Lymphoepithelioma-like carcinoma (LELC) is a rare lymphoproliferative malignancy that has been described in many organs over the years. LELC in the duodenum has rarely been described in literature. This article aims to present a rare cause of melena in a young man and the diagnostic challenge that ensued to throw more light on this rare disease. In this article, we describe a 43-year-old man who presented with melena and weight loss and was subsequently diagnosed with LELC after multiple endoscopic biopsies. The patient was also found to have celiac disease in association with his LELC.

Fluid overload is a common complication in patients with cirrhosis. B-type natriuretic peptide (BNP) is a marker of increased blood volume, commonly used in heart failure, that has been shown to be elevated in patients with liver disease. This study examined if BNP levels can be used to determine prognosis and predict worsening of ascites in patients with cirrhosis without concomitant heart disease. A retrospective study was performed at a large urban hospital in Chicago, Illinois and included 430 patients with cirrhosis who had BNP levels ordered during their hospital stay. Patients with clinical heart failure, arrhythmias or pulmonary hypertension were excluded. The primary outcome was 90-day mortality and the secondary outcome was a requirement for therapeutic paracentesis in the 90 days following BNP results. 53 patients (12%) had BNP levels ≥ 300 pg/mL. They had significantly increased serum levels of creatinine, bilirubin, and International Normalized Ratio (INR) when compared to those with BNP < 300 pg/mL. Patients with higher BNP had significantly higher mortality rates (HR 3.49; p = 0.037) and were more likely to require therapeutic paracentesis (HR 2.26; p = 0.02) in the next 90 days. A BNP ≥ 300 pg/mL had specificity of 88.2% in predicting 90-day mortality. BNP may serve as a practical and reliable marker of underlying disease severity in patients with cirrhosis, with potential to be included in prognostication tools for assessment of end-stage liver disease.

Background An adequate bowel preparation prior to colonoscopy is a major quality-limiting factor that determines both the diagnostic and therapeutic yield of a colonoscopy. Colonoscopy is considered the gold standard for colon cancer screening and it is the primary approach to the workup of hematochezia, diarrhea and iron deficiency anemia (IDA). Several modifiable factors of bowel prep adequacy have been identified, that account for around 25% of inadequate bowel preparations in outpatient colonoscopies. However, the literature is sparse when examining the factors associated with inadequate preparations and procedure cancellations in an inpatient hospital setting. We aim to identify factors that affect bowel preparation adequacy and procedure cancellations among diagnostic colonoscopies performed during hospitalization. Methods We retrospectively reviewed the electronic medical records of 1,500 consecutive patients who had a diagnostic colonoscopy as an inpatient at a tertiary level hospital over a 2-year period. All patients were administered a clear liquid diet the day prior to the colonoscopy. Patients were then instructed to drink 4 L of polyethylene glycol (PEG, Golytely) between 5 am to 9 am on the day of the procedure. The clinical course of each case was followed to identify quality of preparations, cancelled procedures and the reasons for cancellations. We applied univariate and multivariate logistic regression analysis to identify variables to predict cancellation and poor preparation. Results A total of 1,029 patients were included in the study. 194 (18.8%) patients had colonoscopy cancellations and 268 (26.0%) had poor bowel preparations. Multivariate analysis revealed these factors to be associated with colonoscopy cancellations: education at the graduate school level [odds ratio (OR) =1.93, P=0.04], Hispanic ethnicity (OR =0.47, P<0.01), hemoglobin level <10 g/dL (OR =1.41, P=0.05) and if the colonoscopy was done for other indications (OR =0.53, P=0.04). Factors associated with poor bowel preparation on multivariate analysis, were dementia (OR =2.44, P=0.02), gastroparesis (OR =3.97, P=0.01) and inpatient opioids use (OR =1.69, P=0.04). Conclusions The rate of colonoscopy cancellations and poor bowel preparations in inpatient colonoscopies were high, and we were able to identify predictors of inadequate colon preparation and procedure cancellations. Exploring more individualized colon preparation regimens based on personal risk factors could reduce the number of inadequate and cancelled colonoscopies in an inpatient setting.

