Melchor Demetria

Assessment of the Effects of Plasmapheresis on Patients with Hypertriglyceridemia-induced Acute Pancreatitis

Abstract Objectives: Plasmapheresis has been repetitively reported as an effective treatment in hypertriglyceridemiainduced acute pancreatitis (HTG-AP). However, due to heterogeneity in presenting severity, different definition of clinical end-points and lack of well-matched control group, a definitive role of plasmapheresis is yet to be determined. Methods: We reviewed a cohort of 142 unique patients of HTG-AP, in which 15 cases were treated with plasmapheresis. We compared the epidemiologic characteristics, presenting clinical severity and various clinical end-points between plasmapheresis group and non-plasmapheresis group directly and after successful propensity score match. The clinical trajectory of plasmapheresis group and post-match nonplasmapheresis group were plotted and compared. Results: Patients who underwent plasmapheresis had higher triglyceride levels on admission, and had a trend toward more severe pancreatitis. The unmatched cohort revealed that plasmapheresis group had longer hospital stay, required more intravenous insulin, and had longer duration of nil per os. However post-match comparison revealed that plasmapheresis had no effect on clinical outcomes. Despite the successful match of epidemiologic characteristics and presenting clinical severity, plasmapheresis group was responding slower than post-match nonplasmapheresis group, which suggests the existence of unmeasured confounding factors and possibility of obscured benefit given the similarities in various end-points. Conclusions: Although plasmapheresis had no apparent benefit or harm, there likely was residual confounding based on the different clinical trajectories between the plasmapheresis and non-plasmapheresis groups. Randomized controlled trial, or a larger multicentre observational study taking into consideration the clinical trajectory is needed to further evaluate the role of plasmapheresis in HTG-AP.

Efficacy and Safety of Indwelling Pleural Catheters in Management of Hepatic Hydrothorax: A Systematic Review of Literature

Hepatic hydrothorax (HH) is an infrequent but debilitating and therapeutically challenging complication of advanced liver cirrhosis. As evidence suggests against chest tube placement in HH, many clinicians are reluctant to place indwelling pleural catheters (IPCs) for non-malignant effusions like HH. We aim to study the efficacy and safety of IPCs as an alternative treatment option in our systematic review. A literature search was conducted using the electronic database engines MEDLINE, PubMed, EMBASE, Ovid, Scopus and Cochrane Library (Cochrane Central Register of Controlled trials and Cochrane Database of Systematic Reviews) from inception to April 2018 to identify published articles and reports addressing outcomes in patients treated for HH with IPCs. The risk of bias was rated for each study using the Cochrane criteria. The search strategy retrieved 370 papers, of which four case series were selected with a total of 111 patients. After the insertion of IPCs for HH, spontaneous pleurodesis was achieved in 16 (31.4%) out of 51 patients at a mean duration of 73-222 days. As far as secondary outcomes were concerned, the frequency of pneumothorax during or after the procedure was 0 (0%) out of 92 patients, pain at insertion site 12 (20%) out of 60 patients, catheter blockage two (2.9%) out of 68 patients, pleural fluid infection five (4.5%) out of 111 patients and catheter-site cellulitis one (3.1%) out of 32 patients. Re-accumulation of pleural fluid after catheter removal was mentioned in one study, wherein 12 (20%) out of 60 patients developed recurrence of pleural effusion. We conclude IPCs as an acceptable therapeutic option for the management of refractory pleural effusion in patients with HH. Although trans-jugular intrahepatic portosystemic shunt (TIPS) and liver transplantation are the gold standards for the management of pleural effusion in these patients, cost and availability are the major concerns with these treatment modalities. IPCs are a safe and efficacious alternative with a reasonable rate of spontaneous pleurodesis.

Carcinoma in situ arising in a tubular adenoma of ampulla of vater

alcohol abuse presented with coffee-ground emesis and melena. He denied abdominal pain, heartburn or dysphagia. Patient reported drinking Listerine (Up to 32 ounces daily). His abdominal exam was unremarkable. On Admission Hb 10.0 mg/dl, Hct 29, normal chem.-7, liver test, normal PT/PTT. Patient was placed on Pantoprazole 40mg IV QD. On EGD he was found to have a normal esophagus and multiple ulcers covered with exudate in the body and fundus. The duodenum was remarkable for patchy erythema as well as multiple erosions covered with exudate. There was multiple petechiae present in the proximal second portion of the duodenum. Pathology revealed moderately active chronic Gastritis with focal glandular regeneration and regenerative atypia. Mouthwash has been documented to produce stomatitis. The manifestations included erythema, petechiae, keratosis, tongue coating, geographic tongue type lesion and ulceration. A PubMed search did not yield any publications describing chemical gastritis caused by mouthwash. There are cases reporting fatal alcohol intoxication from the abuse of mouthwash. The use of mouthwashes and other sources of Ethanol by alcoholics is more prevalent in States where the sale of alcohol is prohibited on Sundays. Listerine is the mouthwash with the highest Ethanol content 26.9 %. Other brands range from 6 to 21 %. This case could illustrate the long term effects of Ethanol (from Listerine) on the upper gastrointestinal tract.

