Factors Associated with Delayed Paracentesis in Patients with Spontaneous Bacterial Peritonitis.

BACKGROUND AND AIM: In patients with spontaneous bacterial peritonitis (SBP), studies show that delayed paracentesis (DP) is associated with worse outcomes and mortality. We aimed to assess the rate of DP in the community setting and associated factors with early versus delayed paracentesis. METHODS: Patients hospitalized with SBP were retrospectively studied between 12/2013 and 12/2018. DP was defined as paracentesis performed > 12 h from initial encounter. Data collected included: patient factors (i.e., age, race, symptoms, history of SBP, MELD) and physician factors (i.e., admission service, shift times, providers ordering and performing paracentesis). Logistic regression analysis was performed to assess for factors associated with DP. RESULTS: DP occurred 82% of the time (n = 97). The most significant factors in predicting timing of paracentesis were ordering physician [emergency department (ED) physician was associated with early paracentesis (57% vs 8%, p < 0.001) and specialty of physician performing paracentesis (interventional radiology was associated with DP (88% vs 48%, p < 0.001)]. Younger patients were more likely to receive early paracentesis. In regression analysis, the factor most associated with early paracentesis was when the order was made by the ED provider (OR 0.07, 95% CI 0.02-0.22). No differences were observed in patients with prior history of SBP, abdominal pain, encephalopathy, or creatinine level. CONCLUSIONS: Studies have suggested that DP is associated with increased mortality in patients with SBP. Despite this, DP is common in the community setting and is influenced by ordering physician and specialty of physician performing paracentesis. Future efforts should assess interventions to improve this important quality indicator.

The Cloaked Intruder: An Unexpected Case of Eosinophilic Cholangitis.

Often, when biliary strictures are evaluated, malignancy is high on the differential. However, it is important to consider benign and malignant causes because approximately 10% of biliary strictures are benign. Eosinophilic cholangitis is an extremely rare benign disorder of the biliary tract caused by fibrosis and stricture from eosinophilic infiltration. The etiology of the disease remains unclear, and often, patients present with obstructive jaundice. We present a young man who presented with obstructive jaundice and abdominal pain, with a biliary stricture and peripheral eosinophilia. The final surgical pathology revealed eosinophilic cholangitis.

Pseudomelanosis intestini "from pylorus to jejunum:" A rare endoscopic finding in a patient with GI bleeding.

Pseudomelanosis of the gastrointestinal (GI) tract is a rare condition used to describe the accumulation of pigment deposits in the intestinal mucosa. Its underlying cause is not well understood. It has been described in association with gastrointestinal hemorrhage, chronic kidney disease, hypertension, diabetes mellitus, and medications such as hydralazine, ferrous sulfate, and furosemide. Melanosis coli is a well-known condition associated with the use of anthranoid laxatives; however, pseudomelanosis of the small intestine is extremely rare and most commonly described in the duodenum, with few cases in the gastric mucosa and even more rare in the jejunum. Herein, we report a case of pseudomelanosis intestini involving the pylorus, duodenum, and proximal jejunum in a patient presented with GI bleeding. The clinical significance of this condition is unknown; however, gastroenterologists should be aware of its existence.