Patients Who Undergo Colectomy for Pediatric Ulcerative Colitis at Low-Volume Hospitals Have More Complications

Background & Aims: Adults with ulcerative colitis (UC) who undergo colectomy at high-volume centers have better outcomes and fewer complications than those at low-volume centers. We aimed to evaluate the hospital volume of total abdominal colectomy (TAC) for pediatric patients with UC and explore time trends in the proportion of colectomies performed at high-volume centers. We then evaluated the association between hospital colectomy volume and complications. Methods: We performed a cross-sectional analysis of pediatric patients (age, ó18 y) hospitalized for UC using the Kids? Inpatient Database, a nationally representative database of pediatric hospitalizations. We identified UC hospitalizations with a procedural code (International Classification of Diseases, 9th or 10th revision) for TAC from 1997 through 2016. We defined complications using diagnosis codes adapted from published algorithms. We defined high-volume as hospitals that performed 10 or more TACs annually. We used multivariate statistics to evaluate the association between hospital volume and in-hospital complications. Results: A total of 1453 hospitalizations of children with UC included a TAC (2306 colectomies nationwide). A total of 766 hospitals performed 1 or more annual colectomies and only 36 (4.7%) were high-volume hospitals, accounting for 21% of colectomies. The proportion of colectomies at high-volume hospitals decreased over time. The absolute risk of complication was 16% at high-volume centers compared with 22% at low-volume centers (adjusted odds ratio, 0.7; 95% CI, 0.5?0.9). The effect of annual TAC volume on complication risk was not statistically significant for nonemergent admissions. Conclusions: Pediatric patients with UC who undergo colectomy at high-volume centers have fewer complications. However, only a small proportion of pediatric colectomies (<5%) are performed at high-volume centers

Weekend Surgical Admissions of Pediatric IBD Patients Have a Higher Risk of Complication in Hospitals Across the US

Background: Weekend surgical admissions to the hospital are associated with worse clinical outcomes when compared with weekday admissions. We aimed to evaluate the association of weekend admission and in-hospital complications for pediatric inflammatory bowel disease (IBD) hospitalizations requiring urgent abdominal surgery. Methods: We performed a cross-sectional analysis of pediatric (18 years old and younger) IBD hospitalizations between 1997 and 2016 using the Kids' Inpatient Database (KID), a nationally representative database of pediatric hospitalizations. We included discharges with a diagnosis code for Crohn's disease (CD) or ulcerative colitis (UC) undergoing a surgical procedure within 48 hours of admission. We used logistic regression to evaluate the association of weekend admission and complications, controlling for confounding factors. Results: Our study included a total of 3255 urgent surgical hospitalizations, representing 4950 hospitalizations nationwide. The risk difference for weekend CD surgical hospitalizations involving a complication vs weekday hospitalizations was 4%. Adjusted analysis demonstrated a 30% increased risk for complications associated with weekend CD hospitalizations compared with weekday hospitalizations (OR 1.3, 95% CI, 1.0-1.7). The risk difference for weekend UC hospitalizations involving a complication compared with the weekday hospitalizations was 7%. Adjusted analysis demonstrated a 70% increased risk of complication for UC weekend surgical hospitalizations compared with weekday hospitalizations (OR 1.7, 95% CI, 1.2-2.3). Conclusion: Pediatric IBD hospitalizations involving urgent surgical procedures have higher rates of complications when admitted on the weekend vs the weekday. The outcome disparity requires further health services research and quality improvement initiatives to identify contributing factors and improve surgical outcomes

Thrombotic and Infectious Risks of Parenteral Nutrition in Hospitalized Pediatric Inflammatory Bowel Disease

