Jagpal S. Klair

Diagnosis of Minimal Hepatic Encephalopathy Using Stroop EncephalApp: A Multicenter US-Based, Norm-Based Study.

Objectives:Diagnosing minimal hepatic encephalopathy (MHE) is challenging, and point-of-care tests are needed. Stroop EncephalApp has been validated for MHE diagnosis in single-center studies. The objective of the study was to validate EncephalApp for MHE diagnosis in a multicenter study.Methods:Outpatient cirrhotics (with/without prior overt hepatic encephalopathy (OHE)) and controls from three sites (Virginia (VA), Ohio (OH), and Arkansas (AR)) underwent EncephalApp and two gold standards, psychometric hepatic encephalopathy score (PHES) and inhibitory control test (ICT). Age-/gender-/education-adjusted values for EncephalApp based on direct norms, and based on ICT and PHES, were defined. Patients were followed, and EncephalApp cutoff points were used to determine OHE prediction. These cutoff points were then used in a separate VA-based validation cohort.Results:A total of 437 cirrhotics (230 VA, 107 OH, 100 AR, 36% OHE, model for end-stage liver disease (MELD) score 11) and 308 controls (103 VA, 100 OH, 105 AR) were included. Using adjusted variables, MHE was present using EncephalApp based on norms in 51%, EncephalApp based on PHES in 37% (sensitivity 80%), and EncephalApp based on ICT in 54% of patients (sensitivity 70%). There was modest/good agreement between sites on EncephalApp MHE diagnosis using the three methods. OHE developed in 13% of patients, which was predicted by EncephalApp independent of the MELD score. In the validation cohort of 121 VA cirrhotics, EncephalApp directly and based on gold standards remained consistent for MHE diagnosis with >70% sensitivity.Conclusions:In this multicenter study, EncephalApp, using adjusted population norms or in the context of existing gold standard tests, had good sensitivity for MHE diagnosis and predictive capability for OHE development.

Myasthenia gravis masquerading as dysphagia: unveiled by magnesium infusion

Myasthenia gravis (MG) is a neuromuscular disorder that typically affects the ocular, bulbar, neck, proximal limbs and respiratory muscles. Dysphagia can occasionally be the only presenting symptom leading to extensive but ultimately futile gastrointestinal workup. Delay in diagnosis and use of certain pharmacological agents in the interim can lead to a myasthenic crisis, which though diagnostic is life threatening. We document a case of dysphagia as the only symptom of myasthenia, diagnosed after a magnesium infusion precipitated myasthenic crisis. A 70-year-old Caucasian woman who had had progressive dysphagia for 2 years, for which multiple oesophageal dilations were performed. During a hosptalisation for further gastrointestinal workup, she went into myasthenic crisis (respiratory failure) after receiving magnesium replacement. She required ventilatory support and received five plasma exchange (PLEX) treatments after myasthenia was confirmed by the detection of high antiacetylcholine receptor antibody. Though her symptoms improved, she had a prolonged hospital stay (25 days) and required 18 days of mechanical ventilation. This underscores the morbidity associated with a delay in diagnosis of this condition. This case report suggests that neuromuscular causes should be considered early in elderly patients presenting with dysphagia. Timely diagnosis, initiation of management and avoidance of drugs that affect neuromuscular transmission may help reduce the morbidity and mortality associated with myasthenic crisis.

Endoscopic management of post-liver transplant biliary complications.

Biliary complications are being increasingly encountered in post liver transplant patients because of increased volume of transplants and longer survival of these recipients. Overall management of these complications may be challenging, but with advances in endoscopic techniques, majority of such patients are being dealt with by endoscopists rather than the surgeons. Our review article discusses the recent advances in endoscopic tools and techniques that have proved endoscopic retrograde cholangiography with various interventions, like sphincterotomy, bile duct dilatation, and stent placement, to be the mainstay for management of most of these complications. We also discuss the management dilemmas in patients with surgically altered anatomy, where accessing the bile duct is challenging, and the recent strides towards making this prospect a reality.

A rare benign intrathoracic mass in a patient with history of rocket explosion

Thoracic splenosis is rare benign condition that follows trauma leading to diaphragmatic injury. Most of the patients including ours present with a clear traumatic event leading to autotransplantation of spleen in thoracic cavity. Mostly diagnosed incidentally and we need to avoid unnecessary workup including radiological and invasive. It is a very important case which signifies importance of good history taking and initial imaging for making diagnosis and making our pulmonogist and internist aware of this diagnosis.

