Bhupesh Pokhrel

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• Pokhrel, B. (2022).

  An Unexpected Diagnosis Underlying Acute Necrotizing Pancreatitis

  . Elsevier. doi:10.1053/j.gastro.2022.07.019
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  Question: A 65-year-old man with a past medical history of diabetes mellitus and prostate cancer in remission (prostate specific antigen 0.41 ng/mL) presented with intractable severe abdominal pain accompanied by nausea and nonbloody, nonbilious emesis that developed during the past day. The patient’s medications included metformin monotherapy and he did not have a history of tobacco or alcohol use disorder, and he had no known family history of gastrointestinal malignancies. On evaluation, patient was afebrile with vital signs notable for tachycardia at 105 beats per minute. Physical examination revealed scleral icterus, diffuse jaundice, and epigastric tenderness to palpation. Informed consent was obtained from the patient. No personal identifying characteristics were used in this case report. Serologic evaluation revealed a white blood cell count of 11.1 x 103/μL, hemoglobin of 13.5 g/dL, platelets of 375 x 103/μL, lipase of 11,673 U/L, total bilirubin of 2.4 mg/dL, alkaline phosphatase of 301 U/L, aspartate aminotransferase of 81 U/L, and alanine aminotransferase of 125 U/L. Cross-sectional imaging and magnetic resonance cholangiopancreatography (MRCP) revealed extensive inflammatory changes surrounding the enlarged pancreas, which were consistent with acute necrotizing pancreatitis, in addition to moderate intrahepatic biliary duct dilation and proximal common bile duct (CBD) dilation up to 1.3 cm with filling defects seen, concerning for choledocholithiasis or stricturing disease (Figure A). The patient underwent endoscopic retrograde cholangiopancreatography (ERCP) with biliary sphincterotomy, however, no calculi or stone debris was retrieved from the CBD or intrahepatic ducts on biliary sweeping. Therefore, a 4-French (Fr) 3-cm plastic stent was placed in the pancreatic duct (PD) for drainage. The patient was discharged after conservative medical management, with close outpatient follow-up with the Department of General Surgery and the Department of Interventional Gastroenterology. The leading diagnosis was resolved choledocholithiasis leading to severe acute necrotizing pancreatitis. The patient was readmitted 1 month later with acute cholangitis due to stent migration and gallstones. A pigtail 7-Fr 5-cm stent with internal flap and 10-Fr 9-cm stent were placed in the PD and CBD, respectively. Thereafter, ERCP was continued every 3–6 months. With each ERCP, the patient had various indeterminant strictures throughout the common hepatic duct, PD, and CBD requiring various stent placements. Brush sampling with each ERCP excluded malignancy, and the patient underwent cholecystectomy 7 months after initial admission with no pathologic abnormality noted in his gallbladder. Of note, a colonoscopy performed 3 years prior was concerning for indeterminant colitis with ileocecal valve biopsy showing chronic active colitis, cryptitis, and crypt abscesses. Two years later, the patient presented with painless jaundice. MRCP (Figure B) revealed multiple diffuse intrahepatic and extra hepatic biliary stricture. Long smooth stricture from CBD through the pancreatic head was noted. Endoscopic ultrasound/ERCP (Figure C) revealed 3-cm CBD stricture and multiple severe diffuse biliary strictures in the main bile and left hepatic duct that were negative for malignant cells. Given the chronicity of the patient’s symptoms and recurrence of disease, suspicion arose for sclerosing cholangitis, and a liver biopsy was obtained revealing plasma cell infiltration. The patient was started on a trial of glucocorticoids and was demonstrated to have clinical and endoscopic improvement. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Liver biopsy revealed plasma cell infiltration, which prompted investigation into autoimmune pancreatitis. Immunoglobulin (Ig) panel revealed IgG4 of 343.9 U/L (>3x the upper limit of normal). The patient underwent a trial of high-dose glucocorticoid therapy with taper, which prompted resolution of jaundice, improved biliary structuring, and led to a reduction of IgG4 to 209 U/L. The diagnosis of Type 1 autoimmune pancreatitis (AIP) was made. He had recurrence of disease with steroid de-escalation and required to be started on rituximab. Diagnosis of Type 1 AIP revolves around 5 cardinal features: histology, imaging, serology, other organ involvement, and response to therapy.1Shimosegawa T. Chari S.T. Frulloni L. et al.International Association of Pancreatology. International consensus diagnostic criteria for autoimmune pancreatitis: guidelines of the International Association of Pancreatology.Pancreas. 2011; 40: 352-358Crossref PubMed Scopus (1084) Google Scholar With serum IgG4 levels 3 times the upper limit of normal, ERCP with long stricture of PD, multiple biliary strictures, and clinical response to a trial of glucocorticoid, the patient met the international consensus diagnostic criteria for Type 1 AIP. Additionally, given the presence of IgG4-related diffuse intrahepatic and extrahepatic biliary stricture disease and presence of plasma cells on liver biopsy, this led to the diagnosis of IgG4-associated cholangitis using HISORt (histology, imaging, serology, other organ involvement and response to therapy) criteria. The presence of IgG4-associated cholangitis is commonly associated with Type 1 AIP, but also further supports diagnosis of Type 1 AIP with extrapancreatic IgG4-related disease.1Shimosegawa T. Chari S.T. Frulloni L. et al.International Association of Pancreatology. International consensus diagnostic criteria for autoimmune pancreatitis: guidelines of the International Association of Pancreatology.Pancreas. 