US Nationwide Insight Into All-cause 30-day Readmissions following Inpatient Endoscopic Retrograde Cholangiopancreatography.

BACKGROUND AND AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) is associated with a high risk for morbidity, mortality, and hospital readmission. Data regarding those risks in the United States is scarce. We assessed post-ERCP 30-day readmission rates, their etiologies, and impact on the health care system using national data. METHODS: Using the National Readmission Database 2016, we identified patients who underwent inpatient ERCP from January 2016 to December 2016 using ICD-10-CM procedure codes. The primary endpoint was all-cause 30-day readmission rate. Etiologies of readmission were identified by tallying primary diagnosis. Multivariable logistic regression with complex survey design was used to identify independent risk factors associated with readmission. RESULTS: A total of 130,145 patients underwent ERCP, 16,278 (12.5%) were readmitted within 30 days, with an associated cost of 268 million dollars. Nearly 40% of readmissions occurred within 7 days, and 47.9% were related to gastrointestinal etiologies. Male gender, increased comorbidities, cirrhosis, Medicare insurance, and pancreatitis or pancreatitis-related indications for ERCP were readmission risk factors. Performance of cholecystectomy on index hospitalization decreased odds of readmission by 50% (adjusted odds ratio: 0.48, 95% confidence interval: 0.45-0.52, P <0.0001). While academic and nonacademic centers had similar readmission rates, high ERCP volume centers had higher rates compared with low-volume centers (adjusted odds ratio:1.10, P =0.008). CONCLUSION: All-cause 30-day readmission rates after inpatient ERCPs are high, mostly occur shortly postdischarge, and impose a heavy health care system burden. Large, multicenter prospective studies assessing the impact of center procedure volume on complications and readmission rates are needed.

Improved Mortality But Increased Economic Burden of Disease in Compensated and Decompensated Cirrhosis: A US National Perspective.

INTRODUCTION: Cirrhosis remains a major burden on the health care system despite substantial advances in therapy and care. Studies simultaneously examining mortality, readmission, and cost of care are not available. Here, we hypothesized that improved patient care in the last decade might have led to improved outcomes and reduced costs in patients with cirrhosis. MATERIALS AND METHODS: We identified compensated cirrhosis (CC) and decompensated cirrhosis (DC) patients using carefully chosen ICD-9/ICD-10 codes from the Nationwide Readmission Database (NRD) (years 2010 to 2016). We evaluated trends of 30-day all-cause mortality, 30-day readmission, and inflation-adjusted index hospitalization and readmission costs. Factors associated with mortality and readmission were identified using regression analyses. RESULTS: A total of 3,374,038 patients with cirrhosis were identified, of whom nearly 50% had a decompensating event on initial admission. The 30-day inpatient mortality rate for both CC and DC patients decreased from 2010 to 2016. The 30-day readmission rate remained stable for DC and declined for CC. Over the study period, 30-day readmission costs increased for DC and remained unchanged for CC. The median cost for index hospitalization remained nearly unchanged, but the cost of readmission increased for both CC and DC groups. Gastrointestinal diseases and infections were the leading cause of readmission in CC and DC patient groups. CONCLUSION: Inpatient mortality has decreased for CC and DC patients. Readmission has declined for CC patients and remained stable for DC patients. However, the economic burden of cirrhosis is rising.

Efficacy of Combining Aggressive Hydration With Rectal Indomethacin in Preventing Post-ERCP Pancreatitis: A Systematic Review and Network Meta-Analysis.

Postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common complication of endoscopic retrograde cholangiopancreatography pancreatitis (ERCP). No randomized controlled trial (RCT) has compared the efficacy of the American Society of Gastrointestinal Endoscopy and European Society of Gastrointestinal Endoscopy recommended interventions for PEP prevention. We assessed the effectiveness of these interventions using network meta-analysis. PubMed, EMBASE, and Cochrane databases were searched to identify RCTs investigating guideline-recommended interventions and their combinations [rectal nonsteroidal anti-inflammatory drugs (NSAIDs): indomethacin or diclofenac, pancreatic stent (PS), aggressive hydration (AH), sublingual nitrate) for PEP prevention. We performed direct and Bayesian network meta-analysis, and the surface under the cumulative ranking curve to rank interventions. Subgroup network meta-analysis for high-risk populations was also performed. We identified a total of 38 RCTs with 10 different interventions. Each intervention was protective against PEP on direct and network meta-analysis compared with controls. Except AH+diclofenac and NSAIDs+ sublingual nitrate, AH+indomethacin was associated with a significant reduction in risk of PEP compared with PS [odds ratio (OR), 0.09; credible interval (CrI), 0.003-0.71], indomethcin+PS (OR, 0.09; CrI, 0.003-0.85), diclofenac (OR, 0.09; CrI, 0.003-0.65), AH (OR, 0.09; CrI, 0.003-0.65), sublingual nitrate (OR, 0.07; CrI, 0.002-0.63), and indomethacin (OR, 0.06; CrI, 0.002-0.43). AH with either rectal NSAIDs or sublingual nitrate had similar efficacy. AH+indomethacin was the best intervention for preventing PEP with 95.3% probability of being ranked first. For high-risk patients, although the efficacy of PS and indomethacin were comparable, PS had an 80.8% probability of being ranked first. AH+indomethacin seems the best intervention for preventing PEP. For high-risk patients, PS seems the most effective strategy. The potential of combination of interventions need to be explored further.

Major gastrointestinal bleeding risk with direct oral anticoagulants: Does type and dose matter? - A systematic review and network meta-analysis.

The relative risk of major gastrointestinal bleeding (GIB) among different direct oral anticoagulants (DOACs) is debatable. Randomized controlled trials (RCTs) comparing DOACs with each other are lacking. We performed network meta-analysis to assess whether the risk of major GIB differs based on type and dose of DOAC. Literature search of PubMed, EMBASE and Cochrane databases from inception to August 2019, limited to English publications, was conducted to identify RCTs comparing DOACs with warfarin or enoxaparin for any indication. Primary outcome of interest was major GIB risk. We used frequentist network meta-analysis through the random-effects model to compare DOACs with each other and DOACs by dose to isolate the impact on major GIB. Twenty-eight RCTs, including 139 587 patients receiving six anticoagulants, were selected. The risk of major GIB for DOACs was equal to warfarin. Comparison of DOACs with each other did not show risk differences. After accounting for dose, rivaroxaban 20 mg, dabigatran 300 mg and edoxaban 60 mg daily had 47, 40 and 22% higher rates of major GIB versus warfarin, respectively. Apixaban 5 mg twice daily had lower major GIB compared to dabigatran 300 mg (OR, 0.63; 95% CI, 0.44-0.88) and rivaroxaban 20 mg (OR, 0.60; 95% CI, 0.43-0.83) daily. Heterogeneity was low, and the model was consistent without publication bias (Egger's test: P = 0.079). All RCTs were high-quality with low risk of bias. DOACs at standard dose, except apixaban, had a higher risk of major GIB compared to warfarin. Apixaban had a lower rate of major GIB compared to dabigatran and rivaroxaban.

Utility of ultrasound elastography in postoperative follow-up of children with unilateral ureteropelvic junction obstruction.

INTRODUCTION: We aimed to determine whether shear wave velocity (SWV) on ultrasound elastography is useful in follow-up of children with ureteropelvic junction obstruction (UPJO) following pyeloplasty. METHODS: Consecutive children with unilateral UPJO who were co-operative for elastography (n = 31) were included. SWV of normal kidney was used as control, and it was compared with that of the affected kidney (UPJO) in the same patient. They were followed up with elastography at 3 months and elastography + renogram at 6 months postoperatively. In patients with a static renogram at 6 months, the study was repeated at 1 year. Patient outcomes were classified as improved at 6 months, static at 6 months, and worsened at 1 year based on ultrasound and renogram findings. The SWV was compared between the different outcomes. RESULTS: Thirty-one children with a median age of 8.5 years were studied (m:f = 29:2; L:R = 22:9). The mean SWV was significantly higher (3.21 m/s) in UPJO kidney compared to the SWV (2.72 m/s) found in normal kidney (P = 0.011). The mean SWV was significantly less at 3 months (2.73 m/s) and 6 months (2.57 m/s) postoperative follow-up (P = 0.018 and P= 0.001). Among the patients who improved, the mean SWV was 2.65 m/s. This SWV was significantly raised (3.57 m/s) in patients whose condition remained static (P = 0.006) and even higher (4.36 m/s) in those who worsened (P = 0.001). CONCLUSIONS: SWV was significantly higher in UPJO compared to normal kidneys in children. It is useful in assessing postoperative resolution, and a rising velocity can be useful as an early marker of recurrence in UPJO.

Colonoscopy videos on YouTube: Are they a good source of patient education?

