Drug-induced cholestasis.

Recent progress in understanding the molecular mechanisms of bile formation and cholestasis have led to new insights into the pathogenesis of drug-induced cholestasis. This review summarizes their variable clinical presentations, examines the role of transport proteins in hepatic drug clearance and toxicity, and addresses the increasing importance of genetic determinants, as well as practical aspects of diagnosis and management.

Safety and efficacy of colonoscopy in the elderly: experience in an innercity community hospital serving African American and Hispanic patients.

Data regarding safety and efficacy of colonoscopy in elderly African American and Hispanic patients is scarce. We designed our study to determine the safety and efficacy of colonoscopy in this population. We retrospectively reviewed records of 1530 patients, who underwent colonoscopy over a nine-year period. The population included the elderly group (age>65 years) comprising 780 patients and control group (aged < or = 65 years) comprising 750 patients. Data about cancer prevalence, complications and 30 day mortality were abstracted. The median age was 77 years (range 66-101, 61% females) for the elderly group and 57 years (range 18-65, 51% females) for controls. The elderly group required lower doses of medications for conscious sedation (P<.0001). The crude completion rate was lower for the elderly group (79.5% vs 89.7%), however the adjusted completion rate was similar in both groups (90.3% elderly vs 90.9% control). There was no significant difference in outcome between the two ethnic groups. Diagnostic yield was higher in the elderly group (69% vs 49%, P<.0001), with a significantly higher rate of cancer detection (7.9% vs 1.8%, P<.0001). There was no statistical difference in complication rate between the two groups (P=.35). There were 2 deaths within 30 days of colonoscopy: one in the elderly group, and one in the control group. Our results suggest that colonoscopy in our elderly patients was safe and effective and resulted in a high diagnostic yield. Therefore, old age alone should not deter colonoscopic evaluation when indicated.

Natural history of Mallory-Weiss tear in African American and Hispanic patients.

The aim of this study was to determine the natural history of Mallory-Weiss tear (MWT) in African American and Hispanic patients. We retrospectively reviewed medical records of all patients with acute upper gastrointestinal bleeding over a 10-year period. Endoscopic diagnosis of MWT was made in 12% (n = 698) of all patients with acute upper gastrointestinal bleeding. More than half of our patients with MWT did not have a preceding history of retching or vomiting. Bleeding episodes were hemodynamically significant in 216 (31%) patients. Most of the patients with MWT (80%) had an uneventful and short hospital stay (range, 1-4 days). Recurrent upper gastrointestinal bleeding within 30 days occurred in 84 (12%) patients. Overall mortality was 10%; endoscopic hemostasis failure and associated comorbidities were the common culprits.

Hepatitis C, metabolic syndrome, and inflammatory markers: results from the Third National Health and Nutrition Examination Survey [NHANES III].

Studies have shown that hepatitis C (HCV) is associated with type 2 diabetes mellitus (DM2) possibly due to insulin resistance and inflammation. Metabolic syndrome is a risk factor for DM2. Our objectives were to assess the relationship between HCV and metabolic syndrome and inflammatory markers. We used data from The Third National Health Nutrition and Examination Survey (NHANES-III). We excluded pregnant women, subjects with diabetes, those taking non-steroidal anti-inflammatory drugs, and those diagnosed with concomitant infection. We analyzed the data controlling for demographic variables, body mass index, use of contraceptives, had arthritis, and had gout. Among the 10,383 subjects, 2.3% had HCV and 16.7% had metabolic syndrome using the ATP III criteria. After controlling for the confounders, HCV was not associated with metabolic syndrome but associated with HOMA insulin resistance and inflammatory marker ferritin. Among subjects with both HCV and metabolic syndrome, the adjusted HOMA insulin level was higher than those without HCV and metabolic syndrome. In addition, the serum ferritin level was a strong predictor of HOMA insulin resistance. In clinical practice, serum ferritin can be obtained along with routine blood tests in any laboratory, and it has a potential to be a surrogate marker of insulin resistance in people with HCV and metabolic syndrome.

