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BACKGROUND: Brain fog has been minimally studied in patients with inflammatory bowel disease (IBD). IBD patients frequently consume probiotics, whether sanctioned by a physician or not. However, probiotic consumption in itself has been shown to increase the incidence of brain fog. We aimed to study the association between brain fog in IBD patients with or without probiotic use. METHODS: We conducted a cross-sectional study among patients visiting a busy IBD clinic. Patients aged >18 with a biopsy-proven diagnosis of inflammatory bowel disease, without pre-existing psychiatric illness or current use of opioid medications were included. They were divided into 2 groups: those using probiotics and those who did not. Patients were given a questionnaire that included details about symptoms of brain fog. Groups were analyzed by chi-square test for differences in baseline demographics, and Mann Whitney U test to compare outcomes between groups. A p-value < 0.05 was considered statistically significant. RESULTS: Of the 66 patients included (mean age 44±2 years), 35 (53%) were female and 59 (89.4%) were Caucasian. Among these patients, 31.8% (n = 21) took probiotics as dietary supplements with the majority (67%, n = 14) taking probiotics for over a year. Overall, there was a trend for an association between probiotic use and brain fog in all patients (p = 0.080) but no statistical significance was attained. However, brain fog was significantly associated with probiotic use among Caucasian patients (p = 0.044). Furthermore, there was a statistically significant association between brain fog and male patients using probiotics (p = 0.004). Duration of probiotic use was also associated with brain fog (p = 0.038). CONCLUSION: Consumption of probiotics was independently associated with brain fog in men, as well as Caucasian patients with IBD respectively. Given the high prevalence of probiotic use in IBD patients, prospective studies are warranted to examine the causal relationship between probiotics and IBD-associated brain fog to guide prescription of probiotic supplements for IBD.
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MenoFit is a widely available over-the-counter synbiotic supplement, which is marketed for use in relieving menopausal symptoms. So far, there is no published data on liver injury because of its use. We present the first reported case of MenoFit-induced liver injury in a patient who presented with 1 week of jaundice and abnormal liver biochemical tests in the absence of other risk factors and negative comprehensive workup for known etiologies of liver disease.
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Hepatopulmonary syndrome is a phenomenon that results in an intrapulmonary shunt leading to dyspnea and hypoxemia with poor response to oxygen supplementation. It is now an indication for liver transplantation; however, some transplants result in subsequent pulmonary hypertension. Postulated mechanisms include unmasking of underlying pulmonary hypertension with liver transplant and increased pulmonary vascular resistance due to increased blood flow in hepatopulmonary syndrome. In this case, we describe pulmonary hypertension developing after orthotopic liver transplant in a cirrhotic patient with hepatopulmonary syndrome.
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Hemosuccus pancreaticus is a life-threatening but rare cause of intermittent upper gastrointestinal bleeding caused by acute/subacute hemorrhage into a pancreatic duct or pancreatic pseudocyst because of a ruptured pseudoaneurysm. This entity is described in patients with pseudoaneurysms that develop in the context of severe pancreatic/peripancreatic inflammatory changes. Hemosuccus pancreaticus presents a difficult diagnostic and therapeutic conundrum because it tends to involve inflamed, friable, and tortuous vascular pathways. We present a rare case of hemosuccus pancreaticus because of splenic pseudoaneurysm presenting as duodenal hemorrhage and discuss trans-splenic embolization with a combined angiographic and ultrasound-guided approach.
