In this edition of VHJOE, Literature in Review, we examine three articles of interest:

Introduction

Beltran, et al, demonstrated the utility of capsule endoscopy (CE), as they evaluated patients with Crohn’s for post operative disease relapse in the neoileum. It is likely that CE will become the non-invasive standard for the evaluation of post operative Crohn’s patients. Early detection of disease relapse will guide the institution of disease modifying treatment strategies.

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Chen and Antillon, have illustrated a novel “high tech” endoscopic intervention for ESLD patients with symptomatic cholelithiasis can bridge these patients until liver transplantation is performed. Dr. Antillon has kindly contributed a video of the peroral cholecystoscopy and lithotripsy procedure for your review.

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Introduction

Cholelithiasis is a common medical condition seen in ~20 of Americans aged 65 yrs and when symptoms arise cholecystectomy is recommended.^1,2 Among healthy persons without liver disease the laparoscopic cholecystectomy is safe with very low procedure related mortality (< 0.5%)^3,4. Persons with ESLD have increased morbidity with any surgery, but especially when it involves the biliary tract. Portal hypertension causes anatomic challenges for even the experienced laparoscopic surgeon. Engorgement of portal vessels, excessive bleeding of “ordinary” vessels, can make identification and dissection within Calot’s triangle very difficult, Figure 1.

Figure 1

Cirrhosis is a significant risk factor for gallstone formation with reported gallstone prevalence of 29-34%.^5,6,7 Gallstones associated with cirrhosis are usually mixed-pigmented type and not responsive to per oral ursodiol dissolution therapy. Fortunately, most cirrhotic patients with gallstones are asymptomatic, but when symptoms arise gallbladder decompression or removal is required. Surgical mortality associated with cholecystectomy for symptomatic gallstones in ESLD patients is reported to be as high as 30%.⁸ Alternative treatment options have included percutaneous cholecystotomy and transpapillary endoscopic stenting of the cystic duct.^9,10,11,12

Chen and Antillon report a case of a 52 year old male awaiting liver transplantation for hepatitis C related ESLD.¹³ The patient had multiple large, symptomatic gallstones. Surgical cholecystectomy was felt to be a high risk due to Childs-Pugh Class C cirrhosis. Percutaneous cholecystotomy was not performed because of concerns related to ascites and coagulopathy. This group performed a total of four ERCP’s to stent, decompress and dilate the cystic duct, and finally lithotripsy and rinse clear gallstones. Mild pancreatitis occurred with one of the ERCP procedures. Once stones where clear the patient was maintained on ursodiol and remained symptom free. Twenty-five months later the patient received a living donor right lobe.

Chen and Antillon have described and illustrated a “high tech” alternative to surgery and interventional radiologic that may serve as an important bridge for ESLD patients with symptomatic gallstones that are awaiting liver transplantation, see Video 1 . Of greater importance, is that Chen and Antillon have demonstrated that there is a peroral transpapillary “window” to see into the gallbladder. In the future, this “window” into the gallbladder may provide an opportunity to evaluate and treat gallbladder polyps, right upper quadrant abdominal pain, and cholelithiasis in selected patients.

References

1. Russo MW, Wei JT, Thiny MT, et al. Digestive and liver disease statistics. Gastroenterology. 2004;126:1448-1453. <Related link>

2. Urbach DR and Stukel TA. Rate of elective cholecystectomy and the incidence of severe gallstone disease. CMAJ. 2005 Apr 12;172(8):1015-9. <Related link>

3. Benvegnu L, Noventa F, Chemello, L, et al. Prevalence and incidence of cholelithiasis in cirrhosis and relation to the etiology of liver disease. Digestion 1997;58:293-8 <Related link>

4. Elzouki AN, Nilsson S, Nilsson P, et al. The prevalence of gallstones in chronic liver disease is related to degree of liver dysfunction. Hepatogastroenterology. 1999;46:2946-50.<Related link>

5. Conte D, Fraquelli M, Fornari F, et al. Close relation between cirrhosis and gallstones: Cross-sectional and longitudinal survey. Arch Intern Med. 1999;159:49-52. <Related link>

6. McSherry CK, Glenn F. The incidence and causes of death following surgery for nonmalignant biliary tract disease. Ann Surg. 1980;191:271-5. <Related link>

7. Bloch R, Allaben R, Walt A. Cholecystectomy in patients with cirrhosis: a surgical challenge. Arch Surg. 1985;120:669-72. <Related link>

8. Befeler AS, Palmer DE, Hoffman M, Longo W, Solomon H, DiBisceglie AM. The safety of Intra-abdominal surgery in patients with cirrhosis. Archives of Surgery. 2005;140:650-654. <Related link>

9. Silberfein EJ, Zhou W, Kougias P, El Sayed HF, Huynh TT, Albo D, Berger DH, Brunicardi FC, Lin PH. Percutaneous cholecystostomy for acute cholecystitis in high-risk patients: experience of a surgeon-initiated interventional program. Am J Surg. 2007 194(5):672-7. <Related link>

10. Conway JD, Russo MW, Shrestha R. Endoscopic stent insertion into the gallbladder for symptomatic gallbladder disease in patients with end-stage liver disease. Gastrointest Endoscopy. 2005;61:32-6. <Related link>

11. Schlenker C, Trotter JF, Shah RJ, et al. Endoscopic gallbladder stent placement for treatment of symptomatic cholelithiasis in patients with end-stage liver disease. AM J Gastroenterol. 2006;101:278-83. <Related link>

12. Hixson LJ, Fennerty MB, Jaffee PE, et al. Peroral cholangioscopy with intracorporeal electrohydralic lithotripsy for cholelithiasis. AM J Gastroenterol. 1992;87:296-9. <Related link>

13. Chen YK, Nichols MT, Antillon MR. Peroral cholecystoscopy with electrohydraulic lithotripsy for treatment of symptomatic cholelithiasis in end-stage liver disease. Gastrointestinal Endoscopy. 2008;67:132-135. <Related link>

Introduction

Lastly, the entity of small intestinal bacterial overgrowth (SIBO) and its recent association with irritable bowel disease (IBS) has lead to the examination of a series of antibiotic treatments for this disorder. The placebo, controlled study, by Pimentel, et al,1 showing that rifaximin 1200 mg per day for 10 days is effective in improving global symptoms of IBS has spurred clinical interest in the treatment of this disease. The report of a dose ranging trial by Scarpelli, et al, showed that a higher dose of rifaximin (1600mg per day) is a safe and more effective in the treatment for these patients. It is likely that future treatment trials with rifaximin for IBS will incorporate higher dosing regimens of this compound to improve on currently demonstrated treatment response rates.

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