Clinical Outcomes of Oral Zinc Therapy in Hepatic Encephalopathy Treatment

BACKGROUND

Additional therapies for hepatic encephalopathy (HE) treatment are warranted. There are data evaluating the use of zinc for HE; however, clinical outcomes, specifically in the United States, are unknown.

OBJECTIVE

To compare 30-day and 1-year all-cause readmission rates in patients with cirrhosis complicated by HE on lactulose and rifaximin to those on lactulose, rifaximin, and zinc.

METHODS

This retrospective study included patients admitted with documented cirrhosis and home medications of lactulose and rifaximin, with or without zinc. Patients were stratified into 2 groups: those receiving lactulose and rifaximin for HE (control) and those receiving lactulose, rifaximin, and zinc for HE (treatment). The primary outcomes were 30-day and 1-year all-cause readmission rates.

RESULTS

One-hundred fifty-seven patients were included (102 in control group, 55 in treatment group). Regarding 30-day and 1-year all-cause readmission rates, there was no difference between the control and treatment groups.

CONCLUSION AND RELEVANCE

This is the first study conducted in the United States evaluating zinc for HE treatment. Zinc did not impact 30-day or 1-year all-cause readmission rates. Further studies are warranted to evaluate the potential benefit of zinc for HE, possibly in correlation with Model for End-stage Liver Disease-Sodium (MELD-Na) scores.

Association of Previous Gastric Bypass Surgery and Patient Outcomes in Alcohol-Associated Cirrhosis Hospitalizations

BACKGROUND AND AIM

Roux-En-Y gastric bypass (RYGB) is associated with risk of alcohol use disorder. The impact of RYGB among patients with alcohol-associated liver disease (ALD) remains unknown.

METHODS

A retrospective cohort from National Inpatient Sample (01/2006-09/2015) database on 421,156 admissions with alcohol-associated cirrhosis (AC) was stratified for non-primary discharge diagnosis of previous RYGB. Admissions with RYGB (cases) were matched 1:3 to without RYGB (controls) based on propensity score on demographics, calendar year, socioeconomic status (insurance and zip code income quartile), obesity, diabetes, anxiety, and alcohol use disorder. Primary outcome was concomitant discharge diagnosis of alcoholic hepatitis (AH) or development of acute on chronic liver failure (ACLF).

RESULTS

Of 10,168 admissions (mean age 49 yrs., 75% females, 79% whites), cases (N = 2542) vs. controls had higher prevalence of concomitant AH (18.8 vs. 17%, P = 0.032), hepatic encephalopathy (31 vs. 25%), infection (28 vs. 24%), and grade 3 ACLF (13 vs. 5%), P < 0.001. Conditional logistic regression models showed higher odds for AH, hepatic encephalopathy, and infection among cases. In-hospital mortality of 6.3% (43% in ACLF) was lower in cases, but similar in the sub-cohorts of AH (N = 1768) or ACLF (N = 768). Results were similar in a sensitivity analysis of matched cohort of 2016 hospitalizations (504 cases) with primary discharge diagnosis of AC.

CONCLUSION

Among patients with AC, previous RYGB is associated with increased likelihood of concomitant AH, hepatic encephalopathy, and infection, but similar in-hospital mortality. Prospective studies are needed to validate, determine causality, and understand mechanisms of these findings among patients with alcohol-associated cirrhosis.

Outcomes of liver transplantation in patients 70 years or older: a systematic review and meta-analysis

INTRODUCTION AND OBJECTIVES

The rate of liver transplantation is increasing among the elderly population; however, data is limited on the post-liver transplantation outcomes in patients ≥70 years. Given the scarcity in liver allograft resources, a meta-analysis on the outcomes of liver transplantation in patients ≥70 years is warranted.

MATERIALS AND METHODS

Multiple databases were searched through March 2022 for studies that reported on the outcomes of liver-transplantation in patients ≥70 years. Meta-analysis was conducted using the random-effects model and heterogeneity was assessed using the I² statistics.

