Abbasi J. Akhtar

DRUG INDUCED CHOLESTASIS

Recent progress in understanding the molecular mechanisms of bile formation and cholestasis have led to new insights into the pathogenesis of drug‐induced cholestasis. This review summarizes their variable clinical presentations, examines the role of transport proteins in hepatic drug clearance and toxicity, and addresses the increasing importance of genetic determinants, as well as practical aspects of diagnosis and management. (HEPATOLOGY 2011;)

Lower gastrointestinal bleeding in elderly patients.

Lower gastrointestinal bleeding (LGIB) is one of the common medical emergencies that can become life-threatening in elderly patients. Increased prevalence of cerebrovascular and cardiovascular diseases, malignancy, polypharmacy, and the use of nonsteroidal anti-inflammatory drugs in elderly patients adversely affects the outcome of LGIB. Diverticular bleeding, vascular ectasia, polyps and hemorrhoids are among the common causes of LGIB in the elderly. In a majority of cases, LGIB stops spontaneously with resuscitation and supportive therapy. In those elderly patients in whom LGIB continues, benefits of endoscopic, angiographic, or surgical intervention should not be withheld because of age alone. However, the timing of tests and the type of intervention should be custom tailored for frail elderly patients. Such a decision should depend upon functional status, its impact on outcome, and the consent process.

Extrapancreatic manifestations of acute pancreatitis in African-American and Hispanic patients.

Objective: Many studies have been published on acute pancreatitis but few, if any, on extrapancreatic manifestations (EPM) in African Americans and Hispanics. We studied the effect of EPM on mortality in these 2 ethnic groups. Methods: Records of 760 acute pancreatitis patients (417 African-American and 343 Hispanic), ages 19–85 years, over a 15-year period were reviewed retrospectively. Data were analyzed for EPM and mortality. Results: Of the 760 patients, alcohol use was identified as the etiology in 53% of cases and gallstones in 42%. EPM were present in 148 patients (19.5%). Gastrointestinal bleeding (22%) was the most common EPM. Patients with EPM did not differ from patients without EPM on demographics or acute pancreatitis–related variables (P > 0.05). Patients with EPM had higher odds of having comorbidity relative to patients without EPM (OR = 2.9, CI = 2.0–4.2). Of 760 patients, 109 died (14%). However, mortality was significantly higher (26%) in patients with EPM in comparison to those without EPM (11%), P = 0.001. Controlling for other variables, patients with EPM had higher odds of mortality relative to patients without EPM (OR = 2.8, CI = 1.7–4.4). Conclusion: Mortality was high in our patients compared with the literature (5%–10%). EPM increased the mortality significantly (26%).

Racial Differences in Preventive Practices of African‐American and Hispanic Women

OBJECTIVES: To compare the use of preventive practices of Hispanic‐ and African‐American women aged 50 and older.

Acute Diarrhea in Frail Elderly Nursing Home Patients

Diarrheal illness is the second most common cause of death worldwide, and one of the four most common infectious illnesses among elderly nursing home residents in the United States. Overall medical cost and loss of productivity due to diarrhea is estimated to be more than

Extrahepatic Conditions and Hepatic Encephalopathy in Elderly Patients

20 billion a year in the United States. However, accurate figures of the cost of diarrheal illness in the elderly population are not available. As the number of elderly increases, the magnitude of this problem and its impact upon healthcare finances is likely to increase in future.

Natural History of Mallory-Weiss Tear in African American and Hispanic Patients

Purpose: Extrahepatic conditions can cause, exacerbate, or mimic hepatic encephalopathy in any patient with advanced liver disease, particularly in older persons. The aim of this study was to characterize the clinical features and frequency of extrahepatic conditions and the effect of therapeutic interventions upon the encephalopathy. Design: Survey. Setting: Inner city community hospital. Methods: Retrospective chart review of 294 elderly patients (age 65‐97) with liver disease and suspected hepatic encephalopathy, during a 15‐year period, that included 188 men and 106 women. Results: Extrahepatic conditions were found in 64 patients (22%); 29 (10%) patients had >1 extrahepatic condition. Category and frequency of the extrahepatic conditions found in these 64 patients were as follows: urinary tract infection, 21 (33%); cellulitis/infected pressure ulcers, 16 (25%); pneumonia, 16 (25%); septicemia (with positive blood cultures), 10 (16%); silent myocardial infarction, 10 (16%); drug toxicity (nonsteroidal anti‐inflammatory drugs, sedatives, hypnotics, antidiabetics), 6 (9%); meningitis, 6 (9%); head injury, 5 (8%); stroke, 5 (8%); and subdural hematoma, 5 (8%). Conclusion: A significant proportion of elderly patients with liver disease and presumptive diagnosis of hepatic encephalopathy may have extrahepatic condition(s), and the treatment of the latter may improve clinical outcome of such patients. A high index of suspicion, low threshold of diagnostic measures, and prompt treatment of any associated extrahepatic condition are essential to prevent significant morbidity and mortality of these patients.

Oral medication-induced esophageal injury in elderly patients

The aim of this study was to determine the natural history of Mallory-Weiss tear (MWT) in African American and Hispanic patients. We retrospectively reviewed medical records of all patients with acute upper gastrointestinal bleeding over a 10-year period. Endoscopic diagnosis of MWT was made in 12% (n = 698) of all patients with acute upper gastrointestinal bleeding. More than half of our patients with MWT did not have a preceding history of retching or vomiting. Bleeding episodes were hemodynamically significant in 216 (31%) patients. Most of the patients with MWT (80%) had an uneventful and short hospital stay (range, 1-4 days). Recurrent upper gastrointestinal bleeding within 30 days occurred in 84 (12%) patients. Overall mortality was 10%; endoscopic hemostasis failure and associated comorbidities were the common culprits.

Conjunctival Edema: A Marker of Increased Mortality in Patients with Advanced Hepatic Encephalopathy and Hepatocellular Failure

&NA; Although oral medication induced esophageal injury (OMIEI), is a well‐known and preventable condition, many cases are still missed, particularly in the elderly patients. Objective: To determine the frequency and outcome of oral medication‐induced esophageal injury in elderly patients. Methods: Records of 390 patients aged over 65 years, with diagnoses of dysphagia, odynophagia, and noncardiac chest pain, over the period of 11 years, were selected for a retrospective review. Patients who had barium studies only, in whom endoscopy was not done or was unsuccessful, and those with incomplete data were excluded, leaving 250 patients for further review. Results: Diagnosis of OMIEI was made in 27% (68 of 250) patients. Fifty‐one of 68 (75%) patients with OMIEI responded to conservative management, including H2 blockers, proton pump inhibitors, antacids, or sucralfate. The remaining 17 patients (25%) developed esophageal strictures requiring dilation. Conclusions: A high index of clinical suspicion and low threshold for empiric treatment and diagnostic measures (endoscopy, barium swallow study), may be helpful, if indicated, for early diagnosis and prompt therapy of OMIEI.

Original ContributionsSafety and efficacy of digital rectal examination in patients with acute myocardial infarction

Conjunctival edema in the absence of overt ophthalmologic disease is seen in some patients with advanced hepatic encephalopathy and hepatocellular failure. We conducted an observational study in an inner city teaching hospital. Three hundred patients with advanced hepatocellular disease were studied. Three hundred ten intensive care patients were used as controls. The appearance of conjunctival edema and its relation to mortality was noted. Conjunctival edema was seen in 50 patients and was associated with high mortality; 80% in our patients. In conclusion, there was a striking correlation between conjunctival edema and increased mortality in our study population.