2011; 40: 352-358Crossref PubMed Scopus (1084) Google Scholar The overall incidence of autoimmune pancreatitis is 0.9–3.1/100,000, however, the incidence of AIP in the United States is unknown.2Hart P.A. Zen Y. Chari S.T. Recent advances in autoimmune pancreatitis.Gastroenterology. 2015; 149: 39-51Abstract Full Text Full Text PDF PubMed Scopus (163) Google Scholar Most patients with AIP are males presenting in their sixth or seventh decade of life with painless obstructive jaundice, abdominal pain, or extrapancreatic lesions.2Hart P.A. Zen Y. Chari S.T. Recent advances in autoimmune pancreatitis.Gastroenterology. 2015; 149: 39-51Abstract Full Text Full Text PDF PubMed Scopus (163) Google Scholar Less than 1% of patients diagnosed with Type 1 present with acute pancreatitis.2Hart P.A. Zen Y. Chari S.T. Recent advances in autoimmune pancreatitis.Gastroenterology. 2015; 149: 39-51Abstract Full Text Full Text PDF PubMed Scopus (163) Google Scholar To the best of our knowledge this is the first adult patient that has presented with acute Type 1 AIP–associated necrotizing pancreatitis at time of initial presentation. Interestingly, this patient’s previous colonoscopy was concerning for indeterminant colitis. Inflammatory bowel disease (IBD) is seen in in up to 30% of patients with Type 2 AIP as opposed to 2.5% in patient with Type 1 AIP.1Shimosegawa T. Chari S.T. Frulloni L. et al.International Association of Pancreatology. International consensus diagnostic criteria for autoimmune pancreatitis: guidelines of the International Association of Pancreatology.Pancreas. 2011; 40: 352-358Crossref PubMed Scopus (1084) Google Scholar,2Hart P.A. Zen Y. Chari S.T. Recent advances in autoimmune pancreatitis.Gastroenterology. 2015; 149: 39-51Abstract Full Text Full Text PDF PubMed Scopus (163) Google Scholar Although the patient was not formally diagnosed with IBD at the time of AIP, a repeat colonoscopy is pending at this time to re-evaluate the patient for IBD because he does not have clinical features of this condition. The patient’s unusual presentation, severity of illness, and prior colonoscopy with features of possible colitis culminate into a novel case of Type 1 AIP. This patient’s work-up exhibits why it continues to be crucial to keep a broad differential even with commonplace symptoms. We write this vignette to illustrate the clinical difficulty associated with diagnosing a patient with Type 1 AIP.
• Trieu, R., Junna, S., & Pokhrel, B. (2022). An Unexpected Diagnosis Underlying Acute Necrotizing Pancreatitis. Gastroenterology, 163(6), e25-e27.
• Ge, J., Lai, J. C., Boike, J. R., German, M., Jest, N., Morelli, G., Spengler, E., Said, A., Lee, A., Hristov, A., Desai, A. P., Junna, S., Pokhrel, B., Couri, T., Paul, S., Frenette, C., Christian-Miller, N., Laurito, M., Verna, E. C., , Rahim, U., et al. (2021). Nonalcoholic Fatty Liver Disease and Diabetes Mellitus Are Associated With Post-Transjugular Intrahepatic Portosystemic Shunt Renal Dysfunction: An Advancing Liver Therapeutic Approaches Group Study. Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society, 27(3), 329-340.
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  Transjugular intrahepatic portosystemic shunt (TIPS) is an effective intervention for portal hypertensive complications, but its effect on renal function is not well characterized. Here we describe renal function and characteristics associated with renal dysfunction at 30 days post-TIPS. Adults with cirrhosis who underwent TIPS at 9 hospitals in the United States from 2010 to 2015 were included. We defined "post-TIPS renal dysfunction" as a change in estimated glomerular filtration rate (ΔeGFR) ≤-15 and eGFR ≤ 60 mL/min/1.73 m or new renal replacement therapy (RRT) at day 30. We identified the characteristics associated with post-TIPS renal dysfunction by logistic regression and evaluated survival using adjusted competing risk regressions. Of the 673 patients, the median age was 57 years, 38% of the patients were female, 26% had diabetes mellitus, and the median MELD-Na was 17. After 30 days post-TIPS, 66 (10%) had renal dysfunction, of which 23 (35%) required new RRT. Patients with post-TIPS renal dysfunction, compared with those with stable renal function, were more likely to have nonalcoholic fatty liver disease (NAFLD; 33% versus 17%; P = 0.01) and comorbid diabetes mellitus (42% versus 24%; P = 0.001). Multivariate logistic regressions showed NAFLD (odds ratio [OR], 2.04; 95% confidence interval [CI], 1.00-4.17; P = 0.05), serum sodium (Na; OR, 1.06 per mEq/L; 95% CI, 1.01-1.12; P = 0.03), and diabetes mellitus (OR, 2.04; 95% CI, 1.16-3.61; P = 0.01) were associated with post-TIPS renal dysfunction. Competing risk regressions showed that those with post-TIPS renal dysfunction were at a higher subhazard of death (subhazard ratio, 1.74; 95% CI, 1.18-2.56; P = 0.01). In this large, multicenter cohort, we found NAFLD, diabetes mellitus, and baseline Na associated with post-TIPS renal dysfunction. This study suggests that patients with NAFLD and diabetes mellitus undergoing TIPS evaluation may require additional attention to cardiac and renal comorbidities before proceeding with the procedure.
• Pokhrel, B. (2020).

