A delayed presentation of splenic laceration and hemoperitoneum following an elective colonoscopy: A rare complication with uncertain risk factors.

Splenic laceration is a rare yet often underreported complication of colonoscopy that is infrequently discussed with the patient during the consent process. Most cases present within 48 h after the inciting colonoscopy; a delayed presentation is rare. We present a case of splenic laceration with hemoperitoneum that manifested 5 days after the initial colonoscopy. The patient was treated conservatively. Traditionally perceived risk factors such as intra-abdominal adhesions, splenomegaly, anticoagulation use, biopsy, polypectomy, a technically challenging procedure, and anesthesia assistance have not been clearly shown to increase the incidence of splenic injury following a colonoscopy. Since the risk factors of splenic injury remain unclear, the clinical presentation is nonspecific, and the consequences can be serious, the endoscopist should make an effort to inform the patient of this rare complication before the procedure.

An Unusual Presentation of Glycogenic Hepatopathy with Bridging Fibrosis.

Glycogenic hepatopathy is a rare and under-recognized complication of poorly controlled diabetes mellitus. We report a patient who presented with predominant elevation in alkaline phosphatase and liver biopsy showing bridging fibrosis, which is an unusual presentation of glycogenic hepatopathy. This case emphasizes the fact that glycogenic hepatopathy can also present with a cholestatic pattern of liver abnormality and with liver fibrosis, which warrants further study because severe fibrosis can progress to cirrhosis.

Glycogenic hepatopathy: A narrative review.

Glycogenic hepatopathy (GH) is a rare complication of the poorly controlled diabetes mellitus characterized by the transient liver dysfunction with elevated liver enzymes and associated hepatomegaly caused by the reversible accumulation of excess glycogen in the hepatocytes. It is predominantly seen in patients with longstanding type 1 diabetes mellitus and rarely reported in association with type 2 diabetes mellitus. Although it was first observed in the pediatric population, since then, it has been reported in adolescents and adults with or without ketoacidosis. The association of GH with hyperglycemia in diabetes has not been well established. One of the essential elements in the pathophysiology of development of GH is the wide fluctuation in both glucose and insulin levels. GH and non-alcoholic fatty liver disease (NAFLD) are clinically indistinguishable, and latter is more prevalent in diabetic patients and can progress to advanced liver disease and cirrhosis. Gradient dual-echo MRI can distinguish GH from NAFLD; however, GH can reliably be diagnosed only by liver biopsy. Adequate glycemic control can result in complete remission of clinical, laboratory and histological abnormalities. There has been a recent report of varying degree of liver fibrosis identified in patients with GH. Future studies are required to understand the biochemical defects underlying GH, noninvasive, rapid diagnostic tests for GH, and to assess the consequence of the fibrosis identified as severe fibrosis may progress to cirrhosis. Awareness of this entity in the medical community including specialists is low. Here we briefly reviewed the English literature on pathogenesis involved, recent progress in the evaluation, differential diagnosis, and management.

Seronegative Autoimmune Hepatitis A Clinically Challenging Difficult Diagnosis.

Autoimmune hepatitis (AIH) is a complex liver disease of unknown cause which results in immune-mediated liver injury with varied clinical presentations. Seronegative AIH follows a similar course to autoantibody-positive disease and diagnosis may be challenging. There are no single serologic tests of sufficient diagnostic specificity, and delay in appropriate treatment may lead to progression of the liver disease and liver failure. The revised conventional diagnostic criteria (RDC) scoring for AIH is complex and not routinely used in the clinical practice. The more recent simplified diagnostic criteria (SDC) scoring proposed by International Autoimmune Hepatitis Group in 2008 has wider application in routine practice facilitating the diagnosis of AIH with a specificity and sensitivity of ~90%. In this report, we describe a case of seronegative autoimmune hepatitis diagnosed using RDC. SDC score calculated in our case was 4 and was not diagnostic for AIH. We subsequently used the complex revised diagnostic criteria for definitive diagnosis. Some of the patients previously diagnosed as cryptogenic active hepatitis of unknown etiology probably had an unrecognized diagnosis of seronegative autoimmune hepatitis. SDC scoring may not be applicable in patients with seronegative autoimmune hepatitis. These patients should be reassessed by using RDC.

