Suresh Kumar Nayudu

Colorectal cancer screening in human immunodeficiency virus population: Are they at average risk?

AIM To evaluate if human immunodeficiency virus (HIV) population is getting adequate screening for colon cancer in the highly active anti-retroviral treatment (HAART) era with improved longevity, and the prevalence of polyps and adenomas in this population, when compared with the general population. METHODS We conducted retrospective chart review of average-risk HIV population for colon cancer attending our infectious disease clinic. Individuals who underwent diagnostic colonoscopy were excluded. We extracted various demographic, HIV disease-specific and colonoscopy data including histo-pathological reports in the last 10 years. Total population was divided into a study group, who underwent screening colonoscopy and a control group who did not. We analyzed data using standard statistical methods and software. RESULTS We found that 25% of average-risk HIV-infected population was screened for colon cancer using colonoscopy. There was no difference in gender and ethnic distribution between the groups. We found wider distribution of age (50-84 years with mean 56 years) in the control group when compared to (50-73 years with mean 58 years) the study group. However, there were 89% of subjects with well-controlled HIV disease measured by HIV RNA copies of < 75 in the study group when compared with 70% in the control group (P < 0.0001). We noticed polyp detection rate of 55% and adenoma detection rate of 32% in HIV population. CONCLUSION It is unclear whether HIV or HAART medications play a role in increased prevalence of adenomas. We suggest that when estimating the risk for colonic neoplasms, HIV population should be considered as a high-risk group and screened accordingly.

Downhill Esophageal Varices due to Dialysis Catheter-Induced Superior Vena Caval Occlusion: A Rare Cause of Upper Gastrointestinal Bleeding.

“Downhill” varices are a rare cause of acute upper gastrointestinal bleeding. Rarely these varices are reported in patients receiving hemodialysis as a complication of chronic dialysis vascular access. We present a case of acute upper gastrointestinal bleeding in an individual with end-stage renal disease receiving hemodialysis. Esophagogastroduodenoscopy revealed “downhill” varices in the upper third of the esophagus without any active bleeding at the time of the procedure. An angiogram was performed disclosing superior vena caval occlusion, which was treated with balloon angioplasty. Gastroenterologists should have a high index of suspicion for these rare “downhill” varices when dealing with acute upper gastrointestinal bleeding in patients receiving hemodialysis and manage it appropriately using endoscopic, radiological, and surgical interventions.

Serum Triglyceride Level: A Predictor of Complications and Outcomes in Acute Pancreatitis?

Aim. To study serum triglyceride level as a predictor of complications and outcomes in acute pancreatitis. Methods. In this retrospective observational study, 582 patients admitted with acute pancreatitis, who had serum triglyceride levels measured within the first 24 hours, were divided into two groups. The study group consisted of patients with a triglyceride level ≥2.26 mmol/L (group 2) and the control group consisted of triglyceride level of <2.26 mmol/L (group 1). We collected data for baseline demographics, laboratory values, incidence of complications (local and systemic), admission to the intensive care unit (ICU), ICU length of stay, length of total hospital stay, and death in the two groups. Results. A triglyceride level of ≥2.26 mmol/L was found to be an independent predictor of developing altered mental status (p: 0.004), pancreatic necrosis (p: 0.001), acute respiratory distress syndrome (p: 0001), systemic Inflammatory response syndrome (p: 0.001), acute kidney injury (p: 0.001), hospital length of stay (LOS) (p: 0.002), admission to intensive care unit (ICU) (p: 0.002), and ICU LOS (p: 0.003). Conclusion. A triglyceride level of ≥2.26 mmol/L on admission in acute pancreatitis is an independent predictor of developing local and systemic complications, hospital LOS, admission to ICU, and ICU LOS.

Cholestatic Hepatitis with Small Duct Injury Associated with Celecoxib

Drug-induced liver injury (DILI) is a common clinical entity but is underreported due to various reasons. Cyclooxygenase-2 inhibitors like Celecoxib have been proven to be associated with lesser incidence of adverse drug reactions compared to other nonsteroidal anti-inflammatory drugs (NSAID). However, Celecoxib has been rarely reported to be associated with cholestasis and hepatitis. We present a young Hispanic female presented with cholestatic liver chemistries who has been taking Celecoxib for 3 weeks. Extensive workup did not support diagnosis of viral, autoimmune, or metabolic liver diseases. Liver biopsy revealed findings suggestive of secondary sclerosing cholangitis. Imaging studies were negative for large duct involvement, and endoscopy ruled out inflammatory bowel disease. Liver chemistries normalized after cessation of medication. We recommend that physician should be aware of this rare complication when prescribing Celecoxib.