  Tu1739 RISK OF RECURRENT VARICEAL HEMORRHAGE IN TIPS WITH EMBOLOTHERAPY COMPARED TO TIPS ALONE IN THE ALTA CONSORTIUM

  . Gastroenterology. doi:10.1016/s0016-5085(20)34351-1
• Pokhrel, B., Chang, M., Anand, G., Savides, T., & Fehmi, S. (2020). Appendiceal mucinous neoplasm in an inverted appendix found on prior colonoscopy. VideoGIE : an official video journal of the American Society for Gastrointestinal Endoscopy, 5(1), 34-36.
• Pokhrel, B. (2019).

  312 – Tips Effectively Treats Refractory Hepatic Hydrothorax: A Multi-Center U.S. Retrospective Study of 1,260 Patients

  . Gastroenterology. doi:10.1016/s0016-5085(19)39946-9
• Pokhrel, B. (2018).

  Contemporary practice patterns and outcomes after transjugular intrahepatic portosystemic shunt placement: A multicenter U.S. experience of 1146 patients

  . HHS Public Access, 329-340. doi:10.1016/s0168-8278(18)30375-1
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  Author Manuscript
• Pokhrel, B. (2018).

  Endoscopic Ultrasound Drainage Is Associated With Reduced Hospital Stay in Patients Hospitalized With Pancreatic Pseudocyst

  . The American Journal of Gastroenterology. doi:10.14309/00000434-201810001-00006
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  Introduction: Although endoscopic ultrasound (EUS)-guided pancreatic pseudocyst drainage is increasingly being performed, few small studies have compared the clinical outcomes and cost-effectiveness of EUS drainage with percutaneous and surgical drainage. We designed this study to compare endoscopic, percutaneous and surgical drainage in patients hospitalized with pancreatic pseudocyst. Methods: We used data from the National Inpatient Sample across three study years (2012-2014) to identify patients hospitalized with pancreatic pseudocyst. We compared the outcomes of in-hospital mortality, hospital length of stay, and hospital charges in patients who underwent percutaneous, EUS, and surgical drainage. Analysis included univariate and multivariate linear and logistic regression analysis. Results: Of 31,890 patients hospitalized with pancreatic pseudocyst, 4125 patients had a primary diagnosis of pancreatic pseudocyst. Patients who did not have any procedure (n=29,929) and patients who underwent both percutaneous/endoscopic and surgical drainage (n=41) were excluded from the analysis. Of 1920 study patients, 1213 had percutaneous drainage, 162 had EUS drainage and 545 had surgical drainage. Patients who underwent EUS and surgical drainage had shorter hospital length of stay than patients who underwent percutaneous drainage (mean 13.4 versus 13.8 versus 16.9 days; p
• Basit, S. A., Chouhan, J. S., Ghazala, S., Pokhrel, B., & Shrestha, M. P. (2017).

