IntroductionOesophageal varices (EV) are one of the complications of liver cirrhosis that carries a risk of rupture and bleeding. The safety of performing transesophageal echocardiography (TEE) in patients with pre-existing EV is not well described in literature. Therefore, this retrospective study has been conducted to evaluate the safety of preforming TEE in this group of patients.MethodsThe study population was extracted from the 2016 Nationwide Readmissions Data using International Classification of Diseases, Tenth Revision, Clinical Modification/Procedure Coding System for EV, TEE and in-hospital outcomes. Study endpoints included in-hospital all-cause mortality, hospital length of stay, postprocedural gastrointestinal bleeding and oesophageal perforation.ResultsA total of 81 328 discharges with a diagnosis of EV were identified, among which 242 had a TEE performed during the index hospitalisation. Mean age was 58.3 years, 36.6% female. In comparison to the no-TEE group, the TEE group was associated with comparable in-hospital all-cause mortality (7.0% vs 6.7%, p=0.86) and bleeding (0.9% vs 1.1%, p=0.75); however, TEE group was associated with longer hospital stay (14.9 days vs 6.9 days, p<0.01). There were no reported oesophageal perforations.ConclusionsTEE is not a common procedure performed in patients with pre-existing EV. TEE seems to be a safe diagnostic tool for evaluation of heart diseases in this group of patients.

The definitive treatment for end stage liver disease remains a liver transplant and hence livers are needed for these patients along with cases of acute fulminant liver failure. Hence livers are a scarce and highly valuable commodity in the current time. By extending the pool of donors to include the elderly livers, it allows for increased availability of donors and reduces the mortality that is associated with the waiting list itself. There is an increasing prevalence of end stage liver disease due to conditions like chronic hepatitis B and C, non-alcoholic steatohepatitis, alcoholic liver disease. Many studies show non-inferior outcomes when elderly livers are used as a vigorous selection process is implemented. The process takes into account the characteristics of the donor, graft and recipient allowing for appropriate donor-recipient coupling. To meet the increasing demands of livers, elderly donors should be utilized for liver transplantation. The aim of this review article is to describe the aging process of the liver and the outcomes associated with use of elderly livers for transplantation.

Lay Summary It is recommended that all patients with IBD undergo vaccination against COVID-19. In this commentary, we encourage IBD providers to serve as vaccine advocates and suggest implementing different methods for battling misinformation, paying careful attention to minority population.

Tyrosine kinase inhibitors (TKIs) have been adopted in the treatment of a variety of malignancies. Despite their popularity, the underlying mechanism of the adverse effects seen with the use of TKIs is not completely understood. Acute liver injury is a known side effect of many of these drugs. Some papers have demonstrated that N-acetylcysteine may have a role in non-acetaminophen induced acute liver failure (NAI-ALF). There is little evidence supporting the use of N-acetylcysteine in the treatment of tyrosine kinase inhibitor-induced acute liver injury. This case report adds to the limited body of existing knowledge.We present a 67-year-old Caucasian female with a past medical history of anxiety, hyperlipidemia, in utero exposure to diethylstilbestrol (DES), and well-differentiated angiosarcoma of the right breast. She achieved remission for approximately six years after mastectomy with adjuvant chemotherapy and radiation. Subsequent surveillance imaging revealed new hepatic and cervical lesions. Further investigation with cutaneous biopsy near the occipital region confirmed recurrent metastatic angiosarcoma. The patient was started on high-dose pazopanib and initially tolerated the TKI without any adverse effects. However, after approximately two weeks of therapy, she began to experience dark colored urine, myalgias, and fatigue. These symptoms, along with significant elevations in liver enzymes (alanine transaminase of 1377 units/L, aspartate transaminase of 1212 units/L), prompted admission for evaluation of acute liver injury. The etiology of the acute liver injury was suspected to be secondary to TKI therapy. Treatment with intravenous N-acetylcysteine was initiated for non-acetaminophen induced acute liver failure (NAI-ALF) and resulted in a dramatic improvement in transaminases before discharge.Evidence suggests that there is a beneficial role for N-acetylcysteine in the management of NAI-ALF. However, when it comes specifically to the management of TKI induced acute liver injury, there is limited evidence to support its use. This case report highlights a possible use of N-acetylcysteine in the management of TKI mediated acute liver injury. Additional studies should be conducted to determine the role N-acetylcysteine plays in the management of TKI mediated liver injury.

INTRODUCTION: Endoscopic Retrograde Cholangiopancreatography (ERCP) is a commonly performed procedure for simultaneous diagnosis and treatment of biliary disease, which has several potential post-procedural complications. Few studies have addressed the association between hospital ERCP volume and post procedural complications. This study aims to examine the difference in the rate of post ERCP complications between high and low volume centers. METHODS: The study population was extracted from the 2016 Nationwide Readmissions Database using International Classification of Diseases, Tenth Revision, and Clinical Modification/Procedure Coding System for ERCP and in-hospital outcomes. Centers that performed > 200 ERCPs during the year of 2016 were considered high-volume, whereas centers that performed < 200 ERCPs were considered low-volume. Study endpoints included in-hospital all-cause mortality, length of hospital stay (LOS), post ERCP pancreatitis, and infection rates. RESULTS: A total of 137,825 ERCPs were identified, of which 39.8% were diagnostic ERCPs while 60.2% were therapeutic ERCPs. The mean age of patients was 59.7 years. 56.9% of the study population were female. High-volume centers performed 54,640 procedures while low-volume centers performed 83,185 procedures. In regards to complications, high-volume centers compared to low-volume centers, had a significantly higher rate of all-cause mortality (1.9% vs 1.4%, P < 0.01), post-op pancreatitis (7.0% vs 6.2%, P < 0.01), post-procedural infection (0.7% vs 0.5%, P < 0.01), and LOS (6.7 days vs 5.9 days, P < 0.01). This pattern was consistent for ERCP procedures performed for both diagnostic and therapeutic purposes, with the exception of similar rates of post-procedural pancreatitis associated with ERCP performed for diagnostic purposes in both high and low volume centers. CONCLUSION: In this preliminary analysis of a large database, hospitals with high ERCP volume were associated with a higher rate of complications including post procedural in-hospital mortality, morbidity, and length of stay. While procedural technique and operators vary amongst centers, we hypothesize that the higher rate of complications seen in patients being treated at high volume centers may, in part be due to a higher complexity in patients been seen at high volume centers.