Jaundice in African-American and Hispanic patients with AIDS.

Although abnormalities in hepatic biochemical tests are common in patients with acquired immunodeficiency syndrome (AIDS), overt jaundice is infrequent. The aim of this study was to investigate the etiology and outcome of jaundice in African-American and Hispanic patients with AIDS. We retrospectively reviewed medical records of 1,238 HIV-infected patients with abnormal liver chemistry over a 10-year period. Data were abstracted and analyzed for demography, medications, laboratory tests, abdominal ultrasonography, computerized tomography (CT), magnetic resonance imaging (MRI), endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography (PTC) and liver biopsy results. Of 1,238 patients with abnormal liver chemistry and HIV infection, 1,040 (84%) had AIDS. Of the 1,040 AIDS patients, 102 (10%) had jaundice (serum bilirubin >3 mg/dL). Of the 198 HIV-positive patients without AIDS and with abnormal liver chemistry, none had jaundice. The common causes of jaundice were drugs (29%) and infections (28%). Liver biopsy was performed in 20 AIDS patients, and the common findings included granulomas, Mycobacterium avium complex (25%) and Kaposi's sarcoma (25%). Of 102 patients with AIDS and jaundice, 72 (70%) died. Of the 198 patients without AIDS and without jaundice, 14 (7%) died. In conclusion, liver-associated enzyme abnormality was common among our patients with AIDS; however, jaundice was infrequent and associated with a high mortality; drugs, infections and alcohol were the common culprits.

Organ failure associated with acute pancreatitis in African-American and Hispanic patients.

OBJECTIVE: We studied the relationship between acute pancreatitis and organ failure in African-American and Hispanic patients. METHODS: The medical records of 760 (417 African-American and 343 Hispanic) patients aged 19-85 years diagnosed with acute pancreatitis over 15 years were reviewed retrospectively. We abstracted and analyzed data related to demographics, etiology, type of pancreatitis, organ failure and mortality. RESULTS: Of the 760 patients, 24% had organ failure. Of the 182 patients with organ failure, 125 patients (69%) had multiple organ failure, whereas 57 patients (31%) had single type. Cardiovascular system failure was the common organ dysfunction (28%). Of the 760 patients, 14% died. Patients with organ failure had a higher mortality (40%) compared with those without it (6%) (OR=9.6, 95% CI: 6.0-15.3) (P=0.001). Mortality was higher among those with multiple organ failure (46%) compared with those with single type (25%). Mortality was highest among those with pulmonary failure (57%). CONCLUSION: The prevalence of organ failure in our study was slightly higher than the general population (20%). Mortality from single type was higher than that reported in previous studies (8-11%), especially mortality from pulmonary failure (18%). Prevention, early diagnosis and prompt treatment of organ failure may improve the clinical outcome.

Increasing incidence of clostridium difficile-associated diarrhea in African-American and Hispanic patients: association with the use of proton pump inhibitor therapy.

BACKGROUND: Clostridium difficile-associated diarrhea (CDAD) has been increasingly diagnosed in hospitalized patients. The number of prescriptions for proton pump inhibitors (PPIs) has also increased significantly over time. Few studies have reported an association between CDAD and PPI use; however, the results are inconclusive. OBJECTIVE: To determine the relationship between CDAD and PPI use in African-American and Hispanic patients. METHODS: We retrospectively reviewed medical records of 640 cases with CDAD over nine years, diagnosed by the presence of C. difficile toxin in the stools. Age-/ sex-matched 650 patients with diarrhea but absent C. difficile toxin in stools were used as controls. RESULTS: Of the 640 cases, 576 (90%) received antibiotics and 32 (5%) received chemotherapy during the preceding three months. Of the 650 controls, 540 (83%) received antibiotics and 39 (6%) received chemotherapy during the preceding three months. CDAD was associated with the use of antibiotics or chemotherapy (OR = 2.3, 95% CI: 1.5-3.7). Of the 608 cases receiving antibiotics or chemotherapy, 274 (45%) also received PPI within the preceding three months. Of the 579 controls who received antibiotics or chemotherapy, 169 (29%) also received PPI within preceding three months. CDAD was associated with the use of PPI (OR = 2.0, 95% CI: 1.6-2.6). CONCLUSION: Our findings indicate that PPI may be an emerging and potentially modifiable risk factor for CDAD and point out the importance of vigilance in prescribing PPI, particularly to patients who are hospitalized, taking multiple antibiotics and suffering from multiple comorbidities.

