Mohammad Bilal

Linoleic Acid Induced Acute Hepatitis: A Case Report and Review of the Literature

Several dietary supplements used for weight loss have been reported to cause hepatotoxicity. Conjugated Linoleic Acid (CLA) is a dietary supplement that has been shown to cause reduction in body fat mass. Here, we present the first case of CLA induced acute hepatitis in the United States and only the third case in the worldwide literature along with a brief review of the literature.

Cerebrovascular Outcomes With Proton Pump Inhibitors and Thienopyridines: A Systematic Review and Meta-Analysis

Background and Purpose— Pharmacokinetic and prior studies on thienopyridine and proton pump inhibitors (PPI) coadministration provide conflicting data for cardiovascular outcomes, whereas there is no established evidence on the association of concomitant use of PPI and thienopyridines with adverse cerebrovascular outcomes. Methods— We conducted a systematic review and meta-analysis of randomized controlled trials and cohort studies from inception to July 2017, reporting following outcomes among patients treated with thienopyridine and PPI versus thienopyridine alone (1) ischemic stroke, (2) combined ischemic or hemorrhagic stroke, (3) composite outcome of stroke, myocardial infarction (MI), and cardiovascular death, (4) MI, (5) all-cause mortality, and (6) major or minor bleeding events. After the unadjusted analyses of risk ratios, we performed additional analyses of studies reporting hazard ratios adjusted for potential confounders. Results— We identified 22 studies (12 randomized controlled trials and 10 cohort studies) comprising 131u2009714 patients. Concomitant use of PPI with thienopyridines was associated with increased risk of ischemic stroke (risk ratio, 1.74; 95% confidence interval [CI], 1.41–2.16; P<0.001), composite stroke/MI/cardiovascular death (risk ratio, 1.14; 95% CI, 1.01–1.29; P=0.04), and MI (risk ratio, 1.19; 95% CI, 1.00–1.40; P=0.05). Likewise, in adjusted analyses concomitant use of PPI with thienopyridines was again associated with increased risk of stroke (hazard ratios adjusted, 1.30; 95% CI, 1.04–1.61; P=0.02), composite stroke/MI/cardiovascular death (hazard ratios adjusted, 1.23; 95% CI, 1.03–1.47; P=0.02), but not with MI (hazard ratios adjusted, 1.19; 95% CI, 0.93–1.52; P=0.16). Conclusions— Co-prescription of PPI and thienopyridines increases the risk of incident ischemic strokes and composite stroke/MI/cardiovascular death. Our findings corroborate the current guidelines for PPI deprescription and pharmacovigilance, especially in patients treated with thienopyridines.

Long-Term Follow-Up of Fecal Microbiota Transplantation for Treatment of Recurrent Clostridium difficile Infection in a Dual Solid Organ Transplant Recipient

Clostridium difficile infection is one of the most frequent causes of healthcare-associated infections, and its rates are also increasing in the community. Mounting evidence suggests that fecal microbiota transplantation (FMT) may be effective; however, as there is paucity of data regarding the use of FMT in patients with solid organ transplants, we present a case of successful FMT in a patient with dual solid organ transplant.

Rare case of entero-enteric intussusception caused by small bowel metastasis from a cardiac liposarcoma

Primary cardiac liposarcoma is exceedingly rare and its metastatic potential varies based on the actual tumor subclass. Intestinal intussusception is also an uncommon cause of abdominal pain and bowel obstruction in adults and it usually generates at a malignant lead point in this age group. We report a case of a primary cardiac dedifferentiated liposarcoma in a pregnant woman causing small bowel seeding leading to bowel intussusception.

Evaluation and management of gastrointestinal bleeding

Non-variceal upper gastrointestinal bleeding continues to be an important cause of morbidity and mortality. The most common causes include peptic ulcer disease, Mallory-Weiss syndrome, erosive gastritis, duodenitis, esophagitis, malignancy, angiodysplasias and Dieulafoys lesion. Initial assessment and early aggressive resuscitation significantly improves outcomes. Upper gastrointestinal endoscopy continues to be the gold standard for diagnosis and treatment. We present a comprehensive review of literature for the evaluation and management of non-variceal upper gastrointestinal bleeding.

A Tale of Two Tumors: a Case of Concomitant Esophageal Squamous Papilloma and Granular Cell Tumor

To the editor, Benign esophageal tumors are rare. This includes granular cell tumors (GCTs) which comprise 1% of benign esophageal tumors, and incidence during esophagogastroduodenoscopy (EGD) is estimated at 0.033% [1]. Squamous papillomas (SP) of the esophagus are also rare, with an incidence during EGD estimated from 0.01 to 0.45% [2]. We present a unique case of a patient incidentally found to have esophageal GCTas well as esophageal SP successfully treated with endoscopic mucosal resection (EMR). A 45-year-old male with a past history of renal cell carcinoma status post left nephrectomy was referred to our tertiary care digestive disease center for esophageal polyps seen on EGD. Patient underwent an EGD and colonoscopy for an episode of hematochezia where the EGD showed incidental findings of two polypoid lesions in the midesophagus. One lesion was biopsied and demonstrated a granular cell tumor (GCT), while another more proximal lesion was not biopsied at that time. After evaluation in clinic, an endoscopic ultrasound (EUS) was performed during which two subepithelial lesions in the mid-esophagus were seen. The proximal lesion was 11 mm and the distal lesion was 9 mm in size (Fig. 1). Endoscopic mucosal resection (EMR) of the distal esophageal lesion was performed and pathology was consistent with a GCT (Fig. 2). A repeat EGD was scheduled and EMR of the proximal lesion was performed at that time, with pathology demonstrating esophageal squamous papilloma (SP) (Fig. 2). No complications occurred during the procedures. The patient was discharged and scheduled for surveillance EGD in 1 year. To our knowledge, this is the first reported case of concomitant GCT and SP. In a small, single-center retrospective analysis, GCTs less than 10 mm in diameter underwent successful EMR without complication [3]. In another reported series of patients with esophageal SP resected endoscopically, followup endoscopy between 18 and 48 months demonstrated no further lesions at the site of resection or at any other locations within the esophagus [2]. Transformation of esophageal SP to squamous cell carcinoma has been described, but occurred only in cases where numerous polyps were present. Currently, there are no clear guidelines regarding surveillance of these lesions after resection.

