Bilirubin 9.3 mg/dL (Direct 4.3 mg/dL, Indirect 3.5 mg/dL). CT scan of the abdomen and pelvis showed hepatomegaly with a normal biliary tree. The EBV viral capsid antigen (VCA) IgM was positive at .160 u/ML. Patient underwent a liver biopsy on hospital day 3 which showed sinusoidal patterns of inflammation and an in-situ hybridization study confirmed the diagnosis of EBV hepatitis. She was started on Solumedrol 1 mg/kg with improvement of symptoms and resolution of hepatic and hemolytic anemia lab abnormalities. Discussion: Hepatic involvement due to Epstein-Barr virus infection can be common but is typically subclinical or mild in presentation with only 5% of patients presenting with jaundice. The pathological manifestations can be extensive, as patients can also present with hemolytic anemia, specifically cold agglutinin autoimmune hemolytic anemia. The pathogenesis is believed to be due to EBV IgM antibodies cross reacting with RBC antigens. The pathogenesis of cholestasis in EBV hepatitis involves direct damage of hepatic cells by autoantibody free radical activation and the inflammation of bile ducts. The majority of cases are self-resolving; however, antivirals such as ganciclovir in conjunction with corticosteroids can provide benefit in severe cases. Due to the high global prevalence of Epstein-Barr virus, healthcare professionals should be aware of the diagnosis, management and complications of hepatic manifestations. Introduction:We present a case of acute on chronic liver failure in a patient on chronic Augmentin and total parenteral nutrition (TPN). We highlight the mechanisms and key findings of liver injury associated with intestinal failure and Augmentin, which are relevant for evaluating the risks and benefits of such therapies. Case Description/Methods: A 49-year-old woman with a history of cervical cancer treated with chemoradiation complicated by vaginal stenosis with reconstructive surgery complicated by short gut syndrome with chronic TPN dependency and chronic pelvic infections on Augmentin suppression therapy presented with hyperbilirubinemia and acute renal failure. Initial laboratory results include bilirubin 29.4 (predominantly direct), mildly elevated liver enzymes, normal alkaline phosphatase, INR 1.6, and creatinine 3.64. Her TPN and Augmentin were held. Evaluation for autoimmune markers and acute viral hepatitis serologies were negative. Genetic testing showed heterozygous C282Y mutation. Urinary copper was high with low serum ceruloplasmin, however ophthalmology exam was not concerning for Wilson's disease. Abdominopelvic non-contrast CT showed new abdominopelvic ascites. Liver biopsy revealed cholestatic hepatitis and cirrhosis. Her presentation was likely secondary to acute Augmentin hepatotoxicity in the setting of chronic intestinal-failure associated liver disease (IFALD). The patient ultimately expired due to septic shock. Discussion: Augmentin is a known cause of DILI, with clavulanic acid established as the causative agent. Onset occurs days to months following use and liver...
Introduction: Endoscopic submucosal dissection (ESD) is a minimally invasive technique used for removal of superficial dysplastic or early cancerous colon and rectal lesions. For larger lesions ( .20mm) that are not amenable to endoscopic mucosal resection, superficial biopsies are typically taken prior to referral for ESD. The aim of this study was to evaluate the degree of concordance between superficial forceps biopsies and ESD pathology. Methods: A retrospective medical record review was performed including consecutive patients who underwent ESD of colon and rectal lesions at a tertiary care center between 10/2018 and 11/2021. Pathology results from outside hospital and same institution pre-ESD superficial forceps biopsies were compared to ESD pathology results. The primary outcome was the number of patients found to have higher disease severity on ESD pathology compared with superficial forceps biopsies. Results: Of the 84 patients who underwent ESD of colon or rectal lesions, 72 had pre-ESD superficial forceps biopsies which were taken at an outside hospital (n548) or at the same institution (n536). The average length of time between outside hospital superficial forceps biopsies and ESD was 91 days compared to 75 days for those performed at the same institution. Delays between superficial forceps biopsies and ESD may be related to the COVID-19 pandemic prolonging time between procedures. Pathology findings after ESD differed from superficial forceps biopsies in 31/72 patients (43%) with 21 patients receiving upgraded disease severity and 6 patients receiving a new cancer diagnosis based on ESD pathology. Patients who received a new cancer diagnosis had more days between superficial forceps biopsies and ESD compared with the whole cohort (86 vs 75, respectively). Conclusion: While superficial forceps biopsies of colon and rectal lesions were typically concordant with ESD pathology, 29% of patients in this cohort received upgraded disease severity based on ESD pathology. This shows that while superficial forceps biopsies can aid in diagnosis, en bloc resection via ESD remains critical for accurate diagnosis of large colon and rectal lesions. These results also show that ESD is not only diagnostic but therapeutic given 75% of the patients in this cohort achieved R0 resection.
bowel and dilated loops of small bowel upstream of the mass. The patient was diagnosed with primary enterolithiasis proximal to a radiation induced stricture, causing chronic recurrent partial small bowel obstruction. Two weeks later, she underwent elective robotic-assisted small bowel resection with the retrieval of a brown, green enterolith measuring 5.5x3.8x3.5 cm. The patient was discharged on post-operative day 3 without complications. Discussion: Primary enterolithiasis should be considered as a rare etiology of chronic abdominal pain and bowel obstruction in patients with pre-disposing factors that promote intestinal stasis. Treatment depends on the timely recognition of this entity and endoscopic or surgical management. With the technological advances, better patient outcomes as well mortality rates are expected.[3449] Figure 1. CT enterography showing a large lamellated intraluminal mass in the mid small bowel A) Coronal view, B) Axial view.
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