A comparison of diverticulitis in Crohn's disease versus ulcerative colitis.

BACKGROUND AND AIM: Inflammatory bowel disease (IBD) and diverticulitis both increase morbidity, especially when associated with in-patient hospitalization. This study aimed to evaluate whether hospitalization burden differs for diverticulitis in patients with a history of Crohn's disease (CD) compared to ulcerative colitis (UC). METHOD: All patients hospitalized for acute diverticulitis with pre-existing UC or CD in 2014 were selected using the national in-patient sample. Cases were identified using the International Classification of Diseases, Ninth Edition codes. Primary outcomes were mortality, cost of admission, length of stay (LOS), and colectomy. RESULTS: A total of 1815 patients were admitted with diverticulitis, and those with CD had a hospitalization associated with decreased cost (aOR -14 537, 95% CI -27 316 to -1758; P = 0.026) and LOS (aOR -1.31, 95% CI -2.41 to -0.208; P = 0.02) compared to UC. A second analysis comparing diverticulitis hospitalization between those with CD and those with the absence of IBD showed no significant difference in mortality (aOR 2.47, 95% CI 0.59 to 10.36; P = 0.22), LOS (aOR 0.03, 95% CI -0.47 to 0.54; P = 0.92), or cost of admission (aOR -2196, 95% CI -6933 to 2539; P = 0.36) between the cohorts. CONCLUSION: Patients with UC have worsened hospitalization outcomes when being treated for diverticulitis compared to CD. While the findings may be a result of a difference in colectomy rates, the etiology may also be multifactorial. These conclusions have not been previously described, and further investigations would better characterize these associations.

Association of Autoimmune Hepatitis and Cardiovascular Disease.

BACKGROUND: Autoimmune Hepatitis is a chronic liver disease while Cardiovascular Disease is seen in inflammatory states. This study sought to determine if Cardiovascular Disease was associated with Autoimmune Hepatitis. METHODS: The National Inpatient Sample selected patients with a primary diagnosis of Autoimmune Hepatitis and secondary diagnosis of Cardiovascular Disease in 2014. The primary outcome was the association of Autoimmune Hepatitis with Cardiovascular Disease. Secondary outcomes evaluated the hospital burden with Cardiovascular Disease. RESULTS: 16,375 patients with Autoimmune Hepatitis were included in the study. There was a decreased association between Autoimmune Hepatitis and Cardiovascular Disease (aOR 0.77, 95% CI 0.69-0.85, p < 0.00), Coronary Artery Disease, (aOR 0.75, 95% CI 0.67-0.85, p < 0.00), and Peripheral Vascular Disease (aOR 0.75, 95% CI 0.60-0.93, p = 0.01). Moreover, Coronary Artery Disease comprises 84% of the overall Cardiovascular Disease cohort and did not demonstrate significantly increased length of stay (aOR -0.53, 95% CI -1.16 to 0.12, p = 0.11) or hospitalization cost (aOR -6711, 95% CI -14336 to 912, p = 0.08). DISCUSSION: The decreased association between Autoimmune Hepatitis and Cardiovascular Disease is likely multifactorial in etiology. Consequently, this observation requires further examination with prospective trials.

Hospitalization Burden of Biliary Strictures and Cholangitis After Pancreaticoduodenectomy.

BACKGROUND: Postsurgical biliary disease in Roux-en-y and cholecystectomies has been investigated, but less literature exists regarding biliary complications after Whipple procedure (pancreaticoduodenectomy [PD]). Moreover, the hospital burden incurred after this complication has not been previously examined. The aim of this study is to assess the trends in hospitalization for biliary strictures and cholangitis after PD. MATERIALS AND METHODS: The National Inpatient Sample identified all cases with a PD and a primary diagnosis of biliary complication in 2014. Cases were identified using the International Classification of Diseases, Clinical Modification codes. Primary outcomes were association of biliary complications with mortality, cost of admission, and length of stay. RESULTS: A total of 10,145 patients in 2014 were documented with a previous PD. Mortality was 50-fold greater without biliary complications (2.7% versus 0.05%), but a 95% increased length of stay (25.8 d versus 13.2 d, P = 0.014) and 70% increased cost of admission ($293,894 versus $165,862, P = 0.092) occurred with biliary complications. Regression analysis revealed increased length of stay in all cohorts (adjusted odds ratio: 14.3, P = 0.007) and increased cost of admission with cholangitis (adjusted odds: 458283, P = 0.00). Finally, there was increased biliary strictures, cost of hospitalization, and length of stay from 2011 to 2014. CONCLUSIONS: Biliary disease due to the PD appears to longitudinally increase length of stay and cost of hospitalization. Compared with gastrointestinal bleed and delayed gastric emptying, biliary strictures and cholangitis are still very high acuity, requiring more extensive medical resources. Minimally invasive surgeries and robotics could play a vital role in minimizing biliary complications and the ensuing hospitalization burden.

