Gastrointestinal haemorrhage in extracorporeal membrane oxygenation: insights from the national inpatient sample

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) is associated with gastrointestinal haemorrhage (GIH), which may result from coagulopathy, systemic inflammation, reduced gastric perfusion, and arteriovenous malformation from non-pulsatile blood flow. Data are limited regarding the burden of this complication in the United States. MATERIAL AND METHODS: We analysed the National Inpatient Sample (NIS) database for the years 2007 to 2011 to identify hospitalisations in which an ECMO procedure was performed. Hospitalizations complicated by GIH in this cohort were then identified by relevant codes. RESULTS: Between 2007 and 2011, ECMO hospitalisations increased from 1869 to 3799 (p \u3c 0.01). The proportion of hospitalisations complicated by GIH increased from 2.12% in 2007 to 7.46% in 2011 (p \u3c 0.01). Gastrointestinal haemorrhage was more common in men (56.7%) and in Caucasians (57.4%). Common comorbidities in this population were renal failure (71%), anaemia (55%), and hypertension (26%). All-cause inpatient mortality showed a numerical but nonsignificant increase from 56.7% to 61.9% (p = 0.49). The average cost of care per hospitalisation with GIH associated with ECMO use increased from $132,420 in 2007 to$215,673 in 2011 (p \u3c 0.01). CONCLUSIONS: Gastrointestinal haemorrhage during ECMO hospitalisations occurred in small but significantly increasing proportions. The inpatient mortality rate and costs associated with GIH were substantial and increased significantly during the study period

Gastrointestinal Tuberculosis Presenting as Malnutrition and Distal Colonic Bowel Obstruction

Gastrointestinal (GI) tuberculosis (TB) is rare and can occur in the context of active pulmonary disease or as a primary infection with no pulmonary symptoms. It typically presents with vague abdominal symptoms, making it difficult to discern from alternative disease processes. Although the ileocecal region is the most commonly affected site, tuberculous enteritis can involve any aspect of the GI tract. To demonstrate the importance of maintaining a high clinical suspicion for the disease, we present a case of GI TB presenting as severe malnutrition and segmental colitis of the left colon

Gastrointestinal Tuberculosis Presenting as Malnutrition and Distal Colonic Bowel Obstruction

Gastrointestinal (GI) tuberculosis (TB) is rare and can occur in the context of active pulmonary disease or as a primary infection with no pulmonary symptoms. It typically presents with vague abdominal symptoms, making it difficult to discern from alternative disease processes. Although the ileocecal region is the most commonly affected site, tuberculous enteritis can involve any aspect of the GI tract. To demonstrate the importance of maintaining a high clinical suspicion for the disease, we present a case of GI TB presenting as severe malnutrition and segmental colitis of the left colon

Malignant Carcinoid Tumors of the Appendix, Large Intestine, and Rectum: A Nationwide Analysis of Hospitalization Trends, Comorbidity Measures, Cost of Care, and Outcomes

Introduction: Carcinoid tumors of the colon and rectum arise from amine precursor uptake and decarboxylation cells of the intestine. The vast majority of lesions are asymptomatic found incidentally during endoscopy. Limited epidemiological data exist on national hospitalization trends, demographic variation, comorbidity measures, cost of care, and outcomes

