Endoscopic retrograde cholangiopancreatography in patients with surgically altered gastrointestinal anatomy.

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered upper gastrointestinal anatomy, such as Roux-en-Y gastric bypass (RYGB), can be more challenging compared to those with a normal anatomy. Detailed assessment of cross-sectional imaging features by the radiologist, especially the pancreaticobiliary anatomy, strictures, and stones, is very helpful to the endoscopist in planning the procedure. In addition, any information on enteral anastomoses (for e.g., gastrojejunal strictures and afferent limb obstruction) is also very useful. The endoscopist should review the operative note to understand the exact anatomy prior to procedure. RYGB, which is performed for medically complicated obesity, is the most commonly encountered altered anatomy ERCP procedure. Other situations include patients who have had a pancreaticoduodenectomy or a hepaticojejunostomy. Balloon-assisted deep enteroscopy (single and double-balloon enteroscopy) or rotational endoscopy is often used to traverse the length of the intestine to reach the papilla. In addition, ERCP in these patients is further challenging due to the oblique orientation of the papilla relative to the forward viewing endoscope and the limited enteroscopy-length therapeutic accessories that are currently available. Overall, reported therapeutic success is approximately 70-75% with a complication rate of 3-4%. Alternative approaches include percutaneous transhepatic cholangiography, laparoscopy-assisted ERCP, or surgery. Given the complexity, ERCP in patients with surgically altered anatomy should be performed in close collaboration with body imagers, interventional radiology, and surgical services.

Heparin-induced thrombocytopenia: is it a graft-threatening complication?

Heparin-induced thrombocytopenia (HIT), a prothrombotic complication of heparin therapy, can lead to serious thromboembolic events and cause significant morbidity and mortality. We aim to study the prevalence of HIT in the transplant population at our institute. This is a retrospective, single-center study which looked into the transplant database over a 25-year period. In patients with clinical suspicion of HIT, the 4T score was used, and laboratory tests such as ELISA HIT antibody and functional serotonin release assay, along with clinical manifestation of thromboembolic events were reviewed. Medical records of 2800 patients who underwent transplantation from January 1985 to December 2010 were reviewed. HIT antibody assay was performed in 262 patients from this group in which HIT was suspected. Of these, only 48 patients were HIT antibody positive along with moderate to high 4T score. The mean 4T score was 6.75 ± 1.4. Thrombotic complications were seen in 11 patients, with the highest in cardiac transplant recipients. Direct thrombin inhibitor (DTI) therapy was used in only eight patients who had thrombotic event. No other complications or mortality was reported in any of the HIT antibody-positive transplant patients. To our knowledge, this is the first study of its kind that has shown very low incidence of HIT in the transplant population except for in cardiac transplant recipients.

Eosinophilic esophagitis: imaging features with endoscopic and pathologic correlation.

OBJECTIVE: We aim to review the imaging features of eosinophilic esophagitis on fluoroscopy and present how they can correlate with endoscopic and pathologic findings. RESULTS: Eosinophilic esophagitis is a chronic immune-mediated disease that results in esophageal dysfunction. Upper esophagogastroduodenoscopy is high yield and required for biopsies to demonstrate the hallmark histologic findings of eosinophil-predominant inflammation. While esophagogastroduodenoscopy is currently mandatory for diagnosis, imaging findings can provide valuable information regarding the structural and functional properties of the esophagus. In addition, fluoroscopic studies may be very helpful in the setting of subtle findings and to evaluate fibrotic remodeling changes. CONCLUSION: Radiologic examinations are a valuable tool in the assessment of eosinophilic esophagitis and can highlight changes of fibrostenotic disease, as overall narrowing can be more conspicuous fluoroscopically than endoscopically. As the disease increases in prevalence, it is critical that physicians recognize this condition and facilitate diagnosis and treatment.

De Novo Malignancies After Transplantation: Risk and Surveillance Strategies.

De novo malignancies are one of the leading causes of late mortality after liver and kidney transplantation. Nonmelanoma skin cancer is the most common malignancy, followed by posttransplant lymphoproliferative disorder and solid organ tumors. Immunosuppression is a key factor for cancer development, although many other transplant-related and traditional risk factors also play a role. In this review, the authors summarize risk factors and outcomes of frequently encountered de novo malignancies after liver and kidney transplantation to stratify recipients at highest risk. Future efforts in prospectively validated, cost-effective surveillance strategies that improve survival of these complex patients are greatly needed.

Gastrointestinal bleeding with continuous-flow left ventricular assist devices.

