Risk Factors for Liver Cirrhosis-Related Readmissions in the Largest Ethnic Minority in United States.

BACKGROUND: There are very limited data available on 30-day readmissions for ethnic minority patients with cirrhosis. The aim of the study was to identify the risk factors for 30-day readmission in ethnic minority patients admitted for cirrhosis. METHODS: We did a retrospective review of 1,373 electronic medical records of patients with cirrhosis admitted from 2009 to 2011. Several parameters including alcohol use history, discharge location and cirrhosis severity scores - model for end-stage liver disease (MELD) score and Child-Pugh-Turcotte (CPT) at first admission were assessed. Statistical analysis was done using Chi-square test and t-test for categorical and continuous variables, respectively. RESULTS: There were 79 patients in the readmission group (63% male, 54% Hispanics and 22% African Americans) and 104 in the no readmission group (62% male, 58% Hispanics and 24% African Americans). History of alcohol use within a month prior to admission (55% vs. 33%, P = 0.002), platelet count at discharge (89,000 vs. 124,000, P = 0.003), and discharge with more than seven medications per day (7.3 vs. 5.2, P = 0.005) were identified as risk factors for readmissions by multivariate analysis. CONCLUSION: Platelet count, active alcohol use and more than seven medications at discharge are predictors of readmission. These parameters can guide future interventions to reduce readmission rate and health care costs related to cirrhosis readmissions.

Reevaluation of the Efficacy of First Line Regimen for Helicobacter pylori.

BACKGROUND: Helicobacter pylori is a common cause of gastritis, peptic ulcer disease, and non-ulcer dyspepsia, and is also associated with gastric adenocarcinoma and mucosa associated lymphoid tissue lymphoma. Despite being known about for more than 30 years, finding an effective therapeutic strategy against it remains a challenge. AIM: There are no US studies evaluating the efficacy of a Levofloxacin based therapy for H. pylori infection. We here intend to study the efficacy of Levofloxacin based triple antibiotic regimen as compared to Clarithromycin based triple therapy and Bismuth based quadruple therapy in our patient population. METHODS: This is a retrospective single center observational study. Patients with Helicobacter pylori infection who underwent treatment for H. pylori with one of the three therapies, i.e. Clarithromycin triple, Bismuth Quadruple or Levofloxacin triple, were included in the study and the eradication rates were compared. The confirmation of the H. pylori was done 4 weeks after the completion of anti-microbial therapy. RESULTS: A total of 177 individuals underwent the H. pylori treatment in our retrospective review. Of these, 54% (n=97) of patients were treated with Clarithromycin based triple therapy (Group 1), 35% (n=63) were treated with Levofloxacin based regimen (Group 2), and the remaining 11% (n=17) were treated with Bismuth based quadruple therapy (Group 3). The eradication rates were significantly higher in patients treated with Clarithromycin based triple therapy as compared to Levofloxacin based triple therapy and Bismuth quadruple therapy (78.3% vs 49.2% vs 41.1% P=0.001). CONCLUSION: In conclusion, our study shows significantly lower eradication rates with Levofloxacin triple therapy among a selected US population. Thus, it may not be a good first-line therapy among this US population and the Clarithromycin based regimen may still be used successfully.

Chemical colitis caused by hydrogen peroxide vaginal douche: A case report.

BACKGROUND: Hydrogen peroxide is one of the most common household disinfectants worldwide. Hydrogen peroxide has been documented as a rare cause of chemical colitis. CASE SUMMARY: We present a case of 31 years old lady who presented to our hospital with rectal bleeding and abdominal pain after using hydrogen peroxide vaginal douche as an enema. She underwent colonoscopy which showed findings suggestive of chemical colitis and was managed conservatively. Hydrogen peroxide can induce chemical injury in the colon. Clinical presentation and endoscopic findings of chemical colitis are nonspecific. History taking is an important tool in identifying the underlying etiology. Review of literature showed few case reports, mostly were managed with oral antibiotics and conservative approach. CONCLUSION: Chemical colitis is usually managed conservatively. Complications including perforation, stricture and peritonitis may happen and need aggressive treatment accordingly.