Background and Aims Transient elastography (TE) provides accurate quantification of liver fibrosis. Its usefulness could be significantly amplified in terms of predicting liver-associated clinical events (LACE). Our aim was to create a model that accurately predicts LACE by combining the information provided by TE with other variables in patients with chronic liver disease (CLD). Methods We retrospectively reviewed the electronic medical records of patients who underwent liver elastography, at John H. Stroger Hospital in Cook County, Chicago, IL. The incidences of LACE were documented including decompensation of CLD, new hepatocellular carcinoma, and liver-associated mortality. Significant predicting factors were identified through a forward stepwise Cox regression model. We used the beta-coefficients of these risk factors to construct the Cook Score for prediction of LACE. Receiver-operating characteristic (ROC) curves were plotted for Cook Score to evaluate its efficiency in prediction, in comparison with MELD-Na Score and FIB-4 Score. Results A total of 3097 patients underwent liver elastography at our institution. Eighty-eight LACE were identified. Age (hazard ratio (HR) 1.04, p = 0.002), aspartate aminotransferase to alanine aminotransferase ratio (HR 2.61, p < 0.001), platelet count (HR 0.98, p < 0.001), international normalized ration (INR) (HR 17.80, p < 0.001), and liver stiffness measurement (HR1.04, p < 0.001) were identified as significant predictors. The Cook Score was constructed with two optimal cut-off points to stratify patients into low-, intermediate-, and high-risk groups for LACE. The Cook Score proved superior than MELD-Na Score and FIB4 Score in predicting LACE with an area under curve of 0.828. Conclusion This novel score based on a large robust sample would provide accurate prediction of prognosis in patients with chronic liver disease and guide individualized surveillance strategy once validated with future studies.

Background Advanced liver fibrosis and cirrhosis represent independent risk factors for hepatocellular carcinoma (HCC). There is also evidence suggesting that several etiologies of chronic liver disease elevate the risk for non-hepatic cancers, including nonalcoholic fatty liver disease (NAFLD), alcohol abuse, and hepatitis C infection. In the present study, we aim to characterize the cancer incidence in patients with chronic liver disease and assess the prognostic value of non-hepatic cancer on the decompensation events of this population. Methods We retrospectively reviewed the electronic medical records of patients who underwent transient elastography (TE) of liver, at John H. Stroger Hospital in Cook County, Chicago, IL. We identified patients who had decompensation of cirrhosis. We also extracted their cancer history. The cancer profiles of the cohort were compared by the presence or absence of advanced liver fibrosis. We then performed univariate and multivariate forward stepwise Cox regression analysis to identify the significant risk factors for the decompensation events and plotted Kaplan-Meier curve to demonstrate the significance of cancer in the prediction of decompensation events. Results We identified a total of 3097 patients who underwent TE. A total of 45 liver decompensation events were documented. In the univariate Cox regression model, MELD-Na score (hazard ratio (HR) 1.25, p < 0.001), liver stiffness measurement (HR 1.05, p = 0.004), and history of any cancer (HR 3.81, p = 0.001) emerged as predictors of decompensation. Non-hepatic cancer proved to be a significant predictor of decompensation (HR 3.57, p = 0.002). Conclusion The present study represents the first attempt to the best of our knowledge to describe the cancer incidence in this high-risk population. We found that non-HCC cancers independently predict hepatic decompensation events, which is an intriguing finding. We propose that physicians should be more vigilant to cancer history of patients with chronic liver disease as it might provide valuable prognostic information and guide individualized treatment and surveillance plans.

Background Transarterial chemoembolization (TACE) and bland embolization (TAE), performed for hepatocellular carcinoma (HCC), are often complicated by post-embolization syndrome (PES). There are limited data regarding the incidence of PES after TAE and the role of steroids in PES. We report the incidence of PES post TACE and TAE, identify predictors, and evaluate the role of steroids in PES. Methods Demographic and clinical variables of patients who underwent embolization were collected and PES was identified. Risk factors for PES, TACE and TAE were derived by logistic regression. We compared patients who received dexamethasone to those who did not, regarding baseline characteristics, occurrence of PES, and hospital stay. Results A total of 171 patients, average age 60.5 years, underwent the procedure, 77.8% were male, and 87.7% had cirrhosis. Of these 171, 107 underwent TACE and 64 TAE. Dexamethasone was given to 106 (61.9%) patients, of whom 85 had TACE and 21 TAE. One hundred twenty-four patients (72.5%) developed PES. PES occurred in more patients who underwent TACE, 80 (74.7%) vs. 44 (68.7%), and resulted in a longer hospital stay (1.47 vs. 1.12 days, P=0.034). Predictive factors for PES included female sex (odds ratio [OR] 2.76, 95% confidence interval [CI] 1.04-7.34; P=0.041), and alcohol-related HCC (OR 3.14, 95%CI 1.42-6.95; P=0.005). Dexamethasone did not affect the length of hospital stay (1.43 vs. 1.29 days, P=0.422) or the rate of prolonged hospitalization (18.8% vs. 15.4%, P=0.561). Conclusion There was no difference in the incidence of PES following TACE or TAE and the use of dexamethasone did not reduce the incidence of PES or the duration of hospital stay.

