Hypertriglyceridemia (HTG) is the third most common cause of acute pancreatitis (AP). The incidence of AP is around 10-20% with levels > 2,000 mg/dL. We present here a case of a 44-year-old male with history of uncontrolled diabetes mellitus and HTG admitted with severe abdominal pain. Labs revealed elevated lipase and amylase. CT of abdomen with contrast showed AP. He was found to have a triglyceride (TG) level of 6,672 mg/dL. Besides conventional treatment for AP with intravenous (IV) hydration, he was started on IV regular insulin along with dextrose saline. He had marked improvement in his TG level the next day. He was continued on insulin and dextrose saline with hourly glucose monitoring until TG was < 500 mg/dL. He was discharged on statins and fenofibrate. The goal of management of AP secondary to severe HTG in emergency setting is to lower the TG levels to less than 500 as quickly as possible as lower levels are associated with good clinical outcomes. Apheresis and IV insulin are both helpful in lowering TG levels with no randomized controlled trials showing greater efficacy of one over other. Further episodes of AP can be prevented by lifestyle modification and lipid lowering drugs to keep TG levels below 500 mg/dL. Fibrates are first-line drugs to lower TG and used either alone or in conjunction with statins. Periodic plasmapheresis can also be considered in some non-compliant patients with recurrent episodes of pancreatitis.
Autoimmune hepatitis (AIH) is a chronic inflammation of liver with unclear etiology. It is frequently associated other autoimmune diseases, and its association with celiac disease (CD) is well established. In this article, we describe the case of a 50-year-old male with long-standing AIH taking azathioprine for 10 years, evaluated for flares in transaminases. Despite adding high-dose corticosteroids, his transaminases and bilirubin remained high. Serology for CD was ordered, which revealed elevated tissue transglutaminase antibody IgG and endomysial IgA, which was further confirmed by endoscopic biopsy. Strict gluten-free diet was advised and now for over 2 years he is in remission with azathioprine and budesonide. This emphasizes the role of gluten-free diet in reversing liver dysfunction in patients with AIH, and clinicians should consider screening for CD in patients with AIH with persistent elevation of liver enzymes despite immunosuppressant treatment.
BackgroundAcute pulmonary embolism (APE) is a potentially fatal disease with high mortality. Prior studies have shown an increased frequency of central localization of the clot, right ventricular dysfunction and elevated troponin in patients who present with syncope and APE. Existing evidence regarding mortality and length of hospital stay in these patients is unclear.MethodsWe retrospectively reviewed electronic medical records of patients who were admitted in a tertiary care hospital in rural Upstate New York and diagnosed with APE from July 2014 to July 2016. Two hundred nineteen patients were reviewed in two groups: patients who presented with syncope and those without syncope.ResultsThe prevalence of syncope was found to be 6.8% (15/219). Hypotension on admission was more common among patients with syncope compared to no syncope (26.7% and 7.4%, respectively, P = 0.03). A clinically significant difference was found in 30-day mortality among those with syncope versus no syncope (21.3% vs. 7.4%, P = 0.096). No significant difference was found in length of stay (mean 6.7 days in patients with syncope vs. 6.4 without syncope, P = 0.783), central localization (26.7% with syncope vs. 43.2% without syncope, P = 0.21) or troponin elevation (46.2% in patients with syncope vs. 27.9% without syncope, P = 0.205). On multivariable analysis, hypotension was significantly higher among those with syncope (odds ratio: 5.23, P = 0.0148).ConclusionThis study suggests 30-day mortality may be higher among patients with syncope. It is important to risk stratify patients on admission in order to reduce mortality and morbidity associated with lethal disease.
Liver enzyme elevation is a common reason for referral to a gastroenterologist. Drugs are one of the most common reasons for asymptomatic elevation of liver enzymes. We present here a case of granulomatous hepatitis (GH) secondary to long-term use of allopurinol. An 83-year-old male with a history of chronic gout and hypertension was evaluated for elevation of liver enzymes. He denies any complaints of abdominal pain, nausea, fever, chills, weight loss, night sweats, or yellowness of skin. He denies any use of herbal medications. He was on losartan and allopurinol for years. No new medications reported. Physical examination was unremarkable. Labs showed aspartate transaminase 101 U/L, alanine transaminase 81 U/L, and alkaline phosphatase 645 U/L. Ultrasound of the abdomen showed coarse liver texture. Liver biopsy was done that showed mixed GH. Given negative autoimmune and viral serologies, allopurinol-induced GH was suspected. Allopurinol was held, and repeat liver enzymes were checked in 3 months, which showed improvement in transaminase and alkaline phosphatase levels. This case highlights the importance of reviewing medications carefully when evaluating a patient with liver enzymes elevation, as stopping the offending drug can normalize the abnormalities in liver chemistries and can prevent subsequent expensive testing.
IntroductionInitial management of acute upper gastrointestinal bleeding (UGIB) aims towards aggressive fluid resuscitation to maintain hemodynamic stability. Existing evidence regarding the benefit of early endoscopy is unclear with some studies suggesting mortality benefits and some suggesting otherwise. The purpose of this study is to evaluate if there is any mortality benefit of doing early endoscopy within 24 hours of presentation.MethodsFrom July 2013 to July 2016, 179 patients admitted with a diagnosis of non-variceal UGIB were retrospectively reviewed. Clinical variables including 30-day mortality were then compared between the patients who had endoscopy within 24 hours with those who had endoscopy after greater than 24 hours.ResultsOut of 179 patients admitted for non-variceal UGIB, 146 underwent endoscopy within 24 hours of presentation and 33 underwent endoscopy after 24 hours. The overall mortality associated with UGIB was 6.7% (12/179). There was no statistically significant difference found in 30-day mortality between the two groups (6.8% within 24 hours vs 6.1% after 24 hours). There was also no difference in 30-day readmission or rates of rebleeding among the two groups. The length of stay was also similar in both groups (6.0 days vs 6.1 days).ConclusionThis study did not find any advantage of endoscopy within 24 hours on length of stay, rate of complications, and 30-day mortality. As hemostasis is achieved in almost 90% of patients with supportive management without any endoscopic intervention, focus should be made on aggressive fluid resuscitation to achieve hemodynamic stability before endoscopy.
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