Immune Thrombocytopenic Purpura (ITP) as an Uncommon Extraintestinal Complication of Crohn's Disease: Case Vignette and Systematic Literature Review.

While the association of immune thrombocytopenic purpura (ITP) and inflammatory bowel disease (IBD) has been described in a few case reports, management of ITP as an extraintestinal manifestation of Crohn's disease (CD) is less studied. There are approximately a dozen cases describing the management of patients dually diagnosed with CD/ITP. Previous reports postulated that the mechanism of ITP in CD was through the presence of circulating immune complexes in the serum and antigenic mimicry due to increased mucosal permeability in active colitis, versus increased mucosal production of TH1-type proinflammatory cytokines during CD flares, which may account for remission of ITP with surgery for CD. We present a case of a 27-year-old man who presented with medically refractory CD and ITP who responded to surgical management with colectomy and splenectomy, along with a systematic review of the literature. These cases suggest that colectomy should be considered in the treatment of medically refractory ITP among patients with concomitant CD.

Evaluating the risk of adverse events with interventional endoscopic retrograde cholangiopancreatography and endoscopic ultrasound procedures in cirrhotic patients.

BACKGROUND: Hepatic cirrhosis is associated with greater adverse event rates following surgical procedures and is thought to have a higher risk of complications with interventional procedures in general. However, these same patients often require interventional gastrointestinal procedures such as endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS). While studies examining this scenario exist, the overall body of evidence for adverse event rates associated with ERCP/EUS procedures is more limited. We sought add to the literature by examining the incidence of adverse events after ERCP/EUS procedures in our safety-net hospital population with the hypothesis that severity of cirrhosis correlates with higher adverse event rates. AIM: To examine whether increasing severity of cirrhosis is associated with greater incidence of adverse events after interventional ERCP/EUS procedures. METHODS: We performed a retrospective study of patients diagnosed with hepatic cirrhosis who underwent ERCP and/or EUS-guided fine needle aspirations/fine needle biopsies from January 1, 2016 to March 14, 2019 at our safety net hospital. We recorded Child-Pugh and Model for End-stage Liver Disease (MELD-Na) scores at time of procedure, interventions completed, and 30-day post-procedural adverse events. Statistical analyses were done to assess whether Child-Pugh class and MELD-Na score were associated with greater adverse event rates and whether advanced techniques (single-operator cholangioscopy, electrohydraulic lithotripsy/laser lithotripsy, or needle-knife techniques) were associated with higher complication rates. RESULTS: 77 procedures performed on 36 patients were included. The study population consisted primarily of middle-aged Hispanic males. 30-d procedure-related adverse events included gastrointestinal bleeding (7.8%), infection (6.5%), and bile leak (2%). The effect of Child-Pugh class C vs class A and B significantly predicted adverse events (ß = 0.55, P < 0.01). MELD-Na scores also significantly predicted adverse events (ß = 0.037, P < 0.01). Presence of advanced techniques was not associated with higher adverse events (P > 0.05). When MELD-Na scores were added as predictors with the effect of Child-Pugh class C, logistic regression showed MELD-Na scores were a significant predictor of adverse events (P < 0.01). The findings held after controlling for age, gender, ethnicity and repeat cases. CONCLUSION: Increasing cirrhosis severity predicted adverse events while the presence of advanced techniques did not. MELD-Na score may be more useful in predicting adverse events than Child-Pugh class.