Madhavi Reddy

Acute Hepatitis after Ingestion of a Preparation of Chinese Skullcap and Black Catechu for Joint Pain.

Many herbal preparations are routinely used and have been occasionally associated with a wide range of side effects, from mild to severe. Chinese skullcap and black catechu are herbal medications commonly used for their hepatoprotective and other properties. We report a case of acute toxic hepatitis associated with ingestion of Chinese skullcap and black catechu in one preparation for the alleviation of joint pain.

Atypical Presentation of Gastric Volvulus

Gastric volvulus has been reported in all age groups; however, it is typically diagnosed in the elderly. Organo-axial volvulus is the most common type, followed by the mesentero-axial and the combined types. Depending on the etiology, gastric volvulus can also be classified as primary (idiopathic) or secondary. Treatment of acute gastric volvulus involves laparoscopic or endoscopic procedures/maneuvers, depending on the severity of symptoms and surgical eligibility of the patient. Chronic gastric volvulus is typically managed conservatively, although laparoscopic or endoscopic interventions can also be employed depending on the severity of presentation.

Perioperative Management of Direct Oral Anticoagulants (DOACs): A Systemic Review

Direct oral anticoagulants (DOACs) are in wide use among patients requiring both short- and long-term anticoagulation, mainly due to their ease of use and the lack of monitoring requirements. With growing use of DOACs, it is imperative that physicians be able to manage patients on these medications, especially in the perioperative period. We aim to provide guidance on the management of DOACs in the perioperative period. In this review, we performed an extensive literature search summarizing the management of patients on direct-acting anticoagulants in the perioperative period. A total of four direct-acting oral anticoagulants were considered appropriate for inclusion in this review. The drugs were dabigatran etexilate mesylate (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis), and edoxaban (Savaysa). Management of patients on DOACs in the perioperative period involves an assessment of thromboembolic event risk while off anticoagulation compared to the relative risk of bleeding if such drug is continued. DOACs may not need to be discontinued in minor surgeries or procedures, and in major surgeries, they may be discontinued hours prior depending on drug pharmacokinetics and renal function of the patients.

Gastric schwannoma—a rare benign mimic of gastrointestinal stromal tumor

Abstract Schwannomas most commonly manifest as acoustic neuromas in the vestibulo-cochlear nerve (CN VIII). These may occur unilaterally as primary tumors, or bilaterally secondary to neurofibromatosis type 2. More rarely, they present in extra-cranial sites, including the gastrointestinal tract. Gastrointestinal schwannomas are believed to arise from Auerbach’s plexus in the muscularis propria, and are classified as mesenchymal tumors. Here, we report a rare case of a 49-year-old woman who had surgical resection of a gastric mass which was eventually diagnosed as gastric schwannoma.

Imatinib-induced Hepatitis in a Patient Treated for Gastrointestinal Stromal Tumor: A Rare Adverse Effect

Gastrointestinal stromal tumors (GISTs) are rare neoplasms of the digestive tract. The clinical behavior of GISTs varies greatly, has extended follow-up, and almost all of the tumors have malignant potential. The introduction of imatinib has led to extraordinary improvements in the treatment of individuals with GISTs (as well as those with Philadelphia chromosome-positive chronic myeloid leukemia (CML) and Philadelphia chromosome-positive acute lymphoblastic leukemia (ALL)). However, there have been notable postmarketing reports of adverse drug reactions of hepatotoxicity with the use of imatinib. By our search, among individuals taking imatinib for the treatment of GIST, only six cases of drug-induced liver injury (DILI) have been reported. Here, we present an interesting case of an elderly woman who developed DILI after taking imatinib for the treatment of GIST. As the liver function tests (LFTs) initially did not improve, it was decided to proceed with an interventional radiology (IR)-guided liver biopsy, which showed a histologic pattern of acute hepatitis, consistent with DILI. Ultimately, discontinuation of the antineoplastic agent led to recovery in the patient’s clinical condition along with normalization of her LFTs over the next several weeks. Thus, it is essential that physicians remain alert for and suspect DILI for any patient being treated with imatinib who presents with a sudden elevation of LFTs. The key to making the diagnosis is stopping the offending agent and closely monitoring the liver enzymes for improvement. When discontinuation of imatinib alone does not lead to improvement in LFTs and the patient’s clinical status, a detailed history should be taken and initial diagnostic testing performed to exclude other etiologies. And, if they are negative, a liver biopsy should be considered.

