Physicians' perceptions of risks and practices in venous thromboembolism prophylaxis in inflammatory bowel disease.

BACKGROUND: Hospitalized inflammatory bowel disease (IBD) patients are at a higher risk of venous thromboembolism (VTE). AIMS: We aimed to determine perceptions of VTE risks and self-reported practices regarding VTE prophylaxis in hospitalized IBD patients among American gastroenterologists. METHODS: Gastroenterologists who were members of the American Gastroenterological Association (AGA) and cared for IBD patients in the preceding 12 months were included. A survey assessed physicians' perceptions of VTE risks and their practices regarding VTE prophylaxis among IBD inpatients and other factors that may influence the decision to provide prophylaxis. RESULTS: A total of 135 eligible gastroenterologists responded to the survey, 77 % of whom practiced in academic settings. Most physicians (84%) reported having had IBD patients develop VTE. Only 67% cared for IBD patients in hospitals that had protocols for VTE prophylaxis, and 45% were aware of any published guidelines for VTE prophylaxis in hospitalized IBD patients. While only 7% believed that any rectal bleeding was a contraindication to VTE chemoprophylaxis in hospitalized IBD patients with flares, 14% never administered prophylaxis to IBD inpatients. A significant number of respondents felt that hospitalized IBD patients who were ambulatory (24%) or in remission (28%) did not require VTE prophylaxis. There was wide variation on recommendations for duration of anticoagulation for a first unprovoked VTE in an IBD patient. CONCLUSIONS: There is significant variation in reported practices for VTE prophylaxis in IBD patients among gastroenterologists. A more standardized approach to VTE prophylaxis should be implemented to improve health outcomes for IBD inpatients.

Public versus Private Drug Insurance and Outcomes of Patients Requiring Biologic Therapies for Inflammatory Bowel Disease.

Background. Antitumor necrosis factor (anti-TNF) therapy is a highly effective but costly treatment for inflammatory bowel disease (IBD). Methods. We conducted a retrospective cohort study of IBD patients who were prescribed anti-TNF therapy (2007-2014) in Ontario. We assessed if the insurance type was a predictor of timely access to anti-TNF therapy and nonroutine health utilization (emergency department visits and hospitalizations). Results. There were 268 patients with IBD who were prescribed anti-TNF therapy. Public drug coverage was associated with longer median wait times to first dose than private one (56 versus 35 days, P = 0.002). After adjusting for confounders, publicly insured patients were less likely to receive timely access to anti-TNF therapy compared with those privately insured (adjusted hazard ratio, 0.66; 95% CI: 0.45-0.95). After adjustment for demographic and clinical characteristics, publicly funded subjects were more than 2-fold more likely to require hospitalization (incidence rate ratio [IRR], 2.30; 95% CI: 1.19-4.43) and ED visits (IRR 2.42; 95% CI: 1.44-4.08) related to IBD. Conclusions. IBD patients in Ontario with public drug coverage experienced greater delays in access to anti-TNF therapy than privately insured patients and have a higher rate of hospitalizations and ED visits related to IBD.

Colonoscopy Leads to A Diagnosis of A Jejunal Gastrointestinal Stromal Tumour (GIST).

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors in the gastrointestinal (GI) tract, but are the least common of small intestinal malignant neoplasms. While GI bleeding is the most common clinical presentation of GISTs, intussusception and obstruction are uncommon, as GISTs rarely grow into the lumen. We describe an unusual case of a 50-year-old male who presented with intermittent obscure, overt GI bleeding requiring multiple hospital admissions and blood transfusions. His work-up included abdominal CT imaging, small bowel follow-through, gastroscopies, push enteroscopy, colonoscopies, and anterograde and retrograde double-balloon enteroscopies. Complicating his presentation were colonic angiodysplasias and the development of recurrent venous thromboembolism requiring anticoagulation. Within an hour after an apparently uncomplicated colonoscopy, he developed an acute abdomen secondary to a jejunal intussusception, which led to a laparoscopic small bowel resection and the diagnosis of a jejunal GIST. Given his GIST had no high-risk features, ongoing surveillance with abdominal CT imaging was arranged. This case illustrates the complex presentation and diagnostic difficulty of a jejunal GIST causing obscure, overt GI bleeding and this is the first reported case of a jejunal intussusception following colonoscopy. Due to its submucosal location, multiple endoscopic approaches had failed to diagnose the GIST prior to surgery.