  The Evil Duo: Disseminated Histoplasmosis in a Patient With Neuro-Behchet Syndrome: 2289

  . The American Journal of Gastroenterology, 112, S1254. doi:10.14309/00000434-201710001-02290
• Basit, S. A., Ghazala, S., Pokhrel, B., & Shrestha, M. P. (2017).

  Coming Back With a Vengeance: Very Late Recurrence of Hepatocellular Cancer in a Liver Transplant Recipient Presenting as Spinal Cord Compression: 2290

  . The American Journal of Gastroenterology, 112, S1254-S1255. doi:10.14309/00000434-201710001-02291
• Cunningham, J. T., Gavini, H., Ghazala, S., Junna, S., Pokhrel, B., & Shrestha, M. P. (2017).

  Common Bile Duct Stone Size Is an Independent Predictor of Stone Detection by Magnetic Resonance Imaging: 85

  . The American Journal of Gastroenterology, 112, S38-S39. doi:10.14309/00000434-201710001-00085
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  Introduction: Endoscopic retrograde pancreatography (ERCP) is now primarily considered a therapeutic modality for management of common bile duct (CBD) stones. Endoscopic ultrasound (EUS) and Magnetic resonance imaging (MRI) are less invasive modalities used in the diagnosis of CBD stones prior to ERCP. The aim of the study is to detect if there is an additional diagnostic yield of EUS over MRI in detecting small common bile stones. Methods: A retrospective cross-sectional study was performed in patients who underwent ERCP between July 2011 and March 2017 for suspected CBD stone. The study included patients with CBD stone confirmed on ERCP and had a MRCP and an EUS within 72 hours from ERCP. Patient's demographic data, medical/surgical history, and imaging findings were collected from electronic health record (EHR). Imaging findings included CBD stone size on ERCP (categorized as small ≤5 mm vs. large >5 mm), CBD diameter (categorized as dilated if CBD diameter >8 mm), and presence or absence of CBD stone on EUS and MRCP. Results: A total of 110 patients were identified to have CBD stone on ERCP. In the final analysis, there were 110 patients with MRCP detecting stone in 66.4% patients. Seventy-two (65.5%) patients had small CBD stone and 38 (34.5%) had large CBD stone. Of this study population, the median age was 53 years, and 61.8% were female. The median BMI was 28.5. A total of 41 (37.3%) had hypertension; 22 (19.8%) had hyperlipidemia and 16 (14.4%) had diabetes. Most patients had cholecystectomy (47.3%) after ERCP and 39.1% before ERCP while the rest still have their gallbladder. Sixty-one (55.4%) had dilated CBD (Table 1). The multivariate logistic regression analysis revealed that larger stone size was associated with a higher likelihood of stone detection by MRCP (adjusted odds ratio: 5.57; 95% confidence interval [CI] 1.66 -18.7; P=0.005) (Table 2).Table: Table. Study population characteristics based on CBD stone size (univariate analysis)Table: Table. Multivariate Logistic Regression Results for the CBD stone detection by MRCPConclusion: MRCP has lower detectability rate for small (≤ 5 mm) common bile duct stone compared to EUS and ERCP. Sensitivity of MRCP for stones larger than 5 mm was satisfactory. Patients with a low or intermediate clinical index of suspicion for choledocholithiasis, further investigation with EUS is recommended despite negative MRCP.
• Gholam, S., Ghazala, S., Pokhrel, B., & Desai, A. P. (2017). A Rare Case of Downhill Esophageal Varices in the Absence of Superior Vena Cava Obstruction. The American journal of gastroenterology, 112(3), 413.
• Pokhrel, B. (2017).

