Patterns of healthcare utilization in post-operative Crohn's disease

Background: Surgery rapidly induces remission in Crohn’s disease (CD) but patterns of clinical recurrence and healthcare utilization beyond 1 year have not been well characterized. CD is one of the most significant chronic gastrointestinal condition, that is associated with high morbidity and decreased quality of life. From a 2002 population based study Crohn's disease was found to affect about 400,000- 600,000 people in North America causing a significant public health burden and associated healthcare cost. Methods: Retrospective observational study of CD patients undergoing resection/anastomosis stratified by patterns of healthcare utilization during the two year follow-up: High Utilizer (HU) group who require CD related emergency department visit (ED), hospital admission (HA) or repeat bowel surgery (RS) in the 2 year post-operative period and Low Utilizer (LU) group who have none of these events. Results: There were 45 CD patients with resection and side-to-side anastomosis (49% males, age 40.5 years, 24.4% smokers, 33.3% previous resection, 62.2% laparoscopic). Within 2 years of surgery, 46.7% required abdominal CT scan (78 scans, 21 patients), 33.3% required ED evaluation (70 ED visits, 15 patients), 29% had HA (40 HA, 13 patients) and 6.7% had RS (3 surgeries, 3 patients). There were differences between the LU (N=30) and HU groups (N=15) in the rate of smoking (13% vs. 26%; p=0.02), presence of > 2 co-morbid medical conditions (3.3% vs. 46.7%; p=0.001), biologic use before surgery (23% vs. 60%; p=0.009), biologic use after surgery (13% vs. 47%; p=0.026) and post-operative steroid use ( 10% vs. 53%;p= 0.003). Inflammation on post-operative colonoscopy was identified in 24 % of patients (20% vs. 33%; p=0.4). Conclusions: In the 2 year post-operative period, 33% of patients required ED visit, 47% of patients warranted CT imaging for evaluation of abdominal pain, suggesting increased health care utilization in a subgroup of post-op patients with side-to-side anastomosis. In this era of increasing health care costs, from a public health standpoint, this study implies the need for effective treatment strategies to reduce IBD complications and related healthcare expenditure

Diverticulitis complicated by pylephlebitis: a case report

<p>Abstract</p> <p>Introduction</p> <p>Pylephlebitis is defined as septic thrombophlebitis of the portal venous system, usually secondary to infection or inflammation in the abdomen. In the current report, we present a case of pylephlebitis that complicated the course of a very common pathology, diverticulitis.</p> <p>Case presentation</p> <p>A 62-year-old Caucasian woman with a history of sigmoid diverticulitis presented to our facility with a three-week history of abdominal pain, fevers, chills, loss of appetite and fatigue. Her laboratory test results showed leukocytosis and elevated alkaline phosphatase. A computed tomography scan revealed portal vein thrombosis and a sigmoid diverticulitis with an abscess. Our patient was given pipercillin-tozabactam followed by sigmoid colectomy and loop transverse colostomy. A peritoneal fluid sample culture grew <it>Escherichia coli</it>. Our patient had an uneventful post-operative course and the leukocytosis resolved in the next four days. She improved clinically and was discharged home on ertapenem and enoxaparin. A follow-up computed tomography scan two weeks later showed a new pelvic abscess that was drained by a pigtail catheter but there was no change in the portal venous thrombus. A repeat computed tomography scan one month later revealed resolution of the pelvic abscess but persistence of portal vein thrombus, for which enoxaparin was continued.</p> <p>Conclusions</p> <p>This is a classic case of pylephlebitis that demonstrates the importance of recognizing that the portal vein thrombus is infected and treating the condition appropriately.</p

A challenging case of gastric outlet obstruction (Bouveret's syndrome): a case report

