Thirty-Day Readmission After Esophageal Variceal Hemorrhage and its Impact on Outcomes in the United States.

AIMS: The authors sought to determine the 30-day readmission rate of patients with esophageal variceal hemorrhage (EVH) and its impact on mortality, morbidity, and health care utilization. BACKGROUND: EVH is a common complication of cirrhosis and leads to substantial morbidity and mortality. STUDY: The 2014 National Readmission Database was used to examine adult patients with urgent/emergent admissions and a principal diagnosis of EVH. The primary outcome was 30-day readmission. Secondary outcomes were in-hospital and 30-day mortality rate, most common reasons for readmission, readmission mortality rate, morbidity, and resource utilization. Independent risk factors for readmission were identified using multivariate regression analysis. RESULTS: A total of 2003 patients with EVH were included. The mean age was 57 years and 29% of patients were female individuals. The all-cause 30-day readmission rate was 16.6%. EVH was the cause of readmission in only 5% of readmissions. Independent predictors of readmission were age and insurance type. The in-hospital and 30-day mortality rate for index admissions were 7.3% and 8.2%, respectively. For readmitted patients, the mortality rate was 3.9%. Although morbidity was lower during readmissions (prolonged mechanical ventilation: 0.4% vs. 3.5%, P<0.01 and shock: 1.8% vs. 9.9%, P<0.01), the cumulative additional length of stay was substantial at 2054 days with additional total hospitalization charges of US$20 million. CONCLUSIONS: The all-cause 30-day readmission rate after EVH is 16.6%, with most patients being readmitted for diagnoses unrelated to EVH. Readmission was associated with a substantial increase in in-hospital mortality and resource utilization. Risk factors for readmission were identified, which can potentially be used to decrease readmission rates.

Lower Gastrointestinal Hemorrhage Caused by Superior Rectal Artery Pseudoaneurysm.

Acute lower gastrointestinal (GI) bleeding is self-limiting and managed conservatively. Ongoing bleeding from a lower GI source and hemodynamic instability can create difficult diagnostic and therapeutic dilemmas. The severity of bleeding can necessitate emergent diagnostic and therapeutic interventions. Diverticulosis and angiodysplasias are the most common causes of massive lower GI hemorrhage. Other etiologies that can lead to life-threatening hemorrhage are important to recognize. We present a rare case of massive lower GI hemorrhage attributable to a superior rectal artery pseudoaneurysm. The absence of a preceding traumatic or iatrogenic cause distinguishes this case from other reports in the literature.

Early colonoscopy in patients with acute diverticular bleeding is associated with improvement in healthcare-resource utilization.

BACKGROUND: Diverticular bleeding (DB) is the most common cause of severe acute lower gastrointestinal bleeding (GIB) in developed countries. The role of early colonoscopy (<24 hours) continues to remain controversial and data on early colonoscopy in acute DB are scant. We aimed to evaluate the effect of timing of colonoscopy on outcomes in patients with acute DB using a nationwide inpatient sample. METHODS: Data from the nationwide inpatient sample from 2012 to 2014 were used. The ninth version of the International Classification of Diseases coding system ICD 9 was used for patient selection. We included discharges with the primary and secondary inpatient diagnosis of diverticulosis with bleeding and diverticulitis with bleeding. Discharges with no primary or secondary diagnosis of diverticulosis with bleeding, diverticulitis with bleeding, patients who were less than 18 years old and those who did not undergo colonoscopy during the admission were excluded. The primary outcomes were length of stay (LOS) and total hospitalization costs. RESULTS: A total of 88 600 patients were included in our analysis, amongst whom 45 020 (50.8%) had colonoscopy within 24 hours of admission (early colonoscopy), while 43 580 (49.2%) patients had colonoscopy after 24 hours of admission (late colonoscopy). LOS was significantly lower in patients with early colonoscopy as compared to those with late colonoscopy (3.7 vs 5.6 days, P < 0.0001). Total hospitalization costs were also significantly lower in patients with early colonoscopy ($9317 vs $11 767, P < 0.0001). There was no difference in mortality between both groups (0.7 vs 0.8%). After adjusting for potential confounders, the differences in LOS and total hospitalization costs between early and late colonoscopy remained statistically significant. CONCLUSIONS: Early colonoscopy in acute DB significantly reduced LOS and total hospitalization costs. There was no significant difference in mortality observed. Performance of early colonoscopy in the appropriate patients presenting with acute DB can have potential cost-saving implications. Further research is needed to identify which patients would benefit from early colonoscopy in DB.