Increasing adenoma detection rates in the right side of the colon comparing retroflexion or a second forward view: a systematic review

BACKGROUND AND AIMSnRight-sided lesions are often missed during standard colonoscopy (SC). A second forward-view examination or retroflexion in the right side of the colon have both been proposed as techniques to improve adenoma detection rate (ADR) in the right side of the colon. Comparative data on examining the right side of the colon with a second forward view or retroflexion is not known in a pooled analysis. We performed a systematic review of the literature to assess the yield of a second forward view compared with retroflexion examination for the detection of right-sided adenomas.nnnMETHODSnA systematic literature search was performed using the following databases: PubMed, Embase, Web of Science, and Cochrane. Only full-length published articles that provided information on adenoma detection and miss rates during either a second forward view or retroflexed view of the right side of the colon after the initial standard forward withdrawal (SC) were included. The following outcomes were assessed: comparison of adenoma miss rate (AMR) for second forward view versus retroflexion after SC, AMR of SC compared with second forward view, AMR of SC compared with retroflexion, and right-sided adenoma detection with second forward view and retroflexion. Pooled rates were reported as risk difference or odds ratios (OR) with 95% confidence intervals (CI) with a P valuexa0<.05 indicating statistical significance. Statistical analysis was performed with Review Manager v5.3.nnnRESULTSnWe identified 4 studies with 1882 patients who underwent a second forward view of the right side of the colon after an initial SC. The average age of the patients was 58.3 years. Data on right-sided ADR were available from all 4 studies for the second forward view; however, only 2 of the studies provided information on right-sided ADR with retroflexion. The pooled estimate of AMR of a single SC was 13.3% (95% CI, 6.6%-20%) compared with a second forward-view examination (nxa0= 4), whereas it was 8.1% (3.7%-12.5%) compared with a retroflexion examination (nxa0= 3). However, when the second forward view was compared with retroflexion in terms of AMR from an analysis of 3 eligible studies, there was no statistically significant difference (7.3% vs 6.3%; pooled OR, 1.2; 95% CI, 0.9-1.61; Pxa0= .21). Second forward view of the right side of the colon increased the right-sided ADR by 10% (nxa0= 4; second forward view vs SC, 33.6% vs 26.7%) with a pooled risk difference of 0.09 (95% CI, 0.03-0.15; Pxa0< .01). Retroflexion increased the right-sided ADR by 6% (nxa0= 3; retroflexion vs SC, 28.4% vs 22.7%) with a pooled risk difference of 0.06 (95% CI, 0.03-0.09; Pxa0< 01).nnnCONCLUSIONnAfter SC withdrawal, a second forward view and retroflexed view of the right side of the colon are both associated with improvement in ADR. One of these techniques should be considered during SC to increase ADR and to improve the quality of colonoscopy.

Early colonoscopy in patients with acute diverticular bleeding is associated with improvement in healthcare-resource utilization

Abstract Background Diverticular bleeding (DB) is the most common cause of severe acute lower gastrointestinal bleeding (GIB) in developed countries. The role of early colonoscopy (<24u2009hours) continues to remain controversial and data on early colonoscopy in acute DB are scant. We aimed to evaluate the effect of timing of colonoscopy on outcomes in patients with acute DB using a nationwide inpatient sample. Methods Data from the nationwide inpatient sample from 2012 to 2014 were used. The ninth version of the International Classification of Diseases coding system ICD 9 was used for patient selection. We included discharges with the primary and secondary inpatient diagnosis of diverticulosis with bleeding and diverticulitis with bleeding. Discharges with no primary or secondary diagnosis of diverticulosis with bleeding, diverticulitis with bleeding, patients who were less than 18u2009years old and those who did not undergo colonoscopy during the admission were excluded. The primary outcomes were length of stay (LOS) and total hospitalization costs. Results A total of 88u2009600 patients were included in our analysis, amongst whom 45u2009020 (50.8%) had colonoscopy within 24u2009hours of admission (early colonoscopy), while 43u2009580 (49.2%) patients had colonoscopy after 24u2009hours of admission (late colonoscopy). LOS was significantly lower in patients with early colonoscopy as compared to those with late colonoscopy (3.7 vs 5.6u2009days, Pu2009<u20090.0001). Total hospitalization costs were also significantly lower in patients with early colonoscopy (

Evaluation and management of lower gastrointestinal bleeding

9317 vs

Evaluation and management of variceal bleeding

11u2009767, Pu2009<u20090.0001). There was no difference in mortality between both groups (0.7 vs 0.8%). After adjusting for potential confounders, the differences in LOS and total hospitalization costs between early and late colonoscopy remained statistically significant. Conclusions Early colonoscopy in acute DB significantly reduced LOS and total hospitalization costs. There was no significant difference in mortality observed. Performance of early colonoscopy in the appropriate patients presenting with acute DB can have potential cost-saving implications. Further research is needed to identify which patients would benefit from early colonoscopy in DB.