Sonya Reicher

Acute liver injury induced by weight-loss herbal supplements

We report three cases of patients with acute liver injury induced by weight-loss herbal supplements. One patient took Hydroxycut while the other two took Herbalife supplements. Liver biopsies for all patients demonstrated findings consistent with drug-induced acute liver injury. To our knowledge, we are the first institute to report acute liver injury from both of these two types of weight-loss herbal supplements together as a case series. The series emphasizes the importance of taking a cautious approach when consuming herbal supplements for the purpose of weight loss.

Hypervitaminosis A Inducing Intra-hepatic Cholestasis—A Rare Case Report

The use of over-the-counter supplements is commonplace in todays health conscious society. We present an unusual case of intrahepatic cholestasis caused by vitamin A intoxication. The patient consumed one Herbalife shake with two multivitamin tablets of the same brand for 12 years. When calculated this equated to more than the recommended daily allowance for vitamin A consumption. Deranged liver function tests were consistent with a cholestatic process. Liver biopsy was obtained and revealed features pathognomonic of vitamin A toxicity, without the usual fibrosis. When the supplements were ceased, his jaundice and alkaline phosphatase completely normalized. This case highlights the importance of health care providers documenting non-prescribed dietary supplements and considering them in the etiology of cholestatic liver disease.

Staining for p53 and Ki-67 increases the sensitivity of EUS-FNA to detect pancreatic malignancy

AIM To investigate whether tumor marker staining can improve the sensitivity of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) to diagnose pancreatic malignancy. METHODS Patients who underwent EUS-FNA were retrospectively identified. Each EUS-FNA specimen was evaluated by routine cytology and stained for tumor markers p53, Ki-67, carcinoembryonic antigen (CEA) and CA19-9. Sensitivity, specificity, positive and negative predictive values (PPV and NPV), and positive and negative likelihood ratios (PLR and NLR) were calculated in order to evaluate the performance of each test to detect malignancy. RESULTS Sixty-one specimens had complete sets of stains, yielding 49 and 12 specimens from pancreatic adenocarcinomas and benign pancreatic lesions due to pancreatitis, respectively. Cytology alone had sensitivity and specificity of 41% and 100% to detect malignancy, respectively. In 46% of the specimens, routine cytology alone was deemed indeterminate. The addition of either p53 or Ki-67 increased the sensitivity to 51% and 53%, respectively, with perfect specificity, PPV and PLR (100%, 100% and infinite). Both stains in combination increased the sensitivity to 57%. While additional staining with CEA and CA19-9 further increased the sensitivity to 86%, the specificity, PPV and PLR were significantly reduced (at minimum 42%, 84% and 1, respectively). Markers in all combinations performed poorly as a negative test (NPV 26% to 47%, and NLR 0.27 and 0.70). CONCLUSION Immunohistochemical staining for p53 and Ki-67 can improve the sensitivity of EUS-FNA to diagnose pancreatic adenocarcinoma.

Endoscopic retrograde cholangiopancreatography with intraductal ultrasound in pregnancy without the use of radiation

Goals and background: Biliary disease in pregnancy presents unique challenges. Conservative treatment is associated with recurrent symptoms, and the use of radiographic imaging is limited because of the possibility of fetal exposure. The aim of our study was to evaluate the use of intraductal ultrasound (IDUS) in nonradiation ERCP (ERCP-NR) to treat pregnant women with symptomatic choledocholithiasis or gallstone pancreatitis. Study: From 2008 to 2014, we retrospectively identified ten pregnant patients at our urban safety net teaching hospital who were treated with IDUS-guided ERCP for symptomatic choledocholithiasis or gallstone pancreatitis. The cases were compiled to provide a descriptive review of ERCP with IDUS. Results: Of 10 pregnant patients who underwent ERCP, eight patients had prior EUS demonstrating common bile duct stones, and two had gallstone pancreatitis. There were no immediate procedure-related adverse events and no patients required a repeat procedure. All ERCP procedures were successful for removing the bile duct stones and providing symptomatic relief. There were no known immediate or long-term procedure-related adverse events in the infants. Conclusions: IDUS-guided ERCP-NR provides appropriate biliary imaging without fetal radiation exposure and can be safely and successfully performed in pregnancy. Correspondence to: Dr. Anuj Datta, Division of Gastroenterology/Hepatology, Harbor-UCLA Medical Center, Torrance, CA 90502, USA, Tel: (310) 222-2475; E-mail: adatta@dhs.lacounty.gov