  Sickle Cell Hepatopathy Masquerading as Advance Chronic Liver Disease

  . The American Journal of Gastroenterology. doi:10.14309/00000434-201710001-02288
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  Introduction: The hepatic manifestation of sickle cell disease is described as sickle cell hepatopathy (SCH). Hepatic involvement and dysfunction vary significantly from acute liver failure to chronic hepatopathy in sickle cell disease patients. We present a case of sickle cell hepatopathy in a patient masquerading as advanced liver disease. Case Report 27 years old black female with past medical history of sickle cell disease(SCD), history of sickle cell crises and advanced chronic kidney disease was admitted for jaundice and abnormal liver tests. She has diagnosed with SCD 1 year ago with 85% hemoglobin (Hb) S. She complained of increasing darkness of her urine. She was complaining of mild chest pain. She denied any acute gastrointestinal symptoms. She has no obvious risk factors for chronic liver disease (CLD). Twice in the last 6 months, she was admitted for severe pruritic due to hyperbilirubinemia (Total bilirubin ranged from 30-55) and required multiple sessions of plasmapheresis with symptoms relief. Her admission Hb was 7, total bilirubin was more than 55 and peripheral smear showed brisk sickling. The review of her workup over the last one year showed that she had persistent hyperbilirubinemia with some changes in AST, ALT, Alkaline Phosphatase and persistent thrombocytopenia (concerning of portal hypertension).Ultrasound with doppler of the liver did not show any evidence of Portal or hepatic vein thrombosis but revealed hepatomegaly and some changes of the possible chronic liver disease. MRI abdomen without contrast showed increase iron stores in liver but did not reveal any other hepatic or biliary tree abnormality. Hematology team was consulted to evaluate this patient for bone marrow transplantation, given her organ failures from SCD. As pre-transplant workup, CT guided liver biopsy was requested. Biopsy revealed liver parenchyma with marked congestion of sinusoids with sickled red blood cells, increased parenchymal iron deposition (Grade 2-3 out of 4) and perisinusoidal and periportal fibrosis as shown in figure 1 and 3. Figure 2 showed liver biopsy with sickle cells in the sinusoidal space.Figure: H&E 60x magnification shows sickled red blood cells within liver sinusoids.Conclusion. Significant hyperbilirubinemia in SCD could be multifactorial. A Severe cholestatic picture should raise concern for SCH. Sinusoid could be markedly distended with sickle cell thrombi in SCH. The patient may need treatment with exchange transfusion and plasmapheresis depending upon symptoms. Bone transplant may be a viable option.Figure: H&E 10x magnification shows overview of liver architecture with mild fibrosis and and iron deposition.Figure: Iron stain 40x magnfication shows iron deposition within cytoplasm of parenchymal hepatocytes (visualized as blue globules).
• Pokhrel, B., Desai, A. P., Junna, S., & Knapp, S. M. (2017).

  Factors Affecting Hepatic Encephalopathy and Admission Rates in Post-TIPS Patients: A Single Center Experience: 984

  . The American Journal of Gastroenterology, 112, S552-S553. doi:10.14309/00000434-201710001-00985
• Pokhrel, B. (2016).

  Biliary Tract IPMN Successfully Treated with Roux-en-Y Hepaticojejunostomy

  . The American Journal of Gastroenterology. doi:10.14309/00000434-201610001-01268
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  A 72 year-old lady presented with complaints of jaundice, fatigue, pruritis and anorexia. Her medical history was notable for chronic abdominal pain, GERD and previous cholecystectomy. Admission lab studies revealed a total bilirubin of 7.4, alkaline phosphatase of 194 and an AST of 82. CT and MR imaging showed dilated intra and extrahepatic biliary ducts and suspicion for an ampullary mass. The pancreatic duct was radiographically normal. Initial ERCP revealed haziness in the CBD; two stents were placed after the duct was swept for gelatinous fluid which was cytologically negative for malignancy. She was discharged home but returned two weeks later with persistent complaints of refractory jaundice. Repeat serum studies yielded an increased total bilirubin of 14.1, an alkaline phosphatase of 342 and a stable AST of 84. She underwent repeat EUS/ERCP and intraductal cholangioscopy (with the Spyglass system) which showed a lesion at the hilar and right main hepatic duct suspicious for intraductal papillary mucinous neoplasm (IPMN). She had surgical resection of the extrahepatic bile duct with right hepatectomy, re-excision of the left hepatic duct margin and Roux-en-Y hepaticojejunostomy. The postoperative course was complicated by the development of ascites and septicemia which were successfully treated with diuretics and antibiotics. Excised tissue sent for pathology confirmed primary right hepatic duct IPMN consistent with carcinoma in situ and high grade dysplasia. Furthermore, right partial hepatectomy revealed extensive IPMN involving major and minor ducts and obstructive cholangiopathy of the liver adjacent to the bile duct. Compared to its pancreatic counterpart, biliary tract-IPMN (BT-IPMN) is an uncommon phenomenon and is even rarer when isolated to the intra and extra-hepatic hilar ducts. BT-IPMN is more often associated with invasive features compared to similar pancreatic neoplasms. Patients typically present with abdominal pain, jaundice and elevated total bilirubin and alkaline phosphatase. Historically, BT-IPMNs have been frequently misdiagnosed (as adenocarcinomas, cholangiocarcinomas and cystic neoplasms); there is an emergence of literature substantiating the need for clear diagnostic definitions for this rare diagnosis. BT-IPMN is defined as an intraluminal neoplasm with papillary cyto-architecture and mucin hypersecretion often leading to marked dilatation of affected bile ducts. Treatment is ultimately resection of the involved tissue.
• Pokhrel, B. (2016).

