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Suarez ZK, Samhoun J, Drourr J, Nagi T, Haider MA, Vallejo C, Touqir Z, Forcione D. Successful Endoscopic Retrograde Appendicitis Therapy Following a Recent ST-Elevation Myocardial Infarction. ACG Case Rep J 2024; 11:e01324. [PMID: 38560012 PMCID: PMC10980388 DOI: 10.14309/crj.0000000000001324] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 02/28/2024] [Indexed: 04/04/2024] Open
Abstract
Acute appendicitis is one of the most common abdominal surgical emergencies. A laparoscopic or open appendectomy has traditionally been the gold standard. Antibiotic therapy has recently been found to be noninferior. The treatment of acute uncomplicated appendicitis remains a challenge, especially in the presence of an appendicolith. We present a case of a 59-year-old man with recent ST-elevation myocardial infarction who underwent successful endoscopic retrograde appendicitis therapy.
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Affiliation(s)
- Zoilo K. Suarez
- Internal Medicine Department, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, FL
| | - Jalal Samhoun
- Internal Medicine Department, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, FL
| | - Josh Drourr
- Internal Medicine Department, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, FL
| | - Talwinder Nagi
- Internal Medicine Department, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, FL
| | - Muhammad A. Haider
- Internal Medicine Department, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, FL
| | - Charles Vallejo
- Internal Medicine Department, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, FL
| | - Zahra Touqir
- Internal Medicine Department, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, FL
| | - David Forcione
- Internal Medicine Department, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, FL
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Vallejo C, Gheit Y, Nagi TK, Suarez ZK, Haider M, Zahra T. Pneumatosis Intestinalis Manifesting as an Atypical Presentation of Crohn's Disease. Cureus 2024; 16:e53151. [PMID: 38420063 PMCID: PMC10901041 DOI: 10.7759/cureus.53151] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 01/29/2024] [Indexed: 03/02/2024] Open
Abstract
Crohn's disease is an inflammatory bowel disease that has a bimodal distribution, occurring most frequently between ages 15 to 30 years and 40 to 60 years. It presents with a relapsing and remitting course. The most common area involved is the terminal ileum and right colon and the inflammation oftentimes leads to non-caseating granulomas and ulcerations in both the superficial mucosa and deeper layers. Additionally, pneumatosis intestinalis is defined as the presence of gas and free air in the extraluminal space of the intestines which is an abnormal occurrence and correlates with underlying pathology. There are only a few cases reported in the literature that present pneumatosis intestinalis in the setting of, and possibly linked to, Crohn's disease. Our case presents an elderly male patient with jejunal ulcerations and strictures suggesting Crohn's disease and associated pneumatosis intestinalis as evidenced on outpatient computed tomography (CT) enterography. Upon presentation to the hospital, the patient was non-toxic and was not complaining of any pain. During his inpatient stay, there was a suspicion of Crohn's disease and therefore he was started on Infliximab therapy. We will review the possible pathogenesis of Crohn's disease and other cases presenting pneumatosis intestinalis in the setting of Crohn's disease.
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Affiliation(s)
- Charles Vallejo
- Internal Medicine, Florida Atlantic University, Boca Raton, USA
| | - Yousra Gheit
- Internal Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Talwinder K Nagi
- Internal Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Zoilo K Suarez
- Internal Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Muhammad Haider
- Internal Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Touqir Zahra
- Internal Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
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3
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Vallejo C, Gheit Y, Qi J, Nagi TK, Suarez ZK, Haider MA, Zahra T. Management of Esophageal Squamous Cell Carcinoma With Esophageal Stent Placement in an Elderly Patient With Dysphagia. Cureus 2023; 15:e50483. [PMID: 38226120 PMCID: PMC10788239 DOI: 10.7759/cureus.50483] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 12/13/2023] [Indexed: 01/17/2024] Open
Abstract
Esophageal cancer is typically identified as squamous cell carcinoma or adenocarcinoma. There are multiple risk factors that may contribute to esophageal squamous cell carcinoma including smoking, alcohol consumption, and the human papillomavirus. Lesions may appear ulcerated, friable, and circumferential and may obstruct the esophagus. Therefore, patients may complain of non-specific symptoms including dysphagia, weight loss, and retrosternal discomfort. Clinicians often rely on an upper endoscopy with biopsy to confirm the diagnosis. Computed tomography scans and endoscopic ultrasounds are also employed to assess the extent of malignant spread. Management may involve endoscopic resection for superficial lesions or surgical resection for lesions penetrating the submucosa. Esophageal stents may play a role, specifically as a palliative measure for enhancing oral intake. We present an instance of utilizing a self-expandable, metal-covered esophageal stent with balloon dilation in the setting of a newly diagnosed esophageal squamous cell carcinoma lesion in a 73-year-old female. Ultimately, the use of an esophageal stent in this patient helped improve the patient's oral intake during her course of hospitalization. Her diet was slowly advanced to clear liquids and progressively to a low-residue diet before being discharged to follow-up with her diagnosis as outpatient with gastroenterology.
