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Rozner R, Gisriel S, Damianos J, Grimshaw AA, Rizwan R, Nawaz A, Chan K, Wan D, Pantel H, Bhutta AQ, Fenster M, Brandt LJ, Barbieri A, Robert ME, Feuerstadt P, Li DK. Idiopathic myointimal hyperplasia of the mesenteric veins: A systematic review and individual patient data regression analysis. J Gastroenterol Hepatol 2023. [PMID: 37086041 DOI: 10.1111/jgh.16193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 03/09/2023] [Accepted: 04/04/2023] [Indexed: 04/23/2023]
Abstract
BACKGROUND AND AIM Idiopathic myointimal hyperplasia of the mesenteric veins (IMHMV) is an uncommon cause of colonic ischemia for which surgical treatment is typically curative. We describe clinical, radiologic, and endoscopic findings in IMHMV patients to provide clinicians with a framework for pre-surgical identification of this rare disease. METHODS We performed a systematic review of seven databases for IMHMV cases and identified additional cases from Yale New Haven Hospital records. To identify features specifically associated with colonic ischemia due to IMHMV, we performed multivariate logistic regression analysis incorporating data from a large cohort of patients with biopsy-proven ischemic colitis. RESULTS A total of 124 patients with IMHMV were identified (80% male, mean age 53 years, 56% Caucasian). Presenting symptoms were most commonly abdominal pain (86%) and diarrhea (68%). The most affected areas were the sigmoid colon (91%) and rectum (61%). Complications associated with diagnostic delay occurred in 29% of patients. Radiologic vascular abnormalities including non-opacification of the inferior mesenteric vein were observed in 35% of patients. Of the patients, 97% underwent curative surgical resection. Compared with non-IMHMV colonic ischemia, IMHMV was significantly associated with younger age, male sex, absence of rectal bleeding on presentation, rectal involvement, and mucosal ulcerations on endoscopy. CONCLUSION IMHMV is a rare, underreported cause of colonic ischemia that predominantly involves the rectosigmoid. Our findings suggest younger age, rectal involvement, and absence of rectal bleeding as clinical features to help identify select patients presenting with colonic ischemia as having higher likelihood of IMHMV and therefore consideration of upfront surgical management.
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Affiliation(s)
- Raquel Rozner
- Section of Digestive Diseases, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Savanah Gisriel
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut, USA
| | - John Damianos
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Alyssa A Grimshaw
- Harvey Cushing/John Hay Whitney Medical Library, Yale School of Medicine, New Haven, Connecticut, USA
| | - Rabia Rizwan
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Ahmad Nawaz
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Kevin Chan
- Department of Medicine, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York, USA
| | - David Wan
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York, USA
| | - Haddon Pantel
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Abdul Q Bhutta
- Division of Gastroenterology, Section of Medicine, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Marc Fenster
- Division of Gastroenterology, Department of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Lawrence J Brandt
- Division of Gastroenterology, Department of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Andrea Barbieri
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Marie E Robert
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Paul Feuerstadt
- Section of Digestive Diseases, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- PACT-Gastroenterology Center, Hamden, Connecticut, USA
| | - Darrick K Li
- Section of Digestive Diseases, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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Bernshteyn M, Bhutta AQ, Bordas J, Mehta R, Arif MO. A Rare Case of Juvenile Polyposis Syndrome Mimicking Ménétrier's Disease. Cureus 2022; 14:e23389. [PMID: 35475041 PMCID: PMC9022607 DOI: 10.7759/cureus.23389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2022] [Indexed: 02/05/2023] Open
Abstract
There is a wide differential diagnosis within polyposis syndromes. Our case represents an interesting and diagnostically challenging diagnosis involving a 41-year-old male who presented with an incidental gastric mass on imaging and a colonic mass seen on colonoscopy. Following multiple endoscopic evaluations, histological analysis, and genetic testing, the patient was ultimately diagnosed with juvenile polyposis syndrome (JPS)/hereditary hemorrhagic telangiectasia (HHT) despite the initial suspicion for Ménétrier's disease. His disease course was complicated by an acute upper extremity thrombus and diagnosis of colorectal carcinoma. This case highlights the importance of a thorough evaluation when polyposis syndromes are suspected. Prompt and accurate diagnosis can aid in the treatment, surveillance, and prevention of colorectal carcinoma.