Background and study aims Colonoscopy is an effective tool to prevent colorectal cancer. Social media has emerged as a source of medical information for patients.YouTube (a video sharing website) is the most popular video informative source. Therefore, we aimed to assess the educational quality of colonoscopy videos available on YouTube. Methods We performed a YouTube search using the keyword "colonoscopy" yielded 429 videos, of which 255 met the inclusion criteria. Colonoscopy Data Quality Score (C-DQS) was created to rate the quality of the videos (-10 to +40 points) based on a colonoscopy education video available on the Ameican Society of Gastrointestinal Endoscopy (ASGE) website. Each video was scored by six blinded reviewers independently using C-DQS. The Global Quality Score (GQS) was used for score validation. The intraclass correlation coefficient (ICC) was used to assess the similarity of the scores among reviewers. Results Professional societies had the highest number of videos (44.3 %). Videos from professional societies (6.94) and media (6.87) had significantly higher mean C-DQS compared to those from alternative medicine providers (1.19), companies (1.16), and patients (2.60) ( P  < 0.05). Mean C-DQS score of videos from healthcare providers (4.40) was not statistically different than other sources. There was a high degree of agreement among reviewers for the videos from all sources (ICC = 0.934; P  < 0.001). Discussion YouTube videos are a poor source of information on colonoscopy. Professional societies and media are better sources of quality information for patient education on colonoscopy. The medical community may need to engage actively in enriching the quality of educational material available on YouTube.

Inpatient Mortality Benefit with Transjugular Intrahepatic Portosystemic Shunt for Hospitalized Hepatorenal Syndrome Patients.

BACKGROUND: It has been reported that transjugular intrahepatic portosystemic shunting (TIPS) might be utilized as a salvage option for hepatorenal syndrome (HRS), while randomized controlled trials are pending and real-world contemporary data on inpatient mortality is lacking. METHODS: We conducted an observational retrospective cohort study from the National Inpatient Sample from 2005 to 2014. We included all adult patients admitted with HRS and cirrhosis, using ICD 9-CM codes. We excluded cases with variceal bleeding, Budd-Chiari, end-stage renal disease, liver transplant and transfers to acute-care facilities. TIPS' association with inpatient mortality was assessed using multivariable mixed-effects logistic regression, as well as exact-matching, thus mitigating for TIPS selection bias. The exact-matched analysis was repeated among TIPS-only versus dialysis-only patients. RESULTS: A total of 79,354 patients were included. Nine hundred eighteen (1.2%) underwent TIPS. Between TIPS and non-TIPS groups, mean age (58 years) and gender (65% males) were similar. Overall mortality was 18% in TIPS and 48% in dialysis-only cases (n = 10,379; 13.1%). Ninety six (10.5%) TIPS patients underwent dialysis. In-hospital mortality in TIPS patients was twice less likely than in non-TIPS patients (adjusted odds ratio [aOR] = 0.43, 95% CI 0.30-0.62; p < 0.001), with similar results in matched analysis [exact-matched (em) OR = 0.39, 95% CI 0.17-0.89; p < 0.024; groups = 96; unweighted n = 463]. Head-to-head comparison showed that TIPS-only patients were 3.3 times less likely to succumb inpatient versus dialysis-only patients (contrast aOR = 0.31, 95% CI 0.20-0.46; p < 0.001), with similar findings post-matching (emOR = 0.22, 95% CI 0.15-0.33; p < 0.001; groups = 54, unweighted n = 1457). CONCLUSIONS: Contemporary, real-world data reveal that TIPS on its own, and when compared to dialysis, is associated with decreased inpatient mortality when utilized in non-bleeders-HRS patients. Further randomized studies are needed to establish the long-term benefit of TIPS in these patients.

Mesenteric Panniculitis: An Unusual Presentation of Abdominal Pain.

Sclerosing mesenteritis is a rare autoimmune disease that eventually evolves into fibrotic changes that usually affect the adipose tissue around the mesenteric vessels. It can present through a myriad of gastroenterological as well as constitutional symptoms, including but not limited to abdominal pain, diarrhea, fever, nausea, or vomiting. Although the exact etiology of the disease is yet to be determined, there are several predisposing factors, the most common of which is a previous history of abdominal trauma and/or surgery. Several case series have reported the association of sclerosing mesenteritis with prior abdominal surgery ranging from as low as 24% to as high as 53%.

