Prognostic significance of hypokalemia in hepatic encephalopathy.

BACKGROUND/AIMS: The aim of this study was to investigate whether hypokalemia prognosticates outcomes in hepatic encephalopathy. We also examined other potential prognostic variables such as serum pH, systemic vascular resistance (SVR) and serum ammonia levels. METHODOLOGY: Patients with cirrhosis who were admitted for overt hepatic encephalopathy were included in the study and divided into two groups: Group-I consisted of patients with serum Potassium level < 4.0 mEq/L and Group-II consisted of patients with serum Potassium level > 4.0 mEq/L. We collected the baseline demographic data for both the groups including age, gender, ethnicity and calculated the Model for End Stage Liver Disease scores for both the groups at the time of admission. We analyzed the correlation between serum potassium levels and outcome variables including 30- day mortality rate, length of Intensive Care Unit (ICU)/ hospital stay, mechanical ventilation rate and 30-day readmission rate. RESULTS: A total of 447 patients with diagnosis of cirrhosis were admitted to the hospital with overt hepatic encephalopathy between January 2008 and December 2012. 157 patients with low Potassium level (< 4.0 mEq/L) were included in Group-I while 290 patients with normal Potassium level (> 4.0 mEq/L) and were included in Group-II. Total length of stay in the hospital (P Value= 0.0001) and ICU length of stay (P Value= 0.0003) were significantly longer among the patients with serum potassium level of <4mEq/L. CONCLUSIONS: We observed statistically significant correlation between serum potassium level and length of stay in hospital and ICU.

Risk Factors for Liver Cirrhosis-Related Readmissions in the Largest Ethnic Minority in United States.

BACKGROUND: There are very limited data available on 30-day readmissions for ethnic minority patients with cirrhosis. The aim of the study was to identify the risk factors for 30-day readmission in ethnic minority patients admitted for cirrhosis. METHODS: We did a retrospective review of 1,373 electronic medical records of patients with cirrhosis admitted from 2009 to 2011. Several parameters including alcohol use history, discharge location and cirrhosis severity scores - model for end-stage liver disease (MELD) score and Child-Pugh-Turcotte (CPT) at first admission were assessed. Statistical analysis was done using Chi-square test and t-test for categorical and continuous variables, respectively. RESULTS: There were 79 patients in the readmission group (63% male, 54% Hispanics and 22% African Americans) and 104 in the no readmission group (62% male, 58% Hispanics and 24% African Americans). History of alcohol use within a month prior to admission (55% vs. 33%, P = 0.002), platelet count at discharge (89,000 vs. 124,000, P = 0.003), and discharge with more than seven medications per day (7.3 vs. 5.2, P = 0.005) were identified as risk factors for readmissions by multivariate analysis. CONCLUSION: Platelet count, active alcohol use and more than seven medications at discharge are predictors of readmission. These parameters can guide future interventions to reduce readmission rate and health care costs related to cirrhosis readmissions.

Isolated Gastric Varices due to Essential Thrombocytosis Related to Splenic Vein Thrombosis: A Challenge to Uncover the Concealed Diagnosis.

Essential thrombocytosis is associated with gastrointestinal (GI) vascular thrombosis. Sinistral portal hypertension (left-sided portal hypertension) due to splenic vein thrombosis can lead to isolated gastric varices and should be suspected in a patient with obscure GI bleeding with normal liver function. This case reviews the challenges presented in diagnosing isolated gastric varices due to splenic vein thrombosis through radiologic or endoscopic studies. Unrevealing radiologic or endoscopic studies does not rule out splenic vein thrombosis, which should be suspected in a patient with essential thrombocytosis and obscure GI bleeding.

Computerized Tomography-Guided Paracentesis: An Effective Alternative to Bedside Paracentesis?

BACKGROUND: Ascites remains the most common cause of hospitalization among patients with decompensated cirrhosis. Paracentesis is a relatively safe procedure with low complication rates. Computerized tomography (CT)-guided therapeutic paracentesis could be a safe and effective alternative to unaided or aided (ultrasonogram-guided) bedside paracentesis. In this retrospective study, we aimed to compare the efficacy, safety, and cost-effectiveness of CT-guided paracentesis with bedside paracentesis. METHODS: The period of study was from 2002 to 2012. All patients with cirrhosis who underwent therapeutic paracentesis were included in the study. These patients were divided into two groups. Group I consisted of patients who underwent CT-guided pigtail catheter insertion with ascitic fluid drainage. Group II consisted of patients who underwent beside therapeutic paracentesis after localization of fluid either by physical examination or sonographic localization. We measured the efficacy of CT-guided paracentesis and bedside paracentesis in terms of volume of fluid removed, length of stay, discharge doses of diuretics (spironolactone and furosemide) and number of days to readmission for symptomatic ascites. We also computed the cost-effectiveness of CT-guided therapeutic paracentesis when compared to a bedside procedure. Fischer exact test was used to analyze the distribution of categorical data and unpaired t-test was used for comparison of means. RESULTS: There were a total of 546 unique patients with diagnosed cirrhosis who were admitted to the hospital with symptomatic ascites and underwent therapeutic paracentesis. Two hundred and forty-seven patients underwent CT-guided paracentesis, while 272 patients underwent bedside paracentesis. There was significant inverse correlation between the amount of ascitic fluid removed and total length of stay in the hospital. We found that the volume of fluid removed via a CT-guided pigtail insertion and drainage (2.72 ± 2.02 L) is significantly higher when compared to fluid removed via bedside paracentesis (1.94 ± 1.69). We also found that the interval time period between two successive therapeutic paracenteses was significantly longer for CT group (106.56 ± 75.2 days) when compared to the bedside group (25.57 ± 7.68 days). CONCLUSION: CT-guided paracentesis with pigtail catheter insertion and drainage is a clinically effective, cheap and safe alternative to conventional bedside paracentesis.

