Journal Of Hepatology Research Articles

Call for applications for the Journal of Hepatology: Editor-in-Chief 2015–2020

Call for applications for the Journal of Hepatology: Editor-in-Chief 2015–2020

PWE-115 Alpha-Fetoprotein Measurement in the Diagnosis of Hepatocellular Carcinoma in Real-Life Practice: A Multi-Centre, Retrospective Analysis

IntroductionIn hepatocellular carcinoma (HCC), earlier diagnosisimproves outcome but the optimum method of surveillance in high-risk groups is controversial. Recent AASLD and EASL guidelines[1.2] have recommended six- monthly ultrasound surveillance (USS)...

PWE-060 The Hospital Anxiety and Depression Scale (HADS) Predicts Pain and Distress at Endoscopy

IntroductionTolerability of endoscopy is variable, with pain and distress influencing overall experience. Currently, there is a paucity of work evaluating distress, with no reliable tools established as predictors of endoscopic...

PTU-088 Variation in Practice of Management of Spontaneous Bacterial Peritonitis (SBP)

IntroductionSpontaneous Bacterial Peritonitis (SBP) is the most frequent and life-threatening infection in patients with liver cirrhosis, requiring prompt recognition and treatment. Clinical practise guidelines on management of SBP were released...

PTU-102 Alcoholic Liver Disease in working Age Men Constitutes the Main Burden of Large Volume Paracentesis (LVP) in Devon and Significant Cost Savings are Possible

IntroductionThe burden of liver disease is steadily rising in the UK, partly secondary to alcohol misuse. Ascites requiring LVP is one of the major complications leading to hospital admission in...

Percutaneous hepatic venous stenting for menorrhagia in Budd-Chiari syndrome

Liver InternationalVolume 33, Issue 10 p. 1607-1607 Liver International Images Percutaneous hepatic venous stenting for menorrhagia in Budd–Chiari syndrome P. W. Dhumane, P. W. Dhumane Department of Surgery, PD Hinduja National Hospital, Mumbai, IndiaSearch for more papers by this authorA. V. Kulkarni, A. V. Kulkarni Department of Radiology, PD Hinduja National Hospital, Mumbai, IndiaSearch for more papers by this authorG. Waravdekar, G. Waravdekar Department of Radiology, PD Hinduja National Hospital, Mumbai, IndiaSearch for more papers by this authorS. R. Shah, S. R. Shah Department of Surgery, PD Hinduja National Hospital, Mumbai, IndiaSearch for more papers by this author P. W. Dhumane, P. W. Dhumane Department of Surgery, PD Hinduja National Hospital, Mumbai, IndiaSearch for more papers by this authorA. V. Kulkarni, A. V. Kulkarni Department of Radiology, PD Hinduja National Hospital, Mumbai, IndiaSearch for more papers by this authorG. Waravdekar, G. Waravdekar Department of Radiology, PD Hinduja National Hospital, Mumbai, IndiaSearch for more papers by this authorS. R. Shah, S. R. Shah Department of Surgery, PD Hinduja National Hospital, Mumbai, IndiaSearch for more papers by this author First published: 09 April 2013 https://doi.org/10.1111/liv.12183Citations: 1Read the full textAboutRelatedInformationPDFPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessClose modalShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume33, Issue10November 2013Pages 1607-1607 RelatedInformation RecommendedLong‐term safety and outcome of percutaneous transhepatic venous balloon angioplasty for Budd–Chiari syndromePeng-Xu Ding, Shui-Jun Zhang, Zhen Li, Ming-Ti Fu, Zhao-Hui Hua, Wen-Guang Zhang, Journal of Gastroenterology and HepatologyPTFE‐covered stents improve TIPS patency in Budd‐Chiari syndromeManuel Hernández-Guerra, Juan Turnes, Pablo Rubinstein, Simon Olliff, Elwyn Elias, Jaime Bosch, Juan Carlos García-Pagán, HepatologyBudd‐Chiari syndrome: successful treatment by percutaneous transluminal angioplastyK.M. FOCK A.M., M.B.B.S.M.Med (Int.Med), C.C. CHAN M.B.B.S., M.R.C.P.(UK), T.K. KHOO M.B.B.S., F.R.C.R., Australasian RadiologySuccessful percutaneous stenting of a right gastroepiploic coronary bypass graft using monorail delivery system: A case reportMahmood Alam MD, Arshad M. Safi MD, Mahendra K. Mandawat MD, John E. Anderson MD, Tak Kwan MD, Alan Feit MD, Luther T. Clark MD, Catheterization and Cardiovascular InterventionsDabigatran as an oral anticoagulant in patients with Budd–Chiari syndrome post‐percutaneous endovascular interventionSanchit Sharma, Ramesh Kumar, Gyanranjan Rout, Shivanand R Gamanagatti, Shalimar, Journal of Gastroenterology and Hepatology

