Khalil Honein

Influence of acetaminophen at therapeutic doses on surrogate markers of severity of acute viral hepatitis.

OBJECTIVES Data on the influence of acetaminophen intake on acute viral hepatitis is scarce, but it could play a role in the worsening of this disease. The aim of this study was to determine whether the intake of acetaminophen at therapeutic doses affects the severity of acute viral hepatitis. METHODS This was a prospective study concerning 37 consecutive patients hospitalized for acute viral hepatitis. Acetaminophen consumption and time since last intake were assessed by a questionnaire. Parameters of severity were studied in comparison to time related serum concentrations of acetaminophen. RESULTS Patients hospitalized for acute viral hepatitis (18 male, 19 female patients) had a mean age of 29.2 +/- 11.5 years. The causal virus was HAV (n=23), HBV (n=7) and other viruses (n=8). The mean cumulated dose of acetaminophen was 7.7 +/- 5.65 g. The daily dose did not exceed the therapeutic dosage and the mean was 1.95 +/- 0.81 g (1-3 g). Patients who received 7.5 g of acetaminophen or more had a lower prothrombin index 52.4 +/- 30.3% vs 74.2 +/- 17.2% (P=0.039), and a lower factor V 54.7 +/- 33.2% vs 83.3 +/- 19.6% (P=0.033). Prothrombin index and bilirubinemia were negatively correlated with time related plasma acetaminophen concentrations. CONCLUSIONS The use of acetaminophen at therapeutic doses was associated with greater alterations of surrogate markers of the severity of acute viral hepatitis especially hepatitis A. This was related to cumulated dosages and correlated to the time related acetaminophen plasma concentrations. Acetaminophen use should be interrupted when acute hepatitis is suspected.

Splenic artery aneurysm presenting as a submucosal gastric lesion: A case report

We are reporting the rare case of splenic artery aneurysm of 4 cm of diameter presenting as a sub mucosal lesion on gastro-duodenal endoscopy. This aneurysm was treated by endovascular coil embolization and stent graft implantation. The procedure was uneventful. On day 1, the patient presented an acute severe epigastric pain and cardiovascular arrest. Abdominal computed tomography scan showed an active leak of the intravenous contrast dye in the peritoneum from the splenic aneurysm. We performed an emergent resection of the aneurysm, and peritoneal lavage. Postoperatively, hemorrhagic choc was refractory to large volumes replacement, and intravenous vaso-active drugs. On day 2, he presented massive hematochezia. We performed a total colectomy with splenectomy and cholecystectomy for ischemic colitis, with spleen and gallbladder infarction. Despite vaso-active drugs and aggressive treatment with Factor VIIa, the patient died after uncontrolled disseminated intravascular coagulation.

Isolated fever induced by mesalamine treatment

Adverse reactions to mesalamine, a treatment used to induce and maintain remission in inflammatory bowel diseases, particularly ulcerative colitis, have been described in the literature as case reports. This case illustrates an unusual adverse reaction. Our patient developed an isolated fever of unexplained etiology, which was found to be related to mesalamine treatment. A 22-year-old patient diagnosed with ulcerative colitis developed a fever with rigors and anorexia 10 d after starting oral mesalamine while his colitis was clinically resolving. Testing revealed no infection. A mesalamine-induced fever was considered, and treatment was stopped, which led to spontaneous resolution of the fever. The diagnosis was confirmed by reintroducing the mesalamine. One year later, this side effect was noticed again in the same patient after he was administered topical mesalamine. This reaction to mesalamine seems to be idiosyncratic, and the mechanism that induces fever remains unclear. Fever encountered in the course of a mesalamine treatment in ulcerative colitis must be considered a mesalamine-induced fever when it cannot be explained by the disease activity, an associated extraintestinal manifestation, or an infectious etiology.

Platelet-to-lymphocyte and neutrophil-to-lymphocyte ratios in Crohn's disease: The controversy remains

Crohn’s disease (CD) is an incurable inflammatory bowel disease that is characterized by mucosal inflammation and ulceration anywhere along the gastrointestinal tract. The pathology of CD includes inflammatory cell infiltration and excessive pro-inflammatory cytokine production [1]. Apart from C-reactive protein and erythrocyte sedimentation rate, a growing body of evidence suggests that the neutrophil-tolymphocyte and platelet-to-lymphocyte ratios (NLR and PLR, respectively) could be potential inflammatory biomarkers of systemic inflammation in chronic diseases [2]. However, the studies investigating this matter are sparse in CD. Therefore, we conducted a study to evaluate the potential roles of NLR and PLR as biomarkers for CD. This is an institutional review board approved observational case-control diagnostic study to evaluate the value of PLR and NLR as biomarkers for CD. Patients with endoscopically confirmed diagnoses of CD were included in this study and were ageand sex-matched to a control group of subjects with irritable bowel syndrome (IBS) symptoms and normal endoscopy and mucosal biopsy. All subjects signed an informed consent form and had a complete blood count at diagnosis before the initiation of treatment. We calculated PLR and NLR by dividing the absolute counts of platelets and neutrophils by that of lymphocytes of the patients. The activity of CD was evaluated using the endoscopic index of the severity of CD [3]. We excluded patients with active infections, infections within the last month, and ongoing prednisone treatment. All statistical analyses were performed using SPSS v.20.0 (IBM Corporation, New York, USA). Quantitative data were presented as means and standard deviations (mean ± SD). Univariate logistic regression models with either subject diagnosis (either CD or control)

Prospective Audit of Colonoscopy Practice in a Lebanese University Hospital

Background Colonoscopy has a great impact on diagnosis and management of the diseases of the colon. In general its a safe and accurate procedure. No evaluation has been done of any endoscopic practices in a country where the practice of medicine is totally private. Objectives Prospective audit of technical success and complication rates of both therapeutic and diagnostic colonoscopy. Setting One endoscopy unit of a Lebanese university hospital. Patients and design 407 consecutive colonoscopies were evaluated over a 6-month period. Data were recorded for age and sex of the patients, indication of the colonoscopy, presence of comorbidities, patients risk stratification, administrated dose of anesthetic drugs. Data concerning the procedure itself were also monitored. Intervention Completion rate as well as complications reported during or post colonoscopy. All patients were called back by phone 48 hours and 1 month later to identify any related post-procedural complication. Results 407 patients underwent colonoscopy. All patients were sedated with midazolam, propofol and fentanyl. The overall caecal intubation rate was 99.99%. 70 snare polypectomies and 29 cold forceps excision were performed as well as 5 coagulations with Argon Plasma Coagulation. The most important post-procedural complication was chemical colitis in 2 cases. Limitations Patients and endoscopists satisfaction was not evaluated. Its an audit of a single tertiary French affiliated hospital. It does not necessarily reflect whats really happening on a national level. Conclusion This audit enabled us to change some of our practices; i.e. rinsing method of endoscopes. It stimulated the team to keep a high performance level without neglecting the risk of potential complications.

An unusual internal pile

A 60 year old female underwent total colonoscopy for recurrent painless haematochezia. She reported no past medical history of abdominal or anorectal symptoms. Physical examination was unremarkable. …

Hypoalbuminaemia and gastric mass

A 45 year old woman presented with longstanding dyspepsia associated with oedema and a 4 kg weight loss over the previous six months. She gave no history of haematemesis or blood in stool, …