The Impact of Metabolic Syndrome on the Prognosis of High-Risk Alcoholic Hepatitis Patients: Redefining Alcoholic Hepatitis.

Background: Alcoholic hepatitis (AH) is characterized by acute symptomatic hepatitis associated with heavy alcohol use. This study was designed to assess the impact of metabolic syndrome on high-risk patients with AH with discriminant function (DF) score ≥ 32 and its effect on mortality. Methods: We searched the hospital database for ICD-9 diagnosis codes of acute AH, alcoholic liver cirrhosis, and alcoholic liver damage. The entire cohort was categorized into two groups: AH and AH with metabolic syndrome. The effect of metabolic syndrome on mortality was evaluated. Also, an exploratory analysis was used to create a novel risk measure score to assess mortality. Results: A large proportion (75.5%) of the patients identified in the database who had been treated as AH had other etiologies and did not meet the American College of Gastroenterology (ACG)-defined diagnosis of acute AH, thus had been misdiagnosed as AH. Such patients were excluded from analysis. The mean body mass index (BMI), hemoglobin (Hb), hematocrit (HCT), and alcoholic liver disease/non-alcoholic fatty liver disease index (ANI) were significantly different between two groups (P < 0.05). The results of a univariate Cox regression model showed that age, BMI, white blood cells (WBCs), creatinine (Cr), international normalized ratio (INR), prothrombin time (PT), albumin levels, albumin < 3.5, total bilirubin, Na, Child-Turcotte-Pugh (CTP), model for end-stage liver disease (MELD), MELD ≥ 21, MELD ≥ 18, DF score, and DF ≥ 32 had a significant effect on mortality. Patients with a MELD greater than 21 had a hazard ratio (HR) (95% confidence interval (CI) of 5.81 (2.74 - 12.30) (P < 0.001). The adjusted Cox regression model results showed that age, Hb, Cr, INR, Na, MELD score, DF score, and metabolic syndrome were independently associated with high patient mortality. However, the increase in BMI and mean corpuscular volume (MCV) and sodium significantly reduced the risk of death. We found that a model including age, MELD ≥ 21, and albumin < 3.5 was the best model in identifying patient mortality. Our study showed that patients admitted with a diagnosis of alcoholic liver disease with metabolic syndrome had an increased mortality risk compared to patients without metabolic syndrome, in high-risk patients with DF ≥ 32 and MELD ≥ 21. A bivariate correlation analysis revealed that patients with AH with metabolic syndrome were more likely to have infection (43%) compared to AH (26%) with correlation coefficient of 0.176 (P = 0.03, CI: 0.018 - 1.0). Conclusion: In clinical practice, the diagnosis of AH is inaccurately applied. Metabolic syndrome significantly increases the mortality risk in high-risk AH. It signifies that the presence of features of metabolic syndrome modifies the behavior of AH in acute settings, warranting different therapeutic strategies. We propose that in defining AH, patients overlapping with metabolic syndrome may need to be excluded as their outcome is different with regard to risk of renal dysfunctions, infections and death.

The Missing Link: A Case of Plummer-Vinson Syndrome in a Young Pacific-Islander Woman With Helicobacter Pylori.

Plummer-Vinson syndrome (PVS), the triad of dysphagia, iron-deficiency anemia (IDA), and esophageal webs, is a relatively rare disease entity that is mostly observed in the Caucasian populations of Scandinavia and North America. As these regions have become more developed with improved nutrition, PVS is now more commonly seen in the developing regions of the world. We present the case of a 29-year-old Pacific-islander woman who presented with progressive dysphagia and IDA and was found to have an esophageal web and Helicobacter pylori (H. pylori) gastritis on upper endoscopy. She improved with dilation of the web in the esophagus and treatment of H. pylori. Identifying the possibility of this syndrome in clinical practice and the association between H. pylori and PVS, especially given recent changes in its epidemiology, is important given the patient population in Hawaii and the Pacific.

New-Onset Collagenous Colitis in a Patient With Psoriatic Arthritis: Can It Be Secukinumab?

