Bismuth subsalicylate (Pepto-Bismol ® ) and other bismuth-containing compounds have been used for many years to treat gastroenterological complaints. Although safe in the majority of patients, bismuth can cause a well-described toxic state marked by progressive neurological decline. Features of bismuth toxicity include confusion, postural instability, myoclonus, and problems with language [1]. This presentation can masquerade as other causes of progressive neurologic dysfunction including Creutzfeld-Jakob Disease (CJD), Hashimoto's Encephalopathy, and others. In this case study, we present a patient who was using bismuth salicylate in toxic quantities to help control diarrhea. On initial presentation, several diagnoses were entertained before bismuth levels were obtained. This case study highlights the fact that bismuth toxicity, while rare, should be considered in a patient with progressive neurological decline. Also, we hope this case reminds physicians of a severe consequence of a common, readily available medication.Keywords: Bismuth Toxicity; Creutzfeld-Jakob Case ReportA 56 year old woman who had recently begun treatment for collagenous colitis presented to her local hospital with several days of psychomotor retardation, decreased concentration, tremor of her hands, visual hallucinations, and postural instability preventing her from standing on her own. The patient was concurrently being treated on stable doses of medications for irritable bowel syndrome, hypertension, hypothyroidism, and depression.Her husband stated that her concentration had been gradually decreasing for the previous two weeks but had profoundly worsened in the last couple days. There is no record that the patient saw a clinician for mental status deterioration prior to her hospital presentation. During her stay at the hospital, the patient became more delirious and somnolent and began to experience myoclonic jerks and hyperreflexia. Serotonin syndrome was considered, and the patient's serotonergic medications (escitalopram, duloxetine) were held. The patient's lack of improvement over the next three days resulted in transfer to a teaching hospital, where she was admitted to the Neurology Service.Initial physical exam showed temperature 37.0 degrees Celsius, blood pressure 165/94 mm Hg, pulse 117, respirations 16, oxygen saturations 98% on room air. The patient provided one word answers to questions, was lethargic with impaired attention, and could express orientation correctly only to person. Cranial nerves II-XI were intact, but patient could not protrude tongue. Muscle bulk and strength were normal, but tone was markedly rigid throughout. She demonstrated frequent myoclonic jerks and occasionally exhibited intention tremor. Reflex examination demonstrated hyperactive spreading reflexes at all stations with upgoing toes bilaterally. All other aspects of the physical exam were unremarkable. Laboratory tests, including thyroid function tests, B12 levels, RPR, and various microbiological assays were within normal limits. A noncon...
Background. Gastric gastrointestinal stromal tumors (GISTs) that are predominantly endophytic or in anatomically complex locations pose a challenge for laparoscopic wedge resection; however, endoscopic resection can be associated with a positive deep margin given the fourth-layer origin of the tumors. Methods. Patients at two tertiary care academic medical centers with gastric GISTs in difficult anatomic locations or with a predominant endophytic component were considered for enrollment. Preoperative esophagogastroduodenoscopy (EGD), endoscopic ultrasound (EUS) with or without fine needle aspiration (FNA), and cross-sectional imaging were performed. Eligible patients were offered and consented for hybrid and standard management. Results. Over ten months, four patients in two institutions with anatomically complex or endophytic GISTs underwent successful, uncomplicated push-pull hybrid procedures. GIST was confirmed in all resection specimens. Conclusion. In a highly selected population, the hybrid push-pull approach was safe and effective in the removal of complex gastric GISTs. Endoscopic resection alone was associated with a positive deep margin, which the push-pull technique manages with a laparoscopic, full thickness, R0 resection. This novel, minimally invasive, hybrid laparoscopic and endoscopic push-pull technique is a safe and feasible alternative in the management of select GISTs that are not amenable to standard laparoscopic resection.
Liver disease is the leading cause of non-AIDS related morbidity and mortality in human immunodeficiency virus (HIV) infected patients. There are many causes of liver disease in these patients, most commonly co-infection with viral hepatitis or alcoholic liver disease. A far less commonly described entity is autoimmune hepatitis (AIH) in HIV patients. The relationship between HIV and autoimmune diseases is well-described in a few conditions such as systemic lupus erythematosus and diffuse infiltrative lymphocytosis syndrome; however, patients with HIV who subsequently develop autoimmune hepatitis (AIH) has rarely been described in the existing literature. Managing these coexisting morbidities requires careful monitoring, as treating AIH requires the further immunosuppression of an HIV-infected individual. Herein, we present two patients who were diagnosed with and treated for AIH while receiving concurrent highly active anti-retroviral therapy. This case series provides treatment outcome data for a situation that has heretofore been rarely reported.
BackgroundThere are roughly 300,000 hospitalizations for acute pancreatitis annually in the United States. Many of the affected patients at our institution undergo computed tomography (CT) or magnetic resonance imaging (MRI) unnecessarily early during their admissions. We hypothesize that cross-sectional imaging within 48 h of admission in patients meeting the criteria for acute, mild pancreatitis is over-utilized and does not change management.MethodsWe performed a retrospective analysis of patients with a discharge diagnosis of acute pancreatitis from our tertiary care institution from January 1, 2010 to December 31, 2015. Inclusion criteria were a lipase more than three times the upper limit of normal and clinical suspicion of pancreatitis. Exclusion criteria were an etiology of pancreatitis following endoscopic retrograde cholangiopancreatography, recurrent or chronic pancreatitis, severe pancreatitis, and ultrasound findings being the reason for imaging.ResultsOf the 166 patients who met the criteria for analysis, 105 (63.3%) underwent cross-sectional imaging within 48 h of presentation (CT: 104, MRI: 1). Of the examined CTs, 27 (26.0%) showed no abnormality and 55 (52.9%) revealed uncomplicated pancreatitis. The remaining 22 (21.2%) demonstrated at least one of the following: local complications, biliary ductal dilatation or other findings. On thorough chart review, only two patients received a beneficial change in management as a result of the early imaging.ConclusionsThis analysis supports current guidelines that early cross-sectional abdominal imaging (CT or MRI) in patients with suspected acute mild pancreatitis does not alter medical management. Early imaging may lead to unnecessary resource use and patient irradiation.
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