Background Malnutrition is common in inflammatory bowel disease (IBD), requiring timely and sufficient nutritional supplementation. In patients hospitalized for active disease, symptoms and/or altered intestinal function hinder enteral nutrition feasibility. In this scenario, parenteral nutrition (PN) is used. We aimed (1) to assess the frequency of PN use between 1997 and 2012 among hospitalized pediatric patients with IBD, (2) to determine the risk of in-hospital thrombus and infection associated with PN, and (3) to identify predictors of thrombus and infection in pediatric IBD hospitalizations utilizing PN. Methods We performed a cross-sectional analysis of pediatric patients hospitalized between 1997 and 2012. We used the Kids' Inpatient Database (KID) to identify pediatric patients (ó18 years of age) with Crohn's disease (CD) or ulcerative colitis (UC), PN exposure, and primary outcomes including thrombus and infection. We used multivariable regression to identify risk factors for outcomes of interest. Results Parenteral nutrition was utilized in 3732 (12%) of 30,914 IBD hospitalizations. Three percent of PN patients experienced a thrombotic complication, and 5.5% experienced an infectious complication. Multivariate analysis showed PN as an independent risk factor for thrombus (odds ratio [OR], 4.3; 95% confidence interval [CI], 3.2-5.6) and infection (OR, 3.8; 95% CI, 3.1-4.6). Surgery was an independent risk factor for thrombus (OR, 2.0; 95% CI, 1.4-2.7) and infection (OR, 2.5; 95% CI, 2.0-3.1) in hospitalizations exposed to PN. Conclusions Hospitalized pediatric IBD patients, particularly surgical, receiving PN are at increased risk for thrombosis and infection. Clinicians must balance these risks with the benefits of PN

Sex and Race Disparities in Diverticulosis Prevalence

Background & Aims: The prevalence of diverticulosis differs with demographic features of patients, but evidence is limited. Well-defined demographic studies are necessary to understand diverticulosis biology. We estimated the prevalence of diverticulosis among patients of different ages, sexes, and races and ethnicities and calculated odds ratios. Design: Using data from an endoscopic database, we identified 271,181 colonoscopy procedures performed from 2000 through 2012 at 107 sites in the United States. Our analysis included individuals 40 years and older who underwent colonoscopy examination for average-risk screening. The outcome was any reported diverticulosis on colonoscopy. Multivariate analyses were performed using logistic regression to estimate odds ratios (ORs) and 95% CI values, adjusting for confounding variables. Results: The prevalence of diverticulosis increased with age in men and women of all races and ethnicities. Women 40-49 years old had significantly lower odds of any diverticulosis (OR, 0.71; 95% CI, 0.63-0.80) compared with men 40-49 years old, after adjustment. The strength of this association decreased with age. Compared with non-Hispanic white individuals, non-Hispanic black individuals (OR, 0.80; 95% CI, 0.77-0.83) and Asian/Pacific Islanders (OR, 0.38; 95% CI, 0.35-0.41) had lower odds of any diverticulosis. However, non-Hispanic black individuals (OR, 1.53, 95% CI, 1.44-1.62) had increased odds of any proximal diverticulosis, whereas Asian/Pacific Islanders (OR, 3.12; 95% CI, 2.67-3.66) had increased odds of only proximal diverticulosis. Conclusions: In an analysis of data from 271,181 colonoscopy procedures, diverticulosis was less prevalent in women compared with men in the same age groups, indicating that sex hormones might affect pathogenesis. Differences in the odds of diverticulosis by race and ethnicity indicate a genetic contribution to risk

Diverticulosis Is Associated With Internal Hemorrhoids on Colonoscopy: Possible Clues to Etiology

Hemorrhoids are a common but poorly understood gastrointestinal condition. Bowel habits and fiber consumption are frequently cited as risk factors for hemorrhoids, but research has been inconclusive. Recent genome-wide association studies (GWAS) have suggested an association between diverticular disease and hemorrhoids. We sought to investigate the association between colonic diverticulosis and internal hemorrhoids to validate the prediction from the GWAS

An integrated electronic health record-based workflow to improve management of colonoscopy-generated pathology results

