Predictive Model for Positive Video Capsule Endoscopy in Iron Deficiency Anemia.

BACKGROUND AND AIMS: Bleeding from the gastrointestinal tract can contribute to the development of iron deficiency anemia (IDA) among individuals without another obvious source of bleeding. In order to identify patients most likely to benefit from examination of the small bowel, our aim was to create a risk score for positive video capsule endoscopy (VCE) in IDA utilizing a multicenter collection of studies. METHODS: We performed a retrospective multicenter study utilizing VCE studies performed for an indication of IDA between 1/1/2005 and 7/31/2018. VCE findings were graded based on the P0-P2 grading system. The primary outcome of interest was a positive (P2) VCE. Data were analyzed with Student's t test for continuous variables and the Fisher's exact test for categorical variables. Logistic regression was used to identify independent associations with positive VCE. RESULTS: In total, 765 VCE procedures were included with 355 (46.5%) male subjects and a median age of 63.2 (SD 15.3) years. One hundred ninety studies (24.8%) were positive (P2) for small bowel bleeding. Four variables associated with positive VCE which were incorporated into a point scoring system: (+) 1 for age ≥ 66 years, active smoking and cardiac arrythmia and (-) 1 for preceding hemoglobin level ≥ 8.5. The risk probabilities for positive VCE-assigned scores - 1, 0, 1, and 2 + were 12.3% (95% CI 7.3-17.3%), 20% (14.9-25.1%), 34.8% (28.6-41%), and 39% (30-47.8%). CONCLUSION: In order to improve the diagnostic yield of capsule examinations, risk factors should be applied to clinical decision-making. We created a risk score for positive VCE in IDA, including the risk factors of age, smoking, history of cardiac arrythmia, and preceding hemoglobin level.

Exposure to corticosteroids in pregnancy is associated with adverse perinatal outcomes among infants of mothers with inflammatory bowel disease: results from the PIANO registry.

OBJECTIVE: Active inflammatory bowel disease (IBD) during pregnancy may require the use of corticosteroids. The aim of this study was to investigate the impact of in utero corticosteroid exposure on adverse pregnancy outcomes, congenital malformations, infections and neurocognitive development among offspring of mothers with IBD. DESIGN: Using the prospective Pregnancy in Inflammatory Bowel Disease and Neonatal Outcomes registry, data were collected at each trimester, delivery; and in the 12 months post partum. Bivariate statistics and multivariate logistic regression models compared pregnancy outcomes by corticosteroid exposure. RESULTS: A total of 1490 mothers with IBD were enrolled, with 1431 live births recorded. Corticosteroid use was associated with increased risk of preterm birth, small for gestational age, low birth weight (LBW), intrauterine growth restriction and neonatal intensive care unit (NICU) admission. On adjusted multivariate models, corticosteroid use was associated with preterm birth (OR 1.79, 95% CI 1.18 to 2.73), LBW (OR 1.76, 95% CI 1.07 to 2.88) and NICU admission (OR 1.54, 95% CI 1.03 to 2.30). Late corticosteroid use (second and/or third trimester) was associated with serious infections at 9 and 12 months (4% vs 2% and 5% vs 2%, respectively, p=0.03 and p=0.001). There were five newborns with in utero corticosteroid exposure born with orofacial clefts versus one without corticosteroid exposure. Developmental milestones were similar across corticosteroid exposure groups. CONCLUSION: In this prospective pregnancy registry, offspring of women exposed to corticosteroids during pregnancy were more likely to have adverse pregnancy outcomes. This emphasises the importance of controlling disease activity before and during pregnancy with steroid-sparing therapy.

Inflammatory bowel disease in underserved populations: lessons for practice.

PURPOSE OF REVIEW: The incidence of inflammatory bowel disease (IBD) is increasing in minority groups across the USA. There are racial and ethnic disparities in IBD care and outcomes that are rooted in historical injustice and inequities in the social determinants of health. RECENT FINDINGS: Current literature has identified racial, ethnic and sociodemographic disparities in therapeutics and outcomes for IBD, including disease severity, morbidity and mortality. SUMMARY: Strategies to achieve equity in IBD include tackling structural racism as a driver of health disparities and making actionable changes against multilevel barriers to care.

Assessing the Impact of COVID-19 on IBD Outcomes Among Vulnerable Patient Populations in a Large Metropolitan Center.