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Affiliation(s)
- Charles Vallejo
- Internal Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Yousra Gheit
- Internal Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Jerry Qi
- Internal Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Talwinder K Nagi
- Internal Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Zoilo K Suarez
- Internal Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Muhammad A Haider
- Internal Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Touqir Zahra
- Internal Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
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4
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Nagi T, Suarez ZK, Haider MA, Vallejo C, Hernandez O, Doukides T. Acute Cholangitis Masquerading Biliary Neuroendocrine Carcinoma: A Rare Twist to a Typical Presentation. ACG Case Rep J 2023; 10:e01228. [PMID: 38111783 PMCID: PMC10727641 DOI: 10.14309/crj.0000000000001228] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 11/09/2023] [Indexed: 12/20/2023] Open
Abstract
Biliary neuroendocrine carcinoma (BNEC) develops in the biliary tract and is characterized by the presence of neuroendocrine cells and account for less than 1% of all malignancies. We present a patient with no significant risk factors of BNEC who presented with abdominal pain and jaundice. An endoscopic ultrasound with endoscopic retrograde cholangiopancreatography was concerning for neoplasm and less likely Mirizzi syndrome. Pathology revealed well-differentiated grade 3 large-cell neuroendocrine carcinoma of the common bile duct. BNEC has a poor prognosis with a reported 5-year survival rate of less than 20%, which is worse than other biliary tract malignancies such as cholangiocarcinoma. Additional cases and further studies of multimodal treatment are required in the future to improve prognosis. Providers should be aware of the risk factors of BNEC and consider the diagnosis when evaluating patients with the symptoms above.
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Affiliation(s)
- Talwinder Nagi
- Department of Internal Medicine, Florida Atlantic University, Schmidt College of Medicine, Boca Raton, FL
| | - Zoilo K. Suarez
- Department of Internal Medicine, Florida Atlantic University, Schmidt College of Medicine, Boca Raton, FL
| | - Muhammad Adnan Haider
- Department of Internal Medicine, Florida Atlantic University, Schmidt College of Medicine, Boca Raton, FL
| | - Charles Vallejo
- Department of Internal Medicine, Florida Atlantic University, Schmidt College of Medicine, Boca Raton, FL
| | - Oscar Hernandez
- Department of Internal Medicine, Florida Atlantic University, Schmidt College of Medicine, Boca Raton, FL
| | - Theodore Doukides
- Department of Gastroenterology, Florida Atlantic University, Schmidt College of Medicine, Boca Raton, FL
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Nagi TK, Suarez ZK, Haider MA, Holder SS, Vallejo C, Chaudhari SS. Per-Oral Endoscopic Myotomy-Induced Gastroesophageal Reflux Disease and Review of the Efficacy of Proton Pump Inhibitors as a Management Strategy: Review of the Literature. Cureus 2023; 15:e50324. [PMID: 38205455 PMCID: PMC10777338 DOI: 10.7759/cureus.50324] [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] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2023] [Indexed: 01/12/2024] Open
Abstract
Per-oral endoscopic myotomy (POEM) is a minimally invasive procedure that is very effective in the treatment of achalasia, a rare esophageal motility disorder. POEM has become the first-line treatment for achalasia, with high success rates reported in the literature. However, a known complication of POEM is gastroesophageal reflux disease (GERD). The exact cause and risk factors of post-POEM GERD are not fully understood; however, a number of factors have played a role in its development. The management of post-POEM GERD is mainly by conservative measures, such as lifestyle changes and medications, like proton pump inhibitors (PPI), which are often the first-line method of treatment. However, surgical procedures, such as fundoplication, may be necessary in some patients. This literature review will discuss the effectiveness of the use of PPIs as a management strategy for post-POEM GERD, the factors that lead to PPI-resistant GERD, and other management strategies utilized in these cases.