A Rare Thermophilic Bug in Complicated Diverticular Abscess

Actinomycosis is a form of painful abscess in the gastrointestinal tract or in deep tissue caused by actinomyces species. They are one of the commensal bacteria in the oral cavity and gastrointestinal tract of humans but can opportunistically cause infection in immunosuppressive hosts through invasion of breached mucosa or necrotic tissue while mimicking malignancy, gastrointestinal tuberculosis, and inflammatory bowel disease. Actinomyces israelii is, by far, the major and most common human pathogen throughout literatures. By virtue of rarity and diagnostic confusion with masquerading malignancies, only 10% of the cases have been diagnosed preoperatively, so as to be able to verge patients from undergoing unnecessary surgical intervention. Herein, we present a rare case of complicated diverticular abscess manifested by Actinomyces meyeri after postoperative tissue diagnosis.

Plummer-Vinson Syndrome with Proximal Esophageal Web

Plummer-Vinson Syndrome is a condition where iron deficiency is associated with difficulty swallowing due to the presence of an esophageal web. Deficiency of iron-dependent oxidative enzymes causes gradual degradation of the pharyngeal muscles which lead to mucosal atrophy and formation of webs. Although it is a very rare condition, an increased risk of esophageal squamous cell carcinoma makes its identification very important. Dilation of the esophageal web using a Savary dilator is a more effective and safer approach compared to conventional balloon dilation.

Endocuff-Assisted Colonoscopy-A Novel Accessory in Improving Adenoma Detection Rate: A Review of the Literature.

Endocuff (Arc Medical Design) is a U.S. Food and Drug Administration-approved device that is attached like a cap to the distal tip of the colonoscope; it is used to improve adenoma detection rates during colonoscopy. The aim of this review was to summarize and evaluate the clinical and technical efficacy of Endocuff in improving adenoma detection rate. A comprehensive literature review was performed to identify studies describing this technique. In this review article, we have summarized case series and reports describing Endocuff use and results. The reported indications, results, limitations, and complications are discussed.

Through-the-scope endoscopic balloon dilatation of a nonsteroidal anti-inflammatory drug-induced diaphragm-like colonic stricture

A 56-year-old woman with a history of sciatica, who had been taking nonsteroidal anti-inflammatory drugs (NSAIDs) for one year complained of abdominal fullness, rectal bleeding, and decreased stool caliber for the past six months. An endoscope could not be extended beyond a stenosed region within the descending colon. This narrowed area appeared suggestive of a diaphragm-like stricture and was surrounded by areas of healed colitis and fibrosis (Fig. 1). Biopsies revealed lamina propria fibrosis with eosinophilic infiltration (Fig. 1). A through-the-scope sequential balloon dilator (Fig. 2) was used to dilate the stricture (Fig. 2) and an endoscope was subsequently advanced into the cecum, which revealed no further colopathy. The patient tolerated the procedure well; she was advised to avoid NSAIDs, and upon follow up she reported resolution of her symptoms. Colonic diaphragm-like stricture disease was first reported in 1989. An estimated 50 cases have been described in the last 10 years. Most cases were linked to long-term use of NSAIDs [1,2]. The pathophysiology of NSAID-induced colonic strictures is still not clear, but some studies attribute fibrosis to local toxic effects of NSAID preparations on mucosal integrity due to inhibition of protective prostaglandins [3]. Colonic diaphragm-like strictures should be considered in the

Primary hepatic peripheral T-cell lymphoma associated with Epstein-Barr viral infection

Primary hepatic peripheral T-cell lymphoma (H-PTCL) is one of the rarest forms of non-Hodgkin lymphoma. We report a patient who presented with worsening jaundice, abdominal pain, and vomiting. Laboratory values were significant for elevated total bilirubin, alkaline phosphatase, and liver aminotransferases. Following a liver biopsy, histopathology revealed several large dense clusters of atypical T-lymphocytes which were CD2+, CD3+, CD5+, CD7-, CD4+, CD8-, CD56-, CD57-, CD30+ by immunohistochemistry. The proliferation index was approximately 70% by labeling for ki67/mib1. The above histological profile was consistent with peripheral T-cell lymphoma of the liver. Epstein-Barr viral serology indicated a remote infection, a likely risk factor for PTCL. Bone marrow biopsy was negative for malignancy, further supporting hepatic origin.