  Diagnostic Yield of EUS over MRI for Detection of Common Bile Duct Stones: A Single Center Experience

  . The American Journal of Gastroenterology. doi:10.14309/00000434-201610001-00029
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  Introduction: Endoscopic retrograde pancreatography (ERCP) is now primarily considered a therapeutic modality for management of common bile duct (CBD) stones. Endoscopic ultrasound (EUS) and Magnetic resonance imaging(MRI) are less invasive modalities used in the diagnosis of CBD stones prior to ERCP. The aim of the study is to detect if there is an additional diagnostic yield of EUS over MRI in detecting CBD stones. Methods: The study was approved by the institutional review board. Retrospective review of all patients who underwent ERCP between July 2011 and December 2015 for CBD stones and had an EUS and MRI within 72 hours of the ERCP. All MRI's were performed on a MAGNETOM 3T Skyra or 1.5T Avanto (Siemens, Germany).Table 1: Patient characteristicsTable 2: Diagnostic yield of EUS vs MRIResults: A total of 76 patients underwent ERCP for confirmed CBD stones. 18 patients were excluded as MRI was done > 72 hours prior to the ERCP. Six patients were excluded for missing information. The remaining 52 patients (23 men, mean age 51.6 years) were divided into two groups based on stone size. There were 30 patients with small CBD stones (≤5mm) and 22 patients with larger stones(>5mm). MRI missed 50% of small stones(stones5mm) which were subsequently detected on EUS done prior to ERCP Conclusion: EUS has an additional diagnostic yield over MRI for the detection of CBD stones, especially if they are smaller than 5mm. In patients with a high clinical index of suspicion, further investigation with EUS is recommended despite negative MRCP.
• Pokhrel, B. (2016).

  Medical image of the week: Boerhaave syndrome

  . Southwest Journal of Pulmonary and Critical Care. doi:10.13175/swjpcc039-16
• Pokhrel, B. (2014).

  Increased fat in pancreas not associated with risk of pancreatitis post-endoscopic retrograde cholangiopancreatography

  . Clinical and Experimental Gastroenterology. doi:10.2147/ceg.s31333
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  Increased fat in pancreas not associated with risk of pancreatitis post-endoscopic retrograde cholangiopancreatography Bhupesh Pokhrel,1 Eun Kwang Choi,1 Omer Khalid,2 Kumar Sandrasegaran,3 Evan L Fogel,1 Lee McHenry,1 Stuart Sherman,1 James Watkins,1 Gregory A Cote,1 Henry A Pitt,4 Nicholas J Zyromski,4 Beth Juliar,1 Glen A Lehman11Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, 2Department of Gastroenterology, St Louis University School of Medicine, St Louis, MO, 3Department of Radiology, 4Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USABackground: A preliminary study has shown increased pancreatic fat in patients with idiopathic pancreatitis and sphincter of Oddi dysfunction. In this study, we aimed to determine if an increased quantity of pancreatic fat is an independent risk factor for pancreatitis post-endoscopic retrograde cholangiopancreatography (ERCP).Methods: In this case control study, we retrospectively reviewed a local radiological and ERCP database to identify patients who had had abdominal magnetic resonance imaging (MRI) followed by ERCP no more than 60 days later between September 2003 and January 2011. Percentage of fat was determined by recording signal intensity in the in-phase (Sin) and out-of-phase (Sout) T1-weighted gradient sequences, and calculation of the fat fraction as (Sin - Sout)/(Sin) × 2 by an abdominal radiologist blinded to clinical history. Controls matched for age, gender, and other pancreatobiliary disease were selected from a group with no post-ERCP pancreatitis (before fat content of the pancreas was analyzed).Results: Forty-seven patients were enrolled. Compared with controls, subjects with post-ERCP pancreatitis were similar in terms of age (41.4 years versus 41.1 years), gender (21.2% versus 20.2% males), pancreatobiliary disease characteristics, and most ERCP techniques. Measurements of pancreatic head, body, and tail fat and body mass index were similar in patients and controls.Conclusion: Increased pancreatic fat on MRI criteria is not an independent predictor of post-ERCP pancreatitis.Keywords: magnetic resonance imaging, obesity, pancreatic fat, post-ERCP pancreatitis, sphincter of Oddi dysfunction
• Pokhrel, B., Choi, E. K., Khalid, O., Sandrasegaran, K., Fogel, E. L., McHenry, L., Sherman, S., Watkins, J., Cote, G. A., Pitt, H. A., Zyromski, N. J., Juliar, B., & Lehman, G. A. (2014). Increased fat in pancreas not associated with risk of pancreatitis post-endoscopic retrograde cholangiopancreatography. Clinical and experimental gastroenterology, 7, 199-204.
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  A preliminary study has shown increased pancreatic fat in patients with idiopathic pancreatitis and sphincter of Oddi dysfunction. In this study, we aimed to determine if an increased quantity of pancreatic fat is an independent risk factor for pancreatitis post-endoscopic retrograde cholangiopancreatography (ERCP).
• Pokhrel, B. (2012).