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Affiliation(s)
| | - Abdul Q Bhutta
- Gastroenterology, Upstate University Hospital, Syracuse, USA
| | - Jozsef Bordas
- Pathology, Upstate University Hospital, Syracuse, USA
| | - Rohin Mehta
- Pathology, Upstate University Hospital, Syracuse, USA
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Hoilat GJ, Abdu M, Hoilat J, Gitto L, Bhutta AQ. A Rare Case of Pancreatic Tuberculosis Diagnosed via Endoscopic Ultrasound-Guided Fine Needle Aspiration and Polymerase Chain Reaction. Cureus 2020; 12:e8795. [PMID: 32724744 PMCID: PMC7381879 DOI: 10.7759/cureus.8795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Pancreatic tuberculosis (TB) is a very rare condition even in endemic areas of the world where the disease is considered to be highly prevalent. The presenting features are usually vague and its radiological features mimic pancreatitis and pancreatic malignancy. We present a case of a 26-year-old active military male, originally from Virginia with no past medical history who presented to the ED with a two-week history of abdominal pain, increased nausea and vomiting, decreased appetite, increased darkening of his urine, and pale-colored stools. His physical examination was remarkable for conjunctival icterus as well as generalized abdominal tenderness. His laboratory results were remarkable for a total bilirubin of 4.7 mg/dL, direct bilirubin of 3.9 mg/dL, and alkaline phosphatase of 583 U/L. A CT scan was performed showing an intrahepatic dilatation and abrupt obstruction of the common bile duct at the level of a mass. Subsequent MRI of the abdomen was performed which showed a pancreatic mass at the uncinate process obstructing the common bile duct and causing intrahepatic bile dilation. The patient was deemed a surgical candidate and endoscopic retrograde cholangiopancreatography (ERCP)/endoscopic ultrasound (EUS) was performed for the sake of staging and showed a biliary compression in the middle of the common bile duct for which a stent was placed, and fine-needle aspiration (FNA) of the pancreatic mass was performed which was consistent with necrotizing granulomatous lymphadenitis. After further diagnostic studies, the patient was diagnosed with pancreatic TB. This case highlights the unusual presentation of extrapulmonary TB as well as the importance of EUS-guided FNA in diagnosing pancreatic TB which was presumed to be a malignant mass and candidate for unnecessary surgical resection.
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Affiliation(s)
- Gilles J Hoilat
- Internal Medicine, State University of New York (SUNY) Upstate Medical University, Syracuse, USA
| | - Manasik Abdu
- Internal Medicine, Alfaisal University, Riyadh, SAU
| | - Judie Hoilat
- Internal Medicine, Loyola University Medical Center, Chicago, USA
| | - Lorenzo Gitto
- Pathology, State University of New York (SUNY) Upstate Medical University, Syracuse, USA
| | - Abdul Q Bhutta
- Gastroenterology, State University of New York (SUNY) Upstate Medical University, Syracuse, USA
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Bhutta AQ, Garcia-Tsao G, Reddy KR, Tandon P, Wong F, O'Leary JG, Acharya C, Banerjee D, Abraldes JG, Jones TM, Shaw J, Deng Y, Ciarleglio M, Bajaj JS. Beta-blockers in hospitalised patients with cirrhosis and ascites: mortality and factors determining discontinuation and reinitiation. Aliment Pharmacol Ther 2018; 47:78-85. [PMID: 28994122 PMCID: PMC6016372 DOI: 10.1111/apt.14366] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 09/14/2017] [Accepted: 09/18/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND It has been suggested that beta-blockers may increase mortality in patients with cirrhosis and refractory ascites but the effect of beta-blockers discontinuation or reinitiation has not been examined. AIMS To compare, in hospitalised patients with cirrhosis and ascites, the effect of BB on survival and to examine the effect/predictors of beta-blockers discontinuation and reinitiation. METHODS Sub-analysis of NACSELD (North American consortium for the study of end-stage liver disease, database containing prospective data on hospitalised patients with cirrhosis) data from 7 centres enrolling >100 patients with ascites. Data on BB discontinuation and reinitiation were collected by chart review. RESULTS Seven hundred and sixteen patients, 307 (43%) on beta-blockers at admission and 366 (51%) with refractory ascites, were followed to death or hospital discharge. Beta-blocker use was associated with a lower white blood cell count at admission. Beta-blocker use in hospitalised patients with ascites was not associated with a higher mortality, even in those with refractory ascites. No significant changes in mean arterial pressure (MAP) were observed between groups. Discontinuation of beta-blockers (49%) was driven by low MAP, infection and acute kidney injury at time of discontinuation but was not associated with a higher mortality. Beta-blocker reinitiation occurred in 40% prior to discharge and was mainly driven by an increase in MAP. CONCLUSIONS Beta-blocker use is safe in patients with cirrhosis and ascites (including those with refractory ascites) provided beta-blockers are discontinued in the presence of a low MAP and reinitiated once MAP reincreases. A potentially beneficial anti-inflammatory effect of beta-blockers is suggested.