Fecal incontinence in older patients.

Fecal incontinence (FI), the involuntary passage of fecal material through the anus, is a common medical problem in older people, especially in frail older nursing home residents. FI is often associated with urinary incontinence. Severe constipation leading to fecal impaction, laxative abuse, diarrhea, cognitive impairment, senescence, and neuromuscular disorders including autonomic neuropathy, are among the leading causes of FI in older patients. FI affects patients' physical and psychological well-being, and is responsible for considerable morbidity and mortality in older patients. This results in significant healthcare costs. Comprehensive management of this disorder requires a systematic approach including thorough history, physical examination, and step-wise evaluation. This review in contrast to others published in last decade, focuses on management of FI in frail older nursing home patients, who require an individualized approach, which should be minimally invasive and cost-effective. In many cases of FI, treatment of the underlying condition; adequate control of diarrhea, constipation, or fecal impaction; adjustment of medications; and proper feeding may control or reduce FI. Advanced tests are often not necessary in this population.

Racial differences in preventive practices of African-American and Hispanic women.

OBJECTIVES: To compare the use of preventive practices of Hispanic- and African-American women aged 50 and older. DESIGN: A cross-sectional survey. SETTING: Inpatient and outpatient units of a teaching hospital located in South Central Los Angeles. PARTICIPANTS: Convenience sample of 337 women aged 50 and older. MEASUREMENTS: Demographic and lifestyle characteristics and selected preventive practices. Preventive practices reported were self-breast examination, mammography, Papanicolaou (Pap) smear, digital rectal examination and stool occult blood examination, sigmoidoscopy, chemoprophylaxis, and immunization. Information was obtained in a face-to-face interview. RESULTS: African-American women were more likely to have had a Pap smear ever and to have used aspirin prophylaxis than Hispanic women. CONCLUSION: There were no major differences in the use of preventive services by the two ethnic groups except for Pap smear and aspirin use. Immunization and colorectal cancer screening rates were low in African-American and Hispanic women.

Oral medication-induced esophageal injury in elderly patients.

SUMMARY: ABSTRACT Although oral medication induced esophageal injury (OMIEI), is a well-known and preventable condition, many cases are still missed, particularly in the elderly patients. OBJECTIVE To determine the frequency and outcome of oral medication-induced esophageal injury in elderly patients. METHODS Records of 390 patients aged over 65 years, with diagnoses of dysphagia, odynophagia, and noncardiac chest pain, over the period of 11 years, were selected for a retrospective review. Patients who had barium studies only, in whom endoscopy was not done or was unsuccessful, and those with incomplete data were excluded, leaving 250 patients for further review. RESULTS Diagnosis of OMIEI was made in 27% (68 of 250) patients. Fifty-one of 68 (75%) patients with OMIEI responded to conservative management, including H2 blockers, proton pump inhibitors, antacids, or sucralfate. The remaining 17 patients (25%) developed esophageal strictures requiring dilation. CONCLUSIONS A high index of clinical suspicion and low threshold for empiric treatment and diagnostic measures (endoscopy, barium swallow study), may be helpful, if indicated, for early diagnosis and prompt therapy of OMIEI.

Extrahepatic conditions and hepatic encephalopathy in elderly patients.

