Center for Liver Disease

and Transplantation
Spring/Summer 2015

Message from the Director

This is an exciting time for all of us here at the Center for
Liver Disease and Transplantation at Dignity Health St.
Josephs Hospital and Medical Center. Some of our recent
accomplishments:
Establishment of the first clinically available
elastography technology for assessment of liver
fibrosis in Arizona
The Third Annual Current Advances in Liver Disease
CME program, held September 2014 at St. Josephs
with over one hundred attendees
Establishment of our active satellite hepatology clinics
in Tucson and Flagstaff
National recognition for having developed one of the
largest Hepatitis C practices in the United States
Rapid expansion of our clinical trial and research
programs
Completion of our 2 year $500,000 CDC grant for
teleconferencing support of primary care hepatitis C
treatment in rural and medically underserved areas
(Project ECHO)

Recruitment of Drs. Justin Reynolds (GI/Hepatology),

Robert Gish (GI/Hepatology) and Anita Kohli
(Infectious Disease), consistent with 100% of our
physicians being fully subspecialty board certified
The approval of our UNOS application for liver
transplantation, under the surgical leadership of
James Cashman MD and Jeffrey Brink MD, and with
Justin Reynolds MD serving as Medical Director, Liver
Transplant Service
Presentation on our successful Project ECHO program
at the Annual Meeting of the American Association for
the Study of Liver Disease in Boston, November 2014
We are grateful for the overwhelming support for our new
liver program from our colleagues throughout the region
and we look forward to an exciting future!
Richard A. Manch, MD, FAASLD, FACP, FACG

Chief of Hepatology
Center for Liver and Hepatobiliary Disease
St. Josephs Hospital and Medical Center
Phoenix, Arizona
Clinical Professor of Medicine, University of Arizona
Professor of Medicine, Creighton University

New Liver Transplant Program

Justin A. Reynolds, MD

St. Josephs Hospital and Medical Center has been approved by UNOS (United Network for Organ
Sharing) to provide liver transplantation services. Dr. Justin Reynolds will serve as Medical Director
of the Liver Transplant Service and Drs. James Cashman and Jeffrey Brink will provide the surgical
expertise. St. Josephs will have 4 board certified transplant hepatologists available to see referrals.
This completes our efforts to establish a fully functioning liver service at St. Josephs noted Dr. Richard
Manch, Chief of Hepatology. Dr. Reynolds, who joined the staff last summer, commented that It is
indeed exciting to be involved in a new liver transplant program. We now have the opportunity to provide
high quality transplant care to patients with advanced liver disease and liver cancer. St. Josephs Hospital and Medical
Center already has one of the largest lung transplant programs in the US and initiated kidney transplantation in 2014.
Referrals for liver transplant evaluation can be made by calling the Center for Liver Disease and Transplantation at
602.406.LIVE (5483).

HCC multidisciplinary care

and LI-RADS
As the second most common cause
of cancer-related death throughout
the world, and the fast growing cancer
in the US, hepatocellular carcinoma
(HCC) is a complex disease often
associated with a poor prognosis.
However, recent research has shown
that adopting a multidisciplinary
approach when treating HCC can
dramatically improve patient outcomes.
Beginning in 2012, St. Josephs Center
for Liver Disease and Transplantation
has treated HCC patients with an
17-member team that includes
hepatologists, oncologists, surgeons,
diagnostic radiologists, interventional
radiologists, nurse practitioners and
others. The team approach offers many
advantages not only for patients, but

Elastography and Aixplorer

St. Josephs is the only facility in Arizona/
New Mexico to offer the Aixplorer
ultrasound system to better diagnose
liver disease by measuring liver stiffness.
Since its installation in November 2014,
the center has used the ultrasound
system in the treatment of more than
600 patients.
The Aixplorer features unique
ShearWaveTM Elastography (SWE), a
rapidly growing ultrasound technique
that measures tissue elasticity to
provide structural and pathological
information. Unlike surface waves,
which reflect off an object, shear
waves move through the body of

for care providers, as well.

managed at any time.