Continuous-flow left ventricular assist device (CF-LVAD) insertion is a life-saving procedure that is being increasingly used in patients with advanced heart failure. However, patients with CF-LVADs are at an increased risk of gastrointestinal bleeding (GIB). Bleeding can occur anywhere in the GI tract with lesions being more prevalent in the upper GI tract than in the lower GI tract. The pathophysiology of GIB in patients with CF-LVADs is unique and likely involves three synergistic mechanisms-coagulopathy, acquired von Willebrand disease and continuous non-pulsatile blood flow. Management strategies vary depending on the presentation and site of bleeding. Prevention strategies to prevent GIB in these patients include low pump speed, close hemodynamic monitoring and a low threshold for endoscopy. We aim to review in detail the pathophysiology, management, complications and preventive strategies in patients with CF-LVAD who present with GIB.

A Comprehensive Review of Progressive Familial Intrahepatic Cholestasis (PFIC): Genetic Disorders of Hepatocanalicular Transporters.

Progressive familial intrahepatic cholestasis or PFIC is a general term used to describe a group of genetic disorders involving the hepatocanalicular transporters. These diseases are characterized by persistent cholestasis, pruritus and jaundice. Type I PFIC is characterized by defect in the gene that codes for aminophospholipid translocase protein and maintains canalicular membrane stability. Types 2 and 3 are caused by defect in genes that code for bile acid transporter and a phospholipid translocase, respectively. This review summarizes the genetics, clinical features, diagnosis and treatment of the three types of PFIC.

Severe Symptomatic Hypermagnesemia Associated with Over-the-Counter Laxatives in a Patient with Renal Failure and Sigmoid Volvulus.

Hypermagnesemia is an uncommon but a potentially serious clinical condition. Over-the-counter magnesium containing products are widely used as antacids or laxatives. Although generally well tolerated in patients with normal renal function, their unsupervised use in the elderly can result in severe symptomatic hypermagnesemia, especially in those patients with concomitant renal failure and bowel disorders. We report a case of severe symptomatic hypermagnesemia associated with over-the-counter laxatives in a 70-year-old male patient with renal failure and sigmoid volvulus, who was successfully treated with hemodialysis.

Severe Hypocalcemia due to Denosumab in Metastatic Prostate Cancer.

Denosumab is a monoclonal antibody used for prevention of skeletal-related events (SREs) in patients with bone metastases from solid tumors. Hypocalcemia is a rare and dangerous side effect of the drug Denosumab. We present a case of a patient with metastatic prostate cancer who developed severe hypocalcemia after the administration of the drug. The patient's vitamin D levels were low when checked after administration of the drug, which likely predisposed him to the development of hypocalcemia. He was placed on high doses of oral and intravenous (IV) calcium and vitamin D without any appreciable response in the serum calcium level. His ionized calcium remained below 0.71 mmol/L despite very high doses of oral and IV calcium supplements. During the hospital course, he developed hydronephrosis from the spread of a tumor and did not want to undergo percutaneous nephrostomy tube placement; therefore, it was decided to dialyse him for acute renal failure and to correct his hypocalcemia. Checking calcium and vitamin D levels prior to the administration of Denosumab is vital in preventing hypocalcemia. If hypocalcemia is severe and not responsive to high doses of vitamin D, oral and IV calcium, then hemodialysis with a high calcium bath can correct this electrolyte abnormality.

Black cohosh and liver toxicity: is there a relationship?

Herbal supplements are commonly used by patients for various problems. It is a well-known fact that most patients do not tell their physicians about the use of herbal supplements unless they are specifically asked. As a result, sometimes important information regarding drug side effects is missed in history taking. During our literature search, we found several retrospective studies and other meta-analyses that claim a lacking or weak link between black cohosh use and hepatotoxicity. We present a case of a 44-year-old female who developed subacute liver injury demonstrated on a CT scan and liver biopsy within a month of using the drug to resolve her hot flashes and discuss a possible temporal and causal association between black cohosh use and liver disease. Since the patient was not taking any other drugs, we concluded that the acute liver injury was caused by the use of black cohosh. We agree with the United States Pharmacopeia recommendations that a cautionary warning about hepatotoxicity should be labeled on the drug package.

Tropical spastic paraparesis treated with Combivir (lamivudine-zidovudine).

Tropical spastic paraparesis (TSP) or human T-cell leukemia virus-type 1 (HTLV-I)-associated myelopathy is caused by human T-lymphotropic virus type 1. It is a slow, progressive spastic paraparesis with significant morbidity and causing profound repercussions on quality of life. No therapies have been found to persistently improve the outcome in these patients. We present a patient with HTLV-1-associated myelopathy/TSP (HAM/TSP) who was treated with Combivir (lamivudine-zidovudine, GlaxoSmithKline, London, UK). She was walker-dependent for several years but, soon after treatment with lamivudine-zidovudine, was able to walk using only a cane. The role of lamivudine-zidovudine should be investigated further in this patient population.

A patient with Parkinson's disease benefits from spinal cord stimulation.