Preclinical cardiac disease in nonalcoholic fatty liver disease with and without metabolic syndrome.

BACKGROUND: Metabolic syndrome is associated with preclinical cardiac disease and nonalcoholic fatty liver disease (NAFLD). It is uncertain whether preclinical cardiac disease is present in patients with NAFLD without metabolic syndrome (MetS). OBJECTIVE: To explore preclinical cardiac disease in patients with NAFLD. METHODS: A total of 64 patients with NAFLD, based on computed tomography scans liver attenuation, were identified. A control group, matched to age and gender, comprising of 94 patients was also drafted. Finally, two additional groups of patients with metabolic syndrome, with (n = 40) and without (n = 74) NAFLD, were also identified. Patients with hypertension, diabetes mellitus, and other concomitant liver diseases were excluded from the NAFLD group. Echocardiograms of all groups were reviewed. RESULTS: Severe NAFLD compared to control was associated with a higher left ventricular mass after normalization for height2.7 (LVMHt2.7) (95% CI = 0.39, 12.92) and lower ratio of peak "E" (early) and "A" (late) diastolic ventricular filling velocities (E/A) - 0.39 (95% CI = -0.58, -0.19). Patients with metabolic syndrome (95% CI = 0.02, 0.09), metabolic syndrome with NAFLD (95% CI = 0.02, 0.08), or severe NAFLD (95% CI = 0.02, 0.09) compared to control was associated with a higher relative wall thickness (RWT). CONCLUSION: Healthy adults with NAFLD without metabolic syndrome, after adjusting for body mass index, demonstrated significant echocardiographic changes. Our results show that NAFLD is associated with preclinical cardiac disease, and this association is independent of traditional risk factors like systemic hypertension and diabetes mellitus.

A Rare Cause of Abdominal Pain and Mass in an 18-Year-Old Patient: A Diagnostic Dilemma.

We present a case of an 18-year-old male who presented with complains of abdominal pain, nausea and vomiting for 2 years. An esophagogastroduodenoscopy (EGD) revealed a 3 mm nodule on the lesser curvature of the stomach and prominent gastric folds. Biopsy of the nodule revealed a well-differentiated neuroendocrine tumor (NET) in lamina prop with focal extension into muscularis mucosa consistent with a gastric carcinoid. Tumor cells stained with neuron-specific enolase (NSE), chromogranin and synaptophysin only. The prominent gastric fold biopsy revealed gastric fundic mucosa with mucosal edema and focal mild chronic inflammation. Serum gastrin level was found to be 2,083 pg/mL. Abdomen CT and endoscopic ultrasound (EUS) revealed a mass near the pancreatic neck. These findings were consistent with a functional gastrin producing well-differentiated grade 1 neuroendocrine neoplasm (gastrinoma). The patient underwent exploratory laparotomy with resection of the mass and resulting in normalization of gastrin levels.

Synchronous Adenocarcinoma of the Colon and Rectal Carcinoid.

Primary colonic adenocarcinoma and synchronous rectal carcinoids are rare tumors. Whenever a synchronous tumor with a nonmetastatic carcinoid component is encountered, its prognosis is determined by the associate malignancy. The discovery of an asymptomatic gastrointestinal carcinoid during the operative treatment of another malignancy will usually only require resection without additional treatment and will have little effect on the prognosis of the individual. This article reports a synchronous rectal carcinoid in a patient with hepatic flexure adenocarcinoma. We present a case of a 46-year-old Hispanic woman with a history of hypothyroidism, uterine fibroids and hypercholesterolemia presenting with a 2-week history of intermittent abdominal pain, mainly in the right upper quadrant. She had no family history of cancers. Physical examination was significant for pallor. Laboratory findings showed microcytic anemia with a hemoglobin of 6.6 g/dl. CT abdomen showed circumferential wall thickening in the ascending colon near the hepatic flexure and pulmonary nodules. Colonoscopy showed hepatic flexure mass and rectal nodule which were biopsied. Pathology showed a moderately differentiated invasive adenocarcinoma of the colon (hepatic flexure mass) and a low-grade neuroendocrine neoplasm (carcinoid of rectum). The patient underwent laparoscopic right hemicolectomy and chemotherapy. In patients diagnosed with adenocarcinoma of the colon and rectum, carcinoids could be missed due to their submucosal location, multicentricity and indolent growth pattern. Studies suggest a closer surveillance of the GI tract for noncarcinoid synchronous malignancy when a carcinoid tumor is detected and vice versa.