PURPOSE: Extrahepatic conditions can cause, exacerbate, or mimic hepatic encephalopathy in any patient with advanced liver disease, particularly in older persons. The aim of this study was to characterize the clinical features and frequency of extrahepatic conditions and the effect of therapeutic interventions upon the encephalopathy. DESIGN: Survey. SETTING: Inner city community hospital. METHODS: Retrospective chart review of 294 elderly patients (age 65-97) with liver disease and suspected hepatic encephalopathy, during a 15-year period, that included 188 men and 106 women. RESULTS: Extrahepatic conditions were found in 64 patients (22%); 29 (10%) patients had > 1 extrahepatic condition. Category and frequency of the extrahepatic conditions found in these 64 patients were as follows: urinary tract infection, 21 (33%); cellulitis/infected pressure ulcers, 16 (25%); pneumonia, 16 (25%); septicemia (with positive blood cultures), 10 (16%); silent myocardial infarction, 10 (16%); drug toxicity (nonsteroidal anti-inflammatory drugs, sedatives, hypnotics, antidiabetics), 6 (9%); meningitis, 6 (9%); head injury, 5 (8%); stroke, 5 (8%); and subdural hematoma, 5 (8%). CONCLUSION: A significant proportion of elderly patients with liver disease and presumptive diagnosis of hepatic encephalopathy may have extrahepatic condition(s), and the treatment of the latter may improve clinical outcome of such patients. A high index of suspicion, low threshold of diagnostic measures, and prompt treatment of any associated extrahepatic condition are essential to prevent significant morbidity and mortality of these patients.

Lower gastrointestinal hemorrhage in African-American and Hispanic elderly patients.

OBJECTIVES: To investigate the frequency and etiology of lower gastrointestinal hemorrhage (LGIH) in African-American and Hispanic elderly patients and to determine its natural history and the risks and benefits of therapeutic interventions. SETTING: Inner-city community teaching hospital serving predominantly African-American and Hispanic populations. METHODS: Records of 236 patients, 65 to 103 years of age, with a diagnosis of LGIH were reviewed retrospectively, over a period of 7 years, (9 White and 6 Asian patients were excluded). RESULTS: In 21 patients, the source of bleeding was located in the upper gastrointestinal tract, and these patients were excluded from the study. The source of bleeding remained unidentified in 16 of 200 patients, and they were also excluded. Bleeding was so profuse in 19 patients that satisfactory endoscopy could not be performed and emergency angiography and/or surgery was required. Endoscopic results were available in 165 patients and included: internal hemorrhoids in 60 (active bleeding in 23) patients, diverticular bleeding in 55, angiodysplasia in 50, polyps in 37, cancer in 23, drug-induced (anti-coagulants, non-steroidal anti-inflammatory drugs) lesions in 20, ischemic colitis in 15, ulcerative colitis in 10, solitary rectal ulcer in 9, Crohn's disease in 8, and colonic varices in 6 patients. Forty-eight patients had more than one lesion. Endoscopic therapy was given to 101 patients and was helpful in stopping bleeding and/or delaying surgery in 69 patients. Overall, there were 43 deaths, mostly due to underlying multiple system disease. Mortality rates did not differ by race/ethnicity or gender. Older elderly (76-85 yrs.; P < 0.01) and (> 85 yrs.; P < 0.001) had higher mortality rates. None of the deaths were directly due to endoscopy. CONCLUSIONS: Despite the small number of patients, our study suggests that acute LGIH in African-American and Hispanic elderly patients is a common condition, with the potential to become a life-threatening event. All such patients should be offered the benefits of early endoscopy and therapeutic interventions, unless contraindicated by their advanced directives. A patient's advanced age should not be a deterrent to any of the diagnostic or therapeutic interventions.

Upper gastrointestinal toxicity of nonsteroidal anti-inflammatory drugs in African-American and Hispanic elderly patients.