Upper gastrointestinal hemorrhage is associated with poor outcomes among patients with acute cholangitis: a nationwide analysis.

OBJECTIVE: Acute cholangitis (AC) and upper gastrointestinal hemorrhage (UGIH) are common emergencies encountered by gastroenterologists. We aimed to evaluate the impact of UGIH on in-hospital mortality, morbidity and resource utilization among patients with AC. PATIENTS AND METHODS: Adult admissions with a principal diagnosis of AC were selected from the National Inpatient Sample 2010-2014. The exposure of interest was significant UGIH (requiring red blood cell transfusion). The primary outcome was in-hospital mortality. Secondary outcomes were significant UGIH's incidence, morbidity (shock, prolonged mechanical ventilation and total parenteral nutrition), and resource utilization (length of hospital stay and total hospitalization charges and costs). Confounders were adjusted for using propensity matching and multivariate regression analysis. RESULTS: A total of 50 375 admissions were included in the analysis, 747 of whom developed significant UGIH. After adjusting for confounders, the adjusted odds ratio (aOR) of in-hospital mortality for patients who developed UGIH was 7.1 (95% confidence interval: 2.1-23.9, P<0.01) compared with those who did not. Significant UGIH was associated with substantial increase in morbidity [shock: aOR: 4.1 (2.1-9.3), P<0.01, prolonged mechanical ventilation: aOR: 5.8 (2.2-12.4), P<0.01, total parenteral nutrition: aOR: 4.7 (1.9-10.7), P<0.01], and resource utilization [mean adjusted difference in: length of hospital stay: 7.01 (4.72-9.29), P<0.01 and total hospitalization charges: $81 818 ($58 109-$105 527), P<0.01 and costs: $25 230 ($17 805-$32 653), P<0.01]. Similar results were obtained using multivariate regression analysis. CONCLUSION: Onset of significant UGIH among patients hospitalized with AC has a detrimental effect on in-hospital mortality, morbidity and resource utilization.

Evaluation and management of Non-variceal upper gastrointestinal bleeding.

Non-variceal upper gastrointestinal bleeding continues to be an important cause of morbidity and mortality. The most common causes include peptic ulcer disease, Mallory-Weiss syndrome, erosive gastritis, duodenitis, esophagitis, malignancy, angiodysplasias and Dieulafoy's lesion. Initial assessment and early aggressive resuscitation significantly improves outcomes. Upper gastrointestinal endoscopy continues to be the gold standard for diagnosis and treatment. We present a comprehensive review of literature for the evaluation and management of non-variceal upper gastrointestinal bleeding.

Evaluation and management of variceal bleeding.

Acute variceal bleeding is one of the most fatal complications of cirrhosis and is responsible for about one-third of cirrhosis-related deaths. Therefore, every effort should be made to emergently resuscitate the patients, start pharmacotherapy as soon as possible and do endoscopic therapy in a timely manner. Despite the recent advances in treatment, mortality rate is still high. We provide a comprehensive review of evaluation and management of variceal bleeding.

Heart transplant recipient with mycophenolate mofetil-induced colitis: the great imitator.

In this article, we report a case of a 55-year-old male heart transplant recipient who presented with diarrhoea. An extensive workup for infectious diseases was negative. The patient had a colonoscopy with biopsies showing colitis that mimicked graft-versus-host disease on histopathology. After excluding other potential causes and excluding acute cellular rejection, mycophenolate mofetil was discontinued, and the patient had significant clinical improvement with increased appetite and weight gain.