Magnesium Toxicity-Induced Ileus in a Postpartum Patient Treated for Preeclampsia With Magnesium Sulphate

Hypermagnesemia is a rare and under-recognized cause of paralytic ileus. We report a case of a 21-year-old primigravida who was managed aggressively for preeclampsia and presented with postpartum paralytic ileus. Detailed history was employed to consider hypermagnesemia-induced ileus as the working diagnosis, and the patient improved with correction of the electrolyte imbalance. Hypermagnesemia-induced lethargy, decreased reflexes, muscle weakness, flaccid paralysis, respiratory muscle paralysis, and cardiac arrest are well-described; however, intestinal smooth muscle dysfunction leading to paralytic ileus has never been reported in the setting of magnesium use for peripartum preeclampsia management.

Chiari Network and Aortic Valve Endocarditis with Concurrent Pulmonary and Systemic Embolization

Graphical abstract

Systemic Mastocytosis Causing Refractory Pruritus in a Liver Disease Patient

Systemic mastocytosis (SM) results from clonal, neoplastic proliferation of abnormal mast cells. Patients become susceptible to itching, urticaria, and anaphylactic shock, which occurs due to histamine release from mast cells. SM may coexist alongside other systemic diseases, thus confounding the overall clinical presentation. We discuss a 23-year-old woman with refractory pruritus, which was initially attributed to primary sclerosing cholangitis but had a nonresponse to antihistaminics, ursodiol, and cholestyramine. Concurrent evaluation for polyarthritis revealed increased uptake in the proximal femur on a bone scan, and subsequent bone marrow biopsy revealed indolent SM, and this was understood to be the cause of her intractable pruritus.

Surviving Primary Pancreatic Squamous Cell Carcinoma: A Rare Entity.

Primary squamous cell carcinoma (SCC) is a rare malignancy with a poor prognosis, reported in the literature predominantly as case reports [1–3]. This is primarily due to the fact that the pancreas is devoid of any squamous cells. Therefore, a thorough search for a primary tumor elsewhere is needed before establishing the diagnosis. Management options include surgical resection with adjuvant chemotherapy or concomitant chemo and radiotherapy where surgery is not feasible. However, the outcomes in these patients, irrespective of the treatment modality, have been anecdotally poor with little known about the natural history following treatment.

Leg Swelling and Mildly Deranged Liver Tests: An Unusual Presentation of a Usual Diagnosis

Gastroenterology 2015;149:e10–e11 Question: A 72year-old woman presented to the hospital with progressively worsening left lower extremity swelling and pain of 1 weeks’ duration. She also reported vague right upper abdominal discomfort, but did not complain of nausea, vomiting, shortness of breath, chest pain, fever, or jaundice.Her past history was significant for hypertension and Meniere disease. She had had no prior surgeries and was a lifetime nonsmoker. Her current medications were hydrochlorothiazide-triamtrene, aspirin, calcium-vitamin D, and amultivitamin. On examination, she had 2þ pitting pedal edema with mild tenderness of left lower extremity. Abdomen was soft and nontender with no palpable organomegaly or mass. The rest of the physical examination was unremarkable. Laboratory tests showed: hemoglobin, 11.8 g/dL; platelets, 277,000/mL; International Normalized Ratio, 1.3; total bilirubin, 1.4 mg/dL; alkaline phosphatase, 279 IU/L; alanine aminotransferase, 39 IU/L; and aspartate aminotransferase, 38 IU/L. Lower extremity ultrasound duplex examination was performed and showed deep venous thrombosis of left femoral vein. CT of the abdomen with oral and intravenous contrast was subsequently obtained (coronal sections; Figure A, B). What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

A 'shock-ing' endoscopic finding on esophagogastroduodenoscopy

Black esophagus is a rare clinical entity, first described in 1990 by Goldenberg et al ,1 the pathogenesis of which is not fully understood,2 but is believed to arise as a result of ischaemic insult seen in haemodynamic compromise and low-flow states, corrosive injury from gastric contents in the setting of esophagogastroparesis and gastric outlet obstruction, and decreased function of mucosal barrier systems and reparative mechanisms present in malnourished and debilitated physical states. We present a case of 55-year-old woman with stage-IV metastatic lung adenocarcinoma on tarceva (erlotinib) who was admitted with coffee-ground emesis, sepsis and multiorgan failure. She was on …