OBJECTIVES: To determine the upper gastrointestinal (UGI) toxicity of nonsteroidal anti-inflammatory drugs (NSAIDs), in African-American and Hispanic elderly patients. SETTING: Inner-city community hospital. METHODS: Retrospective review of records of 698 patients, 65 to 101 years old. Upper gastrointestinal (UGI) symptoms and history of NSAIDs consumption were recorded over a 12-year period. Twenty White and 25 Asian patients were excluded. Another 101 patients were excluded because of incomplete data or because endoscopy was not performed. Patients were stratified as NSAID-users or non-users, and the data were analyzed. RESULTS: Among the 552 patients, the most common lesion was gastro-duodenal erosions (34%), while common symptoms were abdominal pain (71%) and bleeding (54%). Both lesions and symptoms were higher among NSAID-users than non-users (P<.05). Endoscopic therapy was given to 296 patients, and was successful in stopping the bleeding and/or delaying surgery in 70% of the patients. Helicobacter pylori tests were done in 238 patients, and were positive in 47% of the patients. Overall 144 deaths occurred (26%). Mortality was significantly higher among elderly patients who used NSAIDs compared to those who did not use them (P<.05). CONCLUSIONS: Our study suggests a higher association between NSAID use and UGI toxicity than is reported in current literature. Patients suffering from UGI toxicity of NSAIDs may remain asymptomatic until complications occur, therefore a high index of suspicion and a low threshold for endoscopy are essential, especially in elderly patients. Avoiding NSAIDs whenever possible, substituting less toxic COX-2 inhibitors, monitoring risk, and providing cotherapy with proton pump inhibitors (PPI), or misoprostol, as suggested in the literature, may decrease NSAIDs associated morbidity and mortality in this patient population.

Syphilis and human immunodeficiency virus co-infection.

Co-infection of syphilis and AIDS has profound implications for the African American community. The purpose of this review is to: evaluate the historical background of HIV and syphilis and their similarities in pathogenesis; review the epidemiology of syphilis and HIV co-infection, and implications for continued prevention efforts; examine the effect of syphilis on HIV transmission and acquisition; and, to examine the effects of HIV infection on syphilis transmission, diagnostic and serologic changes, clinical course, and treatment. The prevalence of HIV is higher in those with syphilis; moreover, the prevalence of HIV and syphilis co-infection is highest in African Americans. There may be humoral and cellular immune similarities. HIV may affect the transmission of syphilis, alter its serologic diagnosis, and accelerate and change the clinical course and response to treatment. In conclusion, combined infection of HIV and syphilis may alter the clinical presentation and course of either disease. There are historical and immunologic similarities and the high prevalence in African Americans compared to other groups is of great importance for prevention efforts.

Non-association between acrochordons and colonic polyps in a minority population.

PURPOSE: To determine usefulness of skin tags as a predictor of colonic polyps, in patients of a minority population. SETTING: Inner-city community hospital serving predominantly African Americans and Hispanics. METHODS: Evaluation of 480 consecutive patients undergoing colonoscopy. The presence or absence of skin tags was noted, and their correlation with the colonic polyps determined. RESULTS: Colonic polyps were detected in 92 patients (19%). None of these patients had skin tags, whereas skin tags were found in 87 patients (18%), and none of them had colonic polyps. CONCLUSION: The mere presence of acrochordons (skin tags) should not be used as an indication for screening colonoscopy especially in African Americans and Hispanics.

Dyspepsia in African-American and Hispanic patients.

Dyspepsia is a common disorder with a prevalence of up to 40% in the general population. The presence of alarm features (age >50 years, loss of appetite, early satiety, loss of weight, dysphagia, abdominal mass, gastrointestinal bleeding, and/or anemia) increase the likelihood of an organic etiology. Despite a plethora of information written on this subject, the literature is sparse in minority populations. We studied the etiology of dyspepsia in relation to age and the presence or absence of alarm features in 678 African-American and Hispanic patients. Five-hundred-thirty patients were investigated by upper gastrointestinal (UGI) endoscopy, 88 by barium radiographs of the UGI tract, and 60 patients had both endoscopy and barium studies. The most common alarm feature in our study was age >50 years, followed by anemia, weight loss, gastrointestinal bleeding, loss of appetite, early satiety, abdominal mass, and dysphagia. The presence of alarm features and older age increased the likelihood of finding an organic lesion. It is concluded, therefore, that endoscopy in our dyspeptic patients who had alarm features appears to increase the diagnostic yield and may consequently result in a more favorable therapeutic outcome.