Abstract 2175: Src homology region 2 domain-containing phosphatase-1 is a major target of sorafenib in hepatocellular carcinoma.

Abstract Sorafenib is the only clinical approved drug in hepatocellular carcinoma (HCC). Previously, we have investigated that Signal transducer and activator of transcription 3 (STAT3) is a kinase-independent target of sorafenib (Journal of Hepatology, 2012). Here, we report that sorafenib relieves the anto-inhibited Src homology region 2 domain-containing phosphatase-1 (SHP-1) to increase its phosphatase activity and inhibit p-STAT3-related signaling. Sorafenib increases SHP-1 activity either in HCC cell-based test or purified recombinant SHP-1 protein directly. Deletion of N-SH2 domain (dN1) or point mutation (D61A) of SHP-1 abolished the effect of sorafenib on SHP-1 and phospho-STAT3 (p-STAT3) and apoptosis in HCC, suggesting that sorafenib may affect SHP-1 by switching the transformation from auto-inhibition to the active form. The significant correlation between inhibited SHP-1 and overexpression of p-STAT3 was demonstrated in immunohistochemistry of clinical HCC samples. Novel sorafenib derivatives, SC-43 and SC-40, showed more potent effects than sorafenib on enhancing the activity of SHP-1 activity, inhibiting p-STAT3, induction apoptosis and overcoming sorafenib resistance in HCC. SC-43 showed better survival benefits than sorafenib in orthotopic HCC tumors. SHP-1 represents a major target of sorafenib in HCC. Sorafenib derivatives (SC-43 and SC-40) show better anti-HCC effects than sorafenib by targeting SHP-1. Further clinical investigations may be warranted. Citation Format: Wei-Tien Tai, Chung-Wai Shiau, Pei-Jer Chen, Ann-Lii Cheng, Kuen-Feng Chen. Src homology region 2 domain-containing phosphatase-1 is a major target of sorafenib in hepatocellular carcinoma. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 2175. doi:10.1158/1538-7445.AM2013-2175

Blockade of CCR5 to protect the liver graft in HIV/HCV co-infected patients

Background: Graft-versus-host disease (GVHD) is a major barrier to successful allogeneic hematopoietic stem-cell transplantation (HSCT). The chemokine receptor CCR5 appears to play a role in alloreactivity. We tested whether CCR5 blockade would be safe and limit GVHD in humans. Methods: We tested the in vitro effect of the CCR5 antagonist maraviroc on lymphocyte function and chemotaxis. We then enrolled 38 high-risk patients in a single-group phase 1 and 2 study of reduced-intensity allogeneic HSCT that combined maraviroc with standard GVHD prophylaxis. Results: Maraviroc inhibited CCR5 internalization and lymphocyte chemotaxis in vitro without impairing T-cell function or formation of hematopoietic-cell colonies. In 35 patients who could be evaluated, the cumulative incidence rate (±SE) of grade II to IV acute GVHD was low at 14.7 ± 6.2% on day 100 and 23.6 ± 7.4% on day 180. Acute liver and gut GVHD were not observed before day 100 and remained uncommon before day 180, resulting in a low cumulative incidence of grade III or IV GVHD on day 180 (5.9 ± 4.1%). The 1-year rate of death that was not preceded by disease relapse was 11.7 ± 5.6% without excessive rates of relapse or infection. Serum from patients receiving maraviroc prevented CCR5 internalization by CCL5 and blocked T-cell chemotaxis in vitro, providing evidence of antichemotactic activity. Journal of Hepatology 20