Since implementing the

multidisciplinary team approach,
our patients have experienced
improvements in coordination of care,
quality of life and treatment outcomes,
says Dr Richard Manch. And from a
clinical standpoint, working as a team
gives our providers an additional forum
for sharing ideas and standardizing
procedures and treatment protocols.

Because accurate diagnosis and

monitoring are a crucial component
of the treatment plan, diagnostic
and interventional radiology play a
key role in the care of HCC patients.
St. Josephs radiologists utilize the
Liver Imaging Reporting and Data
System (LI-RADS), an algorithm that
standardizes CT and MRI imaging
for HCC, to ensure consistency and
enhance communication among team
members. The tool can also be used to
classify patients with cirrhosis who are
at risk of developing HCC.

Patients with a suspected or confirmed

diagnosis of HCC undergo a detailed
assessment at St. Josephs, where
they have access to all potential
therapies, including surgical resection,
targeted transarterial chemotherapy
and transplant referral when indicated.
The treatment team meets regularly to
coordinate care for the centers many
HCC patients who are being actively

an object. Measuring
the speed of shear wave
propagation helps determine
tissue elasticity, which
is particularly useful in
assessing the extent of
fibrosis, for example.
Recent studies have shown
that SWE offers improved
diagnostic performance
compared to transient elastography.
Research has also demonstrated
improved image reproducibility among
providers. The Aixplorer also features an UltraFastTM Doppler, which
manages data significantly faster than
conventional ultrasound. Acquiring images at 20,000 Hz compared to 100
Hz in other systems this technology
captures high quality, real-time images
that are displayed on a color-coded
map of the entire region of interest.
The color-coding system allows for
easier interpretation of tissue stiffness,
and therefore, a faster diagnosis.
This technology allows us to provide
fast and accurate diagnoses in the
convenience of the clinic setting. A

To refer a patient with diagnosed or

suspected HCC to St. Josephs Center
for Liver Disease and Transplantation,
call 602.406.LIVE (5483).

diagnosis that may have taken

days or weeks in the past can
now be done in minutes and
noninvasively, which is an
added benefit, says Dr Richard
Manch, Chief of Hepatology
at St. Josephs. The Aixplorer
has allowed us to significantly
reduce the amount of biopsies
taken, while at the same time
improving the accuracy of those
biopsies that are performed. notes Dr.
Robert Gish, Senior Medical Director of
the liver program.
In addition to diagnosing liver disease,
the Aixplorer allows providers to
better monitor disease progression
and regression. Additional clinical
advantages include better imaging in
patients with ascites and obesity, more
accurate needle placement for biopsies
and paracentesis, and easier posttransplant monitoring.
Elastography studies can be ordered
directly, without hepatology consultation
by calling the radiology department
directly at 602.406.6700. Ask for
Courtney Mitchell, MD, Radiology.

Liver Transplantation Special Interest

Group at AASLD Spotlights Successful
Outreach Through Project ECHO
Dr. Manch presented at the November AASLD Liver
Meeting in Boston about Project ECHO, a
collaborative model of medical education and care
management that trains clinicians to provide better
care to people in rural and underserved communities.
He discussed how the ECHO program can be
implemented in hepatology and liver transplant
practice.
ECHO stands for Extension for Community
Healthcare Outcomes. Its mission is to expand the
capacity to provide best practice care for common
and complex diseases in rural and underserved
areas and to monitor outcomes. Project ECHO is a
model for lifelong medical learning and collaborative
practice that links front-line primary care clinicians
with specialist care teams at university medical
centers to manage patients who have chronic
conditions requiring complex care. Research
compared treatment for hepatitis C viral infection
at the University of New Mexicos HCV clinic with
treatment by primary care clinicians at 21 ECHO
sites in rural areas and prisons in New Mexico,
enrolling patients with chronic HCV infection who had
received no previous treatment. The study showed
that the ECHO model is an effective way to treat
HCV infection in underserved communities. Using
telehealth technology, including videoconferencing,
the ECHO program offers primary care providers
from underserved areas training, advice and support
in delivering best-practice care for patients with
complex health conditions, such as chronic HCV
infection.
Dr. Manch described how he and his colleagues
implemented the ECHO program to provide
HCV therapy in rural areas of Arizona, where the
prevalence of HCV was high, but there were few
treatment centers. They started the program in
collaboration with North County Healthcare, a health
system with multiple clinics in Northern Arizona.
The program requires a teleconferencing room,
teleconferencing hardware and software or the
participation of local providers who have personal
computers with webcams, as well as a dedicated
hepatologist and a small team of nurse practitioners
or physician assistants and data managers, he said.
Funding from the CDC and industry sources allowed
St. Josephs to initiate the program, which has now
expanded to multiple sites in Arizona.

