Cardiovascular disease and nonalcoholic fatty liver disease: does histologic severity matter?

GOALS: We aimed to investigate the prevalence of cardiovascular disease in patients with nonalcoholic steatohepatitis (NASH) versus non-NASH fatty liver. BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is associated with an increased risk of cardiovascular disease, which is a leading cause of death in this patient population. NASH is a subset of NAFLD that carries a higher risk of progression to cirrhosis and its associated complications. STUDY: We conducted a retrospective chart review of patients with biopsy-confirmed NAFLD, including NASH and non-NASH fatty liver, within the Gastroenterology and Hepatology clinic at Brooke Army Medical Center. Patients with secondary causes of chronic liver disease were excluded. The patients' records were reviewed for the presence of significant cardiovascular disease, which was defined as a history of stroke, unstable angina, myocardial infarction, congestive heart failure, or need for revascularization. RESULTS: Nine hundred thirteen patients were identified and 377 patients met inclusion and exclusion criteria and were included in the final analysis. Of these, 219 patients had biopsies showing the presence of at least grade I NASH. The overall prevalence of cardiovascular disease was 6.63%. After controlling for age, sex, body mass index, and the presence of diabetes, there was no significant increase in the prevalence of cardiovascular disease in the NASH cohort over the non-NASH group. CONCLUSIONS: Cardiovascular disease is common among patients with NAFLD. However, no increased risk of cardiovascular disease was found among those patients with NASH as compared with those with non-NASH fatty liver.

Labor-associated eosinophilic gastroenteritis.

A 30-year-old woman who was 2 weeks postpartum presented with intermittent dysphagia since delivery. Esophagogastroduodenoscopy (EGD) revealed linear furrowing, trachealization, and a B-type distal esophageal ring with normal appearing stomach and duodenum. Biopsies showed eosinophilic esophagitis. Over 3 weeks, she developed severe midepigastric pain. Laboratory studies revealed an elevated absolute eosinophil count of 990/dL (normal 0-450/dL), and a computed tomography scan showed proximal jejunal thickening. Repeat esophagogastroduodenoscopy showed gastric erythema and edema of the duodenal mucosa. Biopsies revealed greater than 50 eosinophils per high power field in the intraepithelial mucosa with extension into the muscularis and serosa, consistent with eosinophilic gastroenteritis (EG). EG represents an uncommon inflammatory disease marked by gastrointestinal symptoms, eosinophilic infiltration in one or more areas of the gastrointestinal tract, and absence of parasitic or extraintestinal disease. Approximately 300 cases have been reported since 1937. This case contains two unique aspects. First, the clinical and endoscopic progression of gastrointestinal eosinophilic disease from the esophagus to the stomach and small bowel was chronologically documented. This proximal to distal luminal progression has not been previously reported. The possible link to her pregnancy is also notable as only two previous cases of labor-associated EG have been published.

Olanzapine and benztropine as a cause of ischemic colitis in a 27-year-old man.

Ischemic colitis is a rare adverse effect of antipsychotic medications and is most commonly associated with the phenothiazine class of antipsychotics and atypical antipsychotics such as clozapine and olanzapine. The risk is further increased when antipsychotics are taken in conjunction with anticholinergics. A 27-year-old man with a history of bipolar disorder and depression presented to the emergency department with 6 days of constipation, abdominal pain, nausea, and nonbloody vomiting. He later developed multiple episodes of hematochezia and fever. Within the preceding 2 weeks, his medication regimen of divalproex sodium, aripiprazole, and trihexyphenidyl, had been changed to olanzapine, benztropine, and bupropion. The patient's physical examination showed diffuse abdominal tenderness, guarding, and distension and laboratory tests revealed a leukocytosis. A computed tomographic scan of the abdomen/pelvis showed colitis extending from the splenic flexure to the sigmoid colon, without evidence of perforation. A colonoscopy revealed severe ischemic colitis involving the descending and sigmoid colon, which was confirmed on biopsy. Given the temporal association between the new medications and onset of symptoms, the patient's ischemic colitis was likely caused by olanzapine or the combination of olanzapine and benztropine, likely secondary to their anticholinergic properties. Thus, providers should take a thorough history and counsel patients regarding the risks of constipation when starting antipsychotic medications, particularly those with anticholinergic activity. Despite the fact that ischemic colitis is such a rare adverse effect of antipsychotic medications, it is important to consider because of its potentially fatal outcomes.

Reconstructive outcomes in patients undergoing contralateral prophylactic mastectomy.

BACKGROUND: As the rate of contralateral prophylactic mastectomy in breast cancer patients increases, more women are seeking immediate bilateral breast reconstruction. The authors evaluated complication rates in the index and prophylactic breasts in patients undergoing bilateral immediate reconstruction. METHODS: The authors retrospectively reviewed the outcomes of all consecutive patients undergoing immediate postmastectomy bilateral reconstruction for an index breast cancer combined with a contralateral prophylactic mastectomy between 2005 and 2010. Patient, tumor, reconstruction, and outcome characteristics were compared between the index and prophylactic breasts in the same patient. Patients were classified by reconstruction method: implant, abdominal flap, or latissimus dorsi flap/implant. Regression models evaluated patient and reconstruction characteristics for potential predictive or protective associations with postoperative complications. RESULTS: Of 497 patients included, 334 (67.2 percent) underwent implant reconstruction, 142 (28.6 percent) had abdominal flap reconstruction, and 21 (4.2 percent) had latissimus dorsi flap/implant reconstruction. Index reconstructions had a complication rate (22.5 percent) equivalent to that of contralateral prophylactic mastectomy reconstructions (19.1 percent; p=0.090). Overall, 101 patients (20.3 percent) developed a complication in one reconstructed breast, and 53 (10.7 percent) developed complications in both breasts. Of the 154 patients who developed complications, 42 (27.3 percent) developed a complication in the prophylactic breast. CONCLUSIONS: Immediate index and contralateral prophylactic breast reconstructions appear to have equivalent outcomes, both overall and across reconstruction classifications. Together, patients, reconstructive surgeons, and extirpative surgeons should carefully consider the oncologic benefits of a contralateral prophylactic mastectomy in light of the risk of increased surgical morbidity of this type of mastectomy and reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.