Benign Peptic Ulcer as a Cause of Gastrocolic Fistula.

Gastrocolic fistula is a rare complication and can occur in various conditions, most commonly gastric or colonic adenocarcinoma, followed by benign gastric ulcers secondary to nonsteroidal anti-inflammatory drug use. We report a case of an 82-year-old man with a benign peptic ulcer that led to a gastrocolic fistula, which was not associated with a history of nonsteroidal anti-inflammatory drug use or malignancy. The exact cause of this patient's gastrocolic fistula is unclear, but the patient's medical history of microscopic lymphocytic colitis may have increased his risk of fistula formation.

Impact of Gender on Gastroesophageal Reflux Disease Complications: Analysis of 27 Million Hospitalizations.

BACKGROUND AND AIMS: Previous studies have reported gender differences in patients with gastroesophageal reflux disease (GERD). These studies have also reported differences based on gender in the rates of complications. In this study, we aim to identify gender disparities in the rates of GERD complications in the United States. METHODS: We queried the 2016-2020 National Inpatient Sample database to identify patients with GERD. Patients with eosinophilic esophagitis or missing demographics were excluded. We compared patient demographics, comorbidities and complications based on gender. Multivariate logistic regression analysis was used to identify the impact of gender on complications of GERD. RESULTS: 27.2 million patients were included in the analysis. Out of them, 58.4% of the hospitalized patients with GERD were female. Majority of the women were White (75%), aged>65 years (57.5%) and were in the Medicare group (64%). After adjusting for confounders, females were noted to have lower odds of esophagitis (aOR=0.85, 95%CI: 0.84-0.86, p<0.001), esophageal stricture (aOR=0.95, 95%CI: 0.93-0.97, p<0.001), Barrett's esophagus (aOR=0.58, 95%CI: 0.57-0.59, p<0.001) and esophageal cancer (aOR=0.22, 95%CI: 0.21-0.23, p<0.001). CONCLUSIONS: Our study confirms the findings of previous literature that females, despite comprising the majority of the study population, had a lower incidence of GERD related complications. Further studies identifying the underlying reason for these differences are required.

Cystic duct disimpaction for acute cholecystitis in the high-risk cholecystectomy patient: Case report.

Acute cholecystitis is a common cause of Emergency Department presentation and hospital admission. It is usually treated with early surgical removal of the gallbladder; however, some patients may not be fit to undergo the procedure due to critical illness or comorbidities. In these patients, options are limited. Endoscopic retrograde cholangiopancreatography interventions in this population are not well-studied. We present a case of a high-risk 59 year old female patient with a history of end-stage renal disease, heart failure, hypertension, pulmonary hypertension, and type 2 diabetes who presented with acute cholecystitis. She was successfully treated with cystic duct disimpaction without stenting, and continues to do well post-procedure with complete resolution of symptoms and abnormal lab findings.

A Rare Case of Heterozygous C282Y Mutation Causing Hereditary Hemochromatosis With Acute Pancreatitis.

Hereditary hemochromatosis (HH) is the most common autosomal recessive genetic disorder globally for Caucasians. HH is known as an iron metabolism disorder where there is an increase in iron absorption in the body. HH is not localized but a systemic disease; the manifestations of HH include cirrhosis, diabetes mellitus, cardiomyopathy, and pancreatitis. This case is about a 53-year-old female with a past medical history of heterozygous hereditary hemochromatosis who presents to the emergency department with abdominal pain, nausea, and vomiting and was found to have acute pancreatitis. This case report helps signify the importance of identifying and treating symptomatic heterozygous carriers of the HH gene mutation.

The impact of Clostridioides difficile infection on outcomes among kidney transplant recipients.

BACKGROUND: Clostridioides difficile infection (CDI) is a significant cause of morbidity and mortality among hospitalized patients, particularly those who are immunosuppressed. We aim to assess the outcomes of CDI among kidney transplant (KT) recipients. METHODS: Nationwide Inpatient Sample from 2016 to 2020 was used to identify patients with KT and stratify based on the presence of CDI. Data were collected regarding demographics and comorbidities. Outcomes included in-hospital mortality, acute kidney injury, intensive care unit admission, transplant rejection, transplant failure, length of stay, and total hospitalization charges. The relationships between variables of interest and outcomes were analyzed using multivariate regression. RESULTS: A total of 557,635 KT recipients were included. CDI prevalence was 2.4%. The majority of patients in the CDI group were age >65 (43.6%), female (51%), White (55.3%), and had Medicare insurance (74.9%). On multivariate regression analysis, CDI was associated with increased odds of acute kidney injury (aOR 2.06, p < 0.001), intensive care unit admission (aOR 2.47, p < 0.001), and mortality (aOR 1.90, p < 0.001). CDI was also associated with longer length of stay (9.35 days vs 5.42 days, p < 0.001) and higher total hospitalization charges ($110,063 vs $100,006, p < 0.001). There was no difference in transplant rejection, complication, failure, or infection among KT recipients with CDI and those without. CONCLUSIONS: We found that CDI was associated with worse outcomes and higher costs. KT patients should be monitored closely for signs of CDI in order to initiate appropriate management.