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Affiliation(s)
- Talwinder K Nagi
- Internal Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Zoilo K Suarez
- Internal Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Muhammad Adnan Haider
- Internal Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Shaniah S Holder
- Medicine, American University of Barbados School of Medicine, Bridgetown, BRB
| | - Charles Vallejo
- Internal Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Sandipkumar S Chaudhari
- Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, USA
- Family Medicine, University of North Dakota School of Medicine and Health Sciences, Grand Forks, USA
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Suarez ZK, Finke AC, Hospedales E, Perez E, Sharifzadeh A, Foster J, Ferris A. An unusual case of checkpoint-inhibitor-induced pleuropericarditis. J Oncol Pharm Pract 2023; 29:1525-1528. [PMID: 37254508 DOI: 10.1177/10781552231179369] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
INTRODUCTION Pembrolizumab is an immune checkpoint inhibitor that promotes effector T-cell functions on malignant cells by binding to programmed cell death protein 1 (PD-1). Pembrolizumab is well tolerated in most cases with an adverse event profile consisting mainly of pruritus, fatigue, and anorexia. Cardiotoxicity comprises 1% of the total adverse events. CASE REPORT We present a case of a 64-year-old female with non-small cell lung cancer (NSCLC) who developed pleuropericarditis following pembrolizumab therapy. MANAGEMENT & OUTCOME The patient was successfully managed with colchicine, furosemide, and timely initiation of methylprednisolone with the improvement of her symptoms. The decision to discontinue pembrolizumab was made, and six months after this intervention, the patient has remained asymptomatic. DISCUSSION Clinicians should recognize these potential immune-mediated adverse effects to provide effective and timely management and optimize patient care.
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Affiliation(s)
- Zoilo K Suarez
- Internal Medicine Department, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, FL, USA
| | - Ana C Finke
- Internal Medicine Department, Universidad Iberoamericana, Santo Domingo, Dominican Republic
| | - Emilio Hospedales
- Internal Medicine Department, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, FL, USA
| | - Ernesto Perez
- Internal Medicine Department, Kendall Regional Medical Center, Kendall, FL, USA
| | - Arya Sharifzadeh
- Internal Medicine Department, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, FL, USA
| | - Jennifer Foster
- Internal Medicine Department, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, FL, USA
| | - Allison Ferris
- Internal Medicine Department, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, FL, USA
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Vallejo C, Gheit Y, Nagi TK, Suarez ZK, Haider MA. A Rare Case of Achalasia Sigmoid Esophagus Obstructed by Food Bolus. Cureus 2023; 15:e45567. [PMID: 37868376 PMCID: PMC10586877 DOI: 10.7759/cureus.45567] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2023] [Indexed: 10/24/2023] Open
Abstract
Achalasia is a primary esophageal motility disorder that involves a failure of the lower esophageal sphincter to relax in response to swallowing. Specifically, the lower esophageal sphincter becomes hypertensive, and there is an absence of peristalsis in the esophagus. The pathophysiology is thought to be due to a loss of inhibitory nerve function from an autoimmune attack that targets the esophageal myenteric nerves. As a result, these abnormalities lead to a functional obstruction at the gastroesophageal junction. In severe cases, achalasia may present as a "sigmoid esophagus," a term used to describe the dilation and distortion of the cervical esophagus. In this case report, we discuss a patient with a known history of achalasia who presented with extra-esophageal symptoms including respiratory distress and tracheal compression from an esophagus dilated with a food impaction. She was found to have a sigmoid esophagus and required direct endoscopy and removal of the food bolus. We will review the pathogenesis of achalasia as well as medical and surgical approaches to treating severe achalasia as presented through other case reports.