170 Post ERCP de novo fever and de novo bacteremia: Insights from the national inpatient database

Background: The aim of the study was to assess the incidence of post ERCP fever and bacteremia in the national cohort. The secondary aims were to evaluate the in-hospital mortality, length of stay and total hospitalization charges. Methods: This was a retrospective cohort study using the 2016 Nationwide Inpatient Sample (NIS). Patients with ICD-10 CM procedure codes for ERCP were included. Patients were excluded from the study if they had an ICD-10 CM code for a principal diagnosis of acute cholangitis and principal diagnosis of sepsis. Post-ERCP bacteremia was defined as an ICD-10 CM code for a secondary diagnosis of infection or septic shock or fever in patients who received an ERCP. Primary outcome was incidence of post-ERCP bacteremia. Secondary outcomes included in-hospital mortality, length of stay (LOS)and total hospitalization charges. Proportions were compared using fisher’s exact test and continuous variables using student t-test. Multivariable and Poisson regression was performed. Results: We included a total of 152,924 ERCP procedures which were performed in hospitals in the year 2016 across the US. Fever with no signs of bacteremia or sepsis after ERCP was noticed in 0.2% of the population. Post ERCP bacteremia was noticed in 0.5% of all the procedures. 9% of patients with sepsis after ERCP progressed to septic shock. Hispanics were less likely to develop signs of sepsis versus fever alone after ERCP (15% vs 21%, p\u3c0.001)which persisted after adjustment of confounders. ERCP with placement of biliary stent and pancreatic stent was associated with increased odds of developing de novo sepsis by 3 times and 5 times respectively. There was no significant difference in terms of post ERCP percutaneous cholecystectomy or bile duct exploration in the two cohorts. Fever alone did not increase the odds of mortality. However, mortality risk is increased by almost 3 times after the development of sepsis (OR 2.96 (1.36-6.46), p = 0.006). The mean length of stay was significantly higher in patients with post ERCP bacteremia as compared to fever with no sepsis (8 days vs 16 days, p\u3c0.001)which was significant even after adjustment of confounders for Poisson regression. Post ERCP bacteremia is associated with higher total hospitalization charges (114,381 $vs 188,835$, p\u3c0.001). Discussion/conclusion: The study shows that occurrence of fever and post ERCP sepsis from national database is 0.7%. Febrile episode after ERCP leads to prolonged stay which might indicate physicians being cautious. Further studies are warranted to determine any racial and genetic differences, given that hispanics had lower incidence of progression to sepsis. Placement of biliary stent and pancreatic stent were associated with increased progression and therefore further studies might be needed to elucidate which patients might benefit from prophylactic antibiotics. [Figure presented][Figure presented

Gastrointestinal Hemorrhage in Acute Kidney Injury Patients on Hemodialysis

Background Gastrointestinal bleeding (GIB) has been reported to be more common in patients with chronic renal failure and end-stage renal disease requiring hemodialysis with higher mortality than in the general population. Limited epidemiological data exist on the annual number of hospitalizations, demographic variation, cost of care, and outcomes for GIB in patients with acute kidney injury (AKI) requiring and not requiring hemodialysis (HD). The main objective of this study was to analyze the trends of GIB in patients with AKI requiring HD and those not requiring HD during hospitalization. Methods and Results We analyzed the National (Nationwide) Inpatient Sample (NIS) database for all subjects with a discharge diagnosis of AKI as the primary or secondary diagnosis during the period from 2001 to 2011. Subjects with a discharge diagnosis of hemodialysis and GIB were then identified from the pool and trends were analyzed. A significant rise in the annual number of hospitalizations with AKI was found with a greater proportion being discharged without HD. From 2001 to 2011, there were 19,393,811 hospitalizations with a discharge diagnosis of AKI of which 1,424,692 (7.3%) received HD (HD group), whereas 17,969,119 (92.7%) did not receive HD (non-HD group) (p \u3c 0.0001). The male gender was more commonly affected by GIB than the female gender in both groups (p \u3c 0.0001). The cost of care per hospitalization for GIB patients in the HD group increased over the study period with average found to be $61,463 (adjusted for inflation, p \u3c 0.0001), whereas for GIB patients in the non-HD group, it showed a slight decrease in trend with the average found to be$28,419 (p \u3c 0.0001). All-cause mortality was higher for GIB patients in the HD group (38.1%) than in the non-HD group (25.1%) (p \u3c 0.0001). Conclusions GIB is more common and associated with higher all-cause inpatient mortality in patients receiving HD in comparison to non-HD patients

Management of Anastomotic Biliary Strictures After Liver Transplant: Role of Covered Metal Stents

