For children and adolescents with mild-to-moderate hypertension, on the basis of a cutoff of 5% to 20% abnormal results to define a useful test, the initial evaluation can range from a serum cholesterol level and ambulatory blood pressure monitoring to a panel that consists of a fasting lipid profile, renal ultrasound, echocardiogram, and ambulatory blood pressure monitoring. Additional assessment should be guided by specific clinical features and the nature of the patient population.
Background: Metabolic acidosis refers to any process that increases the hydrogen ions in the body and reduces the bicarbonate concentration. Metabolic acidosis is subdivided based on presence of anion gap (AG), and AG metabolic acidosis is most often due to ketoacidosis, lactic acidosis, renal failure, or toxic ingestions. AG metabolic acidosis is frequently encountered in the clinical practice. Rarely, the underlying cause of the AG metabolic acidosis is considered a diagnostic dilemma as the established algorithm allows the physicians to identify the etiology. Case presentation: A fifty-three-year-old Black woman with well-controlled human immunodeficiency virus (HIV), hypertension, and asthma presented with recurrent episodes of severe anion gap metabolic acidosis. The patient’s AG metabolic acidosis always corrected with the administration of intravenous normal saline. Laboratory studies were always negative for common causes of acidosis. Conclusion: Nucleoside reverse transcriptase inhibitors-associated lactic acidosis has been reported in the literature. The shift to anaerobic mitochondrial metabolism induced by the HIV medications used in this patient could be explain the recurrent severe metabolic acidosis.
INTRODUCTION: Over the last few years there has been an increase in the frequency of findings of intra-ductal papillary mucinous neoplasms (IPMNs). This is likely due to the increased use of advanced abdominal imaging as well as in increase in the quality of these images. In most cases, decisions are based on consensus rather than evidence based as to how to proceed with regard to follow up imaging, biopsy, or even surgical resection. At ACG 2017, we presented the outcomes of and natural history of patients with IPMNs in the Brooklyn VA. Since that presentation, we have an update regarding further data points as well as in increase in the number of patients we analyzed. METHODS: Retrospective chart review was performed on patients with diagnosis, based on coding) of pancreatic cyst, pancreatic lesion, and intra-ductal pancreatic mucinous neoplasm from the New York Harbor Veterans Affairs Hospital from 2000 to 2015. 767 patients were initially flagged, and based on either radiology reports or clinic notes 104 were determined to actually have an IPMN. We looked at basic demographics, risk factors and survival data. RESULTS: Baseline characteristics are outlined in Table 1 of the 104 patients formally diagnosed with an IPMN. In summary, 101 are male. The average age at the time of initial diagnosis was 71.5 years old, the median age was 72 years old. The average Body Mass index was 27.3. The subjects in this study were overwhelmingly African American (40.6%) and White (42.6%). There was a small Hispanic component (14.6%). There were no Asian patients in the study. Nine patients underwent surgical resection. 33 patients died and the median time to survival was not able to be calculated at this time. The average age at the time of death was 78.9 years old. In the 33 patients that died only 6 Patients (5.7% of total patients diagnosed) died from pancreatic causes. CONCLUSION: The management of IPMNs presents a clinical challenge for gastroenterologists today. To date, the levels of evidence in which the current guidelines are based on is poor. Our study is limited by factors such as advanced age, gender and multiple comorbidities preventing further invasive interventions. It is due to these factors, that our study is not applicable to the general population. Therefore, we recommend further larger multicenter trials with a diverse cohort to establish the risk of IPMN’s and their effect on mortality from pancreatic cancer.
Introduction: Dieulafoy lesions (DL) consist of dilated aberrant submucosal arteries which may potentially lead to life-threatening gastrointestinal (GI) bleeding upon erosion of overlying mucosa. They are most commonly located in the lesser curvature of the stomach followed by duodenum and colon. The esophagus is an exceedingly rare location for DL. We report a hemodynamically unstable patient with distal esophageal DL who presented with massive hematemesis. Case Description/Methods: A 57-year-old man was brought to the hospital with massive hematemesis and unresponsiveness requiring intubation in the field. His medical history was significant for alcoholinduced cirrhosis decompensated with ascites. Previous upper endoscopy revealed LA class D esophagitis but no evidence of varices. Upon presentation, the patient was tachycardic to 130 bpm and hypotensive to 89/56 mmHg. Physical exam was remarkable for distended abdomen and positive fluid wave. Initial blood work showed hemoglobin of 4.3 g/dL and platelet of 36/uL. Nasogastric tube suction aspirated 2000 ml of coffee ground content and frank blood. The patient was emergently resuscitated with intravenous fluid and massive transfusion protocol. Subsequently, bedside esophagogastroduodenoscopy revealed active pulsatile bleeding from an exposed vessel in the distal portion of the esophagus (Figure A). Two hemostatic clips were successfully deployed and hemostasis was achieved (Figure B). The patient was then transferred to the critical care unit and maintained on proton pump inhibitor infusion. Hospital course was further complicated by hepatic encephalopathy and hepatorenal syndrome. Given MELD-Na score of 40, the patient was eventually transferred to an advanced center for liver transplantation. Discussion: DL in the esophagus is an extremely rare entity with few cases published to date. Lesions are due to persistently dilated caliber of submucosal artery, as opposed to normal narrowing, as the vessel approaches overlying mucosa. Continuous arterial pulsation may damage the mucosa with a stream of arterial bleeding, as in our case. Upper endoscopy is the mainstay of diagnosis and treatment for DL. Band ligation, electrocautery or hemoclips can be deployed through endoscopy, as with our case. Due to the intermittent nature of bleeding, endoscopy is not always diagnostic and angiography with embolization is an alternative option. Surgery is always a last resort.[2439] Figure 1. A) Active pulsatile bleeding from an exposed vessel in the distal portion of the esophagus. B) Hemostatic clip successfully deployed with complete hemostasis.
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