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Affiliation(s)
- Charles Vallejo
- Internal Medicine, Florida Atlantic University, Boca Raton, USA
| | - Yousra Gheit
- Internal Medicine, Florida Atlantic University, Boca Raton, USA
| | | | - Zoilo K Suarez
- Internal Medicine, Florida Atlantic University, Boca Raton, USA
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8
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Haider MA, Gheit YS, Nagi T, Vallejo C, Suarez ZK, Hernandez OL, Gaisinskaya P, Markwart N. Severe Acetaminophen Toxicity From the Use of Oxycodone-Acetaminophen With Normal Liver Function Tests and a Completely Asymptomatic Course of Hospitalization. ACG Case Rep J 2023; 10:e01126. [PMID: 37601301 PMCID: PMC10435042 DOI: 10.14309/crj.0000000000001126] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 07/17/2023] [Indexed: 08/22/2023] Open
Abstract
Acetaminophen (N-acetyl-p-aminophenol, APAP), after being metabolized to toxic N-acetyl-p-benzoquinone imine, can cause irreversible hepatic necrosis. The mainstay of treatment includes N-acetylcysteine and fomepizole or liver transplant in patients who further deteriorate. Currently, many overdoses unintentionally occur in the setting of ingesting combined products that contain APAP. We report a rare case of a 60-year-old woman who presented with altered mental status and APAP toxicity in the setting of oxycodone-APAP overdose. She had a toxic serum APAP level on arrival. During hospitalization, her APAP level remained at the toxic level on the Rumack-Matthew nomogram. However, her liver function tests remained within normal limits, and she remained completely asymptomatic. To our best knowledge, this is the second case report with asymptomatic APAP toxicity and normal liver function tests. We will explore the effect of concomitant oxycodone ingestion on possibly delaying APAP absorption and thus resulting in a more favorable prognosis without hepatotoxicity.
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Affiliation(s)
| | - Yousra S. Gheit
- Florida Atlantic University Hospital, Schmidt College of Medicine, Boca Raton, FL
| | - Talwinder Nagi
- Florida Atlantic University Hospital, Schmidt College of Medicine, Boca Raton, FL
| | - Charles Vallejo
- Florida Atlantic University Hospital, Schmidt College of Medicine, Boca Raton, FL
| | - Zoilo K. Suarez
- Florida Atlantic University Hospital, Schmidt College of Medicine, Boca Raton, FL
| | - Oscar L. Hernandez
- Florida Atlantic University Hospital, Schmidt College of Medicine, Boca Raton, FL
| | - Polina Gaisinskaya
- Florida Atlantic University Hospital, Schmidt College of Medicine, Boca Raton, FL
| | - Nathan Markwart
- Florida Atlantic University Hospital, Schmidt College of Medicine, Boca Raton, FL
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Nagi TK, Gheit Y, Hernandez OL, Suarez ZK, Vallejo C, Haider MA, Zahra T. Myositis as an Extraintestinal Manifestation of Ulcerative Colitis: A Case Report and Literature Review. Cureus 2023; 15:e42336. [PMID: 37614279 PMCID: PMC10443962 DOI: 10.7759/cureus.42336] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2023] [Indexed: 08/25/2023] Open
Abstract
Ulcerative colitis (UC) is an inflammatory bowel disease (IBD) that is thoroughly studied and known to have a strong genetic component. It affects the mucosa and submucosa of the colon and rectum, causing diffuse friability and superficial erosions leading to bleeding. Common presenting symptoms include diarrhea that is often bloody or purulent and abdominal pain or cramping. There are also extraintestinal manifestations of UC such as cutaneous rashes, eye inflammation, and oral ulceration. A rarer manifestation of IBD is myositis, either dermatomyositis, polymyositis, or even rhabdomyolysis. Based on the literature review, myositis has been documented more so in cases of Crohn's disease versus UC. In this report, we discuss a patient with known UC who presented during a flare and subsequently complained of diffuse myalgia. She was found to have an elevated creatine kinase (CK), thus suggesting some form of myositis. We will review possible pathogenesis and other cases of UC presenting with myositis that have been documented.
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Affiliation(s)
- Talwinder K Nagi
- Internal Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Yousra Gheit
- Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Oscar L Hernandez
- Internal Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Zoilo K Suarez
- Internal Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Charles Vallejo
- Internal Medicine, Florida Atlantic University, Boca Raton, USA
| | - Muhammad Adnan Haider
- Internal Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Touqir Zahra
- Internal Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
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10
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Hernandez OL, Suarez ZK, Nagi T, Vallejo C, Ferris A. Dormant Crohn's Disease Reactivated by Clostridioides difficile Infection. Cureus 2023; 15:e37062. [PMID: 37153283 PMCID: PMC10155633 DOI: 10.7759/cureus.37062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2023] [Indexed: 04/05/2023] Open
Abstract
Crohn's disease (CD) is a type of inflammatory bowel disease (IBD) characterized by chronic transmural inflammation of any portion of the gastrointestinal tract. The etiology of CD remains unknown although genetic, immunological, and acquired factors have been recognized as contributing to its development. Alterations of intestinal microbiota, including Clostridioides difficile (C. difficile), are theorized to alter humoral immunity and contribute toward CD flare pathogenesis. As such, cases of IBD remission can be undone by alterations in the gut microbiota and subsequently confound the diagnosis of inflammatory or infectious etiologies of diarrhea. We present a case of a 73-year-old female with dormant CD for 25 years who experienced an atypical course of diarrhea found to have a CD flare in the setting of acute C. difficile colitis.