Editorial introductions

Current Opinion in Organ Transplantation was launched in 1996. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of organ transplantation is divided into 18 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. SECTION EDITORS Ernest van HeurnErnest van HeurnErnest van Heurn is a transplant surgeon and Professor at the Maastricht University Medical Centre in the Netherlands. He qualified as Medical Doctor at Leiden University, the Netherlands, in 1988 and was a fellow at the cardiothoracic transplant department of Papworth Hospital, Cambridge, UK (Sir Terence English) afterwards. He received his formal specialist training in general surgery and later in transplant surgery from Professor Gauke Kootstra at the Maastricht University Medical Centre, where he also obtained his PhD degree in 1997. Dr van Heurn succeeded his former chief as head of the surgical transplantation department and the organ preservation laboratory in 2002. Next to his clinical work as transplant surgeon, he is trainer-surgeon of the national abdominal organ procurement teams and responsible for regional organ donation and procurement in the Maastricht area. His research interests include kidney transplantation from donors after cardiac death, organ preservation and renal ischaemia reperfusion injury. His research group focuses on transplantation of marginal kidneys, particularly of ischaemically damaged kidneys from donors after cardiac death. The emphasis is on kidney preservation techniques, viability testing and strategies to improve kidney function before or immediately after transplantation, which are studied both clinically and in animal models. Ernest van Heurn is member of the Editorial Board of several international journals and is presently one of the chairs of the European expert panel to provide recommendations for transplantation of kidneys from donors after cardiac death. Jeffrey L. PlattJeffrey L. PlattJeffrey L. Platt, M.D. is Professor of Surgery and of Microbiology at the University of Michigan, USA. He co-directs the Transplantation Biology Program. Dr Platt graduated from the University of Southern California School of Medicine, USA and trained in pediatrics (Childrens Hospital of Los Angeles, USA) and nephrology (University of Minnesota, USA). Dr Platt's research addresses such questions as how T cells and B cells and their products interact with tissues to cause disease, how these interactions induce protection against further injury (accommodation), how novel technologies can be directed at replacing organ function and restoring immunological fitness and how fusion of one cell with another impacts on genomic integrity and cellular function. Dr Platt has published 550 papers and 4 books. He is a long standing member of the American Society of Nephrology, the American Heart Association, the FASEB (Immunology and Experimental Pathology), the Association of American Physicians and the Institute of Medicine of the National Academy of Sciences (USA). Anton I. SkaroAnton I. SkaroAfter completing a multi-organ transplant surgery fellowship at Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA, Dr Skaro was appointed as an Assistant Professor in the Department of Surgery. He performs adult and pediatric abdominal solid organ transplants at Northwestern Memorial Hospital and Lurie Children's Hospital of Chicago, USA. Dr Skaro's clinical and academic interests have evolved and are now focused on risk stratification and the econometrics of liver, and kidney transplantation with an emphasis on utilization of organs donated after cardiac death and risk aversion in transplantation. As his interests shifted toward risk stratification in transplantation, he was appointed as the Director of Quality Assessment and Performance Improvement and Associate Director of Kidney and Pancreas Transplantation at the Comprehensive Transplant Center of Northwestern University. The advances in risk assessment particularly relating to donation after cardiac death (DCD) liver transplantation have been recognized nationally. Dr Skaro has been acknowledged as an expert in the field of Donation after Cardiac Death, having been invited to present at the American Transplant Congress, Academic Surgical Congress, and American Association for the Study of Liver Diseases Meeting. Furthermore, he has published several reports examining the economic and clinical outcomes of DCD liver transplant which appear in Surgery, Liver Transplantation, Annals of Surgery and the Journal of Hepatology. Dr Skaro has more recently focused on investigating the unintended consequences of regulatory oversight including risk averse transplant center behavior. Dr Skaro is an active member in multiple nationally based committee efforts sanctioned by the American Society of Transplant Surgeons, the United Network for Organ Sharing, and the Health Resources and Services Administration including the Standards Committee, Reimbursement Committee, Operations and Patient Safety Committee, and Donor Management Taskforce.

