Early intervention with double balloon enteroscopy for higher yield for inpatient overt obscure gastrointestinal bleeding: A propensity matched analysis.

Background and Aim: Overt obscure gastrointestinal bleeding (OOGIB) is defined as continued bleeding with unknown source despite esophagogastroduodenoscopy (EGD) and colonoscopy evaluation. Small bowel evaluation through video capsule endoscopy (VCE) or double balloon enteroscopy (DBE) is often warranted. We studied the timing of DBE in hospitalized OOGIB patients regarding diagnostic yield, therapeutic yield, and GI rebleeding. Methods: We performed a retrospective review of DBEs performed at a tertiary medical center between November 2012 and December 2020. The inclusion criterion was first admission for OOGIB undergoing DBE. Those without previous EGD or colonoscopy were excluded. Patients were stratified into two groups: DBE performed within 72 h of OOGIB (emergent) and beyond 72 h of OOGIB (nonemergent). Propensity score matching was used to adjust for the difference in patients in the two groups. Logistic regression analysis was used to assess factors associated with diagnostic and therapeutic yield. Kaplan-Meir survival curve showed GI bleed-free survival following initial bleed and was compared using the log rank test. Results: A total of 154 patients met the inclusion criterion, of which 62 had emergent DBE and 92 had nonemergent DBE. The propensity-score-matched sample consisted of 112 patients, with 56 patients each in the emergent and nonemergent groups. Univariate and multivariable logistic regression analysis showed a significant association between VCE and emergent DBE and diagnostic and therapeutic yield (P < 0.05). Emergent DBE patients had increased GI bleed-free survival compared to those in the nonemergent group (P = 0.009). Conclusion: Our data demonstrate that emergent DBE during inpatient OOGIB can impact the overall diagnostic yield, therapeutic yield, and GI rebleeding post DBE.

Hepatitis C Treatment in Patients With Porphyria Cutanea Tarda.

BACKGROUND: Hepatitis C virus (HCV) infection is a common susceptibility factor for porphyria cutanea tarda (PCT). Experience on HCV treatment in patients with PCT is limited. Recently, HCV treatment has improved with direct-acting antivirals (DAA). We review our experience on HCV treatment in patients with PCT with older and newer regimens. MATERIALS AND METHODS: A retrospective chart review was conducted. HCV treatment was attempted 22 times in 13 patients with PCT (5 attempts in 1, 2 in 5 and 1 in the other 7 patients). RESULTS: Before starting HCV treatment, PCT was in complete remission in 16, partial remission in 2, unknown status in 2 and active in 2 instances. PCT relapsed during therapy 6 times (all interferon-based regimens and 2 including telaprevir), 4 requiring treatment interruption. Treatment was interrupted for reasons other than PCT relapse in 2 patients treated with interferon-based regimens. To prevent PCT recurrence, hydroxychloroquine was continued during HCV therapy 6 times (3 interferon regimens, 2 ribavirin regimens without interferon and 1 DAA alone). Twelve patients achieved sustained viral response, 3 with interferon regimens and 9 with DAA. Two patients with active PCT were treated with DAA, with reduction of plasma porphyrins in 1 and normalization in the other at the end of HCV therapy. CONCLUSIONS: HCV treatment regimens including interferon or ribavirin may precipitate PCT relapse. Hydroxychloroquine may be useful to prevent such relapses. In this limited experience, DAA were not associated with PCT relapse. Studies are needed to examine DAA as a primary PCT treatment in HCV-infected patients.

Impact of vitamin D on the hospitalization rate of Crohn's disease patients seen at a tertiary care center.

AIM: To study the association between vitamin D level and hospitalization rate in Crohn's disease (CD) patients. METHODS: We designed a retrospective cohort study using adult patients (> 19 years) with CD followed for at least one year at our inflammatory bowel disease center. Vitamin D levels were divided into: low mean vitamin D level (< 30 ng/mL) vs appropriate mean vitamin D level (30-100 ng/mL). Generalized Poisson Regression Models (GPR) for Rate Data were used to estimate partially adjusted and fully adjusted incidence rate ratios (IRR) of hospitalization among CD patients. We also examined IRRs for vitamin D level as a continuous variable. RESULTS: Of the 880 CD patients, 196 patients with vitamin D level during the observation period were included. Partially adjusted model demonstrated that CD patients with a low mean vitamin D level were almost twice more likely to be admitted (IRR = 1.76, 95%CI: 1.38-2.24) compared to those with an appropriate vitamin D level. The fully adjusted model confirmed this association (IRR = 1.44, 95%CI: 1.11-1.87). Partially adjusted model with vitamin D level as a continuous variable demonstrated, higher mean vitamin D level was associated with a 3% lower likelihood of admission with every unit (ng/mL) rise in mean vitamin D level (IRR = 0.97, 95%CI: 0.96-0.98). The fully adjusted model confirmed this association (IRR = 0.98, 95%CI: 0.97-0.99). CONCLUSION: Normal or adequate vitamin D stores may be protective in the clinical course of CD. However, this role needs to be further characterized and understood.

Budesonide Use and Hospitalization Rate in Crohn's Disease: Results From a Cohort at a Tertiary Care IBD Referral Center.

BACKGROUND: Budesonide is generally not used for periods > 90 days in Crohn's disease (CD). We sought to study the association between cumulative outpatient budesonide use in days and hospitalization rate in CD patients seen at our institution. METHODS: Using a retrospective cohort study design, we selected CD patients > 19 years old and followed for at least 1 year. Days of outpatient budesonide use were calculated by reviewing outpatient clinic notes. Treatment groups included patients who were not given budesonide, received budesonide from 1 to 90 days, and received budesonide > 90 days. We performed univariate analyses and developed generalized Poisson regression models for rate data to estimate incidence rate ratios (IRRs) and 95% confidence intervals (95% CIs) for CD-related hospitalization. RESULTS: Of 767 CD patients, 664 did not receive budesonide, 45 received budesonide from 1 to 90 days, and 58 received budesonide for > 90 days. Incidence rates of hospitalization in patients who received no budesonide vs. 1 - 90 days of budesonide vs. > 90 days of budesonide were 31, 26, and 19 per 100 person-years, respectively. Adjusted models demonstrated that receiving outpatient budesonide from 1 to 90 days and for > 90 days was associated with a lower likelihood of being admitted for a CD exacerbation (1 - 90 days: IRR 0.85; 95% CI 0.65 - 1.10; > 90 days: IRR 0.71; 95% CI 0.56 - 0.91). CONCLUSIONS: Outpatient budesonide use appears to be associated with a lower likelihood of a CD-related hospitalization, notably when used for > 90 days. This association needs to be further assessed before recommending this agent for routine use for > 90 days.