Is renal failure a contraindication for steroid use in acute alcoholic hepatitis

The cricopharyngeal (CP) bar is a common radiographic finding that can cause oropharyngeal dysphagia (OPD). Treatment options include CP myotomy, which is problematic given that CP bars primarily affect elderly patients with comorbidities who are at higher risk for peri-operative complications. The aim of this study was to examine the effectiveness of endoscopic dilation in the management of dysphagia attributed to a CP bar. Review of upper endoscopic (EGD) and videofluoroscopic swallowing studies from 1999-2002 identified 32 patients with CP bars. CP bar was defined by radiology as a distinct posterior impression in the cervical esophagus inferior to the vocal cords. Six of these patients had dysphagia without any other identifiable cause aside from the CP bar. Each of these six patients underwent EGD with Savary (5) or balloon dilation (1) of the upper esophageal sphincter to a diameter of 51–60 Fr. Shortand long-term follow-up was conducted post-dilation at 1–4 weeks and 10–27 months, respectively. The median age of the 32 patients with CP bars was 63 yrs. The 6 symptomatic patients who underwent endoscopic therapy were women with median age of 62 yrs. Each of the 6 patients experienced immediate improvement in dysphagia. None of the patients developed complications of post-dilation pain, bleeding or perforation. Five patients had continued improvement of their OPD at short-term follow-up. One patient who was dilated to 51 Fr using a Savary dilator experienced return of globus sensation after 48 hours, although dysphagia and regurgitation had resolved. A second Savary dilation, one month after the initial procedure, resulted in complete elimination of symptoms at subsequent shortterm follow-up. Four patients had continued complete resolution of OPD at long-term follow-up. The remaining two patients reported the recurrence of significant dysphagia after 6 and 8 months, which they stated was less severe than at initial presentation. None of the patients required surgical or endoscopic myotomy for residual or refractory dysphagia. Every patient was satisfied with the results and stated they would recommend endoscopic dilation to others with the same problem.(1) CP bar is an important cause of dysphagia that affects elderly patients. (2) Endoscopic dilation of symptomatic CP bars can produce long-term relief of dysphagia. (3) Further controlled studies are warranted to better define the efficacy and safety of endoscopic CP bar dilation as an alternative to surgical myotomy in symptomatic patients.

Enteroscopy as a diagnostic modality in the diagnosis of chylous ascites

Chylous ascites is an uncommon cause of ascites and its etiology could be a diagnostic challenge. We present one such case of chylous ascites that was diagnosed in a 44 year-old African-American woman who presented with new onset of ascites and abdominal pain. Physical examination was remarkable for generalized lymphadenopathy and a 8 cm periumblical mass lesion. There was no hepatosplenomegaly. Laboratory data was significant for a normocytic anemia (Hb=8.5) and leucocytosis with a left shift and thrombocytosisD Abnormalities on liver function test were a total protein 4.1, albumin 1.9, cholesterol 128, Alk Phos 371 and GGT 185. Ascitic fluid analysis showed a low SAAG ascites (0.9), TG 341 with WBC count of 610 (L: 73%, N: 5%). Cytology of the fluid was non conclusive. CT abdomen showed large ascites and bulky retroperitoneal lymphadenopathy. With a clinical suspicion of malignancy/lymphoma, an axillary lymph node biopsy was planned for tissue diagnosis, which was inconclusive even after flow cytometry. Hence an open laparotomy was performed. It showed a large 8 cm 10 cm mesenteric mass in the jejunal area, with extension to the mesenteric vessels and periaortic area. Frozen section and biopsy were negative for malignancy. At this point an enteroscopy was performed, which showed diffuse erythematous mucosa with multiple small nodules in the third portion of the duodenum and jejunum. Histopathology of biopsy specimens revealed an atypical large cell malignant lymphoma. Chylous ascites is most commonly caused by cirrhosis and malignancy/ lymphoma. GI tract is the most frequent location for primary extranodal lymphomas. Various modalities can be used in making the diagnosis of the underlying cause. Our case is an example where enteroscopy as an adjunctive test was able to identify the cause of chylous ascites despite inconclusive findings on more invasive interventions.