Several criteria have been described to noninvasively predict the presence of high-risk esophageal varices in patients with compensated advanced chronic liver disease (cACLD). However, a recent study showed that treatment with β blockers could increase decompensation-free survival in patients with clinically significant portal hypertension, thereby making it important to predict the presence of any esophageal varices. We aimed to develop a simple scoring system to predict any esophageal varices. We retrospectively reviewed patients who had vibration-controlled transient elastography (VCTE) at Cook County Hospital, Chicago, USA. Patients with cACLD and liver stiffness measurement (LSM) ≥ 10 kPa with esophagogastroduodenoscopy performed within one year of VCTE were analyzed. We generated a novel score to predict esophageal varices, using the beta coefficient of predictive variables. The score was validated in an external cohort at the University of Iowa Hospital, USA. There were 372 patients in the development cohort and 200 patients in the validation cohort. LSM, platelet count, and albumin were identified as predictors of esophageal varices and were included for generating the Cook County score as “platelet count * − 0.0155872 + VCTE score * 0.0387052 + albumin * − 0.8549209.” The area under receiver operating curve for our score was 0.86 for any varices and 0.85 for high risk varices and avoided more endoscopies than the expanded Baveno VI criteria while maintaining a very low miss rate (negative predictive value > 99%). We propose a new, highly accurate, and easy-to-use scoring system to predict the presence of not only high-risk but any esophageal varices in patients with cACLD.

INTRODUCTION: Non-alcoholic fatty liver disease (NAFLD) describes a condition of pathologic fat accumulation in hepatocytes when a secondary cause cannot be identified (e.g. excessive alcohol use). The spectrum of disease seen in NAFLD includes Non-Alcoholic Fatty Liver (NAFL), and the more pathologic variant, Non-Alcoholic Steatohepatitis (NASH). While NAFL is more common, the hepatocellular injury and inflammation that occurs in NASH contributes significantly to the increased risk of liver failure, cirrhosis, and hepatocellular carcinoma in NAFLD patients. Anti-inflammatory effects of cannabis are well described in experimental literature. Tetrahydrocannabinol (THC) specifically, has been shown to have anti-inflammatory and hepatoprotective activity in myofibroblast and stellate cells. How the hepatoprotective properties of cannabis affect disease manifestation and incidence of NAFLD is the subject of this investigation. The aim of this study is to determine how cannabis use affects the prevalence and progression of NAFLD in obese human subjects. METHODS: We studied the 2016 Healthcare Cost and Utilization Project’s (HCUP) National Inpatient Sample (NIS) discharge records, and gathered data on patients who were obese and at least 18 years of age (N = 879952). The main study outcome was prevalence of the four presentations of NAFLD: Steatosis, Steatohepatitis, Cirrhosis and Hepatocellular Carcinoma. We then compared the prevalence of disease stage between cannabis and non-cannabis users. Lastly, we further matched the non-cannabis group with demographic factors and other patient related confounders. All analysis was done using STATA 14 software. RESULTS: A total of 879,952 obese patients were admitted within the study period. Cannabis users 14,236 (1.6%) had less steatohepatitis (0.4% vs 0.7%, P < 0.001) and cirrhosis (1.1% vs 1.5%, P < 0.001) than non-users. After propensity matched analysis, cannabis use remained significantly associated with less steatohepatitis (0.4% vs 0.5%, P = 0.035). Post-match, there was no statistically significant difference in the prevalence of NAFL, cirrhosis and hepatocellular carcinoma. CONCLUSION: Results from this study suggest that cannabis use is associated with reduced prevalence and progression of steatohepatitis in obese patients. These findings could possibly be explained by the anti-inflammatory and hepatoprotective effect of cannabis on hepatocytes through the endocannabinoid system. Additional studies are needed to further explore this relationship.Table 1a.: Descriptive Statistics of Obese Population: Cannabis and Non-Cannabis Users and Propensity Score MatchTable 1b.: Outcome Statistics of Obese Population: Cannabis and Non-Cannabis Users and Propensity Score Match

