Efficacy and Safety of Variable Treatment Options in the Prevention of Hepatic Encephalopathy: A Systematic Review and Network Meta-Analysis.

There are no guidelines for the most effective medication to reduce hepatic encephalopathy (HE) or the associated mortality. The purpose of this study is to determine the most effective possible treatment among the single treatment options or the combined treatment options for decreasing the morbidity and mortality of HE. We evaluated the outcomes by various parameters such as the quality of life, reduction in ammonia, all causes of mortality, adverse events, reversal of minimal HE, and development of overt HE. We systematically searched PubMed, Cochrane, Web of Science, and Scopus till the 19th of January 2023 for studies that assess various treatment options for HE. Data were extracted from eligible studies and pooled in a frequentist network meta-analysis as standardized mean difference (SMD) and their 95% confidence interval (CI) using the MetaInsight web-based tool. The Cochrane Tool was used to assess the randomized controlled trials' quality (RCT), while the NIH tool was used to assess the quality of the included cohort studies. Utilizing the R software, the network meta-analysis was conducted. In addition to a significant variation in cases of (Lactulose and Rifaximin) compared with Rifaximin (RR= 0.39, 95% CI [0.17; 0.89]), the results demonstrated a significantly lower incidence of overt HE in (Lactulose and Rifaximin) compared with placebo (RR=0.19, 95% CI [0.09; 0.40]). Most arms demonstrated a statistically significant reduction in the incidence of overt HE compared to albumin and placebo. The results also demonstrated a significant reduction in ammonia between L-ornithine-L-aspartate (LOLA) and probiotics (MD= -19.17, 95% CI [-38.01; -0.32]), as well as a significant difference in the incidence of LOLA compared to placebo (MD= -22.62, 95% CI [-39.16; -6.07]). This network meta-analysis has significant data for managing subclinical HE in people without a history of overt HE. Our analysis showed that (Lactulose and Rifaximin), followed by (Rifaximin and L-carnitine), followed by (Lactulose and Rifaximin with zinc) were the best combinations regarding overt HE. LOLA reduced ammonia best, followed by Nitazoxanide and finally Lactulose. (Lactulose and Nitazoxanide) have the least adverse effects, followed by (Rifaximin and L-carnitine), then Probiotics. Yet, all mortality outcomes and quality of life changes yielded no useful findings. Future studies like RCTs must be done to compare our therapies directly.

Role of Plasmapheresis in Hemolysis, Elevated Liver Enzymes and Low Platelets (HELLP) Syndrome.

Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is a rare abnormality comprising a series of symptoms that make up a syndrome. It usually happens during pregnancy or right after delivery. We describe a case of a 31-year-old female G4P2A2 (Gravida 4 Para 2 Abortions 2) who presented to the hospital for normal vaginal delivery but immediately postpartum developed HELLP syndrome. Acute fatty liver of pregnancy was a differential that the patient also met the criteria for. Her condition improved after starting her on plasmapheresis without considering hepatic transplantation. We emphasize distinguishing the overlap of symptoms between HELLP syndrome vs. acute fatty liver of pregnancy and the outcomes of plasmapheresis in managing HELLP syndrome without needing hepatic transplantation.

Incidental Finding of Gastric Schwannoma in a Renal Failure Patient - Managed by a Minimally Invasive Procedure: Report of a Rare Case.

BACKGROUND Schwannomas are benign tumors originating from any nerve with a Schwann cell sheath. It is an extremely rare tumor, accounting for 0.2% of all gastrointestinal tumors and 4% of all benign tumors of the stomach. Clinical differentiation of gastrointestinal mesenchymal tumors is challenging and confirmatory diagnosis requires biopsy. Surgical resection is the treatment of choice when tumor size is less than 30 mm or when it is located within the muscularis propria. Here, we present a case of a large (>50 mm) gastric Schwannoma that was resected using a new laparoscopic technique suitable for larger tumors. CASE REPORT A 69-year-old woman with past medical history of hypertension, diabetes mellitus, and stroke, and CKD stage 4, presented to the Emergency Department (ED) with persistent nausea, vomiting, and weakness. She was found to have uremia requiring emergent hemodialysis. Eventually, she underwent peritoneal catheter insertion for peritoneal dialysis. A mass on the gastric antrum was found incidentally during the procedure. Biopsy confirmed the diagnosis of gastric Schwannoma. The tumor was removed successfully using a minimally invasive procedure via robotic-assisted laparoscopy. CONCLUSIONS Gastric Schwannoma is a rare submucosal tumor arising from Auerbach's plexus in the muscularis propria. It is usually asymptomatic, but can present with symptoms such as epigastric pain, or upper gastrointestinal bleeding. Tissue biopsy and immunohistochemical staining are the criterion standard for diagnosis. It has no tendency for malignant transformation. Tumors smaller than 30 mm are removed endoscopically, while tumors larger than 30 mm can be removed surgically. In this case, the tumor was removed successfully by minimally invasive robotic-assisted laparoscopy.

A Case of Pneumatosis Intestinalis With Pneumoperitoneum as a Potential Delayed Adverse Effect of Capecitabine.

Ileitis and colitis are known complications of capecitabine when used in patients with gastrointestinal cancers. However, to our knowledge, pneumatosis intestinalis (PI) has not previously been reported with this medication. We present a patient with breast cancer, without any metastases to the gastrointestinal tract, who presented with persistent diarrhea 4 weeks after discontinuing adjuvant capecitabine, which was found to be due to PI. As she had no other risk factors or identifiable causes, her PI was attributed to a delayed reaction to capecitabine. This case highlights the need to consider PI earlier in the differential diagnosis in patients with breast cancer who present with unexplained diarrhea after recent discontinuation of capecitabine.