Relative effects of heavy alcohol use and hepatitis C in decompensated chronic liver disease in a hospital inpatient population.

BACKGROUND: Heavy alcohol use has been hypothesized to accelerate disease progression to end-stage liver disease in patients with hepatitis C virus (HCV) infection. In this study, we estimated the relative influences of heavy alcohol use and HCV in decompensated chronic liver disease (CLD). METHODS: Retrospectively, 904 patients with cirrhotic disease admitted to our hospitals during January 2010-December 2012 were identified based on ICD9 codes. A thorough chart review captured information on demographics, viral hepatitis status, alcohol use and progression of liver disease (i.e. decompensation). Decompensation was defined as the presence of ascites due to portal hypertension, bleeding esophageal varices, hepatic encephalopathy or hepatorenal syndrome. Heavy alcohol use was defined as a chart entry of greater than six daily units of alcohol or its equivalent. RESULTS: 347 patients were included based on our selection criteria of documented heavy alcohol use (n = 215; 62.0%), hepatitis titers (HCV: n = 182; 52.5%) and radiological evidence of CLD with or without decompensation (decompensation: n = 225; 64.8%). Independent of HCV infection, heavy alcohol use significantly increased the risk of decompensation (OR = 1.75, 95% CI 1.11-2.75, p < 0.02) relative to no heavy alcohol use. No significance was seen with age, sex, race, HIV, viral hepatitis and moderate alcohol use for risk for decompensation. Additionally, dose-relationship regression analysis revealed that heavy, but not moderate alcohol use, resulted in a three-fold increase (p = 0.013) in the risk of decompensation relative to abstinence. CONCLUSIONS: While both heavy alcohol use and HCV infection are associated with risk of developing CLD, our data suggest that heavy, but not moderate, alcohol consumption is associated with a greater risk for hepatic decompensation in patients with cirrhosis than does HCV infection.

"Fixing a heart": the game of electrolytes in anorexia nervosa.

CASE: A 25-year-old woman with chronic anorexia nervosa and depression presented with sudden weakness and fatigue. Psychosocial history was notable for binge-starve cycles over the past year and a decline in overall well-being. Vitals on presentation were notable for hypothermia, hypotension, and bradycardia. Initial exam was significant for emaciation, lethargy, and lower extremity edema. Laboratory work-up revealed markedly elevated LFTs, hypoglycemia, thrombocytopenia and elevated INR and lipase. ECG showed sinus bradycardia with prolonged QTc. Ultrasound revealed normal liver and biliary tree. Serum acetaminophen, alcohol level, and urinary toxicology were unremarkable. Work up for infectious, autoimmune, and genetic causes of hepatitis was negative. Echocardiogram revealed left ventricular hypokinesis and EF 10-15%. Nutritional support was begun slowly, however electrolyte derangements began to manifest on hospital day 2, with hypophosphatemia, hypokalemia, hypocalcemia, and hypomagnesemia. Multiple medical and psychiatric disciplines were consulted, and aggressive electrolyte monitoring and repletion were done. The patient's overall clinical status improved slowly during her hospital course. Her liver enzymes trended down, and her QTc interval eventually returned toward the normal range. Repeat echocardiogram following treatment revealed improvement of her EF to 40%. DISCUSSION: Anorexia nervosa is an eating disorder characterized by extremely low body weight, fear of gaining weight or distorted perception of body image, and amenorrhea. Anorexia can lead to life threatening medical complications, and thus constitutes a major challenge to manage. Central to the pathogenesis of the refeeding syndrome is a weakened cardiopulmonary system, electrolytes abnormalities, hepatic dysfunction, liver hypoperfusion and failure. CONCLUSION: Given the clinical presentation, this patient likely presented on the brink of developing frank refeeding syndrome, with cardiac dysfunction and hypovolemia, leading to hepatic hypoperfusion and ischemic hepatitis. Subsequently, she developed electrolyte disturbances characteristic of refeeding syndrome, which were managed without major complication. Her hospital course is encouraging not only for her recovery, but for the collaboration of the different teams involved in her care, and it highlights the importance of a multidisciplinary approach to caring for patients with the potential dire complications of a complex psychiatric illness.

Alcohol-Attributable Fraction in Liver Disease: Does GDP Per Capita Matter?

BACKGROUND: The alcohol-attributable fraction (AAF) quantifies alcohol's disease burden. Alcoholic liver disease (ALD) is influenced by alcohol consumption per capita, duration, gender, ethnicity, and other comorbidities. In this study, we investigated the association between AAF/alcohol-related liver mortality and alcohol consumption per capita, while stratifying to per-capita gross domestic product (GDP). METHODS: Data obtained from the World Health Organization and World Bank for both genders on AAF on liver disease, per-capita alcohol consumption (L/y), and per-capita GDP (USD/y) were used to conduct a cross-sectional study. Countries were classified as "high-income" and "very low income" if their respective per-capita GDP was greater than $30,000 or less than $1,000. Differences in total alcohol consumption per capita and AAF were calculated using a 2-sample t test. Scatterplots were generated to supplement the Pearson correlation coefficients, and F test was conducted to assess for differences in variance of ALD between high-income and very low income countries. FINDINGS: Twenty-six and 27 countries met the criteria for high-income and very low income countries, respectively. Alcohol consumption per capita was higher in high-income countries. AAF and alcohol consumption per capita for both genders in high-income and very low income countries had a positive correlation. The F test yielded an F value of 1.44 with P = .357. No statistically significant correlation was found among alcohol types and AAF. Significantly higher mortality from ALD was found in very low income countries relative to high-income countries. DISCUSSION: Previous studies had noted a decreased AAF in low-income countries as compared to higher-income countries. However, the non-statistically significant difference between AAF variances of low-income and high-income countries was found by this study. A possible explanation is that both high-income and low-income populations will consume sufficient amount of alcohol, irrespective of its type, enough to weigh into equivalent AAF. CONCLUSIONS: No significant difference of AAF variance was found between high-income and very low income countries relating to sex-specific alcohol consumption per capita. Alcohol consumption per capita was greater in high-income countries. Type of preferred alcohol did not correlate with AAF. ALD related mortality was less in high-income countries as a result of better developed healthcare systems. ALD remains a significant burden globally, requiring prevention from socioeconomic, medical, and political realms.

