Immediate dilation in esophageal food impaction is safe and effective but performed infrequently: observations from a large Midwest US cohort.

This study aimed to determine the rate and safety of immediate esophageal dilation for esophageal food bolus impaction (EFBI) and evaluate its impact on early recurrence (i.e. prior to interval esophageal dilation) from a large Midwest US cohort. We also report practice patterns among community and academic gastroenterologists practicing in similar settings. We identified adult patients with a primary discharge diagnosis for EFBI from January 2012 to June 2018 using our institutional database. Pregnant patients, incarcerated patients, and patients with esophageal neoplasm were excluded. The primary outcome measured was rate of complications with immediate esophageal dilation after disimpaction of EFBI. Secondary outcomes were recurrence of food bolus impaction prior to scheduled interval endoscopy for dilation, practice patterns between academic and private gastroenterologists, and adherence to follow-up endoscopy. Two-hundred and fifty-six patients met our inclusion criteria. Esophageal dilation was performed in 46 patients (18%) at the time of disimpaction. A total of 45 gastroenterologists performed endoscopies for EFBI in our cohort. Twenty-five (62%) did not perform immediate esophageal dilation, and only 5 (11%) performed immediate dilation on greater than 50% of cases. Academic gastroenterologists performed disimpaction of EFBI for 102 patients, immediate dilation as performed in 20 patients and interval dilation was recommended in 82 patients. Of these 82, only 31 patients (38%) did not return for interval dilation. Four patients who did not undergo immediate dilation, presented with recurrent EFBI prior to interval dilation, within 3 months. None of the patients had complications. Complications with immediate esophageal dilation after disimpaction of EFBI are infrequent but are rarely performed. Failure of immediate dilation increases the risk of EFBI recurrence. Given poor patient adherence to interval dilation, immediate dilation is recommended.

Trends and Outcomes of Hospitalizations Related to Acute Pancreatitis: Epidemiology From 2001 to 2014 in the United States.

OBJECTIVES: The aim of this study was to determine the recent trends of the rates of hospitalization, mortality of hospitalized patients, and associated health care utilization in patients with acute pancreatitis (AP). METHODS: We identified adult patients with primary discharge diagnosis of AP from the National Inpatient Sample database. Patients with chronic pancreatitis and/or pancreatic cancer were excluded. Primary outcomes included age-adjusted incidence of AP and in-hospital mortality based on US standard population derived from the 2000 census data. Secondary outcomes were length of stay, inflation-adjusted hospital costs in 2014 US dollars, and procedural rates. Subgroup analysis included disease etiologies, age, race, sex, hospital region, hospital size, and institution type. RESULTS: From 2001 to 2014, the rate of primary discharge diagnosis for AP increased from 65.38 to 81.88 per 100,000 US adults per year. In-hospital case fatality decreased from 1.68% to 0.69%. Mortality rate is higher in patients with AP who are older than 65 years (3.4%). Length of stay decreased, with a median of 3.8 days; cost per hospitalization decreased since 2007 from $7602 to $6766 in 2014. CONCLUSIONS: The rate of hospitalization related to AP in the United States continues to increase. Mortality, length of stay, and cost per hospitalization decrease. The increase in volume of hospitalization might contribute to an overall increase in health care resource utilization.

An Unusual Case of Chronic Kidney Disease with Mediastinal Lymphadenopathy.

Granulomatous interstitial nephritis (GIN) is a rare histological diagnosis seen in less than 1% of native renal biopsies. This case report describes a 37-year-old male with chronic kidney disease (CKD) and mediastinal lymphadenopathy. The kidney biopsy showed granulomatous interstitial nephritis with mild interstitial fibrosis and variable tubular atrophy, as well as a lymph node biopsy with non-caseating granulomas. All the etiologies for non-caseating granulomas, such as infections (mycobacterial, fungal, bacterial, viral infections), hypersensitivity reactions, autoimmune disorders, and granulomatosis with polyangiitis), were initially considered and later excluded as the workup was negative. The patient was unresponsive to a trial of steroids and continued to be on dialysis. This case highlights the importance of obtaining a kidney biopsy in patients with progressive renal dysfunction without traditional risk factors such as hypertension and diabetes.

New onset hyperglycemia attributed to renal cell carcinoma.

A 61-year-old male was admitted from the outpatient setting for treatment of severe hyperglycemia. Five months earlier, his hemoglobin A1c had been 5 mmol/mol. At presentation, hemoglobin A1c was 11.3 mmol/mol and he required insulin therapy at discharge. Later magnetic resonance imaging (MRI) identified bilateral renal masses, previously seen on ultrasound during workup for chronic kidney disease, as being suspicious for renal cell carcinoma (RCC). He underwent partial nephrectomy and cryoablation with pathology showing papillary type RCC. Hyperglycemia resolved after resection and insulin therapy was discontinued, requiring only an oral hypoglycemic. Hyperglycemia as a paraneoplastic syndrome related to RCC is rare. The cause of this acute hyperglycemia is not understood, though previously suggested mechanisms include ectopic glucagon production, autoimmune causes and interleukin-6 (IL-6) mediated pathways. Severe, new-onset hyperglycemia in the absence of common causes and with a renal mass on imaging may represent an uncommon paraneoplastic syndrome secondary to RCC.

Coexisting Granular Cell Tumor and Tubular Adenoma of the Ileocecal Valve.

Granular cell tumors (GCTs) have been described as neoplasms of Schwann cell origin. They are often benign and notably uncommon in the gastrointestinal tract. Recently, their incidence has become more common, likely as a result of increased colonoscopy screenings. Very few data exist regarding their potential for malignancy, but malignant GCTs have been reported. Here, we report the case of a young female patient who was diagnosed with an atypical GCT on the ileocecal valve with an overlying tubular adenoma which was found incidentally on colonoscopy. This represents the first known report of a GCT with atypical features on the ileocecal valve, as well as a rare case of overlying adenomatous changes. Due to the paucity of cases, there is no clear modus operandi for their management. Furthermore, it is not clear whether surgical or endoscopic interventions or simple observation may be most appropriate. Further studies are needed to evaluate the potential for malignancy of this tumor, as well as its management.

Cardiac Arrhythmias Resulting from a Peripherally Inserted Central Catheter: Two Cases and a Review of the Literature.

We present two cases of patients being treated for diabetic ketoacidosis in the intensive care unit who experienced cardiac arrhythmia secondary to peripherally inserted central catheters (PICCs). In one instance, the patient became bradycardic and experienced related loss of consciousness, ultimately requiring cardiopulmonary resuscitation. In the second case, the patient experienced an episode of nonsustained ventricular tachycardia. We explore the various types of arrhythmias that have been reported secondary to central venous catheters, as well as factors that place patients at an increased risk for arrhythmia while undergoing PICC insertion. Furthermore, we look at the literature for methods to improve the insertion of PICC lines by decreasing the risk of catheter over-insertion as well as the effects of training for PICC placement.