Long-Term Outcomes of the Excluded Rectum in Crohn's Disease: A Multicenter International Study.

BACKGROUND: Many patients with Crohn's disease (CD) require fecal diversion. To understand the long-term outcomes, we performed a multicenter review of the experience with retained excluded rectums. METHODS: We reviewed the medical records of all CD patients between 1990 and 2014 who had undergone diversionary surgery with retention of the excluded rectum for at least 6 months and who had at least 2 years of postoperative follow-up. RESULTS: From all the CD patients in the institutions' databases, there were 197 who met all our inclusion criteria. A total of 92 (46.7%) of 197 patients ultimately underwent subsequent proctectomy, while 105 (53.3%) still had retained rectums at time of last follow-up. Among these 105 patients with retained rectums, 50 (47.6%) underwent reanastomosis, while the other 55 (52.4%) retained excluded rectums. Of these 55 patients whose rectums remained excluded, 20 (36.4%) were symptom-free, but the other 35 (63.6%) were symptomatic. Among the 50 patients who had been reconnected, 28 (56%) were symptom-free, while 22(44%) were symptomatic. From our entire cohort of 197 cases, 149 (75.6%) either ultimately lost their rectums or remained symptomatic with retained rectums, while only 28 (14.2%) of 197, and only 4 (5.9%) of 66 with initial perianal disease, were able to achieve reanastomosis without further problems. Four patients developed anorectal dysplasia or cancer. CONCLUSIONS: In this multicenter cohort of patients with CD who had fecal diversion, fewer than 15%, and only 6% with perianal disease, achieved reanastomosis without experiencing disease persistence.

Patients with distal Crohn's disease often undergo colon resection with a stoma to divert the intestinal stream from the rectum in hopes of achieving sufficient healing to allow ultimate re-establishment of intestinal continuity. Patients and practitioners alike should be aware of the long-term success rates of this procedure. Our retrospective study of 197 patients found that half required later proctectomy and an additional one-quarter remained symptomatic with excluded rectums. Only 14% remained symptom-free after reanastomosis, and only 6% if perianal disease was the initial surgical indication. These data provide estimation of long-term surgical outcomes.

Migraine and Gastroparesis.

PURPOSEOF REVIEW: Migraine is a chronic and disabling disease affecting a significant proportion of the world's population. There is evidence that gastroparesis, a gastrointestinal (GI) dysmotility disorder in which transit of gastric contents is delayed, can occur in the setting of migraine. This article aims to review recent literature on overlap in the pathophysiology and clinical manifestations of migraine and gastroparesis and highlight management considerations when these disorders coexist. RECENT FINDINGS: There has been increasing recognition of the importance of the connection between the GI tract and the brain, and mounting evidence for the overlap in the pathophysiology of migraine and gastroparesis specifically. There exists a complex interplay between the central, autonomic, and enteric nervous systems. Studies show that gastroparesis may be present during and between acute migraine attacks necessitating modification of management to optimize outcomes. Gastric dysmotility in the setting of migraine can impact absorption of oral migraine medications and alternate formulations should be considered for some patients. Noninvasive vagus nerve stimulation has been FDA cleared for migraine treatment and is also being studied in gastroparesis. Dysfunction of the autonomic nervous system is a significant feature in the pathophysiology of gut motility and migraine, making treatments that modulate the vagus nerve attractive for future research.

Rare presentations of COVID-19: PRES-like leukoencephalopathy and carotid thrombosis.

Coronavirus disease 2019 (COVID-19) is a global pandemic, and it is increasingly important that physicians recognize and understand its atypical presentations. Neurological symptoms such as anosmia, altered mental status, headache, and myalgias may arise due to direct injury to the nervous system or by indirectly precipitating coagulopathies. We present the first COVID-19 related cases of carotid artery thrombosis and acute PRES-like leukoencephalopathy with multifocal hemorrhage.

Biventricular takotsubo syndrome with COVID-19 in an Asian male.

Coronavirus disease 2019 (COVID-19) has been shown to affect the cardiovascular system, and several cases of takotsubo syndrome (TTS) induced by COVID-19 have been reported. TTS predominantly affects postmenopausal women in western countries, but the prevalence in men is higher in Asian populations. It should be noted that male patients with either TTS or COVID-19 are associated with higher mortality. Despite the higher prevalence of TTS in Asian men, little is known about Asian men with TTS induced by COVID-19. This is a case report of a 60-year-old Asian male with biventricular TTS precipitated by COVID-19. He presented with acute respiratory distress syndrome, cardiogenic shock, and acute kidney injury. He required intubation, multiple vasopressors, and renal replacement therapy. The left ventricular ejection fraction was 15%, but it normalized in 5 weeks. The patient had a prolonged hospital stay in a critical condition, but was eventually discharged alive. The scarce literature about this condition in Asian male populations and the increasing number of COVID-19 cases in Asian countries highlight the rarity and importance of this case. Further studies are warranted to investigate the uneven sex distribution and outcomes of TTS triggered by COVID-19 in an Asian population. .

Severe Obesity as an Independent Risk Factor for COVID-19 Mortality in Hospitalized Patients Younger than 50.

OBJECTIVE: Coronavirus disease 2019 (COVID-19) continues to spread, and younger patients are also being critically affected. This study analyzed obesity as an independent risk factor for mortality in hospitalized patients younger than 50. METHODS: This study retrospectively analyzed data of patients with COVID-19 who were hospitalized to a large academic hospital system in New York City between March 1, 2020, and May 17, 2020. Data included demographics, comorbidities, BMI, and smoking status. Obesity groups included the following: BMI of 30 to < 40 kg/m2 and BMI ≥ 40 kg/m2 . Multivariable logistic regression models identified variables independently associated with mortality in patients younger and older than 50. RESULTS: Overall, 3,406 patients were included; 572 (17.0%) patients were younger than 50. In the younger age group, 60 (10.5%) patients died. In the older age group, 1,076 (38.0%) patients died. For the younger population, BMI ≥ 40 was independently associated with mortality (adjusted odds ratio 5.1; 95% CI: 2.3-11.1). For the older population, BMI ≥ 40 was also independently associated with mortality to a lesser extent (adjusted odds ratio 1.6; 95% CI: 1.2-2.3). CONCLUSIONS: This study demonstrates that hospitalized patients younger than 50 with severe obesity are more likely to die of COVID-19. This is particularly relevant in the Western world, where obesity rates are high.