RESULTS

Ten studies were included that analyzed 162,725 patients. The pooled rate of 1-year, 3-years and 5-years post liver transplant survival for patients ≥70 years was 78.7% (72.6-83.7; I²=74%), 61.2% (52.3-69.5; I²=87%), and 48.9% (39.3-58.6; I²=96%), respectively. The corresponding 1-year, 3-years and 5-years survival for patients <70 years were 86.6% (82.4-89.9; I²=99%), 73.2% (63-81.3; I²=99%), and 70.1% (66.8-73.2; I²=99%); respectively. Descriptive p-values of comparison were statistically significant at 1-year and 5-years (p = 0.02 and <0.001). The pooled rate of perioperative complications in patients ≥70 years was 40.7% (26.2-57; I²=93%). The pooled rate of graft failure in patients ≥70 years was 6.7% (3.3-13.1; I²=93%) and in patients <70 years was 3.7% (1-12.4; I²=99%). The pooled rate of perioperative mortality in patients ≥70 years was 16.6% (7.6-32.5; I²=99%) and in patients <70 years was 0.8% (0-33.1; I²=88%).

CONCLUSION

Patients ≥70 years undergoing liver transplantation seem to demonstrate significantly lower 1-year and 5-year survival rates as compared to patients <70 years, albeit limited by heterogeneity.

Uremia Preventing Osmotic Demyelination Syndrome Despite Rapid Hyponatremia Correction

Hyponatremia is the most common electrolyte abnormality encountered both in the inpatient and outpatient clinical settings in the United States. Rapid correction leads to a deranged cerebral osmotic gradient causing osmotic demyelination syndrome. Coexisting azotemia is considered to be protective against osmotic demyelination syndrome owing to its counteractive effect on osmolarity change that occurs with rapid hyponatremia correction. In this article, we report the case of a 37-year-old male who presented with altered mentation, acute azotemia, and severe electrolyte derangements, with serum blood urea nitrogen 160 mg/dL, creatinine 8.4 mg/dL, sodium 107 mEq/L, potassium 6.1 mEq/L, bicarbonate 7 mEq/L, and anion gap of 33. Given refractory hyperkalemia with electrocardiogram changes, emergent dialysis was performed. Despite our efforts to avoid rapid correction, serum sodium was corrected to 124 mEq/L and blood urea nitrogen decreased to 87 mg/dL at the end of the 5-hour dialysis session. Fortunately, hospital course and 4-week post-discharge clinic follow-ups were uncomplicated with no neurological sequela confirmed by neurological examination and magnetic resonance imaging.

Deep Venous Aberration

Deep venous thrombosis is a common medical diagnosis. Estimates suggest 60,000 to 100,000 deaths annually from deep venous thrombosis and related complications in the United States of America. The diagnosis is often straightforward using a combination of clinical features and ultrasonography. Once confirmed, the treatment is straightforward as well - anticoagulation. However, we might come across a case where despite the prescribed treatment, there is little clinical improvement. There could be myriad reasons for this. We wish to share our experience with one such treatment failure and how we were able to narrow down the etiology to an anatomical defect. Eventually, we were able to offer curative treatment with vessel stenting. This case refreshed our medical knowledge and we hope to do the same for our colleagues.

Asians Have Higher Risk of Developing Pancreatic Necrosis in Inflammatory Bowel Disease Patient Population: A National Inpatient Sample Database Study

Background 

The aim of this study is to evaluate race-associated risk factors of acute pancreatitis (AP) in inflammatory bowel disease (IBD) patients.

Methods 

A retrospective analysis using 2016 and 2017 National Inpatient Sample database was performed. Inclusion criteria were principal diagnosis of AP and a secondary diagnosis of IBD. Patients below 18 years of age were excluded. The primary outcome was in-hospital mortality rate and secondary outcomes included pancreatic necrosis, surgical necrosectomy, total hospitalization charges, total parenteral nutrition use, and length of stay. For the primary and secondary outcomes, adjusted odds ratios (aORs) and mean difference calculation using multivariate regression were calculated.

Results

A total of 7,060 patients with AP in IBD were identified; of which 53.5% were female. The use of Medicaid was significantly higher in blacks (39.5%), Hispanics (32.6%), and Asian/Pacific Islanders (40%) compared to whites (19.9%). Approximately 63.2% of AP patients in IBD received care at an urban teaching hospital. Pancreatic necrosis was noted to be highest in Asians or Pacific Islanders compared to whites (aOR 12.62, 95% CI 1.00-159.3, p = 0.05).

Conclusion

Our study shows that racial disparities exist among AP in IBD patients with pancreatic necrosis being more common in Asians and Pacific Islanders compared to whites. Identification of potential causes of these disparities is of paramount importance to expand access to healthcare.