Purpose: Biliary complications, including anastomotic biliary strictures (ABS), remain the most common cause of morbidity in liver transplant (LT) patients. Endoscopic therapy has become the frst line treatment for these patients. The use of multiple plastic stents (MPS) in parallel is the current standard of care, but fully-covered self-expandable metal stents (cSEMS) are increasingly being utilized. Here we present one of the largest retrospective reviews regarding the management of ABSs after LT. Methods: We reviewed all endoscopic retrograde cholangiopancreatographs (ERCP) performed between January 2011 and August 2017 in post-LT patients at a single tertiary care center. No patients who underwent initial ERCP after this date were reviewed to allow for adequate follow-up. A total of 151 patients underwent ERCP. ABSs were found in 115 patients. ERCP with initial stent placement was successfully performed in 112/115 (97.4%) patients. Four additional patients were excluded from analysis because of death prior to undergoing repeat ERCP. The remaining 108 patients were eligible for analysis. Results: Plastic stents were the index stent in all 108 patients. Serial ERCPs were performed until ABS resolution or treatment failure. A mean of 2.74 ERCPs were performed with a mean indwelling stent duration of 102.9 days. Stricture resolution was achieved with plastic stents in 95/108 (88.0%) patients. Mean follow-up was 1226.4 days. Of the 13 patients with initial treatment failure, 10 patients received cSEMS placement for salvage therapy and 9 of these patients ultimately achieved ABS resolution (90%). The other three patients required surgery. Twelve of 95 (12.6%) patients with initial stricture resolution had ABS recurrence during the follow-up period. Five of these patients ultimately received cSEMS placement and all 5 showed resolution of ABS. Of the seven other patients, fve received repeat MPS placement with resolution and two required surgical revision. Migration of cSEMS occurred in 4/15 (26.7%) patients. All four patients received repeat cSEMS placement with resolution of ABS. There were no deaths or cases of severe pancreatitis as a result of treatment for ABS. Conclusions: Our retrospective review supports the ongoing use of endoscopic biliary stent placement for the management of ABS in LT patients. Resolution can be attained with either MPS or cSEMS placement. cSEMS are an excellent option for refractory or recurrent ABS with success rates of 90 and 100% respectively. We did experience a high stent migration risk and vigilance to this complication is warranted

Management of Anastomotic Biliary Strictures After Liver Transplant: Role of Covered Metal Stents

Purpose: Biliary complications, including anastomotic biliary strictures (ABS), remain the most common cause of morbidity in liver transplant (LT) patients. Endoscopic therapy has become the frst line treatment for these patients. The use of multiple plastic stents (MPS) in parallel is the current standard of care, but fully-covered self-expandable metal stents (cSEMS) are increasingly being utilized. Here we present one of the largest retrospective reviews regarding the management of ABSs after LT. Methods: We reviewed all endoscopic retrograde cholangiopancreatographs (ERCP) performed between January 2011 and August 2017 in post-LT patients at a single tertiary care center. No patients who underwent initial ERCP after this date were reviewed to allow for adequate follow-up. A total of 151 patients underwent ERCP. ABSs were found in 115 patients. ERCP with initial stent placement was successfully performed in 112/115 (97.4%) patients. Four additional patients were excluded from analysis because of death prior to undergoing repeat ERCP. The remaining 108 patients were eligible for analysis. Results: Plastic stents were the index stent in all 108 patients. Serial ERCPs were performed until ABS resolution or treatment failure. A mean of 2.74 ERCPs were performed with a mean indwelling stent duration of 102.9 days. Stricture resolution was achieved with plastic stents in 95/108 (88.0%) patients. Mean follow-up was 1226.4 days. Of the 13 patients with initial treatment failure, 10 patients received cSEMS placement for salvage therapy and 9 of these patients ultimately achieved ABS resolution (90%). The other three patients required surgery. Twelve of 95 (12.6%) patients with initial stricture resolution had ABS recurrence during the follow-up period. Five of these patients ultimately received cSEMS placement and all 5 showed resolution of ABS. Of the seven other patients, fve received repeat MPS placement with resolution and two required surgical revision. Migration of cSEMS occurred in 4/15 (26.7%) patients. All four patients received repeat cSEMS placement with resolution of ABS. There were no deaths or cases of severe pancreatitis as a result of treatment for ABS. Conclusions: Our retrospective review supports the ongoing use of endoscopic biliary stent placement for the management of ABS in LT patients. Resolution can be attained with either MPS or cSEMS placement. cSEMS are an excellent option for refractory or recurrent ABS with success rates of 90 and 100% respectively. We did experience a high stent migration risk and vigilance to this complication is warranted