Peri-Procedural Aggressive Hydration for Post Endoscopic Retrograde Cholangiopancreatography (ERCP) Pancreatitis Prophylaxsis: Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Periprocedural intravenous hydration is suggested to decrease the risk of post-ERCP pancreatitis (PEP). However, quality of evidence supporting this suggestion remains poor. Here we hypothesized that aggressive hydration(AH) could be an effective preventive measure. METHODS: Pubmed, EMBASE, CINAHL, Google Scholar, Clinical Trials. gov, Clinical Key, International Standard Randomized Trial Number registry as well as secondary sources were searched through January 2019 to identify randomized controlled studies comparing AH to standard hydration (SH) for prevention of PEP. Pooled odds ratio (OR) and 95% confidence intervals (CIs) were calculated using the random-effects model. RevMan 5.3 was used for analysis. RESULTS: A total of 9 RCTs, with 2094 patients, were included in the meta-analysis. AH reduced incidence of PEP by 56% compared to SH (OR = 0.44, CI:0.28-0.69; p = 0.0004). The incidence of post-ERCP hyperamylasemia also decreased with AH compared to SH (OR = 0.51; p = 0.001). Length of stay decreased by 1 day with AH (Mean Difference (MD): -0.89 d; p = 0.00002). There was no significant difference in adverse events related to fluid overload between two groups (OR:1.29; p = 0.81) and post-ERCP abdominal pain (OR:0.35; p = 0.17). Numbers of patient to be treated with AH to prevent one episode of PEP was 17. Final results of the meta-analysis were not affected by alternative effect measures or statistical models of heterogeneity. CONCLUSION: Aggressive hydration is associated with a significantly lower incidence of PEP and it appears to be an effective and safe strategy for the prevention of Post ERCP pancreatitis.

Trends in Hospitalization, Acute Kidney Injury, and Mortality in Patients With Spontaneous Bacterial Peritonitis.

GOALS: The purpose of our study was to evaluate trends of hospitalization, acute kidney injury (AKI) and mortality in cirrhotic patients with spontaneous bacterial peritonitis (SBP). BACKGROUND: SBP is a frequent bacterial infection in cirrhotic patients leading to increased morbidity and mortality. MATERIALS AND METHODS: A total of 4,840,643 patients hospitalized with cirrhosis from 2005 to 2014 were identified using the Nationwide Inpatient Sample database, of which 115,359 (2.4%) had SBP. We examined annual trends and used multivariable mixed-effects logistic regression analyses to obtain adjusted odds ratios by accounting for hospital level and patient level variables. RESULTS: We identified a striking increase in hospitalizations for SBP in cirrhotic patients (0.45% to 3.12%) and AKI in SBP patients (25.6% to 46.7%) from 2005 to 2014. Inpatient mortality decreased over the study period in patients with SBP (19.1% to 16.1%) and in patients with SBP plus AKI (40.9% to 27.6%). Patients with SBP had a higher inpatient mortality rate than those without SBP [15.5% vs. 6%, adjusted odd ratio (aOR): 2.02, P<0.001]. AKI was 2-fold more prevalent in cirrhotics with SBP than those without SBP (42.8% vs. 17.2%, aOR: 1.91, P<0.001) and concomitant AKI was associated with a 6-fold mortality increase (aOR: 5.84, P<0.001). Cirrhotic patients with SBP had higher hospitalization costs and longer length of stays than patients without SBP. CONCLUSIONS: Despite a higher hospitalization rate and prevalence of concomitant AKI, mortality in patients with SBP decreased during the study period. SBP is associated with high likelihood of development of AKI, which in turn, increases mortality.

Acute pancreatitis: Trends in outcomes and the role of acute kidney injury in mortality- A propensity-matched analysis.