Save the Date

4th Annual Current Trends in Liver Disease

Hepatitis C From A to Z
CME
Friday, October 9, 11:30 a.m. - 5 p.m.
St. Josephs Hospital and Medical Center
Sonntag Pavilion
Have lunch and spend a Friday afternoon (and
spare your weekend) learning about the very
latest developments in the treatment of Hepatitis
C. Internationally known experts will join the St.
Josephs faculty in presenting a lively CME program
reviewing key topics, including evolving standard
of care, new drugs in development, payer issues,
special populations, and HIV/HCV co-infection.
Anyone interested in the treatment of HCV should
be sure to attend!
For more information, email Liver@DignityHealth.org
AMA PRA Category 1 Credit TM will be applied for
through St. Josephs Hospital and Medical Center.

The new AASLD fellowship status

Two St. Josephs physicians Robert Gish, MD, and Richard Manch, MD were named inaugural fellows of the
American Association for the Study of Liver Diseases (AASLD), the highest honor bestowed upon association members.
Established in 2014, the fellowship program recognizes individuals who have made a significant contribution to the field
of liver and biliary disease.
The inaugural class included physicians, scientists, researchers and other healthcare providers from throughout the world.
The AASLD Fellow designation has been created and is reserved for those who have made major contributions to studying
and caring for patients with liver disease and is an important way for the Association to recognize their accomplishments,
said Dr. Adrian Di Bisceglie, AASLD President.
Dr. Manch, who joined St. Josephs in 2012, had previously been instrumental in developing the largest liver transplant
program in Arizona, as well as developing an extensive network of liver disease outreach clinics throughout the state. Since
coming to St. Josephs, Dr. Manch has worked with Ann Moore, FNP to initiate our active satellite clinics for liver disease
patients in Tucson and Flagstaff.
Dr. Gishs research emphasis includes viral hepatitis, liver transplantation and the bioartificial liver. He is involved in both
national and international public policy related to liver cancer, liver transplantation and viral hepatitis. His international
advocacy career focuses on public policy in Vietnam, the Philippines, and Armenia. Dr. Gish has been at St. Josephs since
2013.
Drs. Gish and Manch were recognized, along with the other inaugural inductees, at the AASLD annual meeting in November.

Meet the Team

Richard A. Manch, MD
Richard A. Manch, MD, FAASLD, FACP,
FACG is Chief of Hepatology in the Center
for Liver and Hepatobiliary Disease at St.
Josephs Hospital and Medical Center
and Clinical Professor of Medicine with
the University of Arizona. Dr. Manch is board certified
in Internal Medicine, Gastroenterology, and Liver
Transplantation.
Dr. Manchs expertise includes liver disease and
transplantation. He is a Fellow of American Association for
the Study of Liver Diseases, The Transplantation Society,
American Gastroenterological Association and a Fellow of
the American College of Gastroenterology. He has lectured
extensively throughout the region and serves as an advisor
to many organizations and companies involved in the care
and treatment of liver disease.
Dr. Manch received his medical degree from State
University of New York at Buffalo. He completed his
residency in Internal Medicine at Maricopa Medical Center.
He completed his fellowship in Gastroenterology from
University of New Mexico. He also holds a Masters Degree
in Health Administration from the University of Colorado.