Purpose: Managing and communicating colonoscopy-generated pathology results and appropriate follow-up recommendations can be challenging. To improve this process, we developed and implemented a standardized electronic health record-based intervention with built-in decision support. Methods: Fourteen attending endoscopists performed enough colonoscopies to qualify for the study. For each, we randomly sampled and abstracted data from 35 colonoscopies that met prespecified inclusion criteria during both the pre-intervention and also post-intervention periods. Follow-up recommendations were compared to guidelines. We used the Wilcoxon Signed Rank Test to assess the change in the proportion of cases with guideline-concordant results, the proportion with a documented follow-up result letter, and the median time to letter completion. A brief survey assessed endoscopists’ satisfaction with the intervention. Results: In total, 1,947 colonoscopies were extracted, of which 968 met inclusion criteria. The proportion of follow-up recommendations that were guideline concordant increased from a median of 82.9% pre-intervention to 85.7% post-intervention (P=0.72). The proportion of observations with a documented follow-up result letter increased from a median of 88.9% pre-intervention to 97.1% post-intervention (P=0.07). The number of calendar days between the date of the colonoscopy and the date the letter was sent decreased from a median of 7.7 days pre-intervention to 6.8 days post-intervention (P=0.79). Eighty-six percentage of endoscopists were either “very satisfied” or “satisfied” with the overall process. Conclusion: The intervention was not associated with a statistically significant increase in guideline-concordant recommendations or efficiency measures, perhaps due to high baseline performance. The intervention was well received by endoscopists and captured data necessary for important downstream processes

Association of Obesity With Colonic Diverticulosis in Women

Background & Aims: Obesity has been associated with an increased risk of colonic diverticulosis. Evidence for this association is limited. We assessed whether anthropometric measures of obesity were associated with colonic diverticulosis. Methods: We analyzed data from a prospective study of 623 patients undergoing screening colonoscopies from 2013 through 2015; colonoscopies included examinations for diverticulosis. Body measurements were made the day of the procedure. Multivariate analyses were performed using modified Poisson regression to estimate prevalence ratios (PRs) and 95% CIs while adjusting for confounding variables. All analyses were stratified by sex. Results: Among men, there was no association between any measure of obesity and diverticulosis. After adjustment, women with an obese body mass index (BMI ≥ 30) had an increased risk of any diverticulosis (PR, 1.48; 95% CI, 1.08–2.04) compared with women with a normal body mass index (BMI 18.5–24.9). The strength of this association was greater for more than 5 diverticula (PR, 2.05; 95% CI, 1.23–3.40). There was no significant association between measures of central obesity and diverticulosis in women. Stratified by sex, colonic diverticulosis was significantly less prevalent in women compared with men before the age of 51 years (29% vs 45%, P = .06). The prevalence of diverticulosis did not differ by sex in older age groups. Conclusions: In an analysis of data from 623 patients undergoing screening colonoscopies, we found that obesity (BMI ≥30) significantly increased the risk of colonic diverticulosis in women but not men. Colonic diverticulosis was less prevalent in premenopausal-age women compared with similar-age men. These findings suggest that sex hormones may influence the development of diverticulosis

Medication use and microscopic colitis

Background: Microscopic colitis is an increasingly common cause of watery diarrhoea. Several classes of medications have been associated with microscopic colitis in prior studies. Aims: To determine the association between the use of previously implicated medications and microscopic colitis. Methods: This was a case-control study of patients referred for elective, outpatient colonoscopy for diarrhoea. Patients were excluded for inflammatory bowel disease, C difficile, or other infectious diarrhoea. Colon biopsies were reviewed by the study pathologist and patients were classified as microscopic colitis cases or non-microscopic colitis controls. Results: The study population included 110 microscopic colitis cases and 252 controls. The cases were older, better educated and more likely to be female. Cases reported a greater number of loose, watery, or liquid stools, nocturnal stools, more urgency and weight loss compared to controls. There was no association with proton pump inhibitors (PPIs), adjusted OR (aOR) 0.66, 95% CI 0.38-1.13 or nonsteroidal anti-inflammatory drugs, aOR 0.68, 95% CI 0.40-1.17. Cholecystectomy was less common in cases, aOR 0.33, 95% CI 0.17-0.64, but microscopic colitis cases had more frequent bowel movements following cholecystectomy. Conclusion: Compared to similar patients with diarrhoea, cases with microscopic colitis were not more likely to have taken previously implicated medications. They had more diarrhoea following cholecystectomy, suggesting that bile may play a role in symptoms or aetiology. We conclude that the appropriate choice of controls is crucial to understanding risk factors for microscopic colitis

