Herbal and dietary supplement induced liver injury:Highlights from the recent literature

Herbal-induced liver injury(HILI)is an important and increasingly concerning cause of liver toxicity,and this study presents recent updates to the literature.An extensive literature review was conducted encompassing September 2019 through March 2021.Studies with clinically significant findings were analyzed and included in this review.We emphasized those studies that provided a causality assessment methodology,such as Roussel Uclaf Causality Assessment Method scores.Our review includes reports of individual herbals,including Garcinia cambogia,green tea extract,kratom as well as classes such as performance enhancing supplements,Traditional Chinese medicine,Ayurvedic medicine and herbal contamination.Newly described herbals include ashwagandha,boldo,skyfruit,and‘Thermo gun’.Several studies discussing data from national registries,including the United States Drug-Induced Liver Injury(DILI)Network,Spanish DILI Registry,and Latin American DILI Network were incorporated.There has also been a continued interest in hepatoprotection,with promising use of herbals to counter hepatotoxicity from anti-tubercular medications.We also elucidated the current legal conversation surrounding use of herbals by presenting updates from the Federal Drug Administration.The highlights of the literature over the past year indicate interest in HILI that will continue as the supplement industry in the United States grows.

Gastric antral webs in adults:A case series characterizing their clinical presentation and management in the modern endoscopic era

AIMTo investigate the current management of gastric antral webs (GAWs) among adults and identify optimal endoscopic and/or surgical management for these patients. METHODSWe reviewed our endoscopy database seeking to identify patients in whom a GAW was visualized among 24640 esophagogastroduodenoscopies (EGD) over a seven-year period (2006-2013) at a single tertiary care center. The diagnosis of GAW was suspected during EGD if aperture size of the antrum did not vary with peristalsis or if a “double bulb” sign was present on upper gastrointestinal series. Confirmation of the diagnosis was made by demonstrating a normal pylorus distal to the GAW. RESULTSWe identified 34 patients who met our inclusion criteria (incidence 0.14%). Of these, five patients presented with gastric outlet obstruction (GOO), four of whom underwent repeated sequential balloon dilations and/or needle-knife incisions with steroid injection for alleviation of GOO. The other 29 patients were incidentally found to have a non-obstructing GAW. Age at diagnosis ranged from 30-87 years. Non-obstructing GAWs are mostly incidental findings. The most frequently observed symptom prompting endoscopic work-up was refractory gastroesophageal reflux (n = 24, 70.6%) followed by abdominal pain (n = 11, 33.4%), nausea and vomiting (n = 9, 26.5%), dysphagia (n = 6, 17.6%), unexplained weight loss, (n = 4, 11.8%), early satiety (n = 4, 11.8%), and melena of unclear etiology (n = 3, 8.82%). Four of five GOO patients were treated with balloon dilation (n = 4), four-quadrant needle-knife incision (n = 3), and triamcinolone injection (n = 2). Three of these patients required repeat intervention. One patient had a significant complication of perforation after needle-knife incision. CONCLUSIONEndoscopic intervention for GAW using balloon dilation or needle-knife incision is generally safe and effective in relieving symptoms, however repeat treatment may be needed and a risk of perforation exists with thermal therapies.