A Rare Complication of Hyperplastic Gastric Polyp

Hyperplastic gastric polyps are incidentally diagnosed during upper gastrointestinal endoscopy. They are known to cause gastric outlet obstruction and chronic blood loss leading to iron deficiency anemia. However, hyperplastic gastric polyp presenting as acute severe upper gastrointestinal bleeding is very rare. To the best of our knowledge, there have been two cases of hyperplastic gastric polyps presenting as acute gastrointestinal bleeding in the medical literature. We present a case of a 56-year-old African American woman who was admitted to our hospital with symptomatic anemia and sepsis. The patient developed acute upper gastrointestinal bleeding during her hospital stay. She underwent emergent endoscopy, but bleeding could not be controlled. She underwent emergent laparotomy and wedge resection to control the bleeding. Biopsy of surgical specimen was reported as hyperplastic gastric polyp. We recommend that physicians should be aware of this rare serious complication of hyperplastic gastric polyps as endoscopic polypectomy has diagnostic and therapeutic benefits in preventing future complications including bleeding.

Cervical Spinal Cord Compression: A Rare Presentation of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the most common primary malignancy of liver. Distant metastasis to various organs is well known. Skeletal metastasis is also reported to various locations. Vertebral metastasis has been reported mostly to thoracic spine. However, cervical spinal cord involvement leading to cord compression has been reported very rarely in literature. We present a case of 58-year-old male with liver cirrhosis presenting as neck pain. Further work-up revealed metastatic HCC to cervical spinal cord resulting in acute cord compression. Patient has been treated with neurosurgical intervention.

A Rare Coexistence: Drug Induced Hepatitis and Meningitis in Association With Ibuprofen

Ibuprofen, a commonly used NSAID is reported to be associated with drug induced liver injury. Ibuprofen is also known to be associated with drug-induced meningitis especially in patients with connective tissue disorders. However presentation of hepatitis and meningitis in association with Ibuprofen use in the same individual has never been reported. We present a case of young woman who developed abnormal liver chemistries and neurological symptoms while on Ibuprofen. Her liver biopsy findings were suggestive of drug induced liver injury and cerebrospinal fluid analysis was suggestive of aseptic meningitis. Clinical and biochemical improvement was noted on cessation of Ibuprofen.

Glycogen Hepatopathy: A Rare and Underrecognized Cause of Recurrent Transaminitis in Patients with Uncontrolled Type 2 Diabetes Mellitus

Glycogen hepatopathy (GH), characterized by reversible transaminitis and hepatomegaly, results from excessive accumulation of glycogen in hepatocytes. GH has been well described in the literature as a rare cause of transaminitis in children and young patients with uncontrolled type 1 diabetes mellitus and has rarely been reported in type 2 diabetic patients. Hyperglycemia and hyperinsulinemia are believed to be a metabolic substrate for hepatic glycogen accumulation and in order to cause glycogen hepatotoxicity. We present the case of a 54-year-old woman with poorly controlled insulin-dependent type 2 diabetes who was hospitalized twice within 1 month with diabetic ketoacidosis/hyperosmolar hyperglycemic state and reversible transaminitis. Interestingly, she had normal liver function tests performed at the time of admission and transaminitis was noted 1 day later, after she was treated with high doses of intravenous insulin therapy. Subsequently, liver enzymes recovered to normal levels with optimization of glucose control.

Cystic Lymphangioma of the Colon: Endoscopic Removal beyond the Frontiers of Size

Cystic lymphangiomas are benign colonic neoplasms arising from the submucosa. Traditionally, endoscopic resection has been described for smaller lesions, while surgery is reserved for larger symptomatic lesions. We present a case of a 69-year-old asymptomatic individual noted to have a cystic lymphangioma of the colon measuring 5 cm, which was successfully removed with endoloop endoscopic resection without any complications.

Synchronous Adenocarcinoma of the Colon and Rectal Carcinoid.

Primary colonic adenocarcinoma and synchronous rectal carcinoids are rare tumors. Whenever a synchronous tumor with a nonmetastatic carcinoid component is encountered, its prognosis is determined by the associate malignancy. The discovery of an asymptomatic gastrointestinal carcinoid during the operative treatment of another malignancy will usually only require resection without additional treatment and will have little effect on the prognosis of the individual. This article reports a synchronous rectal carcinoid in a patient with hepatic flexure adenocarcinoma. We present a case of a 46-year-old Hispanic woman with a history of hypothyroidism, uterine fibroids and hypercholesterolemia presenting with a 2-week history of intermittent abdominal pain, mainly in the right upper quadrant. She had no family history of cancers. Physical examination was significant for pallor. Laboratory findings showed microcytic anemia with a hemoglobin of 6.6 g/dl. CT abdomen showed circumferential wall thickening in the ascending colon near the hepatic flexure and pulmonary nodules. Colonoscopy showed hepatic flexure mass and rectal nodule which were biopsied. Pathology showed a moderately differentiated invasive adenocarcinoma of the colon (hepatic flexure mass) and a low-grade neuroendocrine neoplasm (carcinoid of rectum). The patient underwent laparoscopic right hemicolectomy and chemotherapy. In patients diagnosed with adenocarcinoma of the colon and rectum, carcinoids could be missed due to their submucosal location, multicentricity and indolent growth pattern. Studies suggest a closer surveillance of the GI tract for noncarcinoid synchronous malignancy when a carcinoid tumor is detected and vice versa.