Cystic Lymphangioma of the Colon: Endoscopic Removal beyond the Frontiers of Size.

Cystic lymphangiomas are benign colonic neoplasms arising from the submucosa. Traditionally, endoscopic resection has been described for smaller lesions, while surgery is reserved for larger symptomatic lesions. We present a case of a 69-year-old asymptomatic individual noted to have a cystic lymphangioma of the colon measuring 5 cm, which was successfully removed with endoloop endoscopic resection without any complications.

Predictors of acute gastrointestinal bleeding in diabetic ketoacidosis: a retrospective observational study in minority population.

BACKGROUND: Diabetic ketoacidosis (DKA) is a common acute complication of diabetes mellitus requiring aggressive medical management. We attempted to study the incidence and various clinical and laboratory variables associated with acute gastrointestinal bleeding (AGIB) and acute upper AGIB (AUGIB) in patients with DKA. METHODS: We conducted a retrospective chart review of all the patients admitted to our hospital with DKA between January 2010 and December 2015. We collected demographic, clinical, laboratory, endoscopy and hospitalization details using an electronic medical-record database. Patients were divided into two groups based on the occurrence of gastrointestinal bleeding. RESULTS: A total of 234 patients with DKA were admitted during this period, of which 27 (11.5%) patients had documented AGIB. The majority of patients had hematemesis (n=22, 9.4%) except two had rectal and three had occult bleeding. We did not notice any difference in age, gender and ethnicity distribution between the two groups. There was no difference in the serum levels of electrolytes, anion gap, pH and hemoglobin A1C between the two groups. However, patients with AGIB had significantly higher initial blood glucose levels (738 vs 613 mg/dL, p =0.014). There was also increased mortality (7.4% vs 4.8%) in patients with AGIB, but this did not reach statistical significance. CONCLUSION: We conclude that higher initial serum blood glucose was associated with increased incidence of AGIB in patients admitted with DKA. We also noted increased in-patient mortality in patients with DKA who had AGIB, even though statistically insignificant. More aggressive measures to correct blood glucose levels may result in decreased incidence of AGIB, thereby reducing mortality during hospitalization in patients with DKA.

Influence of perception of colorectal cancer risk and patient bowel preparation behaviors: a study in minority populations.

BACKGROUND: Large disparities exist in the utilization rates of screening modalities for colorectal cancer (CRC) in different socioeconomic areas. In this study, we evaluated whether the quality of bowel preparation differed significantly among populations with a high risk of CRC compared with that among the general population after matching for potential confounding factors. METHODS: Hispanic and African American patients who underwent routine screening or surveillance colonoscopies in an outpatient setting between 2003 and 2013 were included in this retrospective study. Patients who underwent colonoscopies for emergent indications and repeat routine screening colonoscopies because of prior history of inadequate bowel preparation were excluded from this study. The patients were divided into three groups: patients having an average risk of being diagnosed with CRC (group 1); patients having a high risk of being diagnosed with CRC because of a personal history of adenomatous polyps (group 2); and patients having a high risk of being diagnosed with CRC because of a family history of CRC in first-degree relatives (group 3). All the patients were given preprocedural counseling and written instructions for bowel preparation. Data on demographic information, method of bowel preparation, quality of bowel preparation, comorbidities, and prescription medications were collected. RESULTS: In all, 834 patients had a "high-risk for CRC" surveillance colonoscopy in view of their personal history of adenomatous polyps and were included in group 2. In total, 250 patients had a "high-risk for CRC" screening colonoscopy in view of their family history of CRC in first-degree relatives and were included in group 3. Further, 1,000 patients were selected to serve as controls (after matching for age, sex and ethnicity) and were included in group 1. Bowel preparation was graded as good, fair, or poor by the endoscopist performing the study. We observed a significantly higher number of good bowel preparations in group 2 and group 3 (P=0.0001) when compared with group 1 (controls) after adjusting for comorbidities and usage of prescription medication that could potentially cause colonic dysmotility. These differences were significant in both Hispanic and African American patients. CONCLUSION: Our study showed that perception of CRC risk significantly influenced the bowel preparation behaviors of patients belonging to minority populations, with a significantly greater number of patients with a high risk of CRC having adequate bowel preparations.

Sign of leser-trélat associated with esophageal squamous cell cancer.

The sign of Leser-Trélat is a rare paraneoplastic phenomenon marked by accelerated onset of multiple seborrheic keratoses. The occurrence of the sign often points towards underlying visceral malignancies which in a majority are adenocarcinomas of the gastrointestinal tract. We report this case of a 65-year-old man who presented with sign of Leser-Trélat and was diagnosed with poorly differentiated squamous cell cancer of the esophagus. To our knowledge this is only the second such reported association of Leser-Trélat sign with squamous cell cancer of esophagus.

Incidental finding of isolated colonic neurofibroma.

Neurofibromatosis is a genetic disorder manifested by characteristic cutaneous lesions called neurofibromas. There are two distinct neurocutaneous syndromes named neurofibromatosis type 1 (also called von Recklinghausen disease or NF1) and neurofibromatosis type 2 (NF2). NF1 is by far the most common presentation and is caused by an autosomal dominant mutation in the NF1 gene mapped to chromosome 17q11.2. The literature shows that gastrointestinal involvement is noted in systemic neurofibromatosis in up to 25% of patients, but isolated intestinal neurofibromatosis is a very rare manifestation. We herein present the case of a 70-year-old woman who was diagnosed with an isolated colonic neurofibroma without any systemic signs of neurofibromatosis; only a few case reports of this condition have been published to date.