Hepatopulmonary Syndrome: A Comprehensive Review.

Hepatopulmonary syndrome (HPS) is defined by abnormally dilated blood vessels and shunts within the lungs, leading to impaired oxygen exchange. This condition results from intricate interactions between the liver, the gastrointestinal system, and the lungs. This complex system primarily affects pulmonary endothelial, immunomodulatory, and respiratory epithelial cells. Consequently, this contributes to pathological pulmonary changes characteristic of HPS. A classification system based on the severity of oxygen deficiency has been proposed for grading the physiological dysfunction of HPS. Contrast-enhanced echocardiography is considered the primary radiological evaluation for identifying abnormal blood vessel dilations within the lungs, which, combined with an elevated alveolar-arterial gradient, is essential for making the diagnosis. Liver transplantation is the sole effective definitive treatment that can reverse the course of the condition. Despite often being symptomless, HPS carries a significant risk of mortality before transplantation, regardless of the severity of liver disease. Meanwhile, there is varying data regarding survival rates following liver transplantation. The adoption of the model for end-stage liver disease (MELD) standard exception policy has notably improved the results for individuals with HPS compared to the period before MELD was introduced. This review offers a summary of the present understanding, highlighting recent advancements in the diagnosis and treatment of HPS. Furthermore, it aims to augment comprehension of the condition's fundamental mechanisms through insights derived from experimental models and translational research.

Is it necessary to stop glucagon-like peptide-1 receptor agonists prior to endoscopic procedure? A retrospective study.

BACKGROUND: Glucagon-like peptide-1 receptor agonists (GLP-1 RA) are effective in diabetes and obesity, reducing hyperglycemia by increasing insulin release and delaying gastric emptying. However, they can cause gastroparesis, raising concerns about aspiration during procedures. Recent guidelines advise discontinuing GLP-1 RA before surgery to reduce the risk of pulmonary aspiration. AIM: To evaluate the effect of GLP-1 RAs on gastric residual contents during endoscopic procedures. METHODS: A retrospective chart review at BronxCare Health System, New York, from January 2019 to October 2023, assessed gastric residue and aspiration in GLP-1 RA patients undergoing endoscopic procedures. Two groups were compared based on dietary status before the procedure. Data included demographics, symptoms of gastroparesis, opiate use, hemoglobin A1c, GLP-1 agonist indication, endoscopic details, and aspiration occurrence. IBM SPSS was used for analysis, calculating means, standard deviations, and applying Pearson's chi-square and t-tests for associations, with P < 0.05 as being significant. RESULTS: During the study, 306 patients were included, with 41.2% on a clear liquid/low residue diet and 58.8% on a regular diet before endoscopy. Most patients (63.1%) were male, with a mean age of 60 ± 12 years. The majority (85.6%) were on GLP-1 RAs for diabetes, and 10.1% reported digestive symptoms before endoscopy. Among those on a clear liquid diet, 1.5% had residual food at endoscopy compared to 10% on a regular diet, which was statistically significant (P = 0.03). Out of 31 patients with digestive symptoms, 13% had residual food, all from the regular diet group (P = 0.130). No complications were reported during or after the procedures. CONCLUSION: The study reflects a significant rise in GLP-1 RA use for diabetes and obesity. A 24-hour liquid diet seems safe for endoscopic procedures without aspiration. Patients with upper gastrointestinal symptoms might have a higher residual food risk, though not statistically significant. Further research is needed to assess risks based on diabetes duration, gastroparesis, and GLP-1 RA dosing, aiming to minimize interruptions in therapy during procedures.

Metabolic Dysfunction-Associated Steatohepatitis and Progression to Hepatocellular Carcinoma: A Literature Review.

