Extreme hyperbilirubinemia: An indicator of morbidity and mortality in sickle cell disease.

BACKGROUND: Sickle cell disease (SCD) is a disorder that results in increased hospitalizations and higher mortality. Advances in management have resulted in increases in life expectancy and led to increasing awareness of sickle cell hepatopathy (SCH). However, its impact in patients on the natural history and outcomes of SCD is not known. Our study aims to describe the prevalence of extreme hyperbilirubinemia (EH), one form of SCH, its effect on morbidity and mortality, and correlations between sickle cell genotype and SCH type. We hypothesize that EH is associated with higher morbidity and mortality. AIM: To investigate the effects of EH on morbidity and mortality among patients with SCD. METHODS: This retrospective cohort study was performed using a database of patients with SCD treated at Grady Memorial Hospital between May 2004 and January 2017. Patients with EH (defined as total bilirubin above 13.0 mg/dL) were identified. A control group was identified from the same database with patients with total serum bilirubin ≤ 5.0 mg/dL. Electronic medical records were used to extract demographic information, laboratory values, radiology results, current medications, need for transfusions and mortality data. Two samples T-test, chi-squared test and Fisher's exact test were then used to compare the parameters between the two groups. RESULTS: Out of the database, fifty-seven charts were found of patients with bilirubin > 13 mg/dL. Prevalence of severe SCH as defined by EH was 4.8% (57/1172). There were no demographic differences between patients with and without EH. Significant genotypic differences existed between the two groups, with hemoglobin SS SCD being much higher in the EH group (P < 0.001). Patients with severe EH had a significant elevations in alanine aminotransferase (157.0 ± 266.2 IU/L vs 19.8 ± 21.3 IU/L, P < 0.001), aspartate aminotransferase (256.5 ± 485.9 U/L vs 28.2 ± 14.7 U/L, P < 0.001) and alkaline phosphatase (218.0 ± 176.2 IU/L vs 85.9 ± 68.4 IU/L, P < 0.001). Patients with EH had significantly higher degree of end organ failure measured with quick Sequential Organ Failure Assessment scores (0.42 ± 0.68 vs 0.01 ± 0.12, P < 0.001), increased need for blood products (63% vs 5%, P < 0.001), and exchange transfusions (10.5% vs 1.3%, P = 0.022). CONCLUSION: Among patients with SCD, elevated levels of total bilirubin are rare, but indicative of elevated morbidity, mortality, and need for blood transfusions. Large differences in sickle cell genotype also exist, but the significance of this is unknown.

Management of ascites.

Ascites is the most common complication of cirrhosis, and it often leads to hospitalization. Quality of life and mortality are negatively impacted by ascites. This article highlights the management of this potentially deadly complication.

Endoscopic management of early gastric cancer.

PURPOSE OF REVIEW: Endoscopic mucosal resection for early gastric cancer is a widely accepted and practiced technique in countries such as Japan and China where the prevalence of gastric cancer is significantly higher than in the US. This review discusses standard endoscopic mucosal resection methods, as well as newly developed techniques. Data are reviewed in terms of complete resection rates and disease-free survival so as to allow endoscopists to determine which treatment options are best for their patients. RECENT FINDINGS: Within the past few years, new endoscopic mucosal resection and submucosal dissection techniques have been developed. These techniques may allow for the treatment of lesions that are not suitable for endoscopic treatment, especially in high-risk patients. SUMMARY: As gastroenterologists and surgeons in the West become more familiar and experienced with the techniques of endoscopic mucosal resection and submucosal dissection, patients will benefit from these minimally invasive therapeutic techniques. Although controlled studies are needed, in the future these methods may also be used to treat other early malignant conditions of the gastrointestinal tract.