e16594 Background: The association between liver fibrosis and hepatocellular cancer (HCC) is well established, however there is limitation of data on liver fibrosis and non-HCC cancers. The aim of this study was to explore the link between the degree of liver fibrosis and other cancers. Methods: We searched the electronic medical records of Stroger Hospital who underwent liver elastography from January 1st, 2014 to December 31st, 2018 and had cancer. We extracted variables: demographics, cancer histology and metastatic status and then stratified patient into categories based the fibrosis stage. Results: Our analysis identified 103 patients with non-advanced fibrosis (F0-F2) and 74 with advanced fibrosis (F3-F4). HCC was seen in 33.3% of the patients with advanced fibrosis while genitourinary (GU) was the second most common cancer. Adenocarcinoma comprised 21% of these cancers and around 46% were metastatic. Of the 104 patients with non-advanced fibrosis, HCC was seen in 3.77% while gastrointestinal (GI) and GU cancers were seen in 24.27% and 12.62% respectively. Adenocarcinoma was most common (40%) in this group as well (Table). Conclusions: Our study not only reiterates the fact that the degree of liver fibrosis is proportional to the presence of HCC, but it also reports the association of liver fibrosis with several non-HCC cancers. The meaning of these associations is unclear, but it provides an area of further research to explore if causality exists. [Table: see text]

Purpose of the Study Hepatocellular carcinoma (HCC) has tripled in incidence over the past 20 years and now ranks as the third leading cause of mortality attributed to cancer. Underlying pathophysiology is sustained hepatic inflammation which results in hepatocellular dysplasia and thus an environment prone to HCC. Considering the essential role of inflammation in the pathogenesis of HCC, we evaluated the prognostic utility of ferritin-transferrin ratio (FTR) in HCC. Methods We retrospectively reviewed the electronic medical records of patients with HCC (diagnosed on radiographic criteria and/or biopsy) from 2000 through 2015. We collected data regarding the patient demographics, laboratory investigations at the time of HCC diagnosis and prior to the initiation of treatment. Overall survival was calculated from the time of diagnosis, cases were censored at the date of last follow-up, if date of death was not known. Kaplan-Meier curves were estimated to evaluate the prognostic significance of FTR. Receiver operating characteristics (ROC) curve was plotted for FTR to predict mortality and identify cut-off value by optimized Youden's index. Results Among the 176 patients identified by initial screening, 116 patients were eventually included for analysis. Overall median survival was 11.9 months. FTR, of note, was significantly lower in alive (6.9, p < 0.001). In univariate analysis, alfa-fetoprotein (AFP), aspartate aminotransferase (AST), serum ferritin (SF), transferrin (TFS), and FTR were significantly associated with mortality. On multivariate analysis for mortality, FTR, AFP, and epidemiologic factors predictive of mortality including male gender and advanced HCC were significant. Conclusion The ferritin-transferrin ratio (FTR), calculated at the time of HCC diagnosis could predict mortality in our cohort of patients. With an optimal cut-off of 7.7 for FTR were stratified into high- and low-risk groups. The hazard ratio between the two groups was 2.36 (p < 0.003). Future studies with longitudinal follow-up of FTR at intervals and important time points (e.g., perioperative) might provide more insights to its prognostic value.

Background: The COVID-19 has affected over 950,000 people that primarily manifests as mild to severe respiratory disease However, little is known about gastroi