  Current and past cigarette smoking significantly increase risk for microscopic colitis

  . Crohn's and Colitis Foundation of America, Inc.. doi:10.1002/ibd.22838
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  BackgroundCigarette smoking is an important environmental factor affecting inflammatory bowel disease. The role of smoking has not been rigorously studied in microscopic colitis (MC). The aim of this study was to compare the association of cigarette smoking in individuals with MC compared to a control population without MC.
• Pokhrel, B. (2012).

  Current and past cigarette smoking significantly increase risk for microscopic colitis

  . Inflammatory Bowel Diseases. doi:10.1002/ibd.22838
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  Cigarette smoking is an important environmental factor affecting inflammatory bowel disease. The role of smoking has not been rigorously studied in microscopic colitis (MC). The aim of this study was to compare the association of cigarette smoking in individuals with MC compared to a control population without MC.We reviewed the records of patients with a clinical and histologic diagnosis of collagenous colitis (CC) or lymphocytic colitis (LC). Clinical history, including alcohol and smoking status at the time of diagnosis of MC, were reviewed. In this case-control study, age- and gender-matched patients without diarrhea presenting for outpatient colonoscopy served as the control population.We analyzed a total of 340 patients with MC: 124 with CC and 216 with LC. Overall, any smoking status (former or current) was associated with MC (odds ratio [OR] 2.12, 95% confidence interval [CI]: 1.56-2.88). This risk was more prominent in current smokers (adjusted OR 5.36, 3.81, and 4.37 for CC, LC, and all MC, respectively, 95% CI all greater than 1). The association of smoking was not significantly affected by gender or average alcohol consumption.In our study population, cigarette smoking is a risk factor for the development of both forms of microscopic colitis. There were no significant differences between LC and CC, and current smoking and the development of microscopic colitis affected men and women similarly. We feel that these data are sufficient to discuss the potential risks of tobacco use in patients with microscopic colitis.
• Pokhrel, B. (2012).

  Decreased Colorectal Cancer and Adenoma Risk in Patients with Microscopic Colitis

  . Digestive Diseases and Sciences. doi:10.1007/s10620-011-1852-2
• Pokhrel, B. (2012).

  Sa1136 Increased Fat in Pancreas: A Risk Factor for Post-ERCP Pancreatitis?

  . Gastroenterology. doi:10.1016/s0016-5085(12)60843-9
• Yen, E. F., Pokhrel, B., Bianchi, L. K., Roy, H. K., Du, H., Patel, A., Hall, C. R., & Witt, B. L. (2012). Decreased colorectal cancer and adenoma risk in patients with microscopic colitis. Digestive diseases and sciences, 57(1), 161-9.
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  Microscopic colitis is currently considered to harbor no increased risk for colorectal cancer, based on a few small studies with limited long-term follow-up. Our aim was to identify patients with microscopic colitis, and to compare long-term rates of colorectal cancer or adenoma to a control group of patients without microscopic colitis.
• Yen, E. F., Pokhrel, B., Du, H., Nwe, S., Bianchi, L., Witt, B., & Hall, C. (2012). Current and past cigarette smoking significantly increase risk for microscopic colitis. Inflammatory bowel diseases, 18(10), 1835-41.
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  Cigarette smoking is an important environmental factor affecting inflammatory bowel disease. The role of smoking has not been rigorously studied in microscopic colitis (MC). The aim of this study was to compare the association of cigarette smoking in individuals with MC compared to a control population without MC.
• Chiorean, M. V., Pokhrel, B., Adabala, J., Helper, D. J., Johnson, C. S., & Juliar, B. (2011). Incidence and risk factors for lymphoma in a single-center inflammatory bowel disease population. Digestive diseases and sciences, 56(5), 1489-95.
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  Previous studies on the risk of lymphoma in inflammatory bowel disease (IBD) have yielded conflicting results. We aim to determine the incidence and risk factors for lymphoma in a large IBD population.
• Pokhrel, B. (2011).

