A case report of nifedipine-induced hepatitis with jaundice.

BACKGROUND: Nifedipine is a generic, well-known and commonly-prescribed dihydropyridine calcium channel blocker used in the treatment of hypertension and Prinzmetal's angina. A known but very rare and serious adverse effect of nifedipine is clinically-apparent hepatitis which can take months to resolve. CASE PRESENTATION: Here we present a case of nifedipine-induced hepatitis in a 78-year-old Caucasian female with no prior history of liver or autoimmune disease. We discuss our investigative and management approach, and present a review of prior cases. We offer an approach for patients who present with signs of acute liver injury with jaundice and high elevations in serum transaminases. CONCLUSION: Not much is known about nifedipine-induced hepatitis due to its rare occurrence. Its prevalence is unknown. The disease appears to afflict older men and women. It can present acutely (within days) or subacutely (within 4-8 weeks after medication start) and in an idiosyncratic manner. Chronic or latent cases have also been described, some diagnosed as late as 3 years after medication start. Common symptoms include jaundice, nausea, chills, rigors, diaphoresis, fatigue, and abdominal pain. Laboratory investigations often reveal profound elevations in AST, ALT, GGT, and conjugated bilirubin. Peripheral blood smear may demonstrate eosinophilia. Histology from liver biopsy typically demonstrates infiltration of immune cells, cholestasis, and a picture of steatohepatitis. Treatment involves immediate discontinuation of the drug with supportive care. Thus far, all published instances of nifedipine-induced hepatitis were self-limiting without mortality due to fulminant liver failure. However, this disease can take months to resolve. There is no randomized evidence for other treatments such as corticosteroids.

Orbital fibrosis and intraocular recurrence of retinoblastoma following periocular carboplatin.

A 5-month-old infant with bilateral advanced retinoblastoma underwent six cycles of systemic chemotherapy. In an attempt to salvage the second eye, three serial injections of periocular carboplatin were given for persistent vitreous seeding. Following the third injection, the patient developed periocular ecchymosis and magnetic resonance imaging demonstrated abnormal signal characteristics at the site of injection. An orbital biopsy did not demonstrate extraocular tumor extension, but histopathologic examination revealed severe orbital fibrosis and fat necrosis. Following the biopsy, the patient developed an intraocular tumor recurrence at the same location where the carboplatin injections had been given and enucleation was performed to prevent tumor spread. In this case, a child developed orbital scarring and intraocular tumor recurrence at the site of injection following treatment with periocular carboplatin.

A multicentre, observational study of sodium picosulfate and magnesium citrate as a precolonoscopy bowel preparation.

BACKGROUND: Sodium picosulfate with magnesium citrate (PSMC) has been available as a precolonoscopy bowel preparation in Canada since 2005. A high patient acceptability and preference appears to have contributed to its wide adoption across the country. Despite its frequent use, there are relatively few published studies of this product, especially reports regarding its use in routine clinical practice. Moreover, to date, there have been no Canadian studies of any kind. OBJECTIVE: To conduct a preliminary evaluation of PSMC by prospectively collecting data describing its effectiveness. METHODS: In the present multicentre, observational study, sequential patients used PSMC according to each institution's standard colonoscopy protocol. Differences in bowel cleansing protocols included dose timing, fluid intake, dietary restrictions and administration of bisacodyl. During colonoscopy, preparation quality was rated separately for the right and left sides of the colon. RESULTS: Of the 613 patients entered, 606 were evaluable for efficacy. For the right and left colon, respectively, 93.0% and 96.2% of preparations were rated either 'excellent' or 'adequate'. In the 334 patients who received adjunctive bisacodyl and the 272 patients who did not, the results were similar: for the right and left colon, 92.3% and 97.1% of those who did not, and 93.4% and 95.7% of those who did receive bisacodyl, respectively, were rated either 'excellent' or 'adequate'. CONCLUSIONS: Despite the differences in bowel cleansing protocols used at each hospital (including an additional laxative), PSMC consistently yielded a high percentage of positive ratings for efficacy.

Intravenous proton pump inhibitors before endoscopy in bleeding peptic ulcer with high-risk stigmata: a multicentre comparative study.

BACKGROUND: It is not clear if starting intravenous proton pump inhibitors (IV PPI) before endoscopic therapy provides additional benefit over starting it afterward in patients with high-risk ulcer stigmata of peptic ulcer disease. METHODS: All patients who received IV pantoprazole bolus and infusion and underwent endoscopy in six Canadian hospitals over 20 months were reviewed. Only patients with high-risk ulcer stigmata (arterial bleeding, oozing, nonbleeding visible vessel or adherent clot) were included. Patients receiving IV PPI before endoscopy (before group) were compared with those who received it after endoscopy (after group) with respect to endoscopic findings and, secondarily, to patient demographics and clinical outcomes. RESULTS: The demographics and baseline characteristics of the before group (n=57) and the after group (n=109) were similar. The before group was more likely to have had IV PPI started outside of daytime hours, and median time to endoscopy in patients admitted with upper gastrointestinal bleeding was 24 h (interquartile range 9.5 to 35) in the before group and 11.3 h (interquartile range 3.7 to 17.2) in the after group (P<0.0001). At the time of endoscopy, 33% of patients in the before group had actively bleeding lesions (Forrest 1a or 1b) compared with 54% in the after group (P=0.01), but there were no significant differences in rebleeding, surgical rates, intensive care unit admission or death between the groups. CONCLUSION: IV PPI infusions before endoscopy may lower the proportion of actively bleeding peptic ulcer lesions at endoscopy, but this finding does not appear to affect rates of rebleeding, surgery or death.

Description of prescribing practices in patients with upper gastrointestinal bleeding receiving intravenous proton pump inhibitors: a multicentre evaluation.

BACKGROUND: Intravenous forms of proton pump inhibitors (IV PPI) are routinely used for patients with acute upper gastrointestinal bleeding, but a significant concern for their inappropriate use has been suggested. patients and METHODS: All consecutive patients who received IV PPI (pantoprazole) over 20 months in six Canadian hospitals were reviewed. Prescribing practices, endoscopic findings and outcomes were recorded. RESULTS: A total of 854 patients received IV PPI. Over 90% of patients were given IV PPI for treatment of known or suspected active upper gastrointestinal bleeding. Most patients (69%) underwent upper endoscopy, and 58% of these patients had peptic ulcer disease (PUD). The majority of patients who had endoscopy (57%) had IV PPI administered in advance of the procedure. Of the 334 patients who had IV PPI given in advance, 46 (13.8%) were found to have high risk bleeding PUD stigmata at endoscopy. The remaining 288 patients (86.2%) with advance IV PPI had low-risk PUD lesions or non-PUD lesions; IV PPI was continued after endoscopy in 164 (56.9%) of these patients. CONCLUSIONS: IV PPI is often used before endoscopy in suspected upper gastrointestinal bleed and maintained, regardless of endoscopic findings, after the endoscopy in many Canadian centres. Further study is required to support these clinical practices.