African-American inflammatory bowel disease in a Southern U.S. health center.

BACKGROUND: Inflammatory Bowel Diseases (IBD) remain significant health problems in the US and worldwide. IBD is most often associated with eastern European ancestry, and is less frequently reported in other populations of African origin e.g. African Americans ('AAs'). Whether AAs represent an important population with IBD in the US remains unclear since few studies have investigated IBD in communities with a majority representation of AA patients. The Louisiana State University Health Sciences Center in Shreveport (LSUHSC-S) is a tertiary care medical center, with a patient base composed of 58% AA and 39% Caucasian (W), ideal for evaluating racial (AA vs. W) as well and gender (M vs. F) influences on IBD. METHODS: In this retrospective study, we evaluated 951 visits to LSUHSC-S for IBD (between 2000 to 2008) using non-identified patient information based on ICD-9 medical record coding (Crohn's disease 'CD'-555.0- 555.9 and ulcerative colitis 'UC'-556.0-556.9). RESULTS: Overall, there were more cases of CD seen than UC. UC and CD affected similar ratios of AA and Caucasian males (M) and females (F) with a rank order of WF > WM > AAF > AAM. Interestingly, in CD, we found that annual visits per person was the highest in AA M (10.7 ± 1.7); significantly higher (* -p < 0.05) than in WM (6.3 ± 1.0). Further, in CD, the female to male (F: M) ratio in AA was significantly higher (*- p < 0.05) (1.9 ± 0.2) than in Caucasians (F:M = 1.3 ± 0.1) suggesting a female dominance in AACD; no differences were seen in UC F: M ratios. CONCLUSION: Although Caucasians still represent the greatest fraction of IBD (~64%), AAs with IBD made up >1/3 (36.4%) of annual IBD cases from 2000-2008 at LSUHSC-S. Further studies on genetic and environments risks for IBD risk in AAs are needed to understand differences in presentation and progression in AAs and other 'non-traditional' populations.

Harbingers for Clostridium difficile-associated diarrhea.

PURPOSE: : Recent research has recognized surrogate markers for Clostridium difficile-associated diarrhea (CDAD). Among the most consistently identified markers are the leukocyte count, platelet count, and albumin level. Previous investigators failed to exclude patients with hematologic disorders that may have confounded their results. Therefore, the exclusion of this subset from our study lends it a unique perspective. METHODS: : We undertook a retrospective review of inpatients at our institution that were diagnosed with nosocomial diarrhea and subsequently had a stool sample sent for C. difficile toxins A and B. Patients with major hematologic disorders were excluded. RESULTS: : A total of 77 C. difficile-positive patients and 91 C. difficile-negative patients were studied. Patients with CDAD had a significantly higher leukocyte and platelet count but a lower albumin level compared with patients without CDAD. CONCLUSION: : Our results support the conclusion of preceding studies that leukocytosis, thrombocytosis, and hypoalbuminemia are reliable clinical predictors for CDAD even after careful exclusion of confounding factors.

Biliary spills and collections: causes, diagnosis, and multidisciplinary management.

PURPOSE: To evaluate the role of image-guided percutaneous interventions in patients with bile leaks and bile collections managed by a multidisciplinary team. MATERIAL & METHODS: Selection criteria included those patients from February 1999 to August 2007 who had bile leaks and bile collections in whom an image-guided procedure was performed. Ultrasound (US), computed tomography (CT), and nuclear medicine studies were used for diagnostic imaging. Patients were evaluated and managed in a multidisciplinary fashion by gastroenterologists, surgeons, and interventionists. Parameters measured in the study were drainage indications, cause and location of the biliary injury, location and size of bile collections, volume of fluid drained, fluid microbiology results, duration of catheterization, and patient outcome. Patients were followed up by the interventionist on daily rounds while inpatients and at the interventional clinic as outpatients. RESULTS: There were 31 patients who underwent image-guided percutaneous interventions as part of the management of bile leaks and bile collections. Causes of biliary injuries were surgical procedures, 18 patients (laparoscopic cholecystectomy, 11 patients; hepatectomy, 7 patients); abdominal trauma, 8 patients; percutaneous biliary procedures, 3 patients; liver abscess, 1 patient; gallbladder rupture, 1 patient. Bile collections were localized in 23 patients and diffuse in 8 patients. Localized collections were extrahepatic in 17 patients and intrahepatic in 6 patients. The size of the bile collections ranged from 4 to 12 cm (mean, 8 cm) in maximum diameter. The volume of fluid drained ranged from 25 mL to 4300 mL (mean, 915 mL). Microbiology studies showed sterile bile in 24 patients and bacterial infections in 7 patients. Duration of catheterization ranged from 3 days to 202 days (mean, 36 days). Of the 31 patients, 28 (90%) were cured from their condition and 3 (10%) patients died. Image-guided percutaneous interventions were able to resolve bile leaks and bile collections in 24 (86%) patients while 4 (14%) required additional procedures (endoscopic, 3 patients; surgery, 1 patient). CONCLUSION: Under multidisciplinary management, image-guided interventions are effective for resolution of most bile spills and collections. Additional endoscopic and surgical procedures are necessary when the percutaneous approach fails.

Synthetic Cannabinoid Abuse and a Rare Alpha-1-Antitrypsin Mutant Causing Acute Fulminant Hepatitis: A Case Report and Review of the Literature.

