Identifying patients with complicated diverticulitis, is it that complicated?

Objectives: Discriminating simple from complicated diverticulitis solely on clinical bases is challenging. The aim of this study was to identify clinical predictive factor for the need for invasive treatment for patients presenting with acute diverticulitis in the emergency room. Material and Methods: The records of all patients, who were discharged from a university hospital between January 2010 and March 2018 with "diverticulitis" diagnosis, were reviewed. Data collected included clinical features, whether this was a first or recurrent episode, WBC, and Hinchey score. Patients were divided into conservative and invasive treatment groups. Groups were compared by age, sex, BMI, fever, WBC and CT findings. Hinchey score groups were also compared by age, sex, BMI, fever, WBC. Results: A total of 809 patients were included. Mean age was 60.6 years, with 10% below 40 years. Most patients were treated conservatively (95.9%) while only 4.1% were treated invasively. WBC at presentation was significantly higher in those who required invasive treatment in comparison with the conservative group (13.72 vs. 11.46K/uL, p= 0.024). A statistically significant higher WBC was found among patients with a higher Hinchey score (13.16 vs 11.69, p <0.005). No difference between the groups was found in terms of age, sex, fever or BMI. Conclusion: This study showed that patients who present with acute diverticulitis and an elevated WBC are prone to a more severe disease and a higher Hinchey score. Prudence should be taken with these patients, and CT scan is warranted as there is a greater chance that invasive treatment will be required.

Hiatal Hernia Evaluation Before Bariatric Surgery: Should It Be Routinely Done?

PURPOSE: The necessity of routine preoperative esophagogastroduodenoscopy (EGD) and upper gastrointestinal series (UGIS) in the evaluation of hiatal hernia (HH) among bariatric surgery candidates is controversial since most are detected during surgery, regardless of the preoperative work-up. The aim is to determine the accuracy of preoperative EGD and UGIS for HH diagnosis among bariatric surgery candidates. MATERIAL AND METHODS: The records of bariatric surgery patients between 2011 and 2015 were reviewed. Patients underwent routine UGIS and/or EGD before the surgery. The positive and negative predictive values (PPV, NPV) for each study were calculated based on operative findings. RESULTS: A total of 463 patients were included in the study. Mean age was 44.34 ± 12.99 years. Mean preoperative body mass index (BMI) was 42.7 ± 5.15 kg/m2. A total of 450 patients (97.2%) had a UGIS, 263 patients underwent EGD (56.8%), and 258 (55.7%) patients had both tests. HH was diagnosed in 26 (5.8%), 60 (13%), and 72 (27.8%) patients, respectively. HH was found intra-operatively in 53 patients (11.4%). It was associated with heartburn (P = 0.005) and previous bariatric surgery (P = 0.008). EGD had a greater sensitivity than UGIS (47.4% vs. 30.2%) and a lower specificity (81.4% vs. 97.5%). PPV and NPV for UGIS and EGD were 61.5% and 91.3% vs. 30% and 90.2%, respectively. The sensitivity of both tests when combined together reached 60.5%. CONCLUSIONS: Both EGD and UGIS, whether solely performed or combined, have low sensitivity for diagnosis of HH and can probably be omitted from the preoperative evaluation, except for high-risk patients.

Practical recommendations for kidney transplantation in the COVID-19 pandemic.

Kidney transplantation at the time of a global viral pandemic has become challenging in many aspects. Firstly, we must reassess deceased donor safety (for the recipient) especially in communities with a relatively high incidence of coronavirus disease 19 (COVID-19). With respect to elective live donors, if one decides to do them at all, similar considerations must be made that may impose undue hardship on the donor. Recipient selection is also problematic since there is clear evidence of a much higher morbidity and mortality from COVID-19 for patients older than 60 and those with comorbidities such as hypertension, diabetes, obesity and lung disease. Unfortunately, many, if not most of dialysis patients fit that mold. We may and indeed must reassess our allocation policies, but this must be done based on data rather than conjecture. Follow-up routines must be re-engineered to minimize patient travel and exposure. Reliance on technology and telemedicine is paramount. Making this technology available to patients is extremely important. Modifying or changing immunosuppression protocols is controversial and not based on clinical studies. Nevertheless, we should reassess the need for induction therapy across the board for ordinary patients and the more liberal use of mammalian target of rapamycin inhibitors in transplant patients with proven infection.

Gastric goblet cell carcinoma concurrent with a neuroendocrine tumor.

Goblet cell carcinoma, a tumor that is assumed to originate from crypt base stem cells, is a distinct type of tumor, that occurs typically in the appendix, however, extra-appendiceal locations were also described in few cases. We herein present a unique case of a 48-year-old male with a diagnosis of primary gastric Goblet cell carcinoma that was initially discovered at the time of an endoscopy performed to evaluate an unremitting abdominal pain that was accompanied by remarkable weight loss; four polypoid fragments of the gastric mucosa were sent for histopathologic examination which showed a moderately differentiated goblet cell carcinoma in addition to classical neuroendocrine tumor. Later, laparoscopic D2 total gastrectomy with appendectomy were performed and confirmed the previously mentioned findings along with a normal histopathology of the appendix.

Kidney Transplantation in the Times of COVID-19 - A Literature Review.

Kidney transplantation at the time of the COVID-19 pandemic is challenging. Modifying the immunosuppression protocols is controversial and not evidence based. In this study, we aim to review the published literature of kidney transplant recipients who encountered COVID-19. A literature review was performed using PubMed, ScienceDirect, and World Health Organization databases to identify relevant English-language articles published up to May 7, 2020. There were 24 articles that reported 129 kidney transplant recipients who encountered COVID-19. The age mean was 54.2 years with 73.7% as males. The most commonly reported presentations in order were fever (82.3%), cough (58%), shortness of breath (33.2%), and fatigue (30.7%). Acute kidney injury was observed in 34.1% of patients. Kidney transplant patients encountered COVID-19 were maintained on tacrolimus (Tac, 92%), mycophenolate mofetil (MMF, 78.8%), and prednisone (Pred, 77%) and were manage by holding MMF in 79.1% of patients and holding Tac in 34.4% of patients. In all, 20% of patients needed Intensive Care Unit (ICU) admission and 24.6% of patients required mechanical ventilation. In all, 18.8% of patients had died compared to the reported general population COVID-19 mortality of 3.4%. The clinical presentation of COVID-19 in kidney transplant recipients may be different from the general population with a higher rate of severe disease, complications including renal failure, and mortality.

Intussusception in a pregnant patient caused by an ectopic pancreatic mass.

Small bowel obstruction is an uncommon disease in pregnant women and rare when it is caused by intussusception. Intussusception is a rare cause of intestinal obstruction in adult. When it occurs, it is almost always secondary to an underlying pathology acting as a lead point for invagination, such as polyps, hemartomas, lipomas, leiomyomas, Meckel's diverticulum, adenomas, strictures, and malignancies. Ectopic pancreatic tissue is a very rare pathology acting as the lead point. In this case, we present a very rare case of intussusception in a young pregnant woman, caused by an intramural ectopic pancreatic tissue in the ileum.