Non-celiac Enteropathy and Olmesartan: An Essential Consideration

Emerging evidence has shed light on non-celiac causes of enteropathy in recent years, presenting a diagnostic challenge for clinicians. This study discusses the diagnostic challenges related to non-celiac enteropathy, specifically focusing on olmesartan-induced enteropathy (OIE). A 73-year-old lady presented to the emergency department with a six-month history of watery diarrhea exacerbated by food intake and significant weight loss. The patient at admission was found to be dehydrated with severe hypokalemia and hypocalcemia. The extensive testing that was performed was unremarkable, including celiac disease panel, enteric panel, ova and parasites, Clostridium difficile, fecal calprotectin, and computed tomography of the abdomen and pelvis. A significant electrolyte imbalance was corrected at admission, and subsequent upper endoscopy investigation with duodenal biopsies revealed moderate to severe villi blunting with a significant intraepithelial infiltrate of CD3+ lymphocytes. A colonoscopy that was performed at the same time was unremarkable, with negative biopsies for microscopic colitis. Given the suspicion of OIE, olmesartan was discontinued. One-month follow-up revealed resolution of malabsorption, with electrolyte normalization and duodenal biopsies showing improved duodenitis. This study emphasizes the importance of considering medication history and ruling out other potential causes of enteropathy. Olmesartan is an angiotensin II receptor antagonist that is commonly prescribed for hypertension. However, in rare cases, it may induce enteropathy, which often remains underdiagnosed. This rare side effect may present as chronic diarrhea, weight loss, and signs of malabsorption. Interestingly, OIE presents with overlapping clinical and histopathological features to celiac disease and, therefore, may mislead physicians to an extensive diagnostic investigation. Greater awareness of medication-related diarrheal syndromes such as OIE should be promoted, given that simple discontinuation of the medication can lead to dramatic clinical improvement.

Brunner Gland Hamartomas-Uncommon Presentations and Endoscopic Management

Brunner gland hamartoma (BGH) is a rare condition that requires a high clinical suspicion to diagnose. Large hamartomas may initially present with iron deficiency anemia (IDA) or symptoms suggesting intestinal obstruction. Barium swallow may demonstrate the lesion, but endoscopic evaluation is the acceptable first line management unless a concern for underlying malignancy. The present case report and literature review highlight the uncommon presentations and endoscopic role in large BGHs management. Internists should consider BGH in their differential, especially in patient with occult bleeding, IDA, or obstruction, which can be treated with endoscopic resection of large sized tumors by trained experts.

Adenovirus Hepatitis in Immunocompetent Adults

A 35-year-old female with no medical history presented with fever. Laboratory work was normal except for elevated liver function test (LFT): alkaline phosphatase (AP) (296), aspartate transaminase (AST) (343), alanine transaminase (ALT) (378), and international normalized ratio (INR) (1.23). Ultrasound liver was normal. Infectious workup was negative for hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis C virus (HCV), hepatitis E virus (HEV), cytomegalovirus (CMV), Epstein-Barr virus (EBV), Herpes simplex virus (HSV), and COVID-19. Similarly, autoimmune hepatitis, Wilson, and alpha-1 antitrypsin workup were negative. She reported taking Yogi-Kanthika (ayurvedic-proprietary medicine) on/off for seasonal sore throat, yet RUCAM-score was 2 (unlikely a drug induced injury). Respiratory-viral-panel came positive for adenovirus. With supportive treatment, symptoms and LFT trended down, thus, liver biopsy decision was deferred. We believe this is the first reported case of adenovirus hepatitis in an immunocompetent adult. Hence, we suggest that clinicians should consider a refined differential diagnosis for elevated LFT (that includes adenovirus).

1060 Screening For Obstructive Sleep Apnea In Severe Gastroesophageal Reflux Disease Patients: A Forgotten Association?

Introduction

Obstructive sleep apnea (OSA) is an emerging epidemic in the USA and remains underdiagnosed. Investigations of Gastroesophageal reflux disease (GERD) poses a substantial burden on patient-welfare and costs to the health system. Current literature has highlighted the association between severe GERD and OSA, and other sleep disorders. We conducted a retrospective analysis of patient records undergoing Bravo pH monitoring for refractory GERD to measure the prevalence of OSA and screening.

Methods

Records of patients who underwent outpatient Bravo pH monitoring at a teaching hospital were reviewed from August 2018 to May 2019. 72 records were reviewed in our analysis. Analysis variables included age, gender, body mass index, history of hypertension and OSA. Outpatient records were reviewed for documentation for OSA or screening and demographics were obtained for calculation of a partial STOP-BANG score (a validated OSA screening tool).

Results

8 out of 72 (11%) were excluded due to incomplete documentation regarding their history. Of the remaining 64, 2 had a known diagnosis of OSA (3%) and 1 was due a sleep study for maintenance insomnia. Of the remaining 61 patients, none had documentation of a history pertaining to sleep complaints or full screening for OSA. 4 of the 8 components to the STOP-BANG criteria were documented and used to measure risk of OSA in these patients. 23 (39%) patients had a score of 3 or above characterizing them as intermediate risk. The other 4 components were not used due to a lack of clinical information. 13 of these patients had a positive Bravo test, 2 had an inconclusive result and 8 had a negative result. Of the 61 patients in total, 31 had a positive Bravo result and 9 had an inconclusive result.

Conclusion

In our study, we found that 39% of patients based on demographic data were of intermediate risk of OSA. Over half of these patients had a positive result for GERD. Despite the increased awareness of sleep disorders it is still neglected despite prevalent associated comorbid conditions. This study highlights the failure to screen for this modifiable risk factor within a teaching environment.

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