Background Pouchitis can be a chronic complication of ileal pouch-anal anastomosis. We aimed to determine the efficacy and safety of hyperbaric oxygen therapy (HBOT) for chronic antibiotic-refractory pouchitis (CARP) and other inflammatory conditions of the pouch. Methods This was a retrospective case series of adults with inflammatory bowel disease (IBD) who underwent ileal pouch-anal anastomosis and then developed CARP and received HBOT between January 2015 and October 2019. A modified Pouchitis Disease Activity Index (mPDAI) score was used to quantify subjective symptoms (0–6) and endoscopic findings (0–6) before and after HBOT. Results A total of 46 patients were included, with 23 (50.0%) being males with a mean age of 43.6 ± 12.9 years. The median number of HBOT sessions was 30 (range 10–60). There was a significant reduction in the mean mPDAI symptom subscore from 3.19 to 1.91 after HBOT (P < 0.05). The pre- and post-HBOT mean mPDAI endoscopy subscores for the afferent limb were 2.31 ± 1.84 and 0.85 ± 1.28 (P = 0.006); for the pouch body, 2.34 ± 1.37 and 1.29 ± 1.38 (P < 0.001); and for the cuff, 1.93 ± 1.11 and 0.63 ± 1.12 (P < 0.001), respectively. Transient side effects included ear barotrauma in 5 patients (10.9%) and hyperbaric myopic vision changes in 5 patients (10.9%). Conclusions Despite minor adverse events, HBOT was well tolerated in patients with CARP and significantly improved symptoms and endoscopic parameters.

Background and Aim: There is limited data regarding the safety of endoscopic mucosal resection (EMR) in the cirrhotic population. Our study aimed to evaluate the safety of colonoscopic EMR in cirrhosis. Materials and Methods: This was a retrospective review of cirrhotics who underwent colonic EMR at 8 Cleveland Clinic Centers between January 1, 2006, and December 31, 2018. Patient data including polyp details and complications occurring within 30 days of the procedure were noted. Univariable and multivariable logistic regression analyses were conducted to find risk factors for post-EMR bleeding. Results: A total of 238 patients who underwent EMR were included. There were 145 males (60.9%) and the mean age was 61.9±8.6 years. Immediate and delayed bleeding, and postpolypectomy syndrome rates were 9.2%, 5.8%, and 1.3%, respectively. Significant risk factors for postpolypectomy bleeding were: increased age (P=0.001), procedure duration >37 minutes (P=0.001), antiplatelet use within 5 days (P=0.023), and lesion diameter >15 mm (P=0.004). Multivariable analysis revealed independent predictors of procedure-related bleeding: age above 65 years [odds ratio (OR) 2.14, P=0.044], antiplatelet use within 5 days (OR 2.42, P=0.047), right colon polyp (OR 3.51, P=0.001), and lesion diameter >15 mm (OR 3.22, P=0.003). Conclusions: EMR in cirrhotics has an acceptable bleeding risk. Age above 65 years, right colon polyp, polyp size >15 mm, and use of antiplatelets within 5 days are independent risk factors for bleeding.

INTRODUCTION: Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disorder with unregulated immune activation and inflammation. Primary HLH occurs in infants or young children with or without family history whereas secondary HLH manifests in older children or adults without a family history or gene mutation. Concurrent infection, malignancy or rheumatological disorder usually trigger an uncontrolled immune response in the older age group. Our aim is to raise is awareness among physicians to recognize the early signs and symptoms of this life-threatening condition. CASE DESCRIPTION/METHODS: A 33-year-old female with a history of multiple sclerosis and rheumatoid arthritis presents with elevated LFTs, cholestatic jaundice and intermittent high-grade fever. Imaging studies showed no significant abnormality in the hepatobiliary system. Viral and autoimmune serologies were negative. Lab works revealed low fibrinogen and elevated ferritin and IL-2 receptor levels. Bone marrow biopsy was unremarkable; however, liver biopsy showed features suggestive of HLH. Steroid and etoposide therapy was started but treatment was complicated by pancytopenia and hemodynamic instability despite multiple transfusions and filgrastim administration. With worsening clinical pictures, emapalumab (Interferon gamma blocker) was started. However, the patient developed multiorgan failure with overwhelming sepsis and died within days of emapalumab administration. DISCUSSION: HLH has a wide spectrum of clinical manifestation often masquerading as sepsis or SIRS. Some studies have found that cholestasis and high AST levels are associated with poor outcomes in adult HLH patients. The goal of therapy is to suppress hyper inflammation with agents such as corticosteroids, calcineurin inhibitors, and immunoglobulins. When a patient presents with prolonged fever and liver dysfunction of unknown etiology, HLH should be considered in the differential diagnosis as early recognition and treatment can prevent mortality, which can be high up to 75 % in the adult age group.

INTRODUCTION: The Acute Graft-versus-Host Disease (GVHD) is one of the rare complications after liver transplant (LT) with prevalence up to 2%. Among solid organ transplant, intestinal transplant has the highest incidence followed by LT. Unfortunately, no universal treatment guidelines are available for this disease with poor outcomes and mortality up to 85%. CASE DESCRIPTION/METHODS: 67-year-old male underwent orthotopic LT for end-stage liver failure due to Nonalcoholic steatohepatitis. CMV- patient received ABO identical cadaveric donor liver with CMV + serology. He had no peri-operative complications and was started on immunosuppression and antimicrobial therapies. Within 40 days of LT, he developed leukopenia and early transplant rejection, which was treated with medications. Within 100 days, patient developed rash on extremities and trunk that later spread to face, palms and soles. His course was further complicated by CMV seroconversion around 130 days post-LT. On day 168, patient presented with pancytopenia and continuing skin rash. The initial skin biopsy indicated drug induced reaction, but subsequent biopsy was consistent with GVHD. His treatment regime included steroid, tacrolimus, and rabbit Anti-thymocyte globulin (ATG) with broad-spectrum antimicrobials. Chimerism was initially 19% donor cells in the blood and it was 55% after 4 doses of ATG. He became septic and on day 209 succumbed to massive brain hemorrhage. DISCUSSION: GVHD after LT is in of the lethal complication that usually develops within 3-5 weeks. The key is to have a high index of suspicion with recognition of clinical signs; characteristic itchy palmar skin rash, diarrhea, fever, pancytopenia with normal LFTs. The symptoms are not specific and often diagnosed as infection or drug allergies. GVHD diagnosis can be established with skin lesion or GI tract biopsy and further confirmed with chimerism >30% in the blood of recipient. There is no consensus on treatment. Various strategies are adopted to suppress activated donor lymphocytes, including but not limited to, reduction or even withdrawal of immunosuppression, change in regimen with or without adding steroid boluses, IL-2 antagonist, antithymocyte/lymphocyte globulin, or use of OKT3. Broad-spectrum antimicrobial coverage is pivotal to prevent superimposed infection which is the main cause of death. Further studies are needed to raise the awareness among clinicians and to improve outcomes in patients who develop GVHD following LT.

management of dysplasia in IBD and warrants consideration as first-line therapy when an expert operator is available. Although the risk of developing cancer after endoscopic resection is low, meticulous endoscopic surveillance is crucial to monitor for local or metachronous recurrence for dysplasia.