OBJECTIVES: To assess national trends of AP (acute pancreatitis) admissions, outcomes, prevalence of AKI (acute kidney injury) in AP, and impact of AKI on inpatient mortality. METHODS: We queried the Nationwide Inpatient Sample database from 2003 to 2012 to identify AP admissions using ICD-9-CM codes. After excluding patients with missing information on age, gender, and inpatient mortality, we used ICD-9-CM codes to identify complications of AP, specifically AKI. We examined trends with survey-weighted multivariable regressions and analyzed predictors of AKI and inpatient mortality by multivariate logistic regression. Additionally, both AKI and non-AKI groups were propensity-matched and regressed against mortality. RESULTS: A total of 3,466,493 patients (1.13% of all discharges) were hospitalized with AP, of which 7.9% had AKI. AP admissions increased (1.02%→1.26%) with rise in concomitant AKI cases (4.1%→11.7%) from year 2003-2012. Mortality rate decreased (1.8%→1.1%) in the AP patients with a substantial decline noted in AKI subgroup (17.4%→6.4%) during study period. Length of stay (LOS) and cost of hospitalization decreased (6.1→5.2 days and $13,654 to $10,895, respectively) in AKI subgroup. Complications such as AKI (OR: 6.08, p < 0.001), septic shock (OR: 46.52, p < 0.001), and acute respiratory failure (OR: 22.72, p < 0.001) were associated with higher mortality. AKI, after propensity matching, was linked to 3-fold increased mortality (propensity-matched OR: 3.20, P < 0.001). CONCLUSION: Mortality, LOS, and cost of hospitalization in AP has decreased during the study period, although hospitalization and AKI prevalence has increased. AKI is independently associated with higher mortality.

Acute kidney injury impact on inpatient mortality in Clostridium difficile infection: A national propensity-matched study.

BACKGROUND AND AIM: Acute kidney injury (AKI) is used as a marker of severity in Clostridium difficile infection (CDI) patients. We estimated the true effect of AKI in inpatient mortality of CDI patients, as there are no large-scale, population-based, propensity-matched studies evaluating AKI's effect in this patient cohort. METHODS: A retrospective observational study utilizing the National Inpatient Sample from years 2003 to 2012, including all adults with CDI, excluding cases missing data on age, inpatient mortality or gender. Trends and CDI-related complications as mortality predictors were assessed using survey-weighted multivariable regression. We estimated AKI's independent effect by propensity-matching, post-stratifying by chronic kidney disease status, allowing for multiple comorbidity adjustment. RESULTS: A total of 2 859 599 patients with CDI were included, of which 896 122 (31.3%) had principal diagnosis of CDI. AKI prevalence was 22%. Mortality rate was 8.4%, while among AKI patients was higher (18.2%). In multivariable regression, AKI was associated with higher mortality (odds ratio [OR] = 3.16, 95% confidence interval [CI]: 3.02-3.30; P < 0.001), while after propensity matching, AKI increased mortality by 86% (OR = 1.86, 95% CI: 1.79-1.94; P < 0.001). CDI incidence increased by 1.8, together with the rate of AKI (12.6% in 2003 to 28.8% in 2012, P-trend < 0.001). Despite increasing hospitalizations, mortality over the study period decreased to 7.2% (2012) from 9.0% (2003); P-trend < 0.001. CONCLUSION: Hospital admissions of patients with CDI and concomitant AKI are increasing, but their inpatient mortality has improved over the study period. AKI is a significant contributor to mortality, independently of other comorbidities, complications, and hospital characteristics, emphasizing the need for early diagnosis and aggressive management in such patients.

Trends in Hospitalization and Mortality of Venous Thromboembolism in Hospitalized Patients With Colon Cancer and Their Outcomes: US Perspective.

INTRODUCTION: Venous thromboembolism (VTE) is a major cause of morbidity and mortality in hospitalized patients with colon cancer. We assessed nationwide population-based trends in rates of hospitalization and mortality from VTE among patients with colon cancer to determine its impact. METHODS: We queried the Nationwide Inpatient Sample (NIS) database entries from 2003 to 2011 to identify patients with colon cancer. Bivariate group comparisons between hospitalized patients with colon cancer with VTE to those without VTE were made. Multivariate logistic regression analysis was used to obtain adjusted odds ratios. The Cochrane-Armitage test for linear trend was used to assess occurrences of VTE and mortality rates among patients with colon cancer. RESULTS: The total number patients with colon cancer was 1,502,743, of which 41,394 (2.75%) had VTE. The median age of the study population was 69 years; 51.5% were women. After adjusting for potential confounders, compared with those without VTE, patients with colon cancer with VTE had significantly higher inpatient mortality (6.26% vs. 5.52%, OR 1.15, P < .001) and greater disability at discharge (OR 1.38, P < .001), but were not associated with longer length of stay (LOS) or cost of hospitalization. From 2003 to 2011, despite an increase in hospitalization rate with VTE in patients with colon cancer, their mortality steadily declined. CONCLUSION: VTE in hospitalized patients with colon cancer is associated with a significantly higher inpatient mortality and greater disability, but not with longer LOS or cost of hospitalization. Furthermore, even though there has been a trend toward more frequent hospitalizations in this patient population, their mortality continues to decline.

