A Hidden Cause of Hypertransaminasemia: Liver Toxicity Caused by Chelidonium Majus L.: Report of Two Cases of Herb-Induced Liver Injury and Literature Review.

BACKGROUND: In instances where individuals manifest elevated transaminase levels without a clearly discernible cause, a comprehensive patient history proves invaluable in unveiling latent triggers. In this report, we present 2 cases of herb-induced liver injury (HILI) characterized by severe hypertransaminasemia attributed to the consumption of Chelidonium majus L. (also known as greater celandine [GC]), an agent considered an alternative therapeutic remedy. AREAS OF UNCERTAINTY: Exploring the occurrence and range of clinical manifestations in HILI linked to Chelidonium majus L., while also investigating the potential triggers and predisposing factors for hepatotoxic reactions post Chelidonium majus L. usage, remains challenging due to the absence of definitive laboratory tests to identify the causative agent. DATA SOURCES: Two case reports were detailed, and a systematic literature review using PubMed was conducted including published literature till March 2023. Moreover, a manual search of reference lists of pertinent articles was performed to identify any additional relevant missed publications. RESULTS: In the first case, a 64-year-old woman presented with jaundice, revealing a 1-month history of using GC capsules to manage gallstones. Diagnostic assessment identified HILI, gallstones, and choledocolithiasis, with transaminase levels exceeding 1000 IU/L. After discontinuing GC and receiving intravenous therapy with amino acids and phospholipids, the patient's condition significantly improved. Subsequently, she underwent endoscopic common bile duct stone removal and cholecystectomy. In the second case, a 66-year-old woman presented with elevated liver function test results discovered incidentally during musculoskeletal pain evaluation. Upon further questioning, the patient disclosed regular consumption of GC tea for "health promotion." Following intravenous therapy using amino acids and phospholipids, her transaminase levels returned to normal. The literature review identified 38 cases of HILI associated with GC preparations, primarily in adult women aged 27-77 years, with a predominant reporting location in Germany. Various forms of GC were used, with treatment durations ranging from 1 week to a year. Discontinuation of GC generally led to recovery in these cases. CONCLUSION: Chelidonium majus L., a potent herb often used in alternative medicine, has significant hepatotoxic potential, requiring physicians to be vigilant in cases of unexplained liver injury.

Hemogram-Derived Ratios in the Prognosis of Acute Diverticulitis.

Background and Objectives: It is crucial to quickly identify those patients who need immediate treatment in order to avoid the various complications related to acute diverticulitis (AD). Although several studies evaluated the neutrophil-to-lymphocyte ratio (NLR) suggesting its predictive value in assessing the severity of AD, results have been inconclusive. Therefore, we aimed to assess the relationship between the neutrophil-to-lymphocyte ratio (NLR), the platelet-to-lymphocyte ratio (PLR), the monocyte-to-lymphocyte ratio (MLR), and systemic immune inflammation (SII) with the severity of AD, the ability to predict the presence or absence of complications, and the recurrence rate, based on the values of inflammatory markers. Materials and Methods: We retrospectively reviewed 147 patients diagnosed with AD between January 2012 to February 2023. Patients were divided into 2 groups, uncomplicated and complicated AD. The characteristics and full blood count between both groups were compared. Results: A total of 65 (44.22%) patients were classified as having complicated AD. The area under the ROC curve (AUROC) defining a Hinchey score ≥ 1b was as follows: SII, 0.812 (95% confidence interval (CI), 0.73 -0.888); NLR, 0.773 (95% CI, 0.676-0.857); PLR, 0.725 (95% CI, 0.63-0.813); MLR: 0.665 (95% CI, 0.542 -0.777). An SII cutoff value of > 1200 marked the highest yield for diagnosing complicated AD, with a sensitivity of 82% and a specificity of 76%. The cumulative recurrence rate was not significantly different in the groups of SII ≥ median vs. SII < median (p = 0.35), NLR ≥ median vs. NLR < median (p = 0.347), PLR ≥ median vs. PLR < median (p = 0.597), and MLR ≥ median vs. MLR < median (p = 0.651). Conclusions: Our study indicates that SII, NLR, and PLR are statistically significant and clinically useful classifying ratios to predict higher Hinchey scores. However, they cannot predict recurrences.

Diet and Gut Inflammation: The Effect of Diet on Inflammatory Markers in Inflammatory Bowel Disease - A Scoping Review.

