Severe Upper Gastrointestinal Hemorrhage Caused by Reflux Esophagitis.

BACKGROUND: There are few reports about reflux esophagitis (RE) as a cause of severe upper gastrointestinal bleeding (UGIB). AIMS: This study aims to evaluate (1) changes in its prevalence over the last three decades and (2) clinical and endoscopic characteristics and 30-day outcomes among RE patients with and without focal esophageal ulcers (EUs) and stigmata of recent hemorrhage (SRH). METHODS: A retrospective study of prospectively collected data of esophagitis patients hospitalized with severe UGIB between 1992 and 2020. Descriptive analysis and statistical comparisons were performed. RESULTS: Of 114 RE patients, the mean age was 61.1 years and 76.3% were males. 38.6% had prior gastroesophageal reflux disease (GERD) symptoms; overall 36% were on acid suppressants. Over three consecutive decades, the prevalence of RE as a cause of severe UGIB increased significantly from 3.8 to 16.7%. 30-day rebleeding and all-cause mortality rates were 11.4% and 6.1%. RE patients with focal EUs and SRH (n = 23) had worse esophagitis than those with diffuse RE (n = 91) (p = 0.012). There were no differences in 30-day outcomes between RE patients with and without EUs and SRH. CONCLUSIONS: For patients with severe UGIB caused by RE, (1) the prevalence has increased significantly over the past three decades, (2) the reasons for this increase and preventive strategies warrant further study, (3) most patients lacked GERD symptoms and did not take acid suppressants, and (4) those with focal ulcers and SRH had more severe esophagitis and were treated endoscopically.

Outcomes of patients with ischemic colitis causing severe hematochezia managed medically or surgically.

PURPOSE: To compare short- and long-term outcomes of hospitalized patients with ischemic colitis (IC) presenting with severe hematochezia and treated medically or colectomy and also those with inpatient vs. outpatient start of hematochezia. METHODS: A retrospective analysis of prospectively collected data for IC patients hospitalized for severe hematochezia from two teaching hospitals was done from 1994 to 2020, with the diagnosis of IC made colonoscopically and confirmed histologically. RESULTS: Ninety-seven patients initially all had medical management for IC. Seventy-two (74.2%) were stable and had no further bleeding; 17 (17.5%) had colon resection; and 8 were critically ill and not surgical candidates. Surgical patients and non-surgical candidate had higher comorbidity scores; received more red blood cell (RBC) transfusion (median (IQR) 5 (3-10) vs. 4.5 (3-6.5) vs. 1 (0-4) units, p < 0.001); had significantly longer hospital and ICU days; had higher severe complication rates (35.3% vs. 100%. vs. 5.6%, p < 0.001); and had higher 30-day all-cause mortality rates (23.5% vs. 87.5% vs. 0, p < 0.001). Inpatients developing IC hemorrhage had more RBC transfusions, more complications, longer hospital stays, and higher mortality than patients whose IC bleeding started as outpatients. CONCLUSIONS: The majority of IC patients hospitalized for severe hematochezia were successfully treated medically. Patients who were not surgical candidate had the highest rates of severe complications and mortality. Surgical patients and those who were not surgical candidate had worse outcomes than the medical group. Patients with inpatient start of bleeding from IC had significantly worse outcomes than those with outpatient start of bleeding.

Thoracic Inlet in Cervical Spine CT of Blunt Trauma Patients: Prevalence of Pathologies and Importance of CT Interpretation.

BACKGROUND: The thoracic inlet of blunt trauma patients may have pathologies that can be diagnosed on cervical spine computed tomography (CT) but that are not evident on concurrent portable chest radiography (pCXR). This retrospective investigation aimed to identify the prevalence of thoracic inlet pathologies on cervical spine CT and their importance by measuring the diagnostic performance of pCXR and the predictive factors of such abnormalities. METHODS: This investigation was performed at a level-1 trauma center and included CT and concurrent pCXR of 385 consecutive adult patients (280 men, mean age of 47.6 years) who presented with suspected cervical spine injury. CT and pCXR findings were independently re-reviewed, and CT was considered the reference standard. RESULTS: Traumatic, significant nontraumatic and nonsignificant pathologies were present at 23.4%, 23.6% and 58.2%, respectively. The most common traumatic diagnoses were pneumothorax (12.7%) and pulmonary contusion (10.4%). The most common significant nontraumatic findings were pulmonary nodules (8.1%), micronodules (6.8%) and septal thickening (4.2%). The prevalence of active tuberculosis was 3.4%. The sensitivity and positive predictive value of pCXR was 56.67% and 49.51% in diagnosing traumatic and 8.89% and 50% in significant nontraumatic pathologies. No demographic or pre-admission clinical factors could predict these abnormalities. CONCLUSIONS: Several significant pathologies of the thoracic inlet were visualized on trauma cervical spine CT. Since a concurrent pCXR was not sensitive and no demographic or clinical factors could predict these abnormalities, a liberal use of chest CT is suggested, particularly among those experiencing high-energy trauma with significant injuries of the thoracic inlet. If chest CT is not available, a meticulous evaluation of the thoracic inlet in the cervical spine CT of blunt trauma patients is important.

Risk factors for readmission for early small bowel obstruction following laparoscopic Roux-en-Y gastric bypass: an MBSAQIP analysis.

BACKGROUND: Small bowel obstruction (SBO) following laparoscopic Roux-en-Y gastric bypass (LRYGB) is associated with significant morbidity. OBJECTIVES: To evaluate the rate of and risk factors for readmission for SBO within 30 days of LRYGB. SETTING: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)-accredited centers. METHODS: This is a retrospective study using the MBSAQIP database. A query was performed from 2015-2018 for patients who underwent LRYGB and required readmission for SBO. Those who had a reoperation, intervention, readmission, or expired from causes other than SBO were excluded. Descriptive, bivariate, and binary logistic regression analyses were performed. RESULTS: Among 184,660 patients undergoing LRYGB, 1189 (.64%) required readmission due to SBO. Among the readmission cases, 978 (82.5%) were identified as having intestinal obstruction (unspecified), 108 (9.1%) incisional hernia, and 100 (8.4%) internal hernia. Among these cases, 69% had a reoperation and 1.3% expired during the 30-day period. From a logistic regression model, parameters independently associated with an increased risk for readmission for early SBO include being female (adjusted odds ratio [AOR], 1.53) or black (AOR, 1.41) and having gastroesophageal reflux (AOR, 1.35), a history of myocardial infarction (AOR, 1.76), a history of deep vein thrombosis (AOR, 1.73), previous obesity surgery/foregut surgery (AOR, 1.79), a robotic-assisted procedure (AOR, 1.23), concurrent hiatal hernia repair (AOR, 1.66) and adhesiolysis (AOR, 1.42). CONCLUSION: The rate of readmission for early SBO following LRYGB was less than 1%. The majority of these cases required reoperation. The increased intraoperative complexity of LRYGB is associated with an increased risk of readmission due to early SBO.