<p>Abstract</p> <p>Introduction</p> <p>Bouveret's syndrome is a clinically distinct form of gallstone ileus caused by the formation of a fistula between the biliary tract and duodenum. This case reinforces the need for early recognition and treatment of Bouveret's syndrome, as it is associated with high morbidity and mortality rates.</p> <p>Case presentation</p> <p>An 82-year-old Caucasian woman presented with signs and symptoms of small bowel obstruction. Her laboratory workup showed elevated alkaline phosphatase and amylase levels. Computed tomography of her abdomen revealed pneumobilia, a choledochoduodenal fistula and a gallstone obstructing her distal duodenum. The impacted gallstone could not be extracted endoscopically, so our patient underwent open enterolithotomy successfully. However, the postoperative course was complicated by myocardial infarction, respiratory failure and disseminated intravascular coagulation. She died 22 days after surgery, secondary to cardiopulmonary arrest.</p> <p>Conclusion</p> <p>This case clearly highlights the considerable morbidity and mortality associated with Bouveret's syndrome.</p

Clinical Outcomes of Colonic Stent in a Tertiary Care Center

Introduction. Colonic obstruction is one of the manifestations of colon cancer for which self-expanding metal stents (SEMS) have been effectively used, to restore the luminal patency either for palliative care or as a bridge to resective surgery. The aim of our study is to evaluate the efficacy and safety of large diameter SEMS in patients with malignant colorectal obstruction. Methods and Results. A four-year retrospective review of the Medical Archival System was performed and identified 16 patients. The average age was 70.8 years, of which 56% were females. The most common cause of obstruction was colon cancer (9/16, 56%). Rectosigmoid was the main site of obstruction (9/16) and complete obstruction occurred in 31% of cases. The overall technical and clinical success rates were 100% and 87%, respectively. There were no immediate complications (<24 hours), but stent stenosis due to kinking occurred within one week of stent placement in 2 patients. Stent migration occurred in 2 patients at 34 and 91 days, respectively. There were no perforations or bleeding complications. Conclusion. Large diameter SEMS provide a safe method for palliation or as a bridge to therapy in patients with malignant colonic obstruction with high technical success and very low complication rates

COVID-19 and Acute Esophageal Obstruction Management in the Emergency Department: An U.S. multicenter research network propensity-matched analysis

Introduction- The Coronavirus Disease-2019 (COVID-19) caused by the novel SARS-CoV-2 led to significant strain on the Emergency Department (ED) visits worldwide. Multiple stay-at-home orders were issued during the pandemic unless medical treatment was urgently needed . Acute esophageal obstruction (AEO) due to food/ foreign body impaction usually present to the ED, given its severe symptoms. Most esophageal foreign bodies pass through the gastrointestinal (GI) tract uneventfully, and related mortality is very low. Still, most of these patients receive endoscopic interventions (up to 76%). The number of non-urgent endoscopies plummeted sharply during the pandemic to reduce exposure and preserve personal protective equipment. It is unclear if ED visits for AEO and their endoscopic management changed due to the COVID-19 pandemic in the United States (US). Methods- We utilized a federated cloud-based network database named TriNetX, which provides access to electronic medical records from 92 healthcare organizations from the US. The AEO adult patients hospitalized from January 1, 2020, to December 1, 2020, were compared to a similar timeline in 2019 from TriNetX. We used ICD-10 codes for food/foreign body in esophagus, causing other injury acute food impaction (T18.128 A, T18.12), foreign body esophagus (T18.198, T18.1, T18.19, T18.108, T18.108A). Outcomes of the study included utilization rates of esophagogastroduodenoscopy (EGD), esophageal perforation, inpatient hospitalization, and mortality. The outcomes were measured before and after 1:1 propensity matching of the groups based on the baseline demographics and comorbidities. Results- Prevalence of AEO among all ED visits in 2020 were 0.12% (5890 AEO ED visits among 4,672,024 total visits), compared to 0.17% (23,478 AEO ED visits among 14,199,648 total visits) in 2019. There was a small but significant decrease (0.05%) in AEO ED visits from pre-pandemic compared to pandemic times (P<0.01). Patient with AEO had higher prevalence of eosinophilic esophagitis (mean 270 [4.6%] vs. 885 [3.8%], p=0.004) and alcohol-related disorders (mean 465 5 [7.9%] vs. 1659 [7.1%], p=0.03) in 2020 group vs. 2019 group. Patients in the 2020-group had a lower EGD utilization (RR 0.63,95%CI:0.58–0.67, p<0.001) but esophageal perforation (RR 0.87,95%CI:0.41–1.82) and inpatient hospitalization rates (RR 0.92,95%CI:0.79-1.05) did not differ between two groups. Interestingly, during the pandemic, the AEO patients had a lower mortality rate (RR 0.23, 95%CI:0.17–0.31, p<0.001) than in 2019. Conclusion With the advent of COVID-19, multiple stay-at-home orders were issued in the US, with widespread healthcare services and utilization disruption. Patients have expressed concerns about visiting healthcare facilities due to the potential of the spread of SARS-CoV-2 . Many GI societies also recommended deferring elective procedures. This was due to a concern for potential transmission of the virus from aerosolization of GI secretions and judicious use of PPE, which resulted in an overall reduction in the number of endoscopies during the pandemic. Our study shows a small reduction (0.05%) of AEO ED visits in 2020 compared to 2019. However, EGD utilization plummeted to 63% for AEO in 2020. If this is due to spontaneous resolution of the food impaction or reduced presentations to the ED needs to be studied prospectively