Risk and Severity of Hospital-Acquired Clostridium difficile Infection in Patients Taking Proton Pump Inhibitors.

STUDY OBJECTIVE: To compare the rates and severity of hospital-acquired Clostridium difficile infection (CDI) among patients taking proton pump inhibitors (PPIs) versus those not taking PPIs. DESIGN: Retrospective, single-center, cohort study. SETTING: Tertiary community hospital with a teaching service. PATIENTS: A total of 41,663 patients with CDI who were hospitalized between January 2013 and May 2014; of those, 17,471 patients (41.9%) had received at least one dose of a PPI (PPI group), and 24,192 patients (58.1%) had no PPI exposure (control group). MEASUREMENTS AND MAIN RESULTS: A total of 348 patients had CDI during the study period, with 269 cases present on admission. Hospital-acquired CDI was defined as CDI diagnosis occurring on or after the third calendar day of admission. After excluding those patients with CDI on admission, 65 (0.38%) of 17,302 patients later developed CDI in the hospital in the PPI group compared with only 14 (0.058%) of 24,092 patients in the control group. Of these patients, 36 patients (0.21%) in the PPI group met the definition of severe CDI compared with 8 (0.03%) in the control group. This demonstrated an unadjusted relative risk (RR) of 6.46 (95% confidence interval [CI] 3.63-11.51, p<0.0001) of developing hospital-acquired CDI and an unadjusted RR of 6.27 (95% CI 2.91-13.48, p<0.0001) of developing severe CDI while taking a PPI. When evaluating only patients who developed severe-complicated CDI, there were 22 cases in the PPI group and 2 cases in the control group, demonstrating an unadjusted RR of 15.3 (95% CI 3.6-65.13, p=0.0002) of developing severe-complicated CDI. Confounding variables were similar between groups. CONCLUSION: PPI use was associated with an increase in both the rate and severity of hospital-acquired CDI.

Idelalisib: a rare cause of enterocolitis.

Idelalisib is an oral, phosphatidylinositol 3-kinase delta (PI3Kδ) inhibitor, approved by FDA since July 2014 for the treatment of relapsed follicular B-cell non-Hodgkin lymphoma. Data from three phases of the study involving idelalisib demonstrate diarrhea (47%) to be the common adverse effect. The other side effects are pyrexia (28%), fatigue (30%), nausea (29%), cough (29%), pneumonia (25%), abdominal pain (26%) and rash (21%). The characteristic histological findings of idelalisib colitis include intraepithelial lymphocytosis, neutrophilic cryptitis and epithelial cell apoptosis within the crypts. Histological findings help differentiate among other causes of diarrhea and entero-colitis. We present a female patient with recurrent follicular lymphoma treated with idelalisib and presented with diarrhea. She was found to have entero-colitis and was treated successfully with drug discontinuation and prednisone.

An idiosyncratic reaction to clopidogrel.

Clopidogrel is an irreversible antiplatelet agent belonging to the thienopyridine group that acts to antagonize the adenosine diphosphate P2Y12 receptor on platelets. It thus inhibits the activation of platelet glycoprotein GPIIb/IIIa complex, which is essential for fibrinogen­platelet complex formation. Clopidogrel has widely replaced ticlopidine because of a much better clinical safety profile. Clopidogrel is a prodrug that requires hepatic activation to exert its antiplatelet effect. Hepatotoxicity with use of clopidogrel is a rare but clinically significant phenomenon. We report a case of clopidogrel-induced hepatotoxicity in an elderly white woman.

Obstructive jaundice as an initial manifestation of non-hodgkin lymphoma: treatment dilemma and high mortality.

Introduction. Non Hodgkin lymphoma (NHL) presenting with obstructive jaundice is a rare occurrence. Because of rarity of combination, it is seldom considered in differential diagnosis of patients presenting with obstructive jaundice. It is considered treatable due to the chemosensitive nature of the disease and the recent advances in chemotherapy. Case Series. We present a case series of 2 patients with NHL presenting with obstructive jaundice as an initial manifestation. Both patients presented with obstructive jaundice and were diagnosed by CT guided liver biopsy. One patient died of sepsis and multiorgan failure before initiating chemotherapy and the second patient did not choose to undergo chemotherapy. Conclusion. Biliary obstruction is a sign of poor prognosis. The diagnosis of NHL needs to be considered in patients presenting with biliary obstruction. It can be associated with high mortality and poses treatment dilemma.