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11
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Naveed H, Tirumandyam G, Krishna Mohan GV, Gul S, Ali S, Siddiqui A, Suarez ZK, Khan A. Effect of Discontinuation of Renin Angiotensin-System Inhibitors in Patients With Advanced Chronic Kidney Disease: A Meta-Analysis. Cureus 2023; 15:e37813. [PMID: 37214072 PMCID: PMC10197020 DOI: 10.7759/cureus.37813] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2023] [Indexed: 05/23/2023] Open
Abstract
Renin-angiotensin system inhibitors (RAS) inhibitors include angiotensin receptor blockers (ARBs) and angiotensin-converting enzyme (ACE) inhibitors decrease proteinuria, progression of chronic kidney disease (CKD), and protect against heart failure hospitalizations and cardiovascular events. There is uncertainty about the appropriate time for discontinuing ARB and ACE inhibitor treatment in patients with low estimated glomerular filtration rate (eGFR). In the present meta-analysis, we examined the effect of RAS inhibitor discontinuation on clinical outcomes in patients with advanced CKD compared to the continuation of RAS inhibitors. Two authors conducted electronic database searches in PubMed, the Cochrane Library, and Excerpta Medica Database (EMBASE) for relevant studies published from the inception of the databases to March 15th, 2023, using the following combination of keywords or key terms: "Renin-angiotensin-system," "angiotensin-converting-enzyme inhibitors", "Angiotensin receptor blockers," and "advanced chronic kidney disease." Primary outcomes assessed in this meta-analysis included cardiovascular events. Secondary outcomes assessed included all-cause mortality and end-stage kidney disease (ESKD). A total of four studies were included in this meta-analysis. The pooled analysis showed that cardiovascular events were significantly higher in patients in the discontinuation group compared to the continuation group (HR: 1.38, 95% CI: 1.21-1.58), ESKD was also significantly higher in the discontinuation group (HR: 1.29, 95% CI: 1.18-1.41). No significant differences were reported between the two groups in all-cause mortality. In conclusion, our meta-analysis provides evidence that continuation of RAS inhibitors could be beneficial in patients with advanced CKD, as it is associated with less risk of cardiovascular events and ESKD.
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Affiliation(s)
- Husnain Naveed
- Medicine and Surgery, Shifa Tameer-E-Millat University Shifa College of Medicine, Islamabad, PAK
| | | | | | - Sawara Gul
- Internal Medicine, Lady Reading Hospital, Peshawar, PAK
| | - Shahid Ali
- Internal Medicine, Khyber Medical College, Peshawar, PAK
| | | | - Zoilo K Suarez
- Internal Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Areeba Khan
- Critical Care Medicine, United Medical and Dental College, Karachi, PAK
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12
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Genere JR, Suarez ZK, Kushnir V. Delayed ipsilateral intestinal perforation after endoscopic gastrojejunostomy: A perspective on underlying mechanisms. DEN Open 2023; 3:e229. [PMID: 37035032 PMCID: PMC10076688 DOI: 10.1002/deo2.229] [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] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 03/01/2023] [Accepted: 03/14/2023] [Indexed: 04/11/2023]
Abstract
The endoscopic management for malignant gastric outlet obstruction has expanded with the advent of endoscopic ultrasound-guided gastrojejunostomy. Delayed perforation after endoscopic ultrasound-guided gastrojejunostomy is an important yet rarely reported adverse event, and it is unclear why some patients may suffer this complication. We present a case of intestinal perforation occurring one month after endoscopic ultrasound-guided gastrojejunostomy and discuss potential mechanisms which may contribute to this outcome.