Association between CD14−159C>T polymorphisms and the risk for alcoholic liver disease

The association between CD14-159C>T polymorphisms and alcoholic liver disease (ALD) risk has been investigated in many studies, but the results were inconsistent. Therefore, we performed a meta-analysis to investigate the association between the CD14-159C>T polymorphisms and the risk for ALD. A comprehensive literature search was conducted to identify the relevant studies from PubMed, ISI Web of Science, and Embase. Pooled odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated using either the fixed-effects model or random-effects model on the basis of the heterogeneity test. A total of eight eligible studies were included in the meta-analyses. The combined results showed no significant association between CD14-159C>T polymorphisms and ALD risk when ALD patients were compared with alcoholics without ALD (T vs. C, OR=1.22, 95% CI 0.84-1.77; TT/TC vs. CC, OR=1.43, 95% CI 0.86-2.37) and when ALD patients were compared with nonalcoholics (T vs. C, OR=1.13, 95% CI 0.90-1.43; TT/TC vs. CC, OR=1.05, 95% CI 0.76-1.46). However, a significant association was observed in the heterozygous comparison (TC vs. CC, OR=3.47, 95% CI 1.93-6.22), whereas a marginal association was observed in the dominant model (TT/CT vs. CC, OR=2.43, 95% CI 1.00-5.91) when alcoholic cirrhosis patients were compared with alcoholics without ALD. This meta-analysis suggests that the CD14-159C>T polymorphism may not be significantly associated with the risk for ALD. Although a significant association was observed between the -159C>T polymorphism and the risk for alcoholic cirrhosis, well-designed studies with large sample sizes are warranted to confirm these results.

Efficacy of transarterial chemoembolization with epirubicin for management of hepatocellular carcinoma

Purpose Hypothesis: Epirubicin TACE (eTACE) is as safe and efficacious as TACE with doxorubicin DEB. This is relevant because eTACE is significantly less expensive than DEB TACE (AWP $296 vs $1537). Materials and Methods After IRB approval, retrospective review of patients undergoing eTACE from 1/1/2012- 9/1/2012 was conducted (coinciding with a nationwide shortage of doxorubicin). 77 patients with imaging diagnosis of HCC (20 women, 57 men; mean MELD 10, range 5-22) had 97 eTACE treatments using 50-100 mg of Epirubicin (Hospira), Lipiodol and gelfoam. After excluding those with prior doxorubicin DEB TACE, 41 had imaging and were analyzed by mRECIST to determine tumor response. Safety data was analyzed on all patients and outcomes were liver toxicity and serious adverse events (CTCAE v4.0). Results Note that in Table 1 the comparison trials reflect response following 2 treatments, nearly all of our patients had one treatment (except for 2 PD, 2 PR, and 1 CR had 2 treatments). In our population, 2 patients were downstaged for transplant and 3 maintained on waiting list; all 5 underwent transplant. eTACE was well tolerated, with mean hospital stay of 1 night. There was no liver toxicity at 1 month. There were 2 deaths in the study population: one from retroperitoneal bleed complications and one from declining liver function in a patient with prior DEB. Conclusion Early results show that eTACE is safe and efficacious for HCC. Long-term follow-up is needed to show durability of response and impact on survival.

Correcting thrombocytopenia in patients with liver diseases: A difficult hurdle

Correcting thrombocytopenia in patients with liver diseases: A difficult hurdle

Scientific Publications Regarding Liver Cirrhosis and Portal Hypertension in 6 Science Citation Index Hepatology Specialized Journals from 2009 To 2011

Scientific Publications Regarding Liver Cirrhosis and Portal Hypertension in 6 Science Citation Index Hepatology Specialized Journals from 2009 To 2011 We analyzed the original papers regarding liver cirrhosis and portal hypertension in 6 science citation index journals that are specialized in hepatology (i.e., Hepatology, Journal of Hepatology, Liver International, Hepatology International, Hepatology Research, and Annals of Hepatology). Methods: All original papers published in these journals between 2009 and 2011 were identified. The proportion of original papers regarding cirrhosis and portal hypertension was calculated, and was compared among different journals. Other characteristics of these papers were also reported.Conclusions: A low proportion of original papers regarding cirrhosis and portal hypertension suggested that more high-quality researches should be performed.