Long-term aspirin use in patients hospitalized with ischemic colitis.

Background: Ischemic colitis is a form of mesenteric ischemia that often presents in patients with vascular disease. Long-term aspirin use has been shown to improve the outcomes in patients with cardiovascular or cerebrovascular disease. However, the relationship between aspirin use and ischemic colitis is unclear. Methods: Patients with a diagnosis of ischemic colitis were identified using the 2020 Nationwide Inpatient Sample. Patients were stratified by long-term aspirin use at the time of hospitalization. Data were collected regarding mortality, bowel perforation, peritonitis, shock, blood transfusion, length of stay in days (LOS), hospital charges, age, sex, race, primary insurance, median income, hospital region, hospital size, and comorbidities. The relationship between aspirin use and outcomes was analyzed using multivariate regression analysis. Results: A total of 67,685 patients were included. Aspirin users had a mean age of 72.8 years compared to 66.8 years for non-aspirin users. Long-term aspirin use was associated with a lower risk of in-hospital mortality (P<0.001), bowel perforation (P<0.001), peritonitis (P=0.01), shock (P<0.001), and blood transfusion (P<0.001). The mean LOS was 6.1 days in the aspirin group compared to 9.4 days in the non-aspirin group. Ischemic colitis patients taking aspirin had a mean hospitalization charge of $87,123 compared to $161,610 for those not using aspirin. Conclusions: Our study examined the impact of aspirin use in ischemic colitis patients. Among patients hospitalized with ischemic colitis, we found that long-term aspirin use was associated with a lower risk of in-hospital mortality and adverse events.

The impact of aspirin use on outcomes in patients with inflammatory bowel disease: Insights from a national database.

BACKGROUND: Inflammatory bowel disease (IBD) is an inflammatory disorder that can increase the risk of mortality. Aspirin is an anti-inflammatory drug used for primary prevention of cardiovascular events. A single center analysis previously reported that aspirin use did not impact major outcomes in IBD. In this study, we aim to assess the impact of aspirin use on mortality and other outcomes in patients with IBD using national data. METHODS: National inpatient sample (NIS) 2016-2020 was used to identify adult patients with IBD. Data were collected on patient demographics, hospital characteristics, and comorbidities. The outcomes studied were in-hospital mortality, sepsis, shock, Intensive Care Unit (ICU) admission, and need for surgery. Multivariate logistic regression analysis was performed. RESULTS: A total of 1,524,820 IBD hospitalizations were included. Of these, 137,430 (9%) were long-term aspirin users. The majority of the patients in the aspirin group were aged > 65 years (34.11%), female (56.37%), White (78.83%) and had Medicare insurance (36.77%). Aspirin users had a lower incidence of in-hospital mortality (1.6% vs 1.4%, P = 0.06), sepsis (2.5% vs 2.9%, P < 0.001), shock (2.9% vs 3.4%, P < 0.001), ICU admission (2.6% vs 2.9%, P < 0.001), need for surgery (2.1% vs 4.2%, P < 0.001). After adjusting for confounders, aspirin was associated with a reduction in mortality (adjusted odds ratio: 0.49, 95%CI 0.45-0.55, P < 0.001). CONCLUSION: Our study reports that aspirin use among patients with IBD was associated with a lower risk of death, sepsis, and shock. Aspirin use may have a protective effect in patients with IBD. Further studies are needed to confirm these results.

A Rare Case of Sodium-Glucose Cotransporter-2 Inhibitor-Induced Acute Pancreatitis.

Acute pancreatitis is an acute inflammatory process of the pancreas that requires hospital admission and treatment. There are many causes of pancreatitis, the most common being gallstone and alcohol-induced; other reasons include metabolic, infectious, and medication-induced. A new medication that has come to the market is empagliflozin, which is a sodium-glucose cotransporter-2 inhibitor that is common in managing type 2 diabetes mellitus and congestive heart failure. Although generally considered safe and effective, rare adverse effects have been reported. In this case, we present a 67-year-old female patient who presented with severe acute pancreatitis after two weeks of starting empagliflozin to treat her type 2 diabetes. This case report highlights the importance of considering rare adverse events associated with empagliflozin and the need for close monitoring of patients receiving this medication.