Robert Gish, MD
Robert Gish, MD, FAASLD, FACP, is a
hepatologist in the Center for Liver &
Hepatobiliary Disease at St. Josephs
Hospital and Medical Center. Dr. Gish
is board certified in internal medicine,
gastroenterology, and liver transplantation.
Dr. Gish expertise includes viral hepatitis, liver transplant,
bioartificial liver, and public policy especially related to
liver cancer, liver transplantation and viral hepatitis. He
has published more than 500 original articles, review
articles, abstracts and book chapters.
Dr. Gish is actively involved in numerous professional
societies, including the American Association for the
Study of Liver Disease and the American Society of
Transplant Physicians, and is a fellow of the American
College of Physicians.
Dr. Gish received his medical degree from the University
of Kansas Medical School. He completed his residency
in internal medicine at the University of California, San
Diego, and then completed a gastroenterology fellowship
at the University of California, Los Angeles.

Justin A. Reynolds, MD
Justin A. Reynolds, MD, is a hepatologist
and gastroenterologist in the Center for
Liver and Hepatobiliary Disease at St.
Josephs Hospital and Medical Center.
Dr. Reynolds is board certified in Internal
Medicine, Gastroenterology and Liver Transplantation.
Dr. Reynolds expertise includes liver disease and
transplantation, viral hepatitis, fatty liver disease, and
general gastroenterology. He is a member of the American
Association for the Study of Liver Diseases, American
Society of Transplantation, American Gastroenterological
Association and the American College of Gastroenterology.
He has authored and contributed to multiple book
chapters and research studies presented at both national
and international meetings.
Dr. Reynolds received his medical degree from the
University of Michigan. He completed his residency
in Internal Medicine at Stanford University. He then
completed a fellowship in gastroenterology at the
University of California Los Angeles and an additional
fellowship in transplant hepatology at the Mayo Clinic.

Anita Kohli, MD
Dr. Kohli is an infectious disease
specialist in the Center for Liver and
Hepatobiliary Disease at St. Josephs
Hospital and Medical Center. Dr.
Kohli is board certified in internal
medicine and infectious disease.
Dr. Kohlis expertise includes clinical and
translational research in hepatitis C and B, liver
diseases and HIV. She has been the lead/Principal
Investigator of numerous studies involving treatments
and therapies in HCV and HBV infected patients.
She has published over twenty articles and multiple
abstracts in peer-reviewed journals.
Dr. Kohli has won several awards including the
European Association for the Study of the Liver
(EASL) Young Investigators Travel Award, the UVa
Clinical Investigator Tract Award and the Pfizer-CGH
Scholar Awards in Infectious Disease, among others.
Dr. Kohli received her medical degree from the
University of Virginia School of Medicine. She
completed her residency in internal medicine, clinical
investigator tract, at University of Virginia Hospital
and fellowship in infectious disease at the National
Institutes of Health in Bethesda, Maryland.

Ashley Hepner, ANP

Ashley Hepner, ANP, is a nurse practitioner
in the Center for Liver and Hepatobiliary
Disease at St. Josephs Hospital and Medical
Center. Ashley is board certified by the
American Nurses Credentialing Center.
Ashleys expertise includes liver and kidney
transplantation, gastrointestional disorders and all
aspects of liver disease. She is currently a member of the
American Academy of Nurse Practitioners and
American Association for the Study of Liver Disease.
Ashley received her bachelor of science in nursing from
University of Cincinnati. She then completed her masters
of science in nursing as an adult nurse practitioner from
Ursuline College in Ohio.

Ann Moore, FNP-C

Ann Moore, FNP-C is a nurse practitioner
in the Center for Liver and Hepatobiliary
Disease at St. Josephs Hospital and
Medical Center. Ann is board certified by the
American Academy of Nurse Practitioners.
Anns expertise includes liver and kidney disease and
transplant. She is an associate member of the American
Association for the Study of Liver Disease and a member
of American Academy of Nurse Practitioners and the
Arizona Nurses Association. She has lectured extensively
throughout the region and serves as an advisor to many
organizations and companies involved in the care and
treatment of liver disease.
Ann received her bachelor of science in nursing from
Regents College in New York. She then completed her
masters of nursing from University of Phoenix, where
she also received her post masters as a family nurse
practitioner.