Benefits of prophylactic heme therapy in severe acute intermittent porphyria

Acute intermittent porphyria (AIP), an autosomal dominant inborn error of metabolism, is the most common and severe form of the acute porphyrias. Attacks of severe abdominal pain, often with hypertension, tachycardia, are cardinal features of AIP, often requiring hospital admissions. Frequent recurrent attacks of AIP, defined as >3 attacks in one year, during which at least one attack requires intravenous heme therapy, are associated with significant morbidity, lost productivity, and health care burden. We report two patients with such frequent attacks of AIP, who have been managed with prophylactic heme therapy on a weekly basis. We describe results particularly in relation to symptom control, biochemical findings, health care costs, quality of life, and utilization of resources. During 11-month duration of weekly prophylactic heme infusions, we observed a 100% decrease in acute attacks and inpatient admissions in one subject and a 75% decrease in the other. During this time, we also observed a significant decrease in the number of emergency room visits. The decrease in number of acute attacks requiring hospital admission was associated with significantly decreased health care costs and improved quality of life. Reduction of both emergency room visits and hospital admissions decreased the utilization of health care services. Outpatient weekly infusions were also noted to be associated with better reimbursements and reduced overall costs of health care for the subjects. Both our subjects also endorsed better symptom control, quality of life and better understanding of disease. Thus, prophylactic heme therapy, through a multi-disciplinary approach, decreases the incidence of acute attacks, decreases health care costs and leads to better patient satisfaction and quality of life.

Abstract 451: Beta Blocker Use in Asymptomatic Patients with Sepsis and Elevated Troponin is Associated with Lower Risk of Mortality

Background: In septic patients with elevated Troponin (e-Tn) levels, beta-blockers (BB) are usually avoided to prevent chronotropic incompetence. We examined the unclear association of BB at discharge with mortality in patients with sepsis and e-Tn levels.

Methods: We assessed 936 consecutive patients with e-Tn levels and sepsis on admission. Those with septic shock were excluded. BB use was determined by their presence at the time of discharge. Cox proportional hazard models adjusted for demographics and clinical covariates examined the association of BB use with all-cause mortality.

Results: 417 (44.6%) were on BB therapy with mean peak Tn level of 1.0 ± 0.09 ng/ml. Over a median follow-up of 5 years, 108 (36.5%) versus 236 (40.3%) deaths were reported in the BB versus the non-BB group respectively. On adjusting the Cox model for demographics, peak Tn, baseline cardiovascular disease risk factors, use of anticoagulants, antiplatelet and statins during hospitalization and discharge, BB use associated with a lower risk of mortality (HR 0.72; 95% CI 0.58-0.90, p = 0.004). In addition, BB use had a significant interaction with ischemic EKG changes (interaction p = 0.049) leading to a lower risk of mortality among patients without ischemic EKG changes (HR 0.66; 0.51-0.84, p = 0.0008 vs. HR 1.33; 0.75-2.36, p = 0.32, Figure 1).

Conclusions: In septic patients with e-Tn levels, use of BB on discharge led to a lower risk of mortality and the protective effect was more pronounced in patients without ischemic EKG changes. Future research should focus on its protective mechanism and its use in septic patients with e-Tn in a randomized trial.

Case report of a computerized tomography sign in <em>Strongyloides stercoralis</em> infection

This is a case of strongyloidiasis showing colon enhancement on a computerized tomography (CT) scan. The patient presented with chief complaints of diarrhea and abdominal pain. She gave a history of recent travel to El Salvador and her stool was positive for Strongyloides stercoralis. A CT scan revealed a circumferential enhancement of the sigmoid colon. This CT sign was unusual in strongyloidiasis and when combined with the symptoms, caused us to rule out inflammatory bowel disease and shock bowel. Stool examination revealed ova and parasites of Strongyloides stercoralis. She was then treated with ivermectin which resulted in resolution of her symptoms.

Neuromyelitis optica: an often forgotten cause of intractable nausea and vomiting

Neuromyelitis optica, also known as Devic's disease, is a rare autoimmune disorder in which a patient's immune system affects the optic nerves and the spinal cord, leading to loss of vision and spinal cord dysfunction. We present our experience with a 38-year-old female who presented to our facility with complaints of intractable nausea and vomiting. After extensive evaluation, she was found to have neuromyelitis optica. Her symptoms completely resolved following institution of appropriate therapy. She made a significant recovery and has since been placed on chronic immunosuppressive therapy. Through this article we hope to bring attention to a significant cause of intractable nausea and vomiting that may often be forgotten in general medicine or gastroenterology services.