The prevalence of metabolic-associated fatty liver disease (MAFLD) is increasing globally due to factors such as urbanization, obesity, poor nutrition, sedentary lifestyles, healthcare accessibility, diagnostic advancements, and genetic influences. Research on MAFLD and HCC risk factors, pathogenesis, and biomarkers has been conducted through a narrative review of relevant studies, with a focus on PubMed and Web of Science databases and exclusion criteria based on article availability and language. Steatosis marks the early stage of MASH advancement, commonly associated with factors of metabolic syndrome such as obesity and type 2 diabetes. Various mechanisms, including heightened lipolysis, hepatic lipogenesis, and consumption of high-calorie diets, contribute to the accumulation of lipids in the liver. Insulin resistance is pivotal in the development of steatosis, as it leads to the release of free fatty acids from adipose tissue. Natural compounds hold promise in regulating lipid metabolism and inflammation to combat these conditions. Liver fibrosis serves as a significant predictor of MASH progression and HCC development, underscoring the need to target fibrosis in treatment approaches. Risk factors for MASH-associated HCC encompass advanced liver fibrosis, older age, male gender, metabolic syndrome, genetic predispositions, and dietary habits, emphasizing the requirement for efficient surveillance and diagnostic measures. Considering these factors, it is important for further studies to determine the biochemical impact of these risk factors in order to establish targeted therapies that can prevent the development of HCC or reduce progression of MASH, indirectly decreasing the risk of HCC.

Black Esophagus: A Rare Case of Acute Esophageal Necrosis.

Acute esophageal necrosis (AEN) also known as necrotizing esophagitis or black esophagus is an extremely rare cause of upper gastrointestinal (GI) bleeding. This condition is considerably rare, and the exact pathophysiology of the development of AEN is still unclear. There is consensus that it is caused by a combination of esophageal mucosal injury due to gastric acid and ischemic injury due to vascular compromise. The management of AEN includes correcting the multitude of underlying predisposing conditions as well as agile symptomatic management and close monitoring for signs of hemodynamic compromise. We here present an interesting case of a middle-aged male patient who presented with hematemesis and underwent emergent esophagogastroduodenoscopy (EGD), which revealed severe necrotic esophagus. We also discussed the risk factors, pathophysiology, and management of AEN.

A Rare Case of Cecal Adenocarcinoma Presenting as Intussusception.

Colorectal cancer is widely recognized as one of the most common types of cancer worldwide. The management and outlook for colorectal cancer depend on its specific characteristics and how it presents clinically. Despite the identification of various risk factors and causes, cecal carcinoma, a type of colorectal cancer, is infrequent in Western populations under 50 years of age, and little research has been conducted on its epidemiology. Additionally, intussusception, a medical condition where one part of the intestine slides into another, is relatively rare among younger individuals. In this case report, we present a 36-year-old male who presented with abdominal pain. A physical exam revealed mild right-sided and peri-umbilical tenderness. A computed tomography scan of the abdomen and pelvis with contrast revealed long segment intussusception involving the terminal ileum and cecum. The patient underwent a reduction of intussusception and hemicolectomy. He was diagnosed with invasive cecal adenocarcinoma with metastasis to lymph nodes. He was started on chemotherapy and has been following as an oncology outpatient.

Ruptured Gastroduodenal Artery Pseudoaneurysms as a Complication of Pancreatitis.

Visceral artery pseudoaneurysms is a known vascular complication of pancreatitis that can lead to life-threatening hemorrhages with a high mortality rate if left untreated. We present a case of ruptured gastroduodenal artery pseudoaneurysm in a 68-year-old male with acute pancreatitis presenting with fatal gastrointestinal and retroperitoneal bleeding that was successfully managed with endovascular coil embolization of the involved vasculature. Patients with hemorrhagic pancreatitis or those presenting with unexplained retroperitoneal or gastrointestinal bleeding in the setting of pancreatitis with an unexplained drop in hematocrit or sudden expansion of pancreatic fluid collection should be screened in a timely manner for pseudoaneurysm using CT angiogram of the abdomen, which is the gold standard imaging modality to identify pseudoaneurysms. Once pseudoaneurysm is diagnosed, it should be treated immediately. Endovascular treatment options are now favored over surgical options in most cases.

Associations of Real-Time Ultrasound and Strain and Shear Wave Elastography with Gastrointestinal Organs: A Systematic Review.