Effect of Gender on the Response to Hepatitis C Treatment in an Inner-City Population.

INTRODUCTION: Hepatitis C virus (HCV) is the leading cause of cirrhosis, hepatocellular carcinoma, and liver transplantation in the United States. Response to treatment has improved with the addition of direct acting protease inhibitors. However, there are limited real-world data on the role of gender in achieving a sustained virologic response (SVR). METHODS: We conducted a cross-sectional study in 70 patients treated for HCV, genotype 1 infection with pegylated alpha interferon, ribavirin, and either telaprevir or boceprevir at our inner-city liver clinic. RESULTS: The SVR was significantly lower in women than in men (24% vs. 59%; p < .01). Statistical significance persisted after adjusting for age, race, genotype, prior treatment status, duration of therapy, and stage of fibrosis. The adjusted odds ratio for achieving SVR was significantly lower in women than in men (odds ratio [OR], 0.13; 95% CI, 0.03-0.58; p = .01). Relapse after completing treatment was more likely to occur in women (p = .02). Thirty-four patients (48%) did not complete therapy. Discontinuation because of loss to follow-up was more likely in women, whereas discontinuation owing to therapy limiting adverse drug events were more common in men. Discontinuation rates owing to failure of therapy were similar in men and women. CONCLUSIONS: There was a significant difference in SVR between men and women. Both biological and nonbiological factors, the latter including access to care, adherence to therapy, and attitudes of and toward health care providers all could play a role in contributing to the observed disparity between sexes in treatment response.

An Atypical Case of Eosinophilic Gastroenteritis Presenting as Hypovolemic Shock.

Eosinophilic gastroenteritis is an uncommon condition characterized by focal or diffuse infiltration of eosinophils in the gastrointestinal tract in the absence of secondary causes. The pathogenesis of this condition is not well understood and its clinical presentation depends on the segment and layer of the gastrointestinal tract affected. The definition of eosinophilic gastroenteritis may be difficult, as the normal ranges of eosinophil numbers in normal and abnormal gastric and intestinal mucosa are not standardized. We present the case of a 59-year-old male who came to the hospital with hypovolemic shock and lethargy secondary to severe diarrhea. Laboratory analysis was significant for peripheral eosinophilia, and pathology from both the duodenum and colon showed marked eosinophilic infiltration.

Acute Esophageal Necrosis: A Case of Black Esophagus Associated with Bismuth Subsalicylate Ingestion.

We present a case of acute esophageal necrosis (AEN) likely caused by chronic use of bismuth subsalicylate, an active ingredient in over-the-counter Pepto-Bismol(®), which contains 220 g of salicylic acid in each 30 mL quantity. While aspirin is known to cause gastritis and gastric ulcers, this is the first case, to our knowledge, reporting AEN after chronic bismuth subsalicylate use.

Pheochromocytoma-induced aggression?

OBJECTIVE: To document a case of pheochromocytoma with an unusually high plasma ratio of norepinephrine to epinephrine concentrations (NE:E), and a history of violent and aggressive behavior (which has been reported to be associated with increased NE:E ratios). METHODS: We present the history of present illness, history of aggressive behavior, and the clinical course of a man who was found to have pheochromocytoma with a remarkable catecholamine profile. We also review the literature on the relationship of catecholamine ratios to behavior. RESULTS: A 33-year-old man presented to the emergency department with the chief complaint of palpitations and chest pain. A physical exam revealed markedly elevated blood pressure. On admission, a computed tomographic scan of the abdomen revealed a 10 by 10-cm heterogeneous mass of 20 Hounsfield units superior to the right kidney. His plasma NE:E ratio was 35, and his 24-hour urine ratio of normetanephrine to metanephrine concentrations was greater than 26. The tumor was successfully removed with laparoscopic adrenalectomy, and the histologic findings revealed benign pheochromocytoma. There was no immediate change in the patient's behavior. He was incarcerated the week after surgery, and lost to follow-up. CONCLUSION: Primarily norepinephrine-producing pheochromocytoma may have contributed to this patient's violent and aggressive behavior. Catecholamine levels may remain elevated for 1 week following surgery. Even if this patient's norepinephrine level had dropped rapidly after removal of the pheochromocytoma, and was not elevated a week later when he was arrested, it is possible that his aggressive behavior may have been conditioned by long exposure to elevated levels of norepinephrine.