Autoimmune hepatitis/primary biliary cirrhosis overlap syndrome developed in a patient with vitiligo and Hashimoto thyroiditis

Autoimmune hepatitis (AIH) and primary biliary cirrhosis (PBC) are main autoimmune liver diseases. The term overlap syndrome describes the coexistence of two autoimmune liver diseases in the same patient, and AIH/PBC overlap is the most common form 1–3. Patients with AIH/PBC overlap also have other organ and nonorgan specific autoimmune diseases. In the may issue of the European Journal of Gastroenterology & Hepatology, Efe et al. 4 described this association in a large group of AIH/PBC patients. In this study, they found a 43.6% (31/71) prevalence of extrahepatic autoimmune diseases in patients with AIH/PBC overlap. Autoimmune thyroid diseases, Sjögren syndrome, celiac disease, psoriasis, and rheumatoid arthritis were the most commonly associated autoimmune diseases. To contribute additional information in this area of active investigation, we would like to present a case of AIH/PBC overlap that developed in a patient with Hashimoto thyroiditis and vitiligo. A 52-year-old man with a known history of both Hashimoto thyroiditis and vitiligo first presented to our clinic with fatigue, pruritus, and yellowish discoloration of the sclera and skin. Laboratory examinations yielded the following results: alanine aminotransferase 278 IU/l (0–54 IU/l), aspartate aminotransferase 228 IU/l (0–34 IU/l), alkaline phosphatase 512 IU/l (64–160 IU/l), γ-glutamyl transpeptidase 1315 IU/l (20–64 IU/l), total bilirubin 6.5 mg/dl (0.6–1.2 mg/dl), IgG 36.6 g/l (7–16 g/l), and IgM 3.5 g/l (0.4–2.3 g/l). Antinuclear antibody was positive at the titer of 1/320, smooth-muscle antibody was 1/320, antimitochondrial antibody (AMA-M2) was 1/160, and anti-double-stranded DNA (ds-DNA) was 3.4 (0.1–1.1). Findings on a subsequent liver biopsy were consistent with both AIH and PBC, with moderate interface hepatitis along with proliferation of the bile ducts. With a diagnosis of AIH/PBC overlap syndrome, the patient was started on a daily regimen of 30 mg prednisolone, 50 mg azathiopyrine, and 1250 mg ursodeoxycholic acid (UDCA). After remission was achieved, prednisolone was tapered slowly to a maintenance dose of 5 mg/day whereas azathioprine and UDCA were continued at the same doses. The overlap of AIH and PBC is a very rarely encountered clinical entity in clinical practice. Although still there is no consensus on diagnosis and therapy regimes, the Paris criteria suggested by Chazouillères et al.2 are widely used for the diagnosis of these patients. Our patient fulfilled the criteria of overlap syndrome and also showed concomitant AMA and ds-DNA seropositivity, which was found to be a highly specific serological marker of AIH/PBC overlap 5,6. Therapy of these patients includes UDCA combination with immunosuppressive or UDCA alone 1,7. For our patient, we preferred the combination therapy regime and this led to complete biochemical remission 3 months after the initiation of therapy. The coexistence of AIH and PBC with other autoimmune disorders has been well described in large population-based studies 8,9. However, until recently, this association has been described in only small case-based studies for patients with overlap syndromes 10–12. However, in the study by Efe et al.4, a high prevalence of concurrent autoimmune diseases have been reported in a large population of AIH/PBC overlap patients. This study highlighted the importance of considering the association of AIH/PBC overlap syndrome in patients with other known autoimmune disorders presenting with liver dysfunction or extended screening for existing autoimmune diseases during the routine assessment of patients with overlap syndrome. Acknowledgements Conflicts of interest There are no conflicts of interest.