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Affiliation(s)
- Abdul Q. Bhutta
- Yale-New Haven Hospitalist Service, Yale-New Haven Hospital, New Haven, CT
| | - Guadalupe Garcia-Tsao
- Section of Digestive Diseases, Yale University, New Haven, CT,Section of Digestive Diseases, VA-CT Healthcare System, West Haven, CT
| | | | | | | | | | | | | | | | | | | | - Yanhong Deng
- Department of Biostatistics, Yale School of Public Health, New Haven, CT
| | - Maria Ciarleglio
- Department of Biostatistics, Yale School of Public Health, New Haven, CT
| | - Jasmohan S. Bajaj
- Virginia Commonwealth University, Richmond, VA,McGuire VA Medical Center, Richmond, VA
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Abstract
Acute variceal hemorrhage (AVH) is a lethal complication of portal hypertension and should be suspected in every patient with liver cirrhosis who presents with upper gastrointestinal bleed. AVH-related mortality has decreased in the last few decades from 40% to 15%-20% due to advances in the general and specific management of variceal hemorrhage. This review summarizes current management of AVH and prevention of recurrent hemorrhage with a focus on pharmacologic therapy.
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Affiliation(s)
- Abdul Q Bhutta
- Department of Internal Medicine, Yale University, 330 Cedar St, Boardman 110 P.O. Box 208056, New Haven, CT 06520-8056, USA; Section of Hospital Medicine, Yale-New Haven Hospital, 20 York Street, CB-2041, New Haven, CT 06520, USA
| | - Guadalupe Garcia-Tsao
- Section of Digestive Diseases, Yale University School of Medicine, 333 Cedar St, 1080 LMP, P.O. Box 208019, New Haven, CT 06520-8019, USA; Section of Digestive Diseases, VA-CT Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA.
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Martin CR, Zaman MM, Ketwaroo GA, Bhutta AQ, Coronel E, Popov Y, Schuppan D, Freedman SD. CFTR dysfunction predisposes to fibrotic liver disease in a murine model. Am J Physiol Gastrointest Liver Physiol 2012; 303:G474-81. [PMID: 22679000 PMCID: PMC3423138 DOI: 10.1152/ajpgi.00055.2012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Cystic fibrosis liver disease (CFLD) is a rapidly progressive biliary fibrosis, resembling primary sclerosing cholangitis that develops in 5-10% of patients with cystic fibrosis. Further research and evaluation of therapies are hampered by the lack of a mouse model for CFLD. Although primary sclerosing cholangitis is linked to both ulcerative colitis and loss of cystic fibrosis transmembrane conductance regulator (CFTR) ion channel function, induction of colitis with dextran sodium sulfate (DSS) in cftr(-/-) mice causes bile duct injury but no fibrosis. Since profibrogenic modifier genes are linked to CFLD, we examined whether subthreshhold doses of the profibrogenic xenobiotic 3,5-diethoxycarbonyl-1,4-dihydrocollidine (DDC), along with DSS-induced colitis, lead to bile duct injury and liver fibrosis in mice that harbor loss of CFTR function. Exon 10 heterozygous (cftr(+/-)) and homozygous (cftr(-/-)) mice treated with DDC demonstrated extensive mononuclear cell inflammation, bile duct proliferation, and periductular fibrosis. In contrast, wild-type (cftr(+/+)) littermates did not develop bile duct injury or fibrosis. Histological changes corresponded to increased levels of alkaline phosphatase, hydroxyproline, and expression of profibrogenic transcripts for transforming growth factor-β(1), transforming growth factor-β(2), procollagen α(1)(I), and tissue inhibitor of matrix metaloproteinase-1. Immunohistochemistry demonstrated fibrosis and activation of periductal fibrogenic cells based on positive staining for lysyl oxidase-like-2, α-smooth muscle actin, and collagen I. These data demonstrate that subthreshold doses of DDC, in conjunction with DSS-induced colitis, results in bile duct injury and periductal fibrosis in mice with partial or complete loss of CFTR function and may represent a useful model to study the pathogenic mechanisms by which CFTR dysfunction predisposes to fibrotic liver disease and potential therapies.
