Drug-induced liver injury caused by the histrelin (Vantus) subcutaneous implant.

Drug-induced liver injury (DILI) is the leading cause of acute hepatic failure in the United States. Up to 13% of acute liver failure cases occur due to drugs other than acetaminophen. This clinical diagnosis, made after other causes of liver injury have been excluded, requires establishing a causal relationship between drug exposure and liver injury. The case of a patient with liver injury following a subcutaneous histrelin (Vantus) implant as therapy for advanced prostate cancer is presented.

Granular cell tumor of the biliary system: a report of 2 cases with cytologic diagnosis on endoscopic brushing.

BACKGROUND: Granular cell tumors (GCTs) of biliary system are rare. GCTs show a striking preponderance for young, black females, who generally present with obstructive jaundice. To our knowledge, these are the first 2 reports of GCT of biliary system identifed on endoscopic brushing cytology. CASES: In case 1, a 24-year-old, black woman presented with a 5-month history of pruritus. Radiographic studies demonstrated a mass in the distal common bile duct. Endoscopic biopsy and bile duct brushing were diagnosed as GCT. A Whipple procedure was confirmatory of GCT. In case 2, a 38-year-old, black female presented with a 7-month history of pruritus and jaundice. Radiographic studies showed a stricture of the common hepatic duct at the hilum. Endoscopic brushing cytology of the stricture yielded only a few sheets of granular cells that were missed on initial screening. Suspicion of cholangiocarcinoma prompted surgery, and final histopathology showed GCT. Both patients were well 1 1/2 and 6 years after presentation. CONCLUSION: GCT of the bile duct can be diagnosed on endoscopic brushing and should be considered in the cytologic differential diagnosis in the appropriate clinical settings.

Transnasal endoscopic placement of feeding tubes in the intensive care unit.

BACKGROUND: There is an increasing demand for enteral feeding in intensive care unit (ICU) patients. However, gastroparesis is common, and jejunal placement with gastric decompression leads to delays in feeding. In an attempt to minimize delays, we describe our technique and results with transnasal endoscopic placement of double-lumen gastric aspiration, jejunal feeding tubes (DLFT). METHODS: Fifty-one consecutive ICU patients referred for nutrition support were studied; 29% had respiratory failure, 28% acute head injury, and 33% acute pancreatitis. A 5.8-mm ultraslim video endoscope was used to place a guidewire through the nose terminating beyond the Ligament of Treitz. After withdrawal of the endoscope, a DLFT was passed over the wire. Final position of the tube was checked and adjusted under direct vision by reendoscopy though the opposite nasal passage. RESULTS: Initial placement of the guidewire and DLFT was successful in 46 of 51 patients. Massive gastric dilatation and acute pancreatitis complicated by duodenal compression impeded full duodenoscopy in 5 patients, necessitating fluoroscopy for correct guidewire deployment. In confirming correct tube placement, there was near perfect concordance between reendoscopy and x-ray (45/46). Previously unrecognized upper gastrointestinal tract pathology was detected in most patients, with acute gastritis in 47, superficial gastric ulceration in 24, and erosive esophagitis in 5. CONCLUSIONS: Transnasal endoscopic placement of feeding tubes in the ICU is quick, effective, and minimally disruptive of intensive therapy. In addition, it can reveal unrecognized pathology, which potentially could lead to improvements in overall medical care.