Acquired immunodeficiency syndrome in older African Americans.

The purpose of this study was to determine if older African Americans are disproportionately affected by acquired immunodeficiency syndrome (AIDS), and to review the clinical impact of AIDS and the importance of prevention and treatment efforts. A review of the literature and statistics was obtained using Medline and the AIDS Public Information Data Set offered by the Centers for Disease Control and Prevention. Twenty-seven percent of the U.S. population is above the age of 50, and the number of AIDS cases in this group is growing, with African Americans accounting for the highest proportion of cases and deaths. Testing for HIV may be delayed and symptoms attributed to other illnesses. Though 5% of new cases occur in those over 50, prevention programs, testing, and the perception of risk by providers may be insufficient. There are few research studies on HIV treatment in older patients and no specific guidelines for antiretroviral treatments available. Although death rates for AIDS has been declining, adults over 50 still have the highest mortality rate. Co-morbid conditions, such as heart disease and hypertension, may require taking multiple drugs, which may complicate treatment. Increasing heterosexual transmission rates and a lack of information on HIV reinforces the need for specific prevention programs targeted toward older African Americans.

Gunshot-induced plumbism in an adult male.

Our objective is to present a case of symptomatic lead toxicity (plumbism) with abdominal colic and hemolytic anemia following a gunshot wound. It is a retrospective case report and the setting is in a teaching hospital in south central Los Angeles. The case report is that of a patient who presented with abdominal pain, generalized weakness, and hypertension following multiple gunshot wounds, 15 years previously. Other causes of abdominal pain and weakness--such as diabetes mellitus, alcohol abuse, pancreatitis, and substance abuse--were ruled out. Interventions included treatment with the newer oral chelating agent, Succimer (2, 3-dimercaptosuccinic acid), and subsequent surgery. The main outcome was the initial reduction in blood lead levels with improvement of symptoms. Because of a recurrent rise in the blood lead levels, the patient was again treated with Succimer and underwent surgery to remove two bullet fragments from the face. We conclude that lead toxicity should be ruled out in patients presenting with abdominal cramps and a history of a gunshot wound. Prompt therapy--including environmental intervention and chelation therapy--is mandatory, and surgical intervention may be necessary.

Lower gastrointestinal bleeding in elderly patients.

Lower gastrointestinal bleeding (LGIB) is one of the common medical emergencies that can become life-threatening in elderly patients. Increased prevalence of cerebrovascular and cardiovascular diseases, malignancy, polypharmacy, and the use of nonsteroidal anti-inflammatory drugs in elderly patients adversely affects the outcome of LGIB. Diverticular bleeding, vascular ectasia, polyps and hemorrhoids are among the common causes of LGIB in the elderly. In a majority of cases, LGIB stops spontaneously with resuscitation and supportive therapy. In those elderly patients in whom LGIB continues, benefits of endoscopic, angiographic, or surgical intervention should not be withheld because of age alone. However, the timing of tests and the type of intervention should be custom tailored for frail elderly patients. Such a decision should depend upon functional status, its impact on outcome, and the consent process.

Choledocholithiasis in African American and Hispanic patients: a comparison between painless presentation and classical biliary pain with regards to clinical manifestations and outcomes.

Choledocholithiasis (CDL) usually presents with biliary pain. Painless CDL is also known to occur, especially in the elderly. The purpose of this study is to determine whether the mode of presentation (painful vs. painless) influences the clinical course and outcomes of CDL in African American and Hispanic patients. Ten years of admission and discharge records (January 1998-December 2007) were reviewed retrospectively, yielding 527 community hospital patients, aged 23-97 years, with the final diagnosis of CDL. Patients with painless presentation had higher odds of having comorbidities compared to patients presenting with pain. However, patients who presented with biliary pain were predominantly younger (mean age 34 years), and 59% were Hispanic females (p = 0.001). In our study painless CDL was associated with higher morbidity and mortality.