and number of portal tracts (NoP) on grading and staging of liver biopsy was evaluated. A total of 150 consecutive liver biopsy core (LBC) of patients with CHC were obtained. There were 98 (65.3%) males. Mean length of LBC was 1.45 ± 0.48 cm. Mean number of portal tracts (NoP) was 11±4.6. Mean length of LBC was greater (1.60±0.45 cm) in stage 4 (n=41; 27.3%) and lesser (1.28+0.39) in stage 1 (n=23; 15%, p=0.04). …

Fluorine Substitutions In An Antigenic Peptide Selectively Modulate T Cell Receptor Binding In A Minimally Perturbing Manner, Kurt H. Piepenbrink, Oleg Y. Borbulevych, Ruth F. Sommese, John Clemens, Kathrynq M. Armstrong, Clare Desmond, Priscilla Do, Brian M. Baker

Food for Health: Publications

T cell receptor (TCR) recognition of antigenic peptides bound and presented by major histocompatibility complex (MHC) molecules forms the basis of the cellular immune response to pathogens and cancer. TCRs bind peptide/MHC molecules weakly and with fast kinetics, features which have hindered detailed biophysical studies of these interactions. Modified peptides resulting in enhanced TCR binding could help overcome these challenges. Further, there is considerable interest in using modified peptides with enhanced TCR binding as the basis for clinical vaccines. Here, we studied how fluorine substitutions in an antigenic peptide can selectively impact TCR recognition. Using a structure-guided design approach, we …