Ultrasound elastography is gaining attention for its diagnostic potential across various medical fields, and its physical properties make it valuable in modern clinical medicine. However, its specific attributes, especially in the context of recent medical advancements, remain relatively unexplored. This study aimed to identify instrument-specific characteristics and applications of real-time ultrasound elastography, shear wave elastography, and strain elastography, particularly within gastroenterology. Following PRISMA guidelines, the study examined elastography articles on databases like PubMed, resulting in 78 included articles. Data on patient demographics, organ involvement, specificity, sensitivity, accuracy, positive predictive value, and negative predictive value were extracted. Statistical analysis involved SPSS version 21, with significance set at p < 0.05. The majority of patients were male (50.50%), with a mean age of 42.73 ± 4.41 years. Shear wave elastography was the most prevalent technique (48.7%), and liver investigations were predominant in gastroenterology (34.6%). Gastrointestinal applications showed higher sensitivity, positive predictive value, and negative predictive values (p < 0.05) but lower specificity (p < 0.05). Real-time ultrasound elastography exhibited increased specificity, accuracy, and predictive values (p < 0.05). Ultrasound elastography appears more accurate and effective in gastroenterological settings. Nonetheless, its performance depends on instrument-specific and operator-dependent factors. While promising, further studies are necessary to ascertain optimal utilization in both gastrointestinal and non-gastrointestinal conditions.

Understanding Esophageal Diverticular Bleeding: Causes, Symptoms, and Treatment.

Esophageal diverticulum refers to a sac or protrusion formed by the epithelial-lined tissue of the esophagus. It can exist as either a true diverticulum involving all layers of the esophagus or a false diverticulum. Most cases of esophageal diverticula are acquired conditions that primarily affect older individuals. Typically, patients with a known motility disorder experience dysphagia as a common symptom of esophageal diverticulum; other symptoms include recurrent pneumonia, hoarseness, and halitosis. Failure to diagnose this condition promptly or accurately can result in more severe complications, such as gastrointestinal bleeding, lung abscesses, aspiration pneumonia, and cancer development. In this report, we present the case of a 68-year-old female who arrived at the emergency department with symptoms of epigastric discomfort and hematemesis and was found to have diverticula in the middle portion of the esophagus.

Esophagitis Dissecans Superficialis: Unveiling the Enigmatic Entity of Esophageal Mucosal Sloughing.

Esophagitis dissecans superficialis (EDS), formerly referred to as sloughing esophagitis, is a degenerative condition affecting the squamous epithelium. EDS is known to be a benign condition that resolves on its own. The exact etiology of EDS remains unclear, although associations with medications like bisphosphonates or nonsteroidal anti-inflammatory drugs, skin conditions, heavy smoking, and physical trauma have been reported. The clinical manifestations exhibit a wide range, encompassing both incidental findings and symptomatic presentations related to the esophagus. Here we present an interesting case of a middle-aged female patient with dysphagia who underwent early esophagogastroduodenoscopy (EGD) for timely identification and treatment of EDS, emphasizing the significance of early detection and management.

Novel Therapies for Celiac Disease: A Clinical Review Article.

Celiac disease is emerging as an autoimmune disorder with increasing prevalence and incidence. The mean age of presentation is also increasing with the passage of time. The delay in diagnosis is partly attributable to the asymptomatic state in which most patients present. The diagnosis of the disease is primarily based on biopsy, but serology can also be included for possible screening purposes. Although the primary management strategy is to eliminate gluten from the diet of such patients; however, compliance with the diet and follow-up to detect healing might be difficult to maintain. Therefore, there is a need to investigate further management therapies that can be easily administered and monitored. The aim of the review is to discuss the epidemiology, clinical presentation, and novel therapies being investigated for celiac disease.

Diagnostic Challenge of Small Bowel Neuroendocrine Tumor in a Young Female Patient.

Neuroendocrine tumors (NETs) are rare cancers arising from neuroendocrine cells and are characterized by their ability to secrete functional hormones causing distinctive hormonal syndromes. The incidence of NET has increased over the years, and small bowel neuroendocrine tumor (SBNET) is one of the most challenging to detect due to its varied presentation and poor accessibility with traditional endoscopic methods. Patients with SBNET present with variable hormonal symptoms, such as diarrhea, flushing, and nonspecific abdominal pain, which often delay the diagnosis. We present the case of a young patient who underwent multidisciplinary workups leading to a successful diagnosis of SBNET promptly. The patient was a 31-year-old female who presented to the emergency department with complaints of nausea, vomiting, and sudden-onset, severe, sharp abdominal pain. CT scan of her abdomen showed an area of irregular intraluminal soft tissue density suspicious for a mass in the mid-small bowel. The patient's initial enteroscopy was normal. A video capsule endoscopy showed a small bowel mass, which was consistent with SBNET confirmed by pathology later. This case emphasizes the importance of considering SBNET as a differential diagnosis in young patients with nonspecific symptoms of abdominal pain and highlights the role of multidisciplinary approaches in achieving prompt diagnosis and treatment.

