Dharmesh H. Kaswala

Hydroxycut-induced Liver Toxicity

In the recent era, use of various nutritional supplements is highly encouraged amongst the people of United States. Weight loss supplements are major part of the nutritional supplements and their usage is unregulated in the US. Obesity is a major health concern in the US and Americans spend around

Drug rash with eosinophilia and systemic symptoms syndrome due to anti-TB medication

30 billion a year for weight loss supplements. At times, these supplements can be responsible for documented or undocumented adverse drug effects. The health consequences related to these supplements are often overlooked by the general public, even though FDA issues advisories regarding them. One common supplement used for weight loss was Hydroxycut (Iovate Health Sciences Research, Oakville, Ontario, Canada). Hydroxycut was recalled from the market after a FDA warning in May 2009 because of 23 reports of serious health problems ranging from jaundice and elevated liver enzymes to liver damage. 1 This case report adds evidence for Hydroxycut - induced hepatotoxicity. A 27 year old man with right upper quadrant pain and jaundice was found to have elevated liver enzymes and was taking Hydroxycut along with other supplements. Liver biopsy showed drug induced hepatotoxicity. Discontinuation of Hydroxycut dramatically improved liver functions and related symptoms.

Hemobilia Secondary to Transjugular Intrahepatic Portosystemic Shunt Procedure: A Case Report

Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome is a severe, idiosyncratic, multi-system reaction characterized by the clinical triad of fever, rash, and internal organ involvement. The mortality rate is estimated to be 8%, especially among patients with liver involvement, so early recognition is imperative. Drugs commonly associated with the development of DRESS syndrome include anticonvulsants, long-acting sulfonamides, and anti-inflammatory medications; however, there are no reported cases implicating anti-tuberculosis (anti-TB) medications. We report a case of DRESS syndrome from anti-TB therapy. A 68-year-old male with pulmonary TB presented with pruritic skin eruption and sore throat, 8 weeks after starting Rifampin, Isoniazid, Pyrazinamide, and Ethambutol (RIPE) therapy. He takes metformin and glyburide for diabetes. Physical exam was significant for diffuse, exfoliative erythematous macules with target lesions involving the entire skin surface, without mucosal involvement. Laboratory data was significant for mild transaminitis and new onset eosinophilia. Given suspicion of drug eruption, RIPE therapy was discontinued. Skin biopsy confirmed erythema multiforme. Despite discontinuation of the implicated medications, eosinophilia and transaminitis continued to worsen, and so systemic corticosteroids were started. After 4 weeks of discontinuation of RIPE therapy, the cutaneous eruption resolved and laboratory data returned to normal. The patient is finishing course of anti-TB with cycloserine and moxifloxacin. Upon follow up as outpatient, the rash was resolving and disappeared in 1 month. DRESS syndrome is always considered when there is high eosinophil counts and multisystem involvement with skin eruptions. It can be potentially life threatening with certain drugs and infectious agents in predisposed individuals. It is imperative to discontinue the causative medication and avoid re-exposure.

Metastatic prostate cancer to the duodenum: A rare case

A 59 year-old woman with liver cirrhosis due to hepatitis C, complicated by refractory hepatic hydrothorax was treated with a TIPS (transjugular intrahepatic portosystemic shunt) procedure. The procedure was complicated by substantial gastrointestinal hemorrhage. EGD (esophagogastroduodenoscopy) was performed and revealed hemobilia. A hepatic angiogram was then performed revealing a fistulous tract between a branch of the hepatic artery and biliary tree. Bleeding was successfully stopped by embolization of the bleeding branch of the right hepatic artery. Hemobilia is a rare cause of upper gastrointestinal bleeding with an increasing incidence due to the widespread use of invasive hepatobiliary procedures. Hemobilia is an especially uncommon complication of TIPS procedures. We recommend that in cases of hemobilia after TIPS placement, a physician should immediately evaluate the bleeding to exclude an arterio-biliary fistula.

847 Evaluation of Antibodies to Cytolethal Distending Toxin B (CdtB) and Vinculin in Celiac Disease

Prostate cancer is the third most common cancer in man. About 1 in 6 males developed prostate cancer and 1 in 35 males die of this disease. Prostate cancer behavior ranges from microscopic tumors to aggressive cancer with metastatic potential. While metastasis to bone is relatively common, prostate cancer rarely metastasizes to the cecum, pituitary gland, small bowel, maxillary sinus and skin. Our case report presents a rare presentation of metastatic prostate cancer to the duodenum. Our search of the literature found only 2 cases of prostate metastases to duodenum published from 1966 to the present. To our knowledge this is the third case of metastatic prostate cancer presenting with duodenal metastasis. Although it is rare but in symptomatic patients small intestine metastasis should not be ignored with advanced prostate cancer. The case demonstrates a novel presentation of a common malignancy, and should raise awareness in clinicians and radiologists that prostate cancer can present with distant metastases in absence of any local lymphadenopathy.

Sa1304 Bone Mineral Density in Celiac Disease

Background: Patients with refractory gastroesophageal reflux disease (GERD) may have undiagnosed celiac disease. These patients often undergo esophagogastroduodenoscopy to determine the etiology and severity of GERD. Because a duodenal biopsy is the gold standard for diagnosing celiac disease and a gluten-free diet is an effective treatment, performing routine duodenal biopsy during endoscopy may result in early diagnosis and symptom improvement, allowing for discontinuation of proton pump inhibitor therapy. We aimed to evaluate the cost-effectiveness of performing routine duodenal biopsy during endoscopy for diagnosing celiac disease in patients with refractory GERD. Methods: We constructed a decision tree using data from published literature to calculate cost-effectiveness of endoscopy with and without duodenal biopsy in a cohort of 10,000 40-year-old patients. Results: We found that the biopsy strategy would detect 70 out of 100 celiac disease patients in a cohort of 10,000 GERD patients undergoing endoscopy if the prevalence of celiac disease was 1% in this cohort. Up-front biopsy would increase the remaining quality-adjusted life years (QALYs) by 0.0032. Testing for celiac disease using this approach would increase the lifetime cost by

Lymphangioma of Esophagus Presenting with Dysphagia: A Case Report

389 per patient. Compared with no biopsy, the biopsy strategy cost

Intravenous Glucagon Beneficial During Colonoscopy in Patient with IBS

55,693 per celiac case detected, and

Reprogramming of gastric motility with "pulse therapy" (metoclopramide and erythromycin) in severe gastroparesis

121,875 per QALY gained. The incremental cost-effectiveness ratio (ICER) met the threshold of 1.8%, the specificity of biopsy was >98%, the cost of gluten-free diet was

Henoch-Schonlein Purpura With Gastrointestinal Involvement in an Adult Patient

5,874 per year. Increasing the sensitivity of duodenal biopsy to 100% did not affect the cost-effectiveness threshold. Conclusion: Esophagogastroduodenoscopy with duodenal biopsy for refractory GERD patients can be a cost-effective approach for screening when the prevalence of celiac disease in this patient population is 1.8% or greater.