INTRODUCTION: Inflammatory bowel disease (IBD) is an idiopathic inflammatory process affecting the gastrointestinal tract. Patients with IBD have been shown in several studies to be at higher risk of venous thromboembolism (VTE) and colorectal cancer (CRC) compared to the general population. IBD and CRC have different prothrombotic properties; it is unknown how the interaction of these prothrombotic properties in patients with both IBD and CRC predicts the development of VTE in hospitalized patients necessitating the current study. METHODS: The national inpatient sample (NIS) from 2005-2014 was queried for all patients with a co-diagnosis of IBD and CRC who were hospitalized with a diagnosis of VTE as one of the top three discharge diagnosis using ICD9 codes 4534.X, 4533.X, 4511.X, 4518.X, 4151.X, 4538.X and 4151.X. The main outcome was the predictors of VTE. While secondary outcomes were trend in prevalence, length of stay, total charge and in-patient mortality among patients with VTE. All analysis was done using STATAv14. RESULTS: 7,585 adults with a co-diagnosis of IBD and CRC were included, among which 197 (2.5%) were coded to have VTE as one of their top three diagnoses. Multivariate logistic regression showed that black race patients (10.6% vs 5.2%; aOR 2.33 [1.40-3.89], P = 0.001), patients with metastasis (27.9% vs 16.7%; aOR 1.67 [1.17-2.40], P = 0.005) and with pulmonary circulation disorders (27.4% vs 1.2%) aOR 28.52 [18.8-43.1], P = < 0.001) had more odds of having VTE while patients with uncomplicated diabetes (8.1% vs 15.5%; aOR 0.47 [0.26-0.84], P = 0.012) had less odds of having VTE. Obesity and anemia were significantly associated with VTE in univariate logistic regression analysis but lost its significance on multivariate logistic regression analysis. VTE was also associated with more length of stay (8.41 vs 6.87 days, P = 0.005) and more total charges ($64,388 vs $50,874, P = 0.009). There was no significant trend in the prevalence of VTE neither was VTE associated with a higher odds of mortality. CONCLUSION: VTE was more common in patients with metastatic cancer and pulmonary circulation disorders compared to patients with localized disease while obesity and anemia lost significance after multivariate logistic regression analysis. Patients with IBD and CRC might have peculiar procoagulant properties different from patients with only IBD or CRC and might require tailored strategies to stratify these population into a different category so as to develop more directed VTE prophylaxis regimen.

INTRODUCTION: Fluid overload is the most frequent complication of end-stage liver disease, regardless of its etiology. Levels of brain natriuretic peptide (BNP) have been shown to be elevated in cirrhotic patients when matched to healthy subjects. There are only small observational studies done in Asian and European populations evaluating the role of BNP in predicting mortality of patients with liver disease. The use of BNP to predict 90-day requirement of paracentesis has not been studied. METHODS: Retrospective analysis of medical records of patients with a diagnosis of cirrhosis without heart failure, arrhythmia, coronary artery disease or pulmonary hypertension from John H. Stroger Hospital of Cook County Medical Record's database from 2008 to 2018. IRB approval was obtained. All analysis was done using STATAv14. RESULTS: The cohort included 430 patients with clinical and radiological diagnosis of cirrhosis without systolic dysfunction of which 12% had BNP ≥ 300 pg/mL. Patients with BNP ≥ 300 pg/mL were younger (53.3 vs 55.6 years, P = 0.027), had less proportion of hepatitis B (0% vs 100%, P = 0.013), hepatitis C (7.4% vs 92.6%, P = 0.036), higher mean number of paracentesis (1.60 vs 2.52, P = 0.005), creatinine (2.66 vs 1.03 mg/dL, P=< 0.001), bilirubin (5.36 vs 2.84 mg/dL, P=< 0.001) and INR levels (1.75 vs 1.50, P = 0.003). There was no significant difference in Child-Pugh class between the two groups and MELDNa scores were significantly higher in the BNP ≥ 300 pg/mL group. Kaplan-Meier survival estimates for death within 90 days show increased significant mortality [HR 3.49, P = 0.037] and significantly higher requirement for paracentesis in 90 days [HR 2.26, P = 0.020] with levels of BNP ≥ 300 pg/mL. CONCLUSION: This is, to our knowledge, the largest study done to assess BNP as a prognostication tool in cirrhotic patients. Despite excluding patients with overt cardiac dysfunction, we found that higher BNP levels are significantly associated with higher medium-term mortality, paracentesis requirements and higher MELDNa scores, suggesting high BNP values as an indicator of severity. The presence of hepatitis B and C seem to be a protective factor, most likely due to possible less indolent disease and more accessible treatment methods. In conclusion, BNP seems to be a reliable predictor of severity in this cohort of patients.

Hypoxic hepatitis or ischemic hepatitis is most commonly encountered in critical care patients, most of whom have shock states secondary to cardiac or respiratory failure. We report a case of severe pernicious anemia predisposing to hypoxic hepatitis that had a good prognosis with simple treatment. Care should be taken in management of severe anemia, interpretation of serum vitamin B12 levels after blood transfusion, and the use of intravenous fluids.