Saurabh Chawla

Chronic hepatitis E: A brief review

Hepatitis E viral infection has traditionally been considered an acute, self-limited, water borne disease similar to hepatitis A, endemic to developing countries. However, over the past decade, zoonotic transmission and progression to chronicity in human patients has been identified, resulting in persistently elevated transaminase levels, progressive liver injury and cirrhosis. In addition to liver injury, neurological, renal and rheumatological manifestations have also been reported. Chronic hepatitis E occurs mainly in immunosuppressed individuals such as transplant recipients, human immunodeficiency virus patients with low CD4 counts and in patients with hematological malignancies receiving chemotherapy. Diagnosis is established by persistent elevation of hepatitis E virus RNA in the stool or serum. This population often requires treatment with antiviral agents, particularly ribavirin, as spontaneous clearance with reduction in immunosuppression occurs only in about a third of the patients. The purpose of this review, is to further discuss the clinical presentation, and recent advances in diagnosis, treatment and prophylaxis of chronic hepatitis E.

Platelet count/spleen diameter ratio to predict the presence of esophageal varices in patients with cirrhosis: a systematic review.

Background Esophageal variceal bleeding remains the leading cause of acute mortality in patients with cirrhosis. Platelet count to spleen diameter (PC/SD) ratio less than 909 is one of several parameters proposed for the noninvasive prediction of esophageal varices. The aim of this study is to systematically review the evidence on the diagnostic accuracy of the 909 ratio. Methods We identified relevant studies from a MEDLINE search and performed a meta-analysis to estimate the pooled sensitivity, specificity, and positive and negative likelihood ratios (LRs) using Meta-Disc software. Results Eight studies met the inclusion criteria and included a total of 1275 patients. Meta-analysis yielded a pooled sensitivity of 89% [95% confidence interval (CI) 87–92%; I2 statistic 92.9%] and a pooled specificity of 74% (95% CI 70–78%; I2 statistic 94.5%). The pooled positive LR was 3.5 (95% CI 1.92–6.25; I2 statistic 94.0%) and the pooled negative LR was 0.12 (95% CI 0.05–0.32; I2 statistic 90.8%). The quality of the evidence as assessed by the GRADE methodology was low. Conclusion In its present form, the test characteristics of PC/SD ratio of 909 may not be adequate to completely replace esophagogastroduodenoscopy as a noninvasive screening tool for esophageal varices, given the low grade of evidence. However, it may be potentially useful as part of a prediction rule incorporating other clinical characteristics or varying PC/SD cutoffs. When compared with other noninvasive predictor tools, the PC/SD ratio is elegant, simple, and inexpensive. With some minor modifications, it may become a helpful tool to limit the number of endoscopies in primary prophylaxis to be performed in patients with portal hypertension.

Modifiable and non-modifiable risk factors for pancreatic cancer: A review

Pancreatic ductal adenocarcinoma is associated with a poor prognosis and a high case-fatality rate. The reasons for poor prognosis are low rates of curative resection due to local infiltration and distant metastasis. To increase survival rates of patients with pancreatic cancer, early detection through surveillance and screening is important. However, screening could only be cost-effective in high-risk populations. Identification of significant risk factors therefore assumes significance. Risk factors could be non-modifiable or modifiable. Non-modifiable risk factors include increasing age, familial cancer syndromes, Afro-American race, hereditary and other forms of chronic pancreatitis, diabetes, and non-O blood group. Important modifiable risk factors include smoking, obesity, dietary factors such as non-vegetarian diet, and toxins. Preventive strategies at the population level and an effective screening program targeted at high-risk people may help in prevention and early detection of pancreatic ductal adenocarcinoma.

Endoscopic retrograde cholangiopancreatography under moderate sedation and factors predicting need for anesthesiologist directed sedation: A county hospital experience.