Collagenous colitis is a chronic inflammatory condition and one type of a bigger entity, microscopic colitis. Collagenous colitis is associated with autoimmune diseases, such as psoriatic arthritis, suggesting an immune mechanism involved in the pathogenesis of the disease. New onset and flares of inflammatory bowel disease have been associated with the use of secukinumab, but no cases of microscopic colitis have been reported yet. We present a case of a 41-year-old woman with psoriatic arthritis treated with secukinumab who developed chronic diarrhea and was found to have collagenous colitis.

More Than Just a Polyp: Diagnosis of Tuberculosis From a Screening Colonoscopy.

The diagnosis of tuberculosis (TB) is challenging to make due to the non-specific signs and symptoms that patients usually present with. Furthermore, the endoscopic appearance of colonic TB is not specific and can mimic other more common pathologies such as Crohn's disease and colonic malignancy. We report the case of a 66-year-old female who presented for a routine screening colonoscopy and was diagnosed with disseminated TB after histopathological examination of the discovered polyps.

Management of Helicobacter Pylori in the United States: Results from a national survey of gastroenterology physicians.

BACKGROUND AND AIMS: We sought to determine current knowledge and practices among gastroenterology physicians and assess adherence to current guidelines for H. pylori management. METHODS: Online surveys were distributed in 2014 to practicing gastroenterology physicians for information related to the diagnosis and treatment of H. pylori infection. RESULTS: A total of 582 completed surveys were reviewed. The H. pylori screening test used "almost always" was gastric biopsy obtained during endoscopy (histology) (59%) followed by stool antigen test (20%). Standard triple therapy for 14days was commonly prescribed by 53% of respondents. The stool antigen test was most frequently chosen to confirm H. pylori eradication (51%), although only 58% of physicians checked for eradication in patients who underwent treatment. CONCLUSIONS: Adherence to current American College of Gastroenterology guidelines is low. Although more physicians treat patients with a positive H. pylori test, only half ensure eradication after treatment. Improving knowledge of the resistance patterns of H. pylori may be critical to ensure successful eradication.

Poorly Differentiated Neuroendocrine Tumor of the Rectum Coexistent with Giant Rectal Villous Adenoma Presenting as McKittrick-Wheelock Syndrome.

McKittrick-Wheelock Syndrome is a rare disorder, noted for electrolyte and fluid depletion caused by secretory colorectal adenomas and carcinomas. We report here the first reported case of a 55-year-old man with a large rectal villous adenoma coexistent with a poorly differentiated neuroendocrine tumor of rectum presenting with McKittrick-Wheelock Syndrome. Palliative chemotherapy resulted in complete resolution of symptoms and improved quality of life.

Slower Fibrosis Progression Among Liver Transplant Recipients With Sustained Virological Response After Hepatitis C Treatment.

BACKGROUND: The natural course of hepatic fibrosis in HCV allograft recipients with sustained virological response (SVR) after anti-HCV therapy remains debatable. The aim of this study was to examine the progression of fibrosis in a cohort of patients who achieved SVR compared with those without treatment. METHODS: The 167 patients who met the inclusion and exclusion criteria were chosen from a transplant database. All patients were required to have histological evidence of recurrent HCV infection post-liver transplantation and a follow-up biopsy. The 140 of these patients had received anti-viral therapy. Twenty-seven patients were identified as controls and were matched with the treatment group in all respects. The patients were categorized into four groups based on treatment response: 1) no treatment (control) (n = 27); 2) non-responders (n = 81); 3) relapsers (n = 32); and 4) SVR (n = 27). The endpoint was the stage of fibrosis on the follow-up liver biopsy. RESULTS: The treated and untreated groups were similar in clinical characteristics at the time of transplantation and prior to the initiation of treatment. The 72% of the cohort showed a fibrosis progression of ≥ 1 stage; this change did not significantly differ between the patient groups. Nonetheless, the fibrosis progression rate was the highest in the untreated group and lowest in the patients who achieved SVR. A coefficient of determination was used. Improvements in fibrosis scores were found with greater treatment duration. These improvements were most evident with the achievement of SVR. CONCLUSIONS: In conclusion, SVR after anti-viral therapy for recurrent hepatitis C infection post-transplantation was associated with slower fibrosis progression and significantly improved graft survival.