The Impact of COVID-19 on Outcomes of Ischemic Colitis: A Nationwide Retrospective Analysis.

Background: Ischemic colitis is the most common presentation of mesenteric ischemia and is associated with significant morbidity and mortality. Coagulopathy has been associated with the development of ischemic colitis. Coronavirus disease 2019 (COVID-19) infection can lead to a variety of pathology and physiological derangements, including coagulopathy. Some case reports have described severe ischemic colitis in patients with COVID-19 infection. Our study aimed to elucidate the impact of COVID-19 infection on ischemic colitis outcomes. Methods: Patients with a diagnosis of ischemic colitis were identified using the 2020 Nationwide Inpatient Sample (NIS). Patients were stratified based on the presence of COVID-19 infection. Data were collected regarding mortality, shock, blood transfusion, length of stay, hospital charges, age, gender, race, primary insurance, median income, hospital region, hospital bed size, and comorbidities. The relationship between COVID-19 and outcomes was analyzed using multivariate regression analysis. Results: A total of 67,685 patients were included in the final analysis. COVID-19 was associated with an increased risk of in-hospital mortality (adjusted odds ratio (aOR): 4.006, P < 0.001), shock (aOR: 1.62, P = 0.002), and blood transfusion (aOR: 1.49, P = 0.007). COVID-19 was also associated with an increased length of stay (16.2 days vs. 8.7 days) and higher total hospital charges ($268,884.1 vs. $145,805.9). Conclusions: Among hospitalized patients with ischemic colitis, COVID-19 infection was associated with worse outcomes and higher resource utilization. Further studies are needed to investigate the mechanisms underlying this association.

Unusual sites of hepatocellular carcinoma metastasis: Case report.

Hepatocellular carcinoma is an increasingly frequent cause of cancer-related death. The majority of patients with hepatocellular carcinoma are asymptomatic. In rare cases, patients may present with symptoms of extrahepatic metastases. Early identification can lead to timely treatment and prevent poor outcomes. We report three cases of patients with hepatocellular carcinoma with unusual sites of metastasis, including clival, mandible, and cardiac involvement.

Tongue squamous cell carcinoma metastasis to percutaneous endoscopic gastrostomy site: A case report of an unusual cause of gastrointestinal bleeding.

Percutaneous endoscopic gastrostomy tubes are often placed in patients with head and neck malignancy for long-term nutritional support. Though rare, head and neck squamous cell carcinoma can metastasize to the percutaneous endoscopic gastrostomy tube site and may initially present as a developing mass or as bleeding at the percutaneous endoscopic gastrostomy site. Patients with head and neck squamous cell carcinoma should be evaluated diligently before and after percutaneous endoscopic gastrostomy placement in order to avoid this rare but life-threatening complication. We present a case of tongue squamous cell carcinoma that metastasized to the percutaneous endoscopic gastrostomy tube site causing gastrointestinal bleeding.

McKittrick-Wheelock syndrome: A rare cause of chronic diarrhea treated with endoscopic polypectomy.

Chronic diarrhea is a commonly encountered complaint and a principal cause of health care utilization worldwide. Although there are various etiologies of chronic diarrhea, McKittrick-Wheelock syndrome is a rare syndrome defined as a large villous adenoma with secretory diarrhea causing severe fluid imbalances. We report a case of a patient with McKittrick-Wheelock syndrome who was successfully treated with endoscopic resection. Our case aims to add information to the current literature supporting the endoscopic management of McKittrick-Wheelock syndrome.

A Complex Diagnosis of Ampullary Adenocarcinoma Presenting As Decompensated Cirrhosis.

Neoplasms arising from the ampulla of Vater are exceedingly rare, and there is a paucity of literature regarding their diagnosis and management. Ampullary cancer typically presents with jaundice and signs of biliary obstruction. We present a case of ampullary adenocarcinoma with concomitant choledocholithiasis that proved complex and diagnostically challenging.

Alcohol-related hepatitis: A review article.

Alcohol-related hepatitis (ARH) is a unique type of alcohol-associated liver disease characterized by acute liver inflammation caused by significant alcohol use. It ranges in severity from mild to severe and carries significant morbidity and mortality. The refinement of scoring systems has enhanced prognostication and guidance of clinical decision-making in the treatment of this complex disease. Although treatment focuses on supportive care, steroids have shown benefit in select circumstances. There has been a recent interest in this disease process, as coronavirus disease 2019 pandemic led to substantial rise in cases. Although much is known regarding the pathogenesis, prognosis remains grim due to limited treatment options. This article summarizes the epidemiology, genetics, pathogenesis, diagnosis and treatment of ARH.