BACKGROUND: With the onset of COVID-19, there were rapid changes in healthcare delivery as remote access became the norm. The aim of this study was to determine the impact of changes in healthcare delivery during the COVID-19 pandemic on patients with inflammatory bowel disease (IBD), in both well-resourced and vulnerable populations. METHODS: Using a mixed methods, observational study design, patients receiving IBD care at a university or a safety-net hospital were identified by the electronic health record. Patient demographics, IBD history, and disease activity were acquired from the electronic health record. IBD-related outcomes were compared from the onset of the pandemic in the United States until December 2020 (COVID-19 pandemic year 1) and compared with outcomes in the previous year. A subset of participants provided their perspective on how changes in healthcare delivery and financial stability impacted their IBD through a standardized questionnaire and semi-structured interview. RESULTS: Data from a total of 1449 participants were captured, 1324 at the tertiary care university hospital and 125 at the safety-net hospital. During COVID-19, there was a decrease in healthcare utilization at both sites. Race/ethnicity and primary language were not associated with IBD-related hospitalizations or admissions. Patients that were employed and those with insurance had a higher number of IBD-related emergency department visits at both the university and safety-net hospitals (P = .03 and P = .01, respectively). Patients who did not speak English were more likely to report challenges using technology with telehealth and difficulty contacting IBD providers. CONCLUSIONS: For IBD populations, during COVID-19, in both hospital settings, emergency department visits, hospitalizations, outpatient surgery, and clinic visits were reduced compared with the year prior. Patients with lower socioeconomic status and limited English proficiency reported facing more challenges with changes to healthcare delivery, healthcare access, and conveying changes in IBD activity. These results highlight the need for payors and providers to specifically attend to those populations most susceptible to these systemic and lasting changes in care delivery and promote greater equity in healthcare.

Health Care Disparities, Social Determinants of Health, and Emotional Impacts in Patients with Ulcerative Colitis: Results from a Global Ulcerative Colitis Narrative Patient Survey.

BACKGROUND: The Ulcerative Colitis (UC) Narrative global survey assessed aspects of living with UC. This analysis aimed to identify health care disparities, social determinants of health, and emotional impacts related to UC disease management, patient experience, and quality of life. METHODS: The survey was conducted by The Harris Poll from August 2017 to February 2018 among adults with UC. Responses from 1000 patients in the United States, Canada, Japan, France, and Finland were analyzed based on patient income, employment status, educational level, age, sex, and psychological comorbidities. Odds ratios (ORs) with significant P values (P < .05) from multivariate logistic regression models are reported. RESULTS: Low-income vs high-income patients were less likely to have participated in a peer mentoring (OR, 0.30) or UC education program (OR, 0.51). Patients not employed were less likely to report being in "good/excellent" health (OR, 0.58) than patients employed full time. Patients with low vs high educational levels were less likely to have reached out to patient associations/organizations (OR, 0.59). Patients aged younger than 50 years vs those aged 50 years and older were less likely to have visited an office within an inflammatory bowel disease center/clinic in the past 12 months (OR, 0.53). Males were less likely to be currently seeing their gastroenterologist than females (OR, 0.66). Patients with vs without depression were less likely to agree that UC had made them more resilient (OR, 0.51). CONCLUSIONS: Substantial differences in disease management and health care experience were identified, based on categories pertaining to patient demographics and psychological comorbidities, which may help health care providers better understand and advance health equity to improve patient care.

Patient-reported survey results revealed substantial differences in disease management and health care experience in patients with ulcerative colitis, based on categories pertaining to patient demographics and diagnosed psychological comorbidities, including income level, employment status, educational level, age, sex, depression, and anxiety.

The Current State of Care for Black and Hispanic Inflammatory Bowel Disease Patients.

Research on the care of inflammatory bowel disease (IBD) patients has been primarily in populations of European ancestry. However, the incidence of IBD, which comprises Crohn's disease and ulcerative colitis, is increasing in different populations around the world. In this comprehensive review, we examine the epidemiology, clinical presentations, disease phenotypes, treatment outcomes, social determinants of health, and genetic and environmental factors in the pathogenesis of IBD in Black and Hispanic patients in the United States. To improve health equity of underserved minorities with IBD, we identified the following priority areas: access to care, accurate assessment of treatment outcomes, incorporation of Black and Hispanic patients in therapeutic clinical trials, and investigation of environmental factors that lead to the increase in disease incidence.