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Affiliation(s)
- Juan Reyes Genere
- Department of MedicineWashington University School of MedicineSaint LouisUSA
| | - Zoilo K. Suarez
- Department of Internal MedicineFlorida Atlantic University Charles E. Schmidt College of MedicineBoca RatonUSA
| | - Vladimir Kushnir
- Department of MedicineWashington University School of MedicineSaint LouisUSA
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13
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Chenna VSH, Nagi TK, Suarez ZK, Hernandez OL, Nageye ME, Reyaz N, Reyaz I, Ali N. Comparison of Effectiveness and Safety of Ustekinumab and Adalimumab As Induction or Maintenance Therapy in Patients With Moderate to Severe Crohn's Disease: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e38277. [PMID: 37255887 PMCID: PMC10226155 DOI: 10.7759/cureus.38277] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2023] [Indexed: 06/01/2023] Open
Abstract
This meta-analysis has been conducted to compare ustekinumab and adalimumab as induction or maintenance therapy in patients with moderate to severe Crohn's disease (CD). The current meta-analysis was conducted in accordance with the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Two investigators independently searched online databases including PubMed, Cumulated Index to Nursing and Allied Health Literature (CINAHL), and Cochrane Library for relevant articles published up to April 2023. The initial search terms were "ustekinumab," "adalimumab," and "Crohn's disease". Three studies (with a total of 612 patients) were included in the present meta-analysis. We did not find any significant difference in clinical remission (OR: 1.31, 95% CI: 0.68-2.52), clinical response (OR: 1.39, 95% CI: 0.39-4.91), endoscopic remission (OR: 1.56, 95% CI: 0.66-3.64), and steroid-free remission (OR: 0.98, 95% CI: 0.67-1.42) between patients who received ustekinumab and patients who received adalimumab. In conclusion, this meta-analysis provides valuable insights into the efficacy and safety of ustekinumab and adalimumab in the treatment of moderate to severe CD. Our findings indicate that both drugs have similar effectiveness in achieving clinical remission, clinical response, radiological remission and steroid-free remission.
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Affiliation(s)
| | - Talwinder K Nagi
- Internal Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Zoilo K Suarez
- Internal Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Oscar L Hernandez
- Internal Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Maymona E Nageye
- Internal Medicine-Pediatrics, Avalon University School of Medicine, Willemstad, CUW
| | - Nafisa Reyaz
- Medicine, Jawaharlal Nehru Medical College and Hospital, Aligarh, IND
| | - Ibrahim Reyaz
- Internal Medicine, Christian Medical College and Hospital Ludhiana, Ludhiana, IND
| | - Neelum Ali
- Internal Medicine, University of Health Sciences, Lahore, PAK
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Suarez ZK, Hernandez OL, Diaz PJ, Matott S, Ta Q. Splenic Injury: A Curious Complication of Colonoscopy. Cureus 2023; 15:e36724. [PMID: 37123770 PMCID: PMC10130944 DOI: 10.7759/cureus.36724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 03/26/2023] [Indexed: 03/29/2023] Open
Abstract
Colonoscopies are generally considered a safe procedure with an overall complication rate of 0.5%. Splenic injuries, including laceration, subcapsular hematoma, and rupture, have been thought to be underreported in the currently available literature. The etiology of splenic injury remains unknown, although excessive splenocolic ligament stretching and traction of adhesions have been hypothesized to play a role in its development. Even though conservative, percutaneous, and surgical strategies have been described in the literature, these strategies have been associated with higher mortality, and there is no consensus on the optimal approach to management. We present the case of a patient who sustained a splenic injury after a colonoscopy and was successfully managed with conservative measures.
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Hernandez OL, Hussain M, Suarez ZK, Nagi T, Zahra T. Duodenal Fibrosis Mimicking Neoplastic Obstructive Hepatopathy in the Setting of Lynch Syndrome. Cureus 2023; 15:e35679. [PMID: 37012941 PMCID: PMC10066623 DOI: 10.7759/cureus.35679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2023] [Indexed: 03/06/2023] Open
Abstract
Intestinal fibrosis is a rare complication of chronic inflammation resulting from various etiologies, including surgery, abdominal radiation, and inflammatory bowel disease. Consequences of intestinal fibrosis include intestinal dysmotility, malabsorption, and obstruction. Patients with Lynch syndrome are predisposed to developing intestinal adenocarcinoma including in the small intestines which typically require intra-abdominal procedures that expose them to fibrogenic triggers. Here, we present a rare case of duodenal fibrosis involving the sphincter of Oddi leading to malabsorption and gastrointestinal symptoms in a patient with Lynch syndrome requiring advanced endoscopy interventions.
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