AIM To evaluate variables associated with failure of gastroenterologist directed moderate sedation (GDS) during endoscopic retrograde cholangiopancreatography (ERCP) and derive a predictive model for use of anesthesiologist directed sedation (ADS) in selected patients. METHODS With institutional review board approval, we retrospectively analyzed consecutive records of all patients who underwent ERCPs between July 1, 2009 to October 1, 2011 to identify patient related and procedure related factors which could predict failure of GDS. For patient related factors, we abstracted and analyzed data regarding the age, gender, ethnicity, alcohol and illicit drug use habits. For procedure related factors, we abstracted data regarding initial or repeat procedures, indication for performing ERCP, the interventions performed during ERCP, and the grade d difficulty of cannulation as defined in the American Society for Gastrointestinal Endoscopy guidelines. Our outcome of interest was procedural success. If the procedure was not successful, the reasons for failure of procedures were recorded along with immediate post procedure complications. Multivariate analysis was then performed to define factors associated with failure of GDS and a model constructed to predict requirement of ADS. RESULTS Fourteen percent of patients undergoing GDS could not complete the procedure due to intolerance and 2% due to cardiovascular complications. Substance abuse, male gender, black race and alcohol use were significant predictors of failure of GDS on univariate analysis and substance abuse and higher grade of procedure remained significant on multivariate analysis. Using our predictive model where the presence of substance abuse was given 1 point and planned grade of intervention was scored from 1-3, only 12% patients with a score of 1 would require ADS due to failure of GDS, compared to 50% with a score of 3 or higher. CONCLUSION We conclude that ERCP under GDS is safe and effective for low grade procedures, and ADS should be judiciously reserved for procedures which have a higher risk of failure with moderate sedation.

Acute Pancreatitis as a Rare Initial Manifestation of Wegener's Granulomatosis. A Case Based Review of Literature

CONTEXT Vasculitis is a known cause of pancreatitis and other gastrointestinal symptoms; however, most of these patients have medium vessel vasculitis like polyarteritis nodosa and often there are other associated conditions like hepatitis B or clinical manifestations that suggest the diagnosis. Wegeners granulomatosis is predominantly a reno-pulmonary disorder, rarely having gastrointestinal manifestations. CASE REPORT We report a case of Wegeners granulomatosis initially presenting as acute pancreatitis and then rapidly progressing to severe multi-organ involvement over the next few months. DISCUSSION Pancreatic association as an initial presentation of Wegeners granulomatosis is limited to only a few reports. This extremely rare initial presentation makes the diagnostic process challenging. Two different pancreatic manifestations have been reported: as a pancreatic mass mimicking a tumor or as acute pancreatitis. The patients who presented as pancreatic head masses underwent extensive surgical procedures before the diagnosis was established. Acute pancreatitis as the initial presentation is usually associated with an aggressive course of the vasculitis and often results in a fatal outcome. CONCLUSIONS This case illustrates Wegeners granulomatosis as a rare cause of acute pancreatitis. It emphasizes the need for thorough continued systemic clinical evaluation of patients when the etiology is not readily evident. Also, since most patients with pancreatitis due to Wegeners granulomatosis rapidly progress to severe multiorgan involvement, knowledge of a broad differential of potential etiologies and a low index of suspicion is required for timely diagnosis and treatment.

Rhabdomyolysis: a lesson on the perils of exercising and drinking.

Acute abdomen is a common presentation to the emergency department (ED), accounting for 5% to 10% of ED visits. Of these, 10% require surgery, and 25% go undiagnosed. Usually, most of the cases of undiagnosed abdominal pain are in young women with pelvic etiologies, although occasionally, unusual causes of abdominal pain lead to diagnostic dilemmas and can have adverse clinical outcomes. We present an unusual etiology of abdominal pain in a young man, who presented with acute onset of right lower quadrant pain accompanied by nausea and vomiting. He was an amateur boxer who had recently intensified his training regimen and admitted to binge drinking for several days before presentation. The initial diagnosis was acute appendicitis, but a computed tomographic scan done revealed a normal appendix. Creatine kinase level was then checked and found to be significantly elevated, and a diagnosis of isolated abdominal wall rhabdomyolysis was made.

Portal hypertensive enteropathy

Portal hypertensive enteropathy (PHE) is a condition that describes the pathologic changes and mucosal abnormalities observed in the small intestine of patients with portal hypertension. This entity is being increasingly recognized and better understood over the past decade due to increased accessibility of the small intestine made possible by the introduction of video capsule endoscopy and deep enteroscopy. Though challenged by its diverse endoscopic appearance, multiple scoring systems have been proposed to classify the endoscopic presentation and grade its severity. Endoscopic findings can be broadly categorized into vascular and non-vascular lesions with many subtypes of both categories. Clinical manifestations of PHE can range from asymptomatic incidental findings to fatal gastrointestinal hemorrhage. Classic endoscopic findings in the setting of portal hypertension may lead to a prompt diagnosis. Occasionally histopathology and cross sectional imaging like computed tomography or magnetic resonance imaging may be helpful in establishing a diagnosis. Management of overt bleeding requires multidisciplinary approach involving hepatologists, endoscopists, surgeons, and interventional radiologists. Adequate resuscitation, reduction of portal pressure, and endoscopic therapeutic intervention remain the main principles of the initial treatment. This article reviews the existing evidence on PHE with emphasis on its classification, diagnosis, clinical manifestations, endoscopic appearance, pathological findings, and clinical management. A new schematic management of ectopic variceal bleed is also proposed.