Role of Fecal Microbiota Transplantation in Managing Clostridium Difficile Infection and Inflammatory Bowel Disease: A Narrative Review.

Fecal microbiota transplantation (FMT) has been emerging as an alternate treatment modality in the management of patients with dysbiosis by restoring abnormal gut microbiota composition through the transplantation of normal fecal microbiota from healthy donors. This technique has lately gained a lot of attention in the treatment of recurrent or refractory Clostridium difficile infection (CDI) owing to its high success rates combined with its favorable safety profile. FMT has also been attracting the interest of clinicians as a new treatment option for inflammatory bowel diseases (IBD). Here, we reviewed most of the recent advancements in the use of FMT for CDI as well as its use in the treatment of IBD.

Emphysematous Gastritis: A Case Series on a Rare but Critical Gastrointestinal Condition.

Emphysematous gastritis (EG) is a rare and life-threatening condition characterized by gas-forming microorganisms causing gas to accumulate within the stomach wall. It has a high mortality rate and is associated with risk factors like gastroenteritis, alcohol use disorder, diabetes mellitus, renal failure, recent abdominal surgery, long-term corticosteroid use, and ingestion of corrosive agents. Diagnosis is challenging due to its rarity and nonspecific symptoms, including severe abdominal pain, coffee-ground emesis, fever, and signs of systemic infection. We present two cases of patients with signs and symptoms of EG, where prompt diagnosis and treatment were achieved, avoiding further complications. Surgical intervention was avoided due to the successful response to conservative treatment. These cases highlight the importance of early detection and intervention in improving patient outcomes and preventing complications associated with EG.

Diffuse Large B-cell Lymphoma in a Young Patient Presenting as a Cecal Mass.

Colorectal lymphomas are very rare and are usually found in male patients between the fifth and seventh decade of life. Our patient was a 30-year-old male who presented with the complaint of epigastric pain and abdominal mass for the past three months. Physical examination was remarkable for soft solid abdominal mass extending from the right side of the abdomen toward the left side. Computed tomography showed a large lobulated mass in the right lower quadrant involving multiple loops of bowel. The mass measured 15.1 x 12.5 cm in transverse dimension and 16.2 cm in craniocaudal dimension. Colonoscopy showed a villous and fungating mass occupying the whole cecum and extending into the ascending colon. Pathology from the colonoscopy mass revealed diffuse large B-cell lymphoma, which was CD20 (cluster of differentiation 20) positive. He was started on rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) chemotherapy regimen and is following at the oncology outpatient department. A combination of surgical resection and chemotherapy is used in treating patients with colorectal lymphoma.

Outcomes of Monoclonal Antibody Infusion Treatment During Delta (B.1.617.2) and Omicron (B.1.1.529) COVID 19 Variant Surges among Vaccinated and Unvaccinated Patients.

Background: Coronavirus infection of 2019 (COVID-19) is associated with significant morbidity and mortality. Vaccines supplement public health and social measures in preventing severe illness and mortality from COVID-19; however, vaccination rates remain inadequate in many regions. It is important to continuously explore the effective treatment due to the insufficient vaccination rate and increasing number of patients infected with virus. The emergence of new variants has led to multiple surges throughout the world requiring changes to treatment protocols. Method: We conducted a single-center observational study on all adult patients who received monoclonal antibody (mAb) infusion as a treatment for COVID-19 infection. Based on the predominant variant, patients were either offered Casirivimab (600 mg)/imdevimab (600 mg) or Sotrovimab (500 mg). Forty-six patients were given mAbs; 24 were vaccinated, and the remaining unvaccinated. Result: The mean age was 56 years, and the majority (63.04%) of the patients were female. Clinical symptoms of COVID-19 improved within 3 days of infusion in the majority of the patients (70%). None of the patients who received mAb showed progression of disease or required hospitalization at 30 days follow-up. There were no deaths at 30 days follow-up. Monoclonal antibodies are highly effective in reducing hospitalizations and mortality when given within 7 days of symptoms onset in patients with high-risk factors for progression to severe COVID-19 infection. The mean number of days after the onset at which the mAbs were administered to the patient was 4. Conclusion: Monoclonal antibodies should be considered in both vaccinated and unvaccinated patients with COVID-19 infection if newer antiviral agents are contraindicated. Our study highlights the effectiveness of monoclonal antibody infusions when given early in the course of COVID-19 infection regardless of vaccination status.

