Severe alcoholic hepatitis (SAH) is defined by modified Maddrey discriminant function ≥32 or Model for End-Stage Liver Disease (MELD) >21 and/or hepatic encephalopathy. It has a 3-month mortality rate ≥30-70 %. Patients with severe alcoholic hepatitis need combined, i.e., static (MELD score) and dynamic (Lille's score), prognostication. Systemic inflammation and poor regeneration are hallmarks of SAH, rather than intrahepatic inflammation. SAH is characterized by dysregulated and uncontrolled systemic inflammatory response followed by weak compensatory antiinflammatory response that leads to increased susceptibility to infection and multiple organ failure. Massive necrosis of hepatocytes exceeds the proliferative capacity of hepatocytes. Liver progenitor cells proliferate to form narrow ductules which radiate out into the damaged liver parenchyma. Corticosteroids have been the standard-of-care therapy, albeit controversial. However, the recent Steroids or Pentoxifylline for Alcoholic Hepatitis (STOPAH) trial revealed that prednisolone was not associated with a significant reduction in 28-day mortality, with no improvement in outcomes at 90 days or 1 year. A paradigm shift from antiinflammatory therapy such as corticosteroids to liver regeneration treatment, e.g., granulocyte-colony stimulating factor, molecular targeted treatments, and fecal microbiota transplantation, for severe alcoholic hepatitis is taking place. Liver transplantation should be offered to select patients with severe alcoholic hepatitis who are nonresponsive to medical treatment.
Introduction Unless the full colon is adequately visualised at colonoscopy there is a risk of missing signifi cant pathology including advanced neoplasia and colorectal cancer (CRC). Incomplete colonoscopy occurs in 10%, and while the reasons for failure are well described, overall outcomes of these patients are not. These patients may be subjected to a second investigation or left partially investigated. The aim of this study was to determine the eventual patient outcomes following their initial failed colonoscopy. Methods All incomplete colonoscopies (not reached caecum or ileum) performed between April 2005 and 2010 at the Royal Liverpool University Hospital were identifi ed via the endoscopy database. All were audited (100% uptake) using a standard proforma and entered onto an Access database for interrogation. Results Of the 8910 colonoscopies performed, 693 (58% Female; mean age 61 years) were incomplete (7.8%). Reasons included bowel prep (24.8%), discomfort (22.2%), obstruction (17.2%), looping (13.6%), diverticular (4.3%), adverse events (0.4%), other causes (3.2%) or unrecorded (16.9%). Despite the initial incomplete procedure, CRC were found in 9.7% and signifi cant polyps (>1 cm) in 5.9%. A second investigation was performed in 324 (47%) patients. The most common second investigations were repeat colonoscopy in 35.8% (mean time to test 59 days) followed by CT colonography (CTC) in 20.7% (time 20 days), CT abdomen (CTA) in 17.9% (time 4 days) and barium enema in 16.7% (time 48 days). At second investigation, new diagnoses CRC were made in 0.9% (CTC, CTA and colonoscopy diagnosed 2 each), signifi cant polyps in 0.9%, malignant extracolonic pathology in 1.7% and non-signifi cant extracolonic pathology in 3.8%. Overall yield for signifi cant pathology (cancer or large polyps) was 7% for repeat colonoscopy, 13.4% for CTC, 10.3% for CTA and 1.8% for barium enema. There were 343 (49.5%) patients who had no
Although the risk of CRC is higher in patients who have had a failed colonoscopy, a protocol approach of subsequent investigation should not replace clinical assessment on whether another test is necessary in the light of the good outcome of patients who were not subsequently investigated.
Medullary carcinoma of the small intestine is an exceedingly rare tumor. These tumors account for less than 0.04% of all colorectal cancers and only one case to date has been reported in the ileum. Although the clinical manifestations can be consistent with signs of intestinal obstruction, often times they are discovered incidentally in an asymptomatic patient. Major contributing risk factors to the development include long standing inflammation such as Crohn's disease, and other chronic inflammatory illnesses. Tumor markers and imaging can aid in the diagnosis, however biopsy is needed for definitive diagnosis. Despite the fact that the development of these tumors in the ileum is rare, further enhancement of awareness can aid in the appropriate early detection and appropriate treatment modalities.
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