Obesity is associated with decreased risk of microscopic colitis in women

BACKGROUND Microscopic colitis is a leading cause of diarrhea in the older adults. There is limited information about risk factors. We hypothesized that obesity would be associated with microscopic colitis. AIM To examine the association between obesity and microscopic colitis in men and women undergoing colonoscopy. METHODS We conducted a case-control study at the University of North Carolina Hospitals. We identified and enrolled men and women referred for elective, outpatient colonoscopy for chronic diarrhea. We excluded patients with a past diagnosis of Crohn's disease or ulcerative colitis. A research pathologist reviewed biopsies on every patient and classified them as microscopic colitis cases or non-microscopic colitis controls. Patients provided information on body weight, height and exposure to medications via structured interviews or Internet based forms. The analysis included 110 patients with microscopic colitis (cases) and 252 nonmicroscopic colitis controls. Multivariable analyses were performed using logistic regression to estimate odds ratios and 95% confidence intervals. RESULTS Cases were older and more likely than controls to be white race. Study subjects were well educated, but cases were better educated than controls. Cases with microscopic colitis had lower body mass index than controls and reported more weight loss after the onset of diarrhea. Compared to patients who were normal or under-weight, obese (BMI > 30 kg/m2) patients were substantially less likely to have microscopic colitis after adjusting for age and education, adjusted OR (aOR) 0.35, 95% confidence interval (CI) 0.18-0.66). When stratified by sex, the association was limited to obese women, aOR 0.21, 95%CI: 0.10-0.45. Patients with microscopic colitis were more likely to report weight loss after the onset of diarrhea. After stratifying by weight loss, there remained a strong inverse association between obesity and microscopic colitis, aOR 0.33, 95%CI: 0.10 - 1.11 among the patients who did not lose weight. Ever use of birth control pills was associated with lower risk of microscopic colitis after adjusting for age, education and BMI, aOR 0.38, 95%CI: 0.17-0.84. CONCLUSION Compared to controls also seen for diarrhea, microscopic colitis cases were less likely to be obese. Mechanisms are unknown but could involve hormonal effects of obesity or the gut microbiome

Intraepithelial and Lamina Propria Lymphocytes Do Not Correlate with Symptoms or Exposures in Microscopic Colitis

INTRODUCTION:Microscopic colitis, a common cause of diarrhea, is characterized by a largely normal appearance of the mucosa but increased numbers of lymphocytes in the epithelium and lamina propria on microscopy. We sought to determine whether T-cell percentage was associated with exposures or symptoms.METHODS:We conducted a case-control study that enrolled patients referred for colonoscopy for diarrhea. Patients were classified as microscopic colitis cases or controls by an experienced pathologist. Participants provided information on symptoms and exposures during a telephone or internet survey. Research biopsies from the ascending colon and descending colon were examined using immunofluorescence stains for CD3, CD8, and FOXP3 to determine percent T cells per total epithelial or lamina propria cells. Digital images were analyzed by regions of interest using Tissue Studio.RESULTS:There were 97 microscopic colitis cases and 165 diarrhea controls. There was no association between demographic factors and percentage of intraepithelial or lamina propria T cells. In cases, the mean percent T cells were similar in the right colon and left colon. There was no association between mean percent T cells and stool frequency or consistency. There was no association with irritable bowel syndrome, abdominal pain, or medications purported to cause microscopic colitis.DISCUSSION:The lack of association between the density of T cells and medications raises further doubts about their role in disease etiology. Loose and frequent stools in patients with microscopic colitis are not correlated with T-cell density