We present a case of a 43-year-old woman with a history of Parkinson's disease and chronic neuropathic pain secondary to trauma. She was implanted with a spinal cord simulator to relieve her persistent intractable pain. After the implantation of the device the patient not only was relieved of her neuropathic pain but also found significant improvement in her Parkinson symptoms.

Celiac artery compression syndrome.

Celiac artery compression syndrome is a rare disorder characterized by episodic abdominal pain and weight loss. It is the result of external compression of celiac artery by the median arcuate ligament. We present a case of celiac artery compression syndrome in a 57-year-old male with severe postprandial abdominal pain and 30-pound weight loss. The patient eventually responded well to surgical division of the median arcuate ligament by laparoscopy.

Spontaneous intestinal haematoma associated with neurofibromatosis type-1.

Vasculopathy in patients with neurofibromatosis-1 are rare but serious and have potentially life-threatening complications. It mostly involves the thoracic, abdominal and intracranial vessels. In this case study we describe the first reported case of spontaneous intestinal haematoma in a young male patient. The first episode occurred at the age of 30, following which 2 years later the second episode was noted at the same anatomical site, which was spontaneous without any inciting event.

Vanishing bile duct syndrome: a rare cause of jaundice in Hodgkin's lymphoma.

Vanishing bile duct syndrome refers to a group of disorders which are characterized by prolonged cholestasis as a consequence of progressive destruction and disappearance of intrahepatic bile ducts. We present a case of Hodgkin's lymphoma presenting with vanishing bile duct syndrome. Liver damage is relatively common in Hodgkin's lymphoma. But only a small percentage of these patients develop jaundice. This may be secondary to drug toxicity, hemolysis, direct invasion by malignant cells or by extensive, obstructive lymphadenopathy. Vanishing bile duct syndrome secondary to Hodgkin's lymphoma is a rare cause of cholestasis in these patients. The mechanism of vanishing bile duct syndrome in Hodgkin's lymphoma is poorly explained, but a paraneoplastic effect seems most likely.

Lithium toxicity in the setting of nonsteroidal anti-inflammatory medications.

Lithium toxicity is known to affect multiple organ systems, including the central nervous system. Lithium levels have been used in the diagnosis of toxicity and in assessing response to management. There is evidence that nonsteroidal anti-inflammatory medications (NSAIDs) can increase lithium levels and decrease renal lithium clearance. We present a case of lithium toxicity, which demonstrates this effect and also highlights the fact that lithium levels do not correlate with clinical improvement, especially the neurological deficit.

Polyoma BK Virus: An Oncogenic Virus?

We report a case of a 65-year-old gentleman with a history of end stage renal disease who underwent a successful cadaveric donor kidney transplant four years ago. He subsequently developed BK virus nephropathy related to chronic immunosuppressant therapy. Three years later, misfortune struck again, and he developed adenocarcinoma of the bladder.

Treating symptomatic coronary artery disease in patients with Von Willebrand disease.

There is limited data on the occurrence of coronary artery disease (CAD) in patients with Von Willebrand disease and the literature is even scarce on their management. We at our institute reviewed the medical records of 198 patients with Von Willebrand disease over a period of 15years, of which 6 were found to have symptomatic CAD. Acute coronary syndrome was noted in 3 patients while the remaining 3 had stable angina. Cardiac catheterization showed that left main coronary artery was the culprit vessel in all of these patients. In terms of management, stents were placed in 3 patients, two of them underwent coronary artery bypass grafting, and the remaining one patient was medically managed. Aspirin, and in some patients clopidogrel, was well tolerated with minimal side effects.

Disseminated intravascular coagulation as a possible cause of acute coronary stent thrombosis: a case report and literature review.

Disseminated intravascular coagulation (DIC), as a cause of acute coronary stent thrombosis, has not yet been reported to our knowledge. We report a case of 64-year-old male, who presented with non-ST-segment elevation myocardial infarction (NSTEMI). Coronary angiography revealed right coronary artery (RCA) stenosis and a drug eluting stent was deployed. Fifteen hours following the intervention, the patient developed an inferior wall ST elevation myocardial infarction. Repeat cardiac catheterization showed an acute in-stent thrombosis. Following thrombectomy, another stent was placed. The patient noted to have an acute drop in platelet count following the second intervention. Two hours following repeat intervention, the patient again developed chest pain and EKG showed recurrent ST-segment elevations in leads II, III, and aVF. Prior to repeat cardiac catheterization, the patient became unresponsive and developed cardiogenic shock. The patient was resuscitated and intubated, and repeat catheterization showed complete stent thrombosis. Intracoronary tissue plasminogen activator (tPA) was given. The platelet count further dropped. Additional studies confirmed the diagnosis of DIC. No further cardiac catheterization was done at this point. The patient then later had a cardiac arrest and unfortunately cardiopulmonary resuscitation could not revive him. Amongst the etiologies of acute stent thrombosis, DIC was deemed a possible cause.