  Incidence and Risk Factors for Lymphoma in a Single-Center Inflammatory Bowel Disease Population

  . Digestive Diseases and Sciences. doi:10.1007/s10620-010-1430-z
• Pokhrel, B. (2010).

  Endoscopic Mucosal Resection (EMR) for Barrettʼs and Early Esophageal Cancer: A Single Center U.S. Experience

  . The American Journal of Gastroenterology. doi:10.14309/00000434-201010001-01428
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  Purpose: There are few large reported U.S. experiences with EMR for Barrett's and early esophageal cancer. We report our experience with 292 consecutive patients undergoing EMR for Barrett's. Methods: Retrospective review of 292 consecutive patients undergoing EMR at a single center for Barrett's or early esophageal adenocarcinoma. Results: The pre-EMR diagnosis was cancer or intramucosal cancer in 109 (37%), 140 (48%) had high grade dysplasia (HGD), 30 (10%) had low grade dysplasia (LGD), and 13 had no dysplasia. There were 226 males, and mean Barrett's length was 4.2 +/- 3.6 cm. Nodular disease was present in 211 (72%). The average number of EMR resection specimens was 4.3 and EMR sessions was 1.7. Of the 109 with adenocarcinoma or intramucosal adenocarcinoma, EMR downgraded histology in 20 (18%). Of the 140 with pre-EMR HGD, 23 (16%) were upgraded to adenocarcinoma, 22 (16%) were downgraded to LGD, and 10 (7%) had no dysplasia. Of those with pre-EMR LGD, 7 (23%) had HGD and 8 (27%) had no dysplasia at EMR. 24 patients underwent surgery based on EMR histology. Most patients underwent additional treatments for residual flat disease. Only 2 patients had recurrence of cancer (1 intralumenal and 1 metastatic) during follow up. Strictures developed in 100 (34%) patients and all were managed successfully by dilation (average 3.1 sessions). 10 patients (3.4%) had bleeding and all were treated successfully by clipping or electrocautery. There were 2 perforations, both treated successfully by stenting. Conclusion: EMR plays an essential role in staging nodular dysplasia and early esophageal early cancer. Complications were common but were managed successfully by endoscopy. The rate of development of recurrent or metachronous cancer was low. Disclosure: Dr Rex - research support and speakers bureau Olympus America.
• Pokhrel, B. (2010).

  S1176 Post-Menopausal Malignant Conditions in Women With Microscopic Colitis

  . Gastroenterology. doi:10.1016/s0016-5085(10)60892-x
• Pokhrel, B. (2009).

  112 Concomitant Adenoma Rates in Patients with Microscopic Colitis

  . Gastroenterology. doi:10.1016/s0016-5085(09)60095-0
• Pokhrel, B. (2009).

  Microscopic Colitis and Association with Cigarette Smoking and Alcohol Intake

  . The American Journal of Gastroenterology. doi:10.14309/00000434-200910003-01220
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  Purpose: Microscopic colitis (MC) refers to two medical conditions which cause chronic diarrhea: collagenous colitis (CC) and lymphocytic colitis (LC). While Crohn's disease activity is associated with cigarette smoking, the converse appears to be seen in ulcerative colitis. The role of cigarette smoking has not been rigorously studied in MC. CC but not LC has been associated with smoking in one cohort study. The association of alcohol intake and MC is unknown. The aim of this study was to compare the association of smoking and alcohol intake in individuals with microscopic colitis compared to a reference population without MC. Methods: We reviewed the records of patients with a histologic diagnosis of microscopic colitis, lymphocytic colitis or collagenous colitis, as identified in our pathology database from January 2000 to August 2008. Smoking status (current, former, or non-smoking) as well as alcohol usage (daily, weekly, rarely, and none) at the time of diagnosis of MC was reviewed. Age and gendermatched patients without diarrhea presenting for outpatient colonoscopy from July 2005-March 2007 served as the reference population in a 1:1 fashion. Results: We analyzed a total of 724 patients with MC: 404 with LC and 276 with CC. Information on smoking and alcohol status was found in 633 patients with MC, 359 patients with LC, and 235 patients with CC (Table 1). Overall, any smoking status (former or current) was associated with MC (OR: 1.99, 95% CI: 1.61 - 2.48). Both LC and CC were associated with tobacco use. (OR: 2.19 and 1.92 respectively, 95% CI: 1.62 - 2.96 and 1.49 - 2.49 respectively). Although there was no apparent association with alcohol use (yes or no) and MC, we found a significant trend association with more frequent (daily or weekly) alcohol use (p