Abnormal Liver Function Tests in an Anorexia Nervosa Patient and an Atypical Manifestation of Refeeding Syndrome.

Refeeding syndrome is defined as electrolyte and fluid abnormalities that occur in significantly malnourished patients when they are refed orally, enterally, or parenterally. The principal manifestations include hypophosphatemia, hypokalemia, vitamin deficiencies, volume overload and edema. This can affect multiple organ systems, such as the cardiovascular, pulmonary, or neurological systems, secondary to the above-mentioned abnormalities. Rarely, patients may develop gastrointestinal symptoms and show abnormal liver function test results. We report the case of a 52-year-old woman with anorexia nervosa who developed refeeding syndrome and simultaneous elevations of liver function test results, which normalized upon the resolution of the refeeding syndrome.

Recurrent Renal Cell Carcinoma with Synchronous Tumor Growth in Azygoesophageal Recess and Duodenum: A Rare Cause of Anemia and Upper Gastrointestinal Bleeding.

Renal cell carcinoma (RCC) has potential to present with distant metastasis several years after complete resection. The common sites of metastases include the lungs, bones, liver, renal fossa, and brain. RCCs metastasize rarely to the duodenum, and duodenal metastasis presenting with acute gastrointestinal bleed is infrequently reported in literature. We present a case of synchronous presentation of duodenal and azygoesophageal metastasis manifesting as acute upper gastrointestinal bleeding, four years after undergoing nephrectomy for RCC. The patient underwent further workup and was treated with radiation. The synchronous presentation is rare and stresses the importance of searching for recurrence of RCC in patients presenting with acute gastrointestinal bleeding.

Foscarnet-resistant cytomegalovirus esophagitis with stricturing.

We report the case of a 52-year-old man with HIV-AIDS, non-complaint with highly active antiretroviral therapy, who presented with long-standing dysphagia. He was treated for three episodes of severe Candida esophagitis with fluconazole and later caspofungin due to poor response. In spite of the prolonged treatment courses the patient did not report an improvement in his symptoms. He was also concomitantly being treated for other opportunistic infections including cytomegalovirus (CMV) retinitis with i.v. foscarnet for almost 2 months prior to the index presentation. Upper esophagogastroduodenoscopy revealed multiple superficial ulcers with stricturing. Bougie dilatation was attempted but failed. The biopsy specimens revealed multiple intracellular inclusion bodies pathognomonic of CMV infection. We aim to highlight the increasing resistance of CMV to conventional first-line antiviral agents such as foscarnet.

An Acute Abdominal Catastrophe in a HIV Positive Patient.

We report this case of a 45-year-old man with HIV-AIDS on HAART therapy who presented with acute abdominal pain and renal failure. He was found to have pneumatosis intestinalis on computerized axial tomography scan of the abdomen. He underwent emergent explorative laparotomy, which revealed a necrotic large bowel segment for which a right-sided hemicolectomy and ileostomy were performed. The patient subsequently developed septic shock and hypoxic respiratory failure. He expired a week after the surgical procedure. Acute abdominal events due to vascular catastrophes secondary to hypercoagulability, endothelial dysfunction and accelerated atherosclerosis have been reported in HIV positive patients.