Geriatric Hepatology: The Hepatic Diseases of the Elderly and Liver Transplant

Introduction: With the aging US population, chronic liver diseases are becoming more commonly diagnosed in the geriatric population. Advanced age leads to changes in liver blood flow, volume, morphology and normal physiology. This predisposes elderly patients to develop certain chronic liver diseases. Also, the clinical course and management differ in an older patient when compared to a younger patient. Some causes of chronic liver disease in the geriatric population include Hepatitis A, B, C, Non-Alcoholic Fatty liver disease, prolonged alcohol use and inflammation. Many chronic liver diseases are characterized by a slow, indolent course of progression with non-specific symptoms and thus may lead to diagnosis at a later age. The presence of an advanced liver disease, cirrhosis, and hepatocellular carcinoma are becoming more frequent in older patients and often the first clinical presentation. Aim: The aim of this study is to highlight hepatic diseases in the geriatric population to better understand the scope of the clinical management including liver transplantation. Method: PubMed, MEDLINE, EMBASE, and EMBASE classic were searched to research published articles, case reports, cross-sectional and case-control studies reporting regarding aging and the liver diseases. Result: Decreases in the functioning of the liver and other organs, as well as, alterations in immune functions should be taken into consideration in the management of the liver diseases. Aging has been shown to not only enhance vulnerability to acute liver injury but also increase the susceptibility of the fibrotic response. Aging has a significant impact on the risk and poor prognosis of various liver diseases including NAFLD, ALD, HCV, and liver transplantation. The diagnosis of advanced liver disease is important to make in the elderly population since many of the condition’s features are treatable and can lead to improved quality of life and, most importantly, decrease the likelihood of acute care hospitalization, which carries a high risk of nosocomial infections and therapeutic mishaps in the aged population. Conclusion: Geriatric patients show various changes in the liver, which play a role in the clinical characteristics of liver diseases in these patients. Geriatric patients with risk factors for hepatitis should be screened for liver disease, along with those that have a family history of liver diseases, or a history of long-term or heavy alcohol consumption. Age cannot be a single exclusion criterion from the liver transplantation, and an individualization strategy, which takes into consideration all risk factors of a recipient, needs to be considered. We suggest geriatric patients should be a candidate for liver transplant, and the healthcare team treating our elderly generation to collaborate for these patients for them to have a smoother transition both in pre-transplant phase and post-transplant phase

Proton Pump Inhibitors and Corticosteroids as Synergistic Risk Factors for Candida Esophagitis

Abstract: Introduction: Inhaled & systemic steroids are one of the well-documented risks factors for Candida esophagitis. However, the role of gastric acid suppression remains controversial. Methods: We conducted a retrospective case-control study of 420 patients consisting of 84 cases of Candida esophagitis and 336 matched controls. Our cohort was gathered from subjects evaluated from 2001 to 2012. The diagnosis of Candida esophagitis was based on endoscopic and/or histological criteria. Results: On univariate analysis, proton pump inhibitors were associated with higher risk (OR = 2.14; 95 % CI: 1.30 to 3.54); steroid use also increased the risk (OR = 3.55; 95% CI: 2.10 to 6.00). Furthermore, concurrent use of proton pump inhibitors & steroids substantially raised this risk (OR = 13.8; 95% CI 5.07 to 37.5), suggesting a synergistic effect. When adjusted for covariates (cancer, chemotherapy/radiation, antibiotic use, hypothyroidism, anemia, chronic liver disease & diabetes), anemia decreased the odds ratio for proton pump inhibitors to 1.67 (95% CI 1.02 to 2.75) and steroids to 1.69 (95% CI to 1.03 to 2.87). Hypothyroidism also substantially reduced the observed risk associated with steroid use. However, neither anemia nor hypothyroidism reduced the odds ratio for combined use of steroids and proton pump inhibitors. Conclusions: Our data suggests that patients who have been treated with steroids or proton pump inhibitors are at an increased risk for developing Candida esophagitis. Our data also suggests that steroids and proton pump inhibitors act synergistically to greatly increase the likelihood of Candida esophagitis

Small Bowel Obstruction Mimicking Acute ST-Elevation Myocardial Infarction

We present a case of a 42-year-old female who presented to our institution with a small bowel obstruction and had emergent surgical decompression. Thirteen days postoperatively, the patient became tachycardic and had worsening epigastric pain. Electrocardiogram showed significant ST-segment elevations in leads II, III, aVF, and V3–V6, suggesting the possibility of acute inferolateral myocardial infarction. Subsequent workup revealed the cause of the ST-elevations to be due to recurrent small bowel obstruction. Although intra-abdominal causes of ST-elevation have been reported, our case may be the first to be associated with small bowel obstruction