Clinical efficacy and tolerability of direct-acting antivirals in elderly patients with chronic hepatitis C.

BACKGROUND: There is a lack of evidence-based data on aged patients with newer direct-acting antivirals (DAAs) and with shorter duration of treatment regimens involving DAAs with or without ribavirin (RBV) and pegylated interferon (Peg IFN). PATIENTS AND METHODS: Medical records of 240 patients treated with DAAs with or without Peg IFN and RBV between January 2013 and July 2015 were retrospectively analyzed. Patients were divided into two groups: patients aged 65 years and older (N=84) and patients aged younger than 65 years (N=156). Pretreatment baseline patient characteristics, treatment efficacy, factors affecting sustained virologic response at 12 weeks after treatment, and adverse reactions were compared between the groups. RESULTS: No statistically significant difference was observed with end of treatment response (98.8 vs. 98%, P=0.667) and sustained virologic response at 12 weeks after treatment (93.1 vs. 94.1%, P=0.767) between patients aged 65 and older and those younger than 65 years of age. Fatigue was the most common adverse event recorded (32.5%), followed by anemia (19.6%), leukopenia (11.7%), thrombocytopenia (10%), skin rash (8.3%), and headache (7.9%). The RBV dose was reduced in eight (8%) patients and four patients discontinued the RBV treatment because of severe anemia. RBV dose reduction or discontinuation did not reach statistical significance (P=0.913). Increased fibrosis, cirrhosis, aspartate aminotransferase, alanine aminotransferase, hemoglobin, and platelet levels seem to affect the sustained virologic response in the elderly. Twelve (6.28%) patients failed to respond to treatment and the failure rate was not significant (P=0.767) between the groups. CONCLUSION: DAAs with or without IFN and RBV in the standard recommended 12 or 24-week treatment regimens are effective, well tolerated, and may be safely extended to elderly patients infected with chronic hepatitis C.

Autoimmune hepatitis induced by nitrofurantoin. The importance of the autoantibodies for an early diagnosis of immune disease.

Nitrofurantoin has been in use since 1953 as an effective agent for the prevention of recurrent urinary tract infection. It is associated with a wide range of adverse drug reactions. Chronic active hepatitis has increasingly been observed and many cases have been reported with case fatalities. We present a case of nitrofurantoin induced chronic active hepatitis and briefly review the serology and clinico pathological features of 57 similar cases reported in English literature. The consistent presence of antinuclear antibody, anti smooth muscle antibody, elevated immunoglobulin and pathological feature suggests an immunologic mechanism. Complete recovery is possible in most cases if medication is discontinued in time. Steroids may play a role in management if no improvement occurs despite discontinuation of medication. We suggest all patients who are on prolonged nitrofurantoin therapy be followed up with anti nuclear antibody, anti smooth muscle antibody, serum immunoglobulin and hepatic panel every three months.

Open carpal tunnel release--still a safe and effective operation.

BACKGROUND: Carpal tunnel syndrome is a common cause of neurological symptomatology. Surgical decompression remains the treatment of choice in patients not responding to conservative therapies. The aim of this study was to assess the effectiveness of standard open decompression by analysis of symptomatic and functional improvement and to assess whether a general surgeon can still perform this operation safely. PATIENTS AND METHODS: Patients undergoing standard open carpal tunnel release by a single general surgeon were recruited. A self-administered Boston questionnaire was used to assess symptom severity and functional status pre- and post-surgical intervention. RESULTS: Forty-seven patients (51 hands) underwent carpal tunnel release and 32 patients completed the questionnaire. 88% had a significant reduction in the symptom severity score, while improvement in function status score was achieved in 79% of patients. Mean symptom severity score improved from 3.41 points preoperatively to 1.85 (p < 0.0001) points at the last follow up examination, while the mean function status score improved from 2.73 to 1.99 points (p < 0.0001). Outcome was poor in six patients with slight worsening of either symptom or function status score. Three patients were treated conservatively for minor wound infection without long-term sequelae. DISCUSSION: Standard open carpal tunnel release still provides efficacious symptomatic relief with a low risk of associated complications when performed by a general surgeon.