Anish Shah

Acute Pancreatitis with Normal Serum Lipase: A Case Series

CONTEXT Acute pancreatitis is diagnosed on the basis of clinical features, biochemical tests and imaging studies. Normal serum amylase level has been reported in the setting of acute pancreatitis but normal serum lipase level in acute pancreatitis is extremely rare. CASE REPORT Herein, we present a case series of acute pancreatitis with normal serum lipase levels along with a review of the topic. CONCLUSION In appropriate clinical setting, the diagnosis of acute pancreatitis should be entertained even with normal serum amylase and lipase levels.

Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) in Strongyloides stercoralis Hyperinfection.

Strongyloides stercoralis (S. stercoralis) is a soil transmitted intestinal roundworm that has a unique ability to multiply within the human host and reinfect the human carrier by a process of autoinfection. By this property, S. stercoralis can persist as an occult infection for many decades. In situations of immunosuppression or other permissive gastrointestinal conditions, there occurs a massive increase in parasite multiplication. The parasites penetrate through the intestinal mucosa and are carried in circulation and can cause multisystem involvement. We report a case of a 76-year-old Columbian male who presented with intractable vomiting and hyponatremia who was then diagnosed to have syndrome of inappropriate antidiuretic hormone (SIADH). The patients symptoms improved after treatment with two doses of ivermectin and his serum sodium levels returned to normal. S. stercoralis infection should be suspected in patients from endemic regions who present with gastrointestinal symptoms and unexplained hyponatremia.

Replacement Gastrostomy Tube Causing Acute Pancreatitis: Case Series with Review of Literature

CONTEXT Percutaneous endoscopic gastrostomy (PEG) feedings are generally considered safe with few serious complications. Acute pancreatitis is a rare complication associated with replacement percutaneous endoscopic gastrostomy tubes. CASE REPORT We report two cases of acute pancreatitis induced by migrated replacement percutaneous endoscopic gastrostomy tubes. CONCLUSIONS Migration of a balloon into the duodenum can result in external manipulation of the ampulla of Vater thereby disturbing the flow of pancreatic secretions leading to acute pancreatitis. Recognition of this complication is important and should be included as potential etiology of acute pancreatitis in patients receiving percutaneous endoscopic gastrostomy feedings. Periodic examination and documentation of the distance of the balloon from the skin should be performed to document the position of the tubes or any inadvertent migration of the tubes. The use of Foley catheters as permanent replacement tubes should be considered medically inappropriate.

Association of decreased serum protein fractions with Clostridium difficile infection in the acute care setting: a case-control study

AIM This study examines the association of decreased levels of serum proteins with the occurrence of Clostridium difficile-associated diarrhea (CDAD) in hospitalized patients. MATERIALS & METHODS This is a retrospective case-control study using a case cohort (n = 171) that had been described in an earlier study and a cohort of 332 contemporaneous controls. RESULTS Patients with CDAD had significantly lower serum levels of albumin, total protein and globulins, and decreased albumin/globulin ratio (p < 0.0001 for all parameters). After adjustment for confounders, hypoproteinemia was more closely associated with CDAD than either hypoalbuminemia or albumin/globulin ratio. Hypoproteinemia exhibited an odds ratios of 10.6 (95% CI: 6.62-17.0) after adjustment for race, and 11.0 (95% CI: 6.88-17.1) after adjustment for age. CONCLUSION Decreased total serum protein is more closely associated with CDAD than hypoalbuminemia.

Reversal of liver cirrhosis in autoimmune hepatitis.

Liver cirrhosis is generally considered irreversible but there are reports in which there is documented reversal of fibrosis/cirrhosis in various clinical conditions like Wilsons disease, hemochromatosis, primary biliary cirrhosis and autoimmune hepatitis. The subgroup of patients with autoimmune hepatitis that will have reversal of cirrhosis is not known. We present two cases with documented liver cirrhosis that had reversal of cirrhosis after treatment with immunosuppressive agents. We postulate that patients presenting with acute hepatitis and no other fibrogenic factors have higher chances of reversal of liver cirrhosis as compared to those presenting as chronic liver injury.

Isolated angioedema of the bowel due to C1 esterase inhibitor deficiency: a case report and review of literature

We report a rare, classic case of isolated angioedema of the bowel due to C1-esterase inhibitor deficiency. It is a rare presentation and very few cases have been reported worldwide. Angioedema has been classified into three categories. A 66-year-old Caucasian man presented with a ten-month history of episodic severe cramping abdominal pain, associated with loose stools. A colonoscopy performed during an acute attack revealed nonspecific colitis. Computed tomography of the abdomen performed at the same time showed a thickened small bowel and ascending colon with a moderate amount of free fluid in the abdomen. Levels of C4 (< 8 mg/dL; reference range 15 to 50 mg/dL), CH50 (< 10 U/mL; reference range 29 to 45 U/ml) and C1 inhibitor (< 4 mg/dL; reference range 14 to 30 mg/dL) were all low, supporting a diagnosis of acquired angioedema with isolated bowel involvement. Our patients symptoms improved with antihistamine and supportive treatment. In addition to a detailed comprehensive medical history, laboratory data and imaging studies are required to confirm a diagnosis of angioedema due to C1 esterase inhibitor deficiency.