Fungal Peptic Ulcer Disease in an Immunocompetent Patient.

The lifetime prevalence of peptic ulcer disease (PUD) is 5-10%. While PUD in immunocompetent patients is most commonly associated with Helicobacter pylori infection or the use of non-steroidal anti-inflammatory drugs (NSAIDs), other common causes of PUD must also be considered in the differential diagnosis. We describe a case of endoscopic and histological resolution of PUD related to Candida infection in a healthy, immunocompetent woman. LEARNING POINTS: Peptic ulcer disease (PUD) can be secondary to fungal infections, even in immunocompetent patients.A higher index of suspicion needs to be maintained for fungal causes of PUD, particularly if symptoms do not improve.Recognizing fungal causes of PUD may lead to faster diagnosis and treatment.

Endoscopic and Pathologic Resolution of Chronic Nonsteroidal Anti-Inflammatory Drug-Induced Diaphragm-Like Colonic Strictures and Ulceration.

The chronic use of nonsteroidal anti-inflammatory drugs (NSAIDs) has steadily increased and, as a result, adverse effects have become more common. Isolated case reports have documented diaphragm-like colonic strictures and ulceration as the result of NSAID use. We report a unique case of this rare side effect with documented endoscopic and histologic healing of multiple proximal diaphragm-like colonic strictures and ulceration months after simple discontinuation of NSAID therapy.

Small bowel angioedema from angiotensin-converting enzyme: Changes on computed tomography.

Intestinal angioedema is a rare side effect of angiotensin-converting enzyme inhibitors. We present a 41-year-old woman with sporadic right lower quadrant abdominal pain and diarrhea with multiple computed tomography scans demonstrating enteritis. Suspicion turned to angiotensin-converting enzyme inhibitor use as the cause for the patient's illness after an extensive negative evaluation including labs, stool studies, endoscopies, and capsule endoscopy. Weeks after stopping the medication, the patient's symptoms improved and repeat computed tomography showed a resolution of the previously seen findings of enteritis. This case illustrates the importance of a good medication review to make appropriate clinical decisions and diagnoses.

A Severe Case of Ipilimumab-Induced Ileocolitis Refractory to Glucocorticosteroids and Infliximab.

Ipilimumab is a monoclonal antibody that works as an immunotherapeutic agent through selective targeting of T cells to strengthen the response to metastatic melanoma. It is well known that this pharmaceutical agent can cause the adverse effect of colitis. We report a rare presentation of ileocolitis refractory to both glucocorticosteroids and infliximab with a resultant pneumatosis and perforation requiring subtotal colectomy and end ileostomy.

Thirty-Day Readmission Rate Is High for Hospitalized Patients Discharged With Home Parenteral Nutrition or Intravenous Fluids.

BACKGROUND: Reducing hospital readmissions decreases healthcare costs and improves quality of care. There are no published studies examining the rate of, and risk factors for, 30-day readmissions for patients discharged with home parenteral support (HPS). OBJECTIVE: Determine the rate of 30-day readmissions for patients discharged with HPS and whether malnutrition and other demographic or clinical factors increase the risk. MATERIALS AND METHODS: Retrospective review of patients discharged with HPS from the Cleveland Clinic between July 1, 2013, and June 30, 2014, and followed by the Cleveland Clinic Home Nutrition Support Service. RESULTS: Of the 224 patients studied, 31.6% (n = 71) had unplanned readmissions within 30 days of hospital discharge. Of these, 21.1% (n = 15) were HPS related, with catheter-related bloodstream infection (n = 5) and dehydration (n = 5) the most common. The majority of patients (84.4%) were diagnosed with malnutrition, but the presence or degree did not influence the readmission rate ( P = .41). According to univariable analysis, patients with an ostomy ( P = .037), a small bowel resection ( P = .002), a higher HPS volume at discharge ( P < .001), and a shorter period between HPS consult and hospital discharge ( P < .026) had a lower risk of 30-day readmission than their counterparts. On multivariable analysis, patients had a higher risk of 30-day readmission if they had a history of heart disease ( P = .048) and for every 1-unit increase in white blood cells ( P = .026). CONCLUSIONS: Patients discharged with HPS have a high 30-day readmission rate, although most readmissions were not related to the HPS itself. The presence and degree of malnutrition were not associated with 30-day readmissions.

Malnutrition: laboratory markers vs nutritional assessment.

Malnutrition is an independent risk factor for patient morbidity and mortality and is associated with increased healthcare-related costs. However, a major dilemma exists due to lack of a unified definition for the term. Furthermore, there are no standard methods for screening and diagnosing patients with malnutrition, leading to confusion and varying practices among physicians across the world. The role of inflammation as a risk factor for malnutrition has also been recently recognized. Historically, serum proteins such as albumin and prealbumin (PAB) have been widely used by physicians to determine patient nutritional status. However, recent focus has been on an appropriate nutrition-focused physical examination (NFPE) for diagnosing malnutrition. The current consensus is that laboratory markers are not reliable by themselves but could be used as a complement to a thorough physical examination. Future studies are needed to identify serum biomarkers in order to diagnose malnutrition unaffected by inflammatory states and have the advantage of being noninvasive and relatively cost-effective. However, a thorough NFPE has an unprecedented role in diagnosing malnutrition.

Management of gastroparesis-associated malnutrition.

Gastroparesis (GP) is a chronic debilitating dysmotility characterized by unrelenting nausea, vomiting, bloating, early satiety, postprandial fullness and abdominal pain. Patients with GP experience other associated conditions, including gastroesophageal reflux disease, gastric bezoars and small bowel bacterial overgrowth. Furthermore, GP is associated with poor quality of life, increased emergency room visits, hospitalizations and subsequent increased healthcare costs. Currently, the managements of GP consist of glycemic control, antiemetics, prokinetics and the use of gastric electrical stimulation. However, most GP patients are at risk for significant nutritional abnormalities. As such, it is essential to screen and diagnose malnutrition in these patients. Poor oral intake in such patients could be supplemented by enteral tube feeding. Parenteral nutrition, although a last resort, is associated with a number of complications and should be used only for the short term. In summary, a systematic approach including initial nutritional screening, diet recommendations, medical therapy, nutritional re-evaluation and enteral and parental nutrition should be considered in complex GP patients.