Paper alert

Paper alert

Metastatic Lesions to the Liver

Welcome to this issue of International Journal of Hepatology. The focus will be on metastatic lesions to the liver. We are hopeful that this topic will be of interest to hepatobiliary surgeons, surgical oncologists, medical oncologists, and CT, MR, and interventional radiologists. Liang et al. review hepatic arterial infusion for liver lesions. This therapeutic modality has been propounded since the 1990s by Margaret and Nancy Kemeny, a surgical and medical oncologist, respectively. Liang et al. relate that hepatic arterial infusion may provide good locoregional control of liver tumors. It may be particularly beneficial for colorectal tumors in combination with systemic chemotherapy. Exciting new medications infused through the device may one day lead to stunning advances in this field. Kelly et al. review hepatobiliary contrast-enhanced magnetic resonance imaging for liver metastasis from colorectal cancer. They provide a succinct summary of this topic which should improve the surgeon's ability to plan the appropriate surgical approach and consent patients correctly. Kele et al. revealed a lack of anatomical concordance between preablation and postablation CT images, which may be a risk factor related to ablation site recurrence. This is very important since accurate ablation of metastatic lesions remains the cornerstone of excellent long-term outcomes. Additionally, early detection of recurrence and risk factors for said recurrence are necessary in order to initiate timely retreatment. Bacchetti et al. review, via a meta-analysis,surgical treatment and survival for metastatic neuroendocrine tumors. They found a significantly longer survival in patients treated surgically compared to those treated with embolization. This meta-analysis is another example of advances made in this field including transplantation and new medications. Nguyen-Khac et al. review hepatotoxicity (particularly sinusoidal dilatation) associated with chemotherapy. This is particularly important since many patients receive many courses of chemotherapy before and after surgical intervention. Hopefully, with the advent of new medications, these side effects will be attenuated. We believe this issue is just the beginning in a long line of special issues which will lead to greater understanding of complex hepatologic issues and improved outcomes for our patients.

The More Publication, the Higher Impact Factor: Citation Analysis of Top Nine Gastroenterology and Hepatology Journals

BackgroundThe impact factor (IF), as the most important criterion for journal’s quality measurement, is affected by the self-citation and number of publications in each journal.ObjectivesTo find out the relationship between the number of publications and self-citations in a journal, and their correlations with IF.Materials and MethodsSelf-citations and impact factors of nine top gastroenterology and hepatology journals were assessed during the seven recent years (2005-2011) through Journal Citation Reports (JCR, ISI Thomson Reuters).ResultsAlthough impact factors of all journals increased during the study, five out of nine journals increased the number of publications from 2005 to 2011. There was an increase in self-citation only in the journal of HEPATOLOGY (499 in 2005 vs. 707 in 2011). Impact factors of journals (6.5 ± 3.5) were positively correlated with total number of publications (248.6 ± 91.7) (R: 0.688, P < 0.001). Besides, the self-citation rate (238.73 ± 195.317) was highly correlated with total number of publications in each journal (248.6 ± 91.7) (R: 0.861, P < 0.001). On the other hand, impact factor without self-citation (6.08 ± 3.3) had a correlation (R: 0.672, P < 0.001) with the number of published items (248.6 ± 91.7).ConclusionsThe number of articles and self-citation have definite effects on IF of a journal and because IF is the most prominent criterion for journal’s quality measurement, it would be a good idea to consider factors affecting on IF such as self-citation.

Fluvastatin helps interferon‐based therapy in chronic hepatitis C: Fact or fiction?

Fluvastatin helps interferon‐based therapy in chronic hepatitis <scp>C</scp>: Fact or fiction?

Expanding the therapeutic armamentarium of ulcerative proctitis

Short term remission rates are as high as 90%. 2 Topical 5-ASA is also more effective than topical steroid. When topical 5ASA or steroid fail, oral agents including 5ASA, azathioprine or 6-mercaptopurine and steroids may be used, but they do not always help. 3 Infliximab, an antitumor necrosis factor (TNF) antagonist, can also be effective in these patients; there is a clinical response in 69% and remission in about 30% of patients. 4 Despite these first and second line approaches, there are still a significant proportion of patients with proctitis who do not achieve clinical improvement, let alone remission, with these agents. Resistant proctitis can be extremely challenging to manage. Several novel topical agents in the form of suppositories or enemas havebeeninvestigatedincludingbutyrate,epidermalgrowthfactor, cyclosporine, tacrolimus, arsenic, lidocaine, bismuth, rebamipide and thromboxane, 5 . 6 While some of these agents appear to demonstrate impressive outcomes, the majority have only been examined in small open-label studies, and in some, the findings have never been repeated. More recently, case series have shown that elective appendectomy can be associated with clinical improvement and mucosal healing in patients with proctitis. 7,8 Figure 1 illustrates a suggested treatment algorithm for patients with proctitis. In this issue of the Journal of Gastroenterology and Hepatology, Fukunaga et al. report a placebo-controlled trial evaluating the use of a herbal preparation called Xilei San (XS) in patients with resistant proctitis (defined as patients who had failed rectal 5-ASA or steroids in combination with oral 5-ASA, steroids or azathio

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