Diabetes Mellitus and Metabolic Syndrome—Independent Risk Factors for Hepatocellular Carcinoma

At the annual American College of Gastroenterology (ACG) meeting in 2015, Allison Kasmari, M.D., internal medicine resident, Penn State Health Milton S. Hershey Medical Center, presented findings on behalf of a group of researchers, including Amy Welch, M.D., Thomas Riley, M.D., and Thomas McGarrity, M.D., demonstrating a significantly increased risk (35 percent) of hepatocellular carcinoma (HCC) among individuals with type II diabetes mellitus (DM) and hypertension (23 percent). Based on a retrospective review (2008-2012) of 7,473 patients with HCC using MarketScan, a U.S. insurance claims database, the largest increase in HCC risk (458 percent) was seen among patients with the triple combination of DM, hypertension and hepatitis C virus (HCV), compared to age-matched controls without such diseases (Table). The abstract findings were ranked among the top 10 from a total of more than 2,500 abstracts presented at the ACG meeting and were also featured on Medscape and in an ACG SmartBrief. Continue reading

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Providing Hope to Patients with Carcinomatosis: Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy

Mucin covering the liver

Mucin covering the liver

For patients with peritoneal dissemination of an abdominal malignancy (e.g., carcinomatosis), cytoreductive surgery (CRS) paired with hyperthermic intraperitoneal chemotherapy (HIPEC) can significantly increase survival time.1 According to Colette Pameijer, M.D., FACS, associate professor of surgery, “The CRS/HIPEC technique offers hope to these patients. It adds a significant amount of time to their lives, which would otherwise be counted in months, rather than years.” Metastatic cancer cells implanted within the peritoneal cavity or its surfaces are not detectable by CAT scan, and do not respond well to standard resection and systemic chemotherapy. Patients with carcinomatosis who receive palliative treatment have a median survival time of six months.1 Continue reading

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Large Colorectal Polyp Morphology Predicts Endoscopic Management Patterns

As techniques and technology have rapidly advanced over the past decade, endoscopy has had a large impact on how many gastrointestinal (GI) conditions are treated. “One of the biggest shifts we have made clinically in terms of the number of patients treated is endoscopic resection of large colorectal polyps,” says John Levenick, M.D., Penn State Hershey Gastroenterology and Hepatology. In the past, these would have been automatically referred for open or laparoscopic resection. However, not all large polyps exhibit the same clinical features and some pose relatively greater challenges and risks during resection. Levenick and colleagues determined how well an endoscopic approach performed for management across polyp types based on gross morphology. Continue reading

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Ultrasound-based Elastography for Non-Invasive Monitoring in Chronic Liver Diseases

Non-invasive, ultrasound-based elastography devices are changing and simplifying regular monitoring for scarring and fibrosis in patients with certain chronic liver diseases, in many cases replacing the need for biopsy.1 Karen L. Krok, M.D., Penn State Hershey Gastroenterology and Hepatology, says, “In patients with an established diagnosis of chronic liver disease, such as hepatitis C or B or nonalcoholic steatohepatitis (NASH), elastography can be used to monitor fibrosis and scarring, with a level of accuracy comparable to biopsy. The procedure is quick, painless and less expensive.”

Ultrasound-based methods of elastography use a vibrating device attached to an ultrasound transducer, which is placed in an intercostal position with the patient lying supine. The velocity of vibration waves (also called shear wave velocity), expressed in kilopascals (kPa), is determined by measuring the time the vibration wave takes to travel to and bounce back from the liver. Shear wave velocity is directly related to tissue stiffness, an indicator of hepatic fibrosis (Figure). Ten successful measurements are required for the test to be reliably interpreted; a median value is generated to indicate the degree of liver fibrosis. Krok says, “It’s like bouncing a tennis ball against a soft versus hard surface. The ball will bounce back more quickly from a firm surface like pavement than it would if it were bounced against something soft, like a pillow.” Continue reading

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Gaining a Multidisciplinary Perspective Toward Chronic Abdominal and Pelvic Pain

PATIENT PROFILE: A 22-year-old female presents with recurrent episodes of nausea and vomiting, accompanied by severe, non-localized abdominal pain unexplained by infection or other illness. She has a history of appendectomy and exploratory laparoscopy. Extensive clinical laboratory tests reveal no pathology. She has comorbid generalized anxiety, treated with venlafaxine, but is otherwise healthy.

“Patients with chronic abdominal or pelvic pain may suffer for years through misdiagnoses, incomplete diagnoses and possibly multiple, ineffective surgeries. By the time they are referred to us, they are desperate for relief,” says Deborah M. Bethards, M.D., Penn State Hershey Gastroenterology and Hepatology.

In addition to gastroenterology, the Penn State Hershey Chronic Abdominal and Pelvic Pain (CAPP) Group includes health care providers from anesthesia and pain management, general surgery, gynecologic surgery, physical therapy and pediatric chronic pain. This team helps patients obtain multidisciplinary treatment that may be more effective. With many similar, mutual patients, CAPP meets monthly to discuss cases and present topics. Continue reading

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Endoscopic Suturing Device Offers Minimally Invasive Treatment for Conditions that Otherwise Require Surgery

Endoscopic suturing offers a minimally invasive, incisionless repair of gastrointestinal perforations and fistulas which often occur in critically ill patients in an emergent setting. “With the new generation endoscopic suturing device that is available, the possibilities using an endoscopic approach have dramatically broadened; we can be much more aggressive with endoscopic treatments that used to be limited by traditional suturing methods,” says Abraham Mathew, M.D., Penn State Hershey Gastroenterology and Hepatology.

Physicians at Penn State Hershey Medical Center have been using the Apollo OverStitch™ (Apollo Endosurgery, Inc., Austin, Texas) since it became available in the U.S. They have noted large gains in their ability to use an endoscopic approach for a wider range of indications, including closure of GI fistulas, perforations of the GI lumen and suturing of endoscopic stents in place to avoid migration. Patients whose stomach pouches open widely after gastric bypass surgery can have it reduced using this device. The future holds endoscopic alternatives for laparoscopic sleeve gastrectomies and gastric bypass surgeries. A video of a procedure in which Mathew and his colleagues used the suturing device was shown during the 2015 Digestive Disease Week (May 16-19, Washington, District of Columbia). Continue reading

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Novel, Minimally-Invasive Approach to Life-threatening, Complex Hepatic Abscess

In 2014, the world’s first percutaneous endoscopic debridement of hepatic abscesses was successfully performed by Matthew T. Moyer, M.D., at Penn State Hershey Medical Center. A report of the case was recently published in Gastrointestinal Endoscopy.¹ And, last October, a video of the procedure won first place in the international video forum competition at the 2014 American College of Gastroenterology Annual Conference in Philadelphia.2

Case SummaryIn a novel approach to treat a patient with life-threatening and complex hepatic abscess, Moyer explains that a multidisciplinary approach involving gastroenterologists, surgical oncologists and interventional radiologists was important, and that the approach was built on established principles of endoscopic treatment of pancreatic necrosis.3 “The successes that our interventional endoscopy group has had with endoscopic ultrasound-guided drainage and stenting of pancreatic pseudocysts as well as transluminal endoscopic debridement and washout of pancreatic abscess and necrosis inspired us to attempt adapting the technique to this patient as an alternative to high-risk open or laparoscopic hepatic necrosectomy, where mortality can be as high as 15 percent.” Continue reading

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