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OBJECTIVES: Low molecular weight heparin and vitamin K antagonists are commonly used in cirrhotic patients requiring anticoagulation. However, their monitoring with anti-factor Xa and international normalized ratio (INR) may not be reliable in cirrhosis. Direct oral anticoagulants (DOACs) do not need laboratory monitoring, making these agents a favorable alternative. However, apixaban and rivaroxaban have been avoided in advanced liver disease due to their metabolism in the liver. The purpose of this medication use evaluation was to assess the use of DOACs, specifically apixaban and rivaroxaban, in patients with cirrhosis. METHODS: We performed a retrospective, single-center study. Inpatients who had a diagnosis of cirrhosis and received at least one dose of a DOAC (apixaban or rivaroxaban) from April 2016 through June 2020 at our hospital were included in the analysis. Data collected included the reason for admission, Child-Pugh classification, renal function, if this was a home medication or newly started as an inpatient medication, indication, and dosing. The clinical efficacy outcome (new venous thromboembolic event (VTE) or progression of old VTE), and clinical safety outcome (bleeding event) were analyzed. RESULTS: 41 patients with cirrhosis were treated with apixaban or rivaroxaban. Based on the Child-Pugh classification, 29.3% (n=12/41) were placed on a DOAC outside of the FDA prescribing recommendations. In this subpopulation, 8.3% (n=1/12) patients had venous thromboembolism (VTE) and 16.6% (n=2/12) had bleeding events. Overall, 7.3% patients (n=3/41) had VTE and 4.8% (n=2/41) had bleeding events. In the Apixaban for the Initial Management of Pulmonary Embolism and Deep-Vein Thrombosis as First-Line Therapy (AMPLIFY) trial comparing the efficacy and safety profile of apixaban with enoxaparin/warfarin therapy in acute VTE, 2.3% of patients had VTE and 15% had bleeding events. CONCLUSION: Our study demonstrated that it may be possible to safely use DOACs in patients with advanced cirrhosis. Further studies are needed to evaluate the safety and efficacy of DOACs in this patient population, as our study was limited by the small sample size and its retrospective design.
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Spur cell anemia is acquired hemolytic anemia seen in patients with advanced liver disease, particularly in the setting of alcoholism, and warrants urgent liver transplant evaluation. We describe the case of a 58-year-old female with alcoholic cirrhosis who presented with worsening liver disease, profound anemia poorly responsive to blood transfusions, and multiple spur cells on the peripheral smear. She underwent a liver transplant, which led to the resolution of hematologic abnormalities and the need for transfusions. Our case highlights the significance of spur cell anemia as a harbinger of poor prognosis in patients with advanced liver disease and its reversibility with liver transplantation.
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Primary chest wall abscess due to hematogenous spread is very rare and has seldom been documented in the literature, with most reported cases attributed to Mycobacterium tuberculosis. Prompt diagnosis and management with antibiotics, and evacuation of the abscess, is imperative as the infection can lead to systemic or disseminated infection, including erosion into surrounding bone if left untreated. We describe the case of a 67-year-old female with severe Crohn's disease receiving anti-tumor necrosis factor-alpha (TNF-α) therapy, Etanercept presenting with localized Escherichia coli (E. coli) chest wall abscess with erosion into the surrounding rib. This case highlights a rare clinical entity, chest wall abscess, which is also an unusual site of E. coli infection. Only three previous cases of E. coli primary chest wall abscess can be found in the published literature. This case also highlights a possible association of severe Crohn's disease predisposing to complicated soft tissue infection.
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Acute liver failure carries a high mortality. At present, liver transplant is the definitive treatment along with standard medical support. In the absence of or as a bridge to liver transplant, several liver assist therapies have been derived. Some of the therapies have shown short-term mortality benefits and transplant-free survival over standard medical treatment alone. High volume plasmapheresis (HVP) is one of such therapies and is readily available in hospitals. We discuss the case of a 28-year-old female who presented with acute liver failure, did not qualify for the liver transplant and successfully underwent HVP. Various regimens of plasmapheresis have been described in the literature of which we used the HVP for pre-determined three days. Our case emphasizes the importance of early initiation of HVP in an acute liver failure patient who did not qualify for liver transplant, and adds to the existing evidence of the utility of this particular type of plasmapheresis over other regimens.
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Being one of the most widely prevalent diseases throughout the world, hypertension has emerged as one of the leading causes of global premature morbidity and mortality. Hence, blood pressure (BP) measurements are essential for physicians in the diagnosis and management of hypertension. Current American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend initiating antihypertensive medications on the basis of office BP readings. However, office BP readings provide a snapshot evaluation of the patient's BP, which might not reflect patient's true BP, with the possibility of being falsely elevated or falsely low. Recently, there is ample evidence to show that ambulatory blood pressure monitoring (ABPM) is a better predictor of major cardiovascular events than BP measurements at clinic settings. ABPM helps in reducing the number of possible false readings, along with the added benefit of understanding the dynamic variability of BP. This article will focus on the significance of ambulatory BP, its advantages and limitations compared with the standard office BP measurement and a brief outlook on its use and interpretation to diagnose and treat hypertension.