In this comprehensive review, we examine the epidemiology, clinical presentations, disease phenotypes, treatment outcomes, social determinants of health, and genetic and environment factors in the pathogenesis of IBD in Black and Hispanic patients in the United States.

Recurrent Perihepatic Abscesses Arising from a Gastric Remnant Leak: Delayed Complication of a Revision Roux-en-Y Gastric Bypass.

Roux-en-Y gastric bypass is a procedure commonly used for weight loss associated with improved outcomes and decreased complications when compared to some counterparts. The procedure involves restriction of the stomach that is achieved by creation of a gastric pouch and bypass of the duodenum and a portion of the jejunum to aid in restrictive and malabsorptive weight loss. While many complications, both early and late, have been described following the procedure, recurrent perihepatic abscess has not been described in the literature. We present a case of a 66-year-old woman with recurrent extrahepatic abscesses following revision of a Roux-en-Y gastric bypass.

Cholestatic Hepatitis as a Possible Paraneoplastic Syndrome of Endometrial Carcinoma.

Cholestatic hepatitis has not been reported as a paraneoplastic syndrome of endometrial adenocarcinoma to our knowledge. We present a patient who, shortly after endometrial adenocarcinoma diagnosis, presented with elevated liver chemistries in the setting of an acute, paraneoplastic sensorimotor polyneuropathy. Infectious, autoimmune, pharmacologic, malignant, metabolic, and structural causes of cholestatic hepatitis were screened for and ruled out. Our patient was diagnosed with simultaneous cholestatic hepatitis and acute sensorimotor polyneuropathy as possible paraneoplastic syndromes of endometrial adenocarcinoma. Clinicians should include paraneoplastic processes of cancer in the differential diagnosis for liver injury, especially when workup for alternative causes is unrevealing.

Health Maintenance and Vaccination of Patients With Inflammatory Bowel Disease: Practice and Perception of Responsibility of Gastroenterologists vs Primary Care Providers.

Background: Although it is well established that patients with inflammatory bowel disease (IBD) are at increased risk of complicating diseases and vaccination-preventable infections, whether gastroenterologists (GIs) or primary care providers (PCPs) assume responsibility for these patients' health maintenance is not clear. Methods: We anonymously surveyed a convenience sample of 94 PCPs and 61 GIs at Saint Louis University School of Medicine in St. Louis, MO, about their practice and perception of the health maintenance and vaccination of patients with IBD. Results: Response rates were 82% and 93% for GIs and PCPs, respectively. GIs were as likely as PCPs to screen for smoking (88% vs 89%) and were significantly less likely to screen for depression/anxiety (24% vs 54%) or to provide pertussis (14% vs 44%) or diphtheria (20% vs 48%) vaccines. GIs were significantly more likely than PCPs to assess for colonoscopy need (94% vs 80%); to screen for nonmelanoma skin cancer (62% vs 14%), melanoma (56% vs 7%), osteoporosis (72% vs 51%), or tuberculosis (94% vs 44%); to prescribe calcium/vitamin D (74% vs 53%); to perform nutritional assessment (78% vs 33%); or to provide hepatitis A (60% vs 39%) or hepatitis B (86% vs 56%) vaccines. GIs were as likely as PCPs (64% vs 75%) to perceive that PCPs should order vaccinations and significantly more likely to perceive that GIs should track vaccinations (58% vs 16%) and other health maintenance issues (90% vs 49%). We found positive associations between performing the various health maintenance and vaccination tasks and the perception of responsibility. Conclusion: Several health maintenance aspects are inadequately addressed by GIs and PCPs, in part because of conflicting perceptions of responsibility. Clear guidelines and better GI/PCP communication are required to ensure effective health maintenance for patients with IBD.

Bronchobiliary fistula: a rare complication after pancreaticoduodenectomy.

Biliary anatomic pathologies are rare disease occurrences that can result from a number of causes, most commonly iatrogenic, infectious and malignant aetiologies. Communications between the biliary and bronchial systems are even rarer and few cases have been documented in the literature. The present study describes a case of a 70-year-old man who underwent a pancreaticoduodenectomy (Whipple Procedure) as a curative procedure for an early stage neuroendocrine tumour. He presented nearly a decade after surgery with a communication between the biliary and bronchial tree initially manifesting as bilioptysis. His underlying medical conditions and poor clinical picture made treatment options limited. Therefore, he was treated conservatively with percutaneous biliary balloon dilation of the anastomotic stricture followed by temporary percutaneous internal/external drain and made a full recovery.