BACKGROUND AND AIMS: Inflammatory bowel disease (IBD) is a chronic inflammatory disorder of the gastrointestinal tract. Studies evaluated the effect of several diets on inflammatory markers in IBD patients. Nevertheless, the results have been inconsistent. Therefore, we conducted this review to evaluate the effectiveness of dietary interventions on inflammatory markers in IBD. METHODS: A comprehensive electronic literature search strategy using the PubMed, Embase, and Scopus was conducted in March 2023 and evaluated inflammatory markers included C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and fecal calprotectin (FC), as well as disease severity scores. We included full-text articles that met our inclusion and exclusion criteria. To evaluate the included studies, we used the NHLBI quality evaluation tools. RESULTS: A total of 16 studies were included in our qualitative synthesis. Elemental and polymeric diets showed similar efficacy in reducing Crohn's disease activity index (CDAI) and CRP levels. On the other hand, most studies evaluating the effects of omega 3 fatty acids reported no significant improvement. Moreover, protein supplementation was not seen to improve ESR or CRP levels. Except for improvements in FC levels with IgG4-guided exclusion diet in CD patients with elevated CDAI levels, restrictive diets were successful in controlling functional abdominal symptoms but did not appear to have an impact on inflammation in most studies. Furthermore, disease severity scores, CRP, ESR, and FC levels did not significantly change when eating a high-fiber, low-refined-carb, low-fat diet. CONCLUSIONS: Diet plays a vital role in managing IBD by impacting the inflammatory response. Among the interventions studied, enteral nutrition showed the most promising results, improving patients' inflammatory status. Restrictive diets effectively managed symptoms and clinical remission but had limited impact on inflammatory markers. Supplementing the diet with fatty acids, omega 3, or proteins did not definitively improve patients' condition or inflammation.

Do Colonic Mucosal Tumor Necrosis Factor Alpha Levels Play a Role in Diverticular Disease? A Systematic Review and Meta-Analysis.

Diverticular disease (DD) is the most frequent condition in the Western world that affects the colon. Although chronic mild inflammatory processes have recently been proposed as a central factor in DD, limited information is currently available regarding the role of inflammatory cytokines, such as tumor necrosis factor-alpha (TNF-α). Therefore, we conducted a systematic review and meta-analysis aiming to assess the mucosal TNF-α levels in DD. We conducted a systematic literature search using PubMed, Embase, and Scopus to identify observational studies assessing the TNF-α levels in DD. Full-text articles that satisfied our inclusion and exclusion criteria were included, and a quality assessment was performed using the Newcastle-Ottawa Scale (NOS). The principal summary outcome was the mean difference (MD). The results were reported as MD (95% confidence interval (CI)). A total of 12 articles involving 883 subjects were included in the qualitative synthesis, out of which 6 studies were included in our quantitative synthesis. We did not observe statistical significance related to the mucosal TNF-α levels in symptomatic uncomplicated diverticular disease (SUDD) vs. the controls (0.517 (95% CI -1.148-2.182)), and symptomatic vs. asymptomatic DD patients (0.657 (95% CI -0.883-2.196)). However, the TNF-α levels were found to be significantly increased in DD compared to irritable bowel disease (IBS) patients (27.368 (95% CI 23.744-30.992)), and segmental colitis associated with diverticulosis (SCAD) vs. IBS patients (25.303 (95% CI 19.823-30.784)). Between SUDD and the controls, as well as symptomatic and asymptomatic DD, there were no significant differences in the mucosal TNF-α levels. However, the TNF-α levels were considerably higher in DD and SCAD patients than IBS patients. Our findings suggest that TNF-α may play a key role in the pathogenesis of DD in specific subgroups and could potentially be a target for future therapies.

Chronic Abdominal Pain in General Practice.

Background and Summary: Chronic abdominal pain is a challenging complaint for both primary care providers and gastroenterologists alike, due to a broad differential diagnosis and sometimes extensive and negative workup. In the absence of red flag features that herald more acute conditions, the majority of patients with chronic abdominal pain have a benign cause or a functional disorder (e.g., irritable bowel syndrome). The costs associated with a diagnostic workup are an expensive burden to health care. A systematic approach for evaluating patients and initiating a management plan are recommended in the primary care setting. Undiagnosed abdominal pain should be investigated starting with a detailed history and physical examination. Diagnostic investigations should be limited and adapted according to the clinical features, the alarm symptoms, and the symptom severity. This review will focus on the diagnostic tools which general practitioners utilize in the evaluation of chronic abdominal pain. Key Messages: The primary role of the general practitioner is to differentiate an organic disease from a functional one, to refer to a specialist, or to provide treatment for the underlying cause of pain. The functional disorders should be considered after the organic pathology has been confidently excluded. Once a diagnosis of functional pain is established, repetitive testing is not recommended and the patient should be referred to receive psychological support (e.g., cognitive therapy) associated with available pharmacological therapeutic options.