Acute and chronic hepatobiliary manifestations of sickle cell disease: A review

Sickle cell disease (SCD) is a common hemoglobinopathy which can affect multiple organ systems in the body. Within the digestive tract, the hepatobiliary system is most commonly affected in SCD. The manifestations range from benign hyperbilirubinemia to overt liver failure, with the spectrum of acute clinical presentations often referred to as “sickle cell hepatopathy”. This is an umbrella term referring to liver dysfunction and hyperbilirubinemia due to intrahepatic sickling process during SCD crisis leading to ischemia, sequestration and cholestasis. In this review, we detail the pathophysiology, clinical presentation and biochemical features of various acute and chronic hepatobiliary manifestations of SCD and present and evaluate existing evidence with regards to management of this disease process. We also discuss recent advances and controversies such as the role of liver transplantation in sickle cell hepatopathy and highlight important questions in this field which would require further research. Our aim with this review is to help increase the understanding, aid in early diagnosis and improve management of this important disease process.

Increased Incidence of Benign Pancreatic Pathology following Pancreaticoduodenectomy for Presumed Malignancy over 10 Years despite Increased Use of Endoscopic Ultrasound.

Despite using imaging studies, tissue sampling, and serologic tests about 5–10% of surgeries done for presumed pancreatic malignancies will have benign findings on final pathology. Endoscopic ultrasound (EUS) is used with increasing frequency to study pancreatic masses. The aim of this study is to examine the effect of EUS on prevalence of benign diseases undergoing Whipple over the last decade. Patients who underwent Whipple procedure for presumed malignancy at Emory University Hospital from 1998 to 2011 were selected. Demographic data, history of smoking and drinking, history of diabetes and pancreatitis, imaging data, pathology reports, and tumor markers were extracted. 878 patients were found. 95 (10.82%) patients had benign disease. Prevalence of benign finding had increased over the recent years despite using more EUS. Logistic regression models showed that abdominal pain (OR: 5.829, 95% CI 2.681–12.674, P ≤ 0.001) and alcohol abuse (OR: 3.221, CI 95%: 1.362–7.261, P: 0.002) were predictors of benign diseases. Jaundice (OR: 0.221, 95% CI: 0.084–0.58, P: 0.002), mass (OR: 0.145, 95% CI: 0.043–0.485, P: 0.008), and ductal dilation (OR: 0.297, 95% CI 0.134–0.657, P: 0.003) were associated with malignancy. Use of imaging studies, ERCP, and EUS has not decreased the percentage of benign findings after surgery for presumed pancreatic malignancy.

Pancreatic Insufficiency Secondary to Tobacco Exposure: A Controlled Cross-Sectional Evaluation.

Objectives Tobacco exposure is an established risk factor for pancreatic cancer and chronic pancreatitis; however, its role in pancreatic insufficiency is not clear. Methods This controlled, cross-sectional study examined smokers and nonsmokers with no history of pancreatic disease. Histories and validated inventories of alcohol and tobacco use were obtained, and pancreatic insufficiency was assessed using the fecal elastase-1 assay. Results Of 7854 patients approached, 226 were interviewed and 200 enrolled. The rates of pancreatic insufficiency [18% (18/100)] and severe pancreatic insufficiency [10% (10/100)] were significantly higher in smokers than in controls [6% (6/100), P = 0.009 and 1% (1/100), P = 0.010, respectively]. On multivariate logistic regression, the risk of pancreatic insufficiency in smokers was significantly increased [odds ratio, 4.34 (1.37–13.75); P = 0.012], controlling for alcohol use and relevant covariates. Tobacco exposure was associated with the highest odds ratio for pancreatic insufficiency. Alcohol consumption was strongly associated with tobacco exposure (P < 0.001), but not with pancreatic insufficiency by multivariate analysis (P = 0.792). Conclusions This study suggests that tobacco exposure is independently associated with pancreatic exocrine insufficiency in patients without a prior diagnosis of pancreatic disease. Tobacco exposure seems to have greater detrimental effects on pancreatic function than alcohol in this population.