COVID-19-Induced Myopericarditis Leading to Cardiac Tamponade: An Unusual Case Presentation.

Coronavirus disease 2019 (COVID-19) can manifest differently in different patients, ranging from asymptomatic carriers to acute respiratory distress syndrome (ARDS). Cardiac involvement may occur with COVID-19 even without respiratory tract signs and symptoms of infection. Cardiac manifestations like heart failure (HF), myopericarditis, and cardiac arrhythmias are commonly reported. Cardiac injury with troponin leak is associated with increased mortality in COVID-19, and its clinical and radiographic features are difficult to distinguish from those of HF. COVID-19 is also known to cause pericardial inflammation, likely via direct cytotoxic effects or immune-mediated mechanisms. However, the definite mechanism is still unclear. We present here a case of myopericarditis complicated by pericardial effusion and cardiac tamponade in a COVID-19 infected patient with minimal pulmonary involvement.

Recurrent group G Streptococcus bacteremia: A case report and literature review.

Streptococci group G is an important opportunistic pathogen and causes a wide variety of infections, including pharyngitis, skin and soft tissue infections, bacteremia, endocarditis, septic arthritis, intra-abdominal infections, meningitis, and streptococcal toxic shock-like syndrome. As a result, we discuss an interesting case of recurrent group G streptococcal bacteremia in a 68-year-old man presenting with altered mental status. We also discuss the risk factors, etiology, pathophysiology, diagnosis, and treatment of group G streptococcal bacteremia.

Vandetanib-Induced Hyponatremia and Torsades De Pointes: A Case Report.

Medullary thyroid cancer (MTC) is a neuroendocrine tumor of the parafollicular cells of the thyroid gland. The prognosis is very poor in patients with advanced MTC. Vandetanib was approved for advanced MTC after randomized control trials showed that it had therapeutic efficacy and considerably prolonged progression-free survival. Vandetanib therapy is associated with serious cardiovascular side effects including hypertensive crisis and arrhythmias due to prolonged QTc. We present a case of an 83-year-old female with advanced metastatic MTC who is under treatment with vandetanib 300 mg/day and developed medication-related hyponatremia, QTc prolongation, ventricular fibrillation (VF), and torsades de pointes (TdP). Her vandetanib therapy was held. Subsequently, she did not show recurrences of TdP. This is the second such case report in the literature.

A High-Risk Patient With COVID-19 Vaccine Hesitancy Successfully Treated With Monoclonal Antibodies Through Two Major Surges.

Vaccine hesitancy remains a significant challenge in managing the current pandemic despite highly effective vaccines in the United States. Monoclonal antibodies (mAb) are an essential addition to coronavirus disease 2019 (COVID-19) treatment, along with oral antiviral agents (OAA), for non-hospitalized patients having risk factors for progression to severe COVID-19, especially in unvaccinated people. We present a case of a 74-year-old unvaccinated Hispanic woman with a history of diabetes mellitus, hypertension, coronary artery disease, obesity, and asthma who survived two episodes of severe acute respiratory syndrome coronavirus 2 (SARS­CoV­2) infections in January 2021 and December 2021 with exclusive use of mAb. Our case highlights the importance of using mAbs for treating high-risk patients with SARS-CoV-2 infection, especially in patients with vaccine hesitancy.

An Atypical Presentation of a Severe Case of Anaplasma Phagocytophilum.

We report a case of a 79-year-old male presenting to a South Bronx hospital with complaints of fever, shortness of breath, severe thrombocytopenia, hematuria, elevated liver enzymes, and acute renal failure. The patient rapidly progressed to acute hypoxic respiratory failure requiring mechanical ventilation. Treatment was delayed for six days because the tick-borne disease was not considered in the differential. Empirical treatment of tick-borne illnesses should be considered in the proper clinical setting, and travel history should be relevant in any patient presenting with fever. Delay in appropriate treatment results in the onset of more severe illness.