Thursday, October 6, 2011

Liver and Pancreatic Diseases

Liver and Pancreatic Diseases

These presentations were given at Digestive Disease Week 2011 in Chicago

In the session on liver and pancreatic diseases, Dr. Ira M. Jacobson, AGAF, of Weill Cornell Medical College discussed direct-acting antivirals for hepatitis C treatment. He emphasized that combination therapy must contain a drug with a high barrier to resistance, and he noted that the hope for sustained virologic response should be greater than 70%.

There are also genetic barriers to resistance, such as those seen in genotype 1 patients.Dr. Jacobson emphasized that gastroenterologists treating hepatitis C patients must understand the pros and cons of protease inhibitor therapy, and also said interferon and ribavirin will remain important treatments in the future.

Dr. Anna Mae Diehl of Duke University lectured on nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis(NASH), as related to the obesity epidemic.

Dr. Diehl reported that NAFLD is 20 times more prevalent than chronic hepatitis C in the United States. Diagnostic advances involving serum-,biopsy- and DNA- based testing have been made. These diagnostic advances can help with prediction of the stage of fibrosis.

She also stressed that several effective therapeutic approaches have been identified,including vitamin E therapy, pioglitazone,and lifestyle modifications,and there is hope for individualized therapy involving evaluation of the host’s microbiome and liver repair responses.

Factors that influence the outcomes of NASH are being investigated.Dr. K. Rajender Reddy from the University of Pennsylvania discussed hepatic masses and how they can be treated most effectively.

Dr. Reddy outlined the differences between benign and malignant masses, and emphasized that biopsies usually are not needed. Hepatic adenomas have a less than 5% risk for malignant transformation. Factors that are associated with increased risk include size greater than 5 cm, having beta catenin biomarkers, and being symptomatic.Dr. Reddy also emphasized the use of serial imaging with dynamic CT or MRI for most lesions. Indeterminate lesions and those with symptoms require further investigation. Indeterminate masses should be biopsied, and laparoscopic unroofing is recommended for hepatic cysts.

Dr. Dhiraj Yadav from the University of Pittsburgh lectured on chronic pancreatitis and new risk factors for this disease.

Dr. Yadav reported data from an NIH funded study showing that smoking appears to be a dose-dependant risk factor for chronic pancreatitis; continued alcohol consumption and smoking are linked to progression from acute pancreatitis to chronic pancreatitis. Aggressive counseling can decrease the risk of acute pancreatitis recurrence and progression to chronic pancreatitis. He also emphasized that growing knowledge of genes andgene-environment interactions will soon provide a basis for new diagnostic and treatment approaches.

Dr. Suresh Chari from the Mayo Clinic lectured on autoimmune pancreatic disease and its overlap syndromes. Dr. Chari described two distinct forms of autoimmune pancreatitis (AIP) characterized by clinical, histological, and therapeutic features.Type 1 AIP is a multi-system disease that involves the pancreas. Type 2 AIP isa pancreas-specific disorder. He also explained the HISORt criteria (the mnemonic stands for histology, imaging, serology,other organ involvement, and response to therapy) and the IGG-associated systemic diseases afflicting some patients with autoimmune pancreatic disease.

He emphasized that long-term immunosuppressant therapy may be needed in some patients to maintain disease remission, and noted that rituximab has been used with some success based on anecdotal reports.Overall, the liver and pancreatic disease section was enlightening and very educational,providing clinicians with practical information to use in the diagnosis,treatment, and management of their patients with these diseases.

■DARWIN L. CONWELL, M.D., M.S., is Associate Director, Center for Pancreatic Disease, Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, and Associate Professor of Medicine, Harvard Medical School,Boston

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