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Affiliation(s)
- Camilia R. Martin
- 1Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; ,3Division of Translational Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Munir M. Zaman
- 2Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; and
| | - Gyanprakash A. Ketwaroo
- 2Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; and
| | - Abdul Q. Bhutta
- 2Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; and
| | - Emmanuel Coronel
- 2Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; and
| | - Yury Popov
- 2Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; and
| | - Detlef Schuppan
- 2Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; and
| | - Steven D. Freedman
- 2Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; and ,3Division of Translational Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Martin CR, DaSilva DA, Cluette-Brown JE, DiMonda C, Hamill A, Bhutta AQ, Coronel E, Wilschanski M, Stephens AJ, Driscoll DF, Bistrian BR, Ware JH, Zaman MM, Freedman SD. Decreased postnatal docosahexaenoic and arachidonic acid blood levels in premature infants are associated with neonatal morbidities. J Pediatr 2011; 159:743-749.e1-2. [PMID: 21658712 PMCID: PMC3701520 DOI: 10.1016/j.jpeds.2011.04.039] [Citation(s) in RCA: 160] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Revised: 03/08/2011] [Accepted: 04/20/2011] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To measure the changes in whole blood fatty acid levels in premature infants and evaluate associations between these changes and neonatal morbidities. STUDY DESIGN This was a retrospective cohort study of 88 infants born at <30 weeks' gestation. Serial fatty acid profiles during the first postnatal month and infant outcomes, including chronic lung disease (CLD), retinopathy of prematurity, and late-onset sepsis, were analyzed. Regression modeling was applied to determine the association between fatty acid levels and neonatal morbidities. RESULTS Docosahexaenoic acid (DHA) and arachidonic acid levels declined rapidly in the first postnatal week, with a concomitant increase in linoleic acid levels. Decreased DHA level was associated with an increased risk of CLD (OR, 2.5; 95% CI, 1.3-5.0). Decreased arachidonic acid level was associated with an increased risk of late-onset sepsis (hazard ratio, 1.4; 95% CI, 1.1-1.7). The balance of fatty acids was also a predictor of CLD and late-onset sepsis. An increased linoleic acid:DHA ratio was associated with an increased risk of CLD (OR, 8.6; 95% CI, 1.4-53.1) and late-onset sepsis (hazard ratio, 4.6; 95% CI, 1.5-14.1). CONCLUSION Altered postnatal fatty acid levels in premature infants are associated with an increased risk of CLD and late-onset sepsis.
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Affiliation(s)
- Camilia R. Martin
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Deborah A. DaSilva
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Clementina DiMonda
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Ashley Hamill
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Abdul Q. Bhutta
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Emmanuel Coronel
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Michael Wilschanski
- Pediatric Gastroenterology Unit, Division of Pediatrics, Hadassah University Medical Center
| | - Alisa J. Stephens
- Department of Biostatistics, Harvard School of Public Health, Boston, MA
| | | | - Bruce R. Bistrian
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - James H. Ware
- Department of Biostatistics, Harvard School of Public Health, Boston, MA
| | - Munir M. Zaman
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Steven D. Freedman
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA
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Zaman MM, Martin CR, Andersson C, Bhutta AQ, Cluette-Brown JE, Laposata M, Freedman SD. Linoleic acid supplementation results in increased arachidonic acid and eicosanoid production in CF airway cells and in cftr-/- transgenic mice. Am J Physiol Lung Cell Mol Physiol 2010; 299:L599-606. [PMID: 20656894 DOI: 10.1152/ajplung.00346.2009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Cystic fibrosis (CF) patients display a fatty acid imbalance characterized by low linoleic acid levels and variable changes in arachidonic acid. This led to the recommendation that CF patients consume a high-fat diet containing >6% linoleic acid. We hypothesized that increased conversion of linoleic acid to arachidonic acid in CF leads to increased levels of arachidonate-derived proinflammatory metabolites and that this process is exacerbated by increasing linoleic acid levels in the diet. To test this hypothesis, we determined the effect of linoleic acid supplementation on downstream proinflammatory biomarkers in two CF models: 1) in vitro cell culture model using 16HBE14o(-) sense [wild-type (WT)] and antisense (CF) human airway epithelial cells; and 2) in an in vivo model using cftr(-/-) transgenic mice. Fatty acids were analyzed by gas chromatography-mass spectrometry (GC/MS), and IL-8 and eicosanoids were measured by ELISA. Neutrophils were quantified in bronchoalveolar lavage fluid from knockout mice following linoleic acid supplementation and exposure to aerosolized Pseudomonas LPS. Linoleic acid supplementation increased arachidonic acid levels in CF but not WT cells. IL-8, PGE(2), and PGF(2α) secretion were increased in CF compared with WT cells, with a further increase following linoleic acid supplementation. cftr(-/-) Mice supplemented with 100 mg of linoleic acid had increased arachidonic acid levels in lung tissue associated with increased neutrophil infiltration into the airway compared with control mice. These findings support the hypothesis that increasing linoleic acid levels in the setting of loss of cystic fibrosis transmembrane conductance regulator (CFTR) function leads to increased arachidonic acid levels and proinflammatory mediators.
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