Pancreatic Lesion: Malignancy or Abscess?

BACKGROUND: Pancreatic abscesses are rare. They may be seen in patients with pancreatic inflammation or pancreatitis. Patients with pancreatic abscesses may have abdominal pain, fever, chills, and nausea/vomiting or an inability to eat. Presentation with alternate symptomatology is extremely unusual. CASE REPORT: A 67-year-old Asian male presented with painless, afebrile obstructive jaundice and a CA 19-9 of 1732 IU. He was found to have a 3.1×2.4 cm low-density lesion in the head of the pancreas and the right lobe of the liver, suggesting malignancy. Surgical management was considered, however additional diagnostic workup, including an endoscopic retrograde cholangiopancreatography (ERCP), was performed to complete staging of the presumed mass. A smooth, 3-cm-long, tapering stricture was found it the common bile duct. It was stented from the common hepatic duct to the duodenum. Subsequent endoscopic ultrasound (EUS) evaluation of the pancreatic head lesion revealed a drainable fluid collection that was aspirated and found to contain pyogenic material on pathology. The patient's symptoms resolved, and he was subsequently managed conservatively. A repeat ERCP confirmed complete resolution of the previously visualized cystic lesion. Interestingly, laboratory values showed concomitant normalization of CA 19-9 to 40 IU. CONCLUSIONS: EUS-guided biopsy is not widely regarded as a required step before surgery, in the management of patients with pancreatic masses. It is generally reserved for determination of resectability or staging, and only utilized when clinically indicated. However, this practice may be associated with an inherently significant risk of misdiagnosis and subsequent unnecessary surgery, as illustrated by this case. Malignancy was initially suspected in our patient and surgical resection was recommended. Endoscopic measures were only pursued to complete staging. We propose that EUS-guided biopsy may be a crucial diagnostic step in the management algorithm of pancreatic lesions in selected patients. In addition, we encourage consideration of nonmalignant pancreatic collections in the differential diagnosis of pancreatic masses, especially when present in patients with diabetes mellitus.

Small Bowel Obstruction Mimicking Acute ST-Elevation Myocardial Infarction.

We present a case of a 42-year-old female who presented to our institution with a small bowel obstruction and had emergent surgical decompression. Thirteen days postoperatively, the patient became tachycardic and had worsening epigastric pain. Electrocardiogram showed significant ST-segment elevations in leads II, III, aVF, and V3-V6, suggesting the possibility of acute inferolateral myocardial infarction. Subsequent workup revealed the cause of the ST-elevations to be due to recurrent small bowel obstruction. Although intra-abdominal causes of ST-elevation have been reported, our case may be the first to be associated with small bowel obstruction.

Primary aorto-enteric fistula - a unique complication of poorly differentiated large B-cell lymphoma.

Patient: Male, 76 Final Diagnosis: Aorto-enteric fistula Symptoms: Abdominal pain • bloody vomiting • shock Medication: - Clinical Procedure: CT abdomen with contrast Specialty: Gastroenterology • vascular surgery. OBJECTIVE: Rare disease. BACKGROUND: Primary Aorto-Enteric Fistula (PAEF) is a unique and rare life threatening communication between the Aorta and Gastrointestinal Tract with an unusually high mortality rate and delayed diagnosis. Aortic abdominal aneurysms are implicated in a vast majority of cases while cancer as an etiology of PAEF is extremely rare. CASE REPORT: We present the first case report of a PAEF secondary to Large B-Cell Lymphoma, followed by a review of literature in regards to malignant aorto-enteric fistulae. CONCLUSIONS: We conclude that physicians should maintain a high index of suspicion for PAEF in any patient with unexplained anemia and history of aortic abdominal aneurysm complicated by cancer.