Prevalence, Mechanisms, and Implications of Gastrointestinal Symptoms in COVID-19

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. The infection started as an outbreak of pneumonia-like symptoms in Wuhan, China. Within a few weeks, it spread across the entire globe resulting in millions of cases and thousands of deaths. While respiratory symptoms and complications are well-defined and can be severe, non-respiratory symptoms of COVID-19 are increasingly being recognized. Gastrointestinal manifestations such as nausea, vomiting, diarrhea, and abdominal pain have been added to the list of common COVID-19 symptoms. Their prevalence has been increasing, probably due to increased recognition and experience with the pandemic. Furthermore, diarrhea and stool testing may change prevalence and transmission rates due to suspicion for fecal-oral transmission of the COVID-19. Due to this risk, various countries have started testing wastewater and sewage systems to examine its role in the spread of SARS-CoV-2 among communities. In this review article, we describe the common gastrointestinal manifestations in COVID-19, their prevalence based upon the current literature, and highlight the importance of early recognition and prompt attention. We also note the role of fecal-oral transmission. Furthermore, the mechanisms of these symptoms, the role of medications, and potential contributing factors are also elaborated

Metronidazole Induced Liver Injury: A Rare Immune Mediated Drug Reaction

Drug induced liver injury (DILI) can result either from dose-dependent direct hepatotoxicity or from an unpredictable dose-independent idiosyncratic reaction. Incidence of idiosyncratic DILI is estimated to be approximately 10–15 per 100,000 patient years. Here we report an extremely rare case of metronidazole induced delayed immune-allergic hepatocellular liver injury masquerading as autoimmune hepatitis. A previously healthy 54-year-old Caucasian male, who was treated with metronidazole for Clostridium difficile associated diarrhea, presented 3 months later with right upper quadrant abdominal pain. Laboratory tests revealed total bilirubin level of 12.7 mg/dL, direct bilirubin of 7.2 mg/dL, alanine aminotransferase (ALT) of 973 IU/L, aspartate transaminase (AST) of 867 IU/L, alkaline phosphatase (AP) of 96 IU/L, and an INR of 1.9, suggestive of hepatocellular pattern of injury. A detailed workup for hepatitis revealed no other etiology. A clinical diagnosis of metronidazole induced liver injury was made. With a persistent rise in his bilirubin and transaminase levels, the patient was started on oral prednisone. At the 2-week posthospitalization follow-up visit, the patient reported a significant improvement in his overall sense of being well and liver functions tests trended down substantially (total bilirubin 7.2 mg/dL, ALT 420 IU/L, AST 276 IU/L, AP 183 IU/L, and INR 1.5)