Refractory gastric ulcer bleeding responsive to long-term octreotide.

Upper gastrointestinal tract bleeding is a common condition that can cause hemodynamic instability and death if left untreated. Endoscopic hemostasis is often successful; however, some patients may develop refractory bleeding. Pharmacologic management with octreotide is beneficial in patients with variceal bleeding and has been shown in some studies to be effective in refractory bleeding due to angiodysplasia. There is a paucity of literature regarding the usage of long-term octreotide in refractory bleeding secondary to a peptic ulcer. We present a case of a bleeding gastric ulcer that was refractory to endoscopic management but responsive to long-term octreotide therapy.

Neurosyphilis-Induced Psychosis: A Unique Presentation of Syphilis With a Primary Psychiatric Manifestation.

Syphilis is a predominantly sexually transmitted infection caused by the spirochete Treponema pallidum. The infection presents with four different stages and although rare, can lead to behavioral symptoms if not treated in its earliest form. It can cause psychosis, mania, depression, anxiety, and personality changes. Screening and early treatment of syphilis are essential in preventing neurosyphilis and its neuropsychiatric symptoms. Neurosyphilis is rarely the initial presentation of syphilis. This is a case report of a 30-year-old female with neurosyphilis who presented with psychosis as the primary presentation.

Hepatitis E infection: A review.

Hepatitis E virus (HEV) is a small non-enveloped virus that is transmitted via the fecal-oral route. It is a highly common cause of acute hepatitis, particularly in low to middle income regions of Asia, Africa, and Central America. Most cases are self-limited, and symptomatic patients usually present with acute icteric hepatitis. A subset of patients including pregnant women, older men, those with pre-existing liver disease and immunocompromised patients however, may develop severe disease and hepatic failure. Immunocompromised patients are also at risk for chronic infection, and their immunosuppression should be decreased in order to facilitate viral clearance. HEV can also present with a variety of extra-intestinal manifestations including neurological, renal, hematological, and pancreatic derangements. The gold standard of diagnosis is HEV ribonucleic acid detection via nucleic acid amplification testing. Currently, there are no approved treatments for Hepatitis E, though ribavirin is the most commonly used agent to reduce viral load. Studies assessing the safety and efficacy of other antiviral agents for HEV are currently underway. HEV vaccination has been approved in China, and is currently being investigated in other regions as well. This review article aims to discuss the epidemiology, pathogenesis, presentation, diagnosis, complications, and treatment of Hepatitis E infection.

A Rare Presentation of a Complex Mixed Autoimmune Encephalitis Diagnosis: A Case Report and Literature Review.

This case report presents a unique case of a difficult differential diagnosis of autoimmune encephalitis (AE) in the setting of Mycoplasma pneumoniae. A 40-year-old female with a history of Hashimoto thyroiditis, polycystic ovarian syndrome, and a lower respiratory infection presented to the emergency department with new-onset progressive neurological symptoms. These included generalized tonic-clonic seizure and worsening respiratory status that required intubation and tracheostomy. Blood cultures returned positive for M. pneumoniae. We concluded this to be a mixed diagnosis case of anti-glutamic acid decarboxylase 65 (anti-GAD65), Bickerstaff's brainstem encephalitis (BBE), Hashimoto's encephalopathy (HE), and Miller Fisher Syndrome (MFS) concurrently in the setting of M. pneumoniae. Initial treatment with intravenous immunoglobulin showed minimal improvement; however, subsequent treatment with plasmapheresis proved to be beneficial for the patient. Over the course of the plasma exchange therapy (PLEX), the patient slowly became more alert, attentive, and verbal. She was able to answer simple questions and follow commands. Common trends of age, gender, presenting symptoms, associated antibodies, and sessions of PLEX in different AE diseases were identified through a literature review. Only 69.7% of the cases implemented PLEX or plasmapheresis. Currently, there is no standard protocol for the treatment of AE. Our case report aims to present a clinically complicated example of AE and to provide further evidence to support PLEX as an important therapeutic option.

Perforated Appendicitis Masquerading as Bilateral Tubo-Ovarian Abscess.

Acute appendicitis is a highly common cause of abdominal pain that presents with nausea and vomiting, characteristic physical exam findings, and imaging evidence of appendiceal inflammation. In the absence of these signs, diagnosis can be difficult. This case report demonstrates an uncommon presentation of appendicitis that led to a delay in diagnosis and aims to discuss the ways in which similar misdiagnoses can be avoided for clinicians in the future.