Synthetic cannabinoids (SCs) abuse is on the rise because they are easily obtained over the counter; they are potent psychoactive compounds and routine drug testing does not detect them. As their abuse is on the rise, so are their detrimental side effects; however, the occurrence of acute hepatitis due to SCs abuse has been reported only once before. In this case, testing revealed that the patient was also heterozygous for alpha-1-antitrypsin (A-1-AT) with the phenotype of PI⁎EM. This mutant phenotype has never been reported as a cause of A-1-AT disease and the abuse of SCs in a patient with this phenotype has also never been reported. This case illustrates the possible need to expand routine drug testing for SCs and consider A-1-AT phenotyping in certain clinical scenarios.

Elevated lipase and diabetic ketoacidosis associated with aripiprazole.

CONTEXT: Atypical antipsychotic agents are associated with diabetes mellitus and pancreatitis. Aripiprazole, a new antipsychotic, has never been implicated to cause either diabetes mellitus or pancreatitis. We present a patient who developed diabetes mellitus after being started on aripiprazole. CASE REPORT: A 33 year-old male with schizophrenia presented with fatigue, dyspepsia and epigastric pain. Patient was found to have hyperglycemia, diabetic ketoacidosis, and hyperlipasemia. Imaging studies of the pancreas were normal. Patient was started on aripiprazole treatment 18 months prior to this episode and had experienced progressive weight gain since then. Work up for other causes of pancreatitis was negative. CONCLUSIONS: Diabetes mellitus in this patient was probably a complication of aripiprazole due to progressive weight gain. In the absence of radiologic evidence of pancreatitis, hyperlipasemia was probably secondary to diabetic ketoacidosis. Possible causes of hyperlipasemia and its significance in diabetic ketoacidosis are discussed.

Substitution with Alternative Anti-TNFα Therapy (SAVANT)-Outcomes of a Crohn's Disease Cohort Undergoing Substitution Therapy with Certolizumab.

BACKGROUND: Biological therapy targeting tumor necrosis factor-alfa has revolutionized the treatment of Crohn's disease (CD). Our study retrospectively reviewed clinical outcomes of 60 patients administratively substituted from Infliximab or Adalimumab to Certolizumab. Maintenance of disease and failure rates after substitution of anti-tumor necrosis factor-alfa agents in CD patients were monitored over 1 year, and this is the first outcomes study of patients maintained on Infliximab or Adalimumab substituted to Certolizumab. METHODS: A hospital pharmacy directive required all patients on biological therapy to be administratively substituted to Certolizumab therapy. This single-center retrospective analysis initially included 68 CD patients presenting at Louisiana State University Health Sciences Center-Shreveport. Clinical, endoscopic, and serologic data were compared at baseline and at 4 intervals over 1 year. RESULTS: Of 60 enrolled CD patients, 45 (75%) successfully transitioned to Certolizumab and had stable disease at 1 year. Of the 15 (25%) patients who "failed" substitution at 1 year, 5 were returned to Adalimumab and 7 to Infliximab; 3 were maintained on steroids awaiting subsequent therapy. Importantly, when patients were segregated on the basis of initial disease control, it was found that 3 (12.5%) previously well-controlled patients failed therapy, whereas 12 (33.3%) who initially had active disease failed Certolizumab substitution. CONCLUSIONS: Our study found that 25% of CD patients substituted to Cimzia failed substitution, whereas 75% still exhibited a good clinical response with stable disease at 1 year. Our findings indicate that disease status and behavior at the time of biological substitution may predict therapeutic responsiveness.

Pregnancy and inflammatory bowel diseases: Current perspectives, risks and patient management.

Inflammatory bowel diseases (IBD) are chronic idiopathic inflammatory conditions characterized by relapsing and remitting episodes of inflammation which can affect several different regions of the gastrointestinal tract, but also shows extra-intestinal manifestations. IBD is most frequently diagnosed during peak female reproductive years, with 25% of women with IBD conceiving after their diagnosis. While IBD therapy has improved dramatically with enhanced surveillance and more abundant and powerful treatment options, IBD disease can have important effects on pregnancy and presents several challenges for maintaining optimal outcomes for mothers with IBD and the developing fetus/neonate. Women with IBD, the medical team treating them (both gastroenterologists and obstetricians/gynecologists) must often make highly complicated choices regarding conception, pregnancy, and post-natal care (particularly breastfeeding) related to their choice of treatment options at different phases of pregnancy as well as post-partum. This current review discusses current concerns and recommendations for pregnancy during IBD and is intended for gastroenterologists, general practitioners and IBD patients intending to become, (or already) pregnant, and their families. We have addressed patterns of IBD inheritance, effects of IBD on fertility and conception (in both men and women), the effects of IBD disease activity on maintenance of pregnancy and outcomes, risks of diagnostic procedures during pregnancy and potential risks and complications associated with different classes of IBD therapeutics. We also have evaluated the clinical experience using "top-down" care with biologics, which is currently the standard care at our institution. Post-partum care and breastfeeding recommendations are also addressed.

Gastric cancer in women: A regional health-center seven year retrospective study.

AIM: To investigate whether regional geography influences ethnic and gender trends for the development of gastric cancer (GC). METHODS: This retrospective analysis of the INVISION patient database at Louisiana State University Health Sciences Center-Shreveport (LSUHSC-S), a southern United States regional hospital, was performed from 2005-2011. Using the international statistical classification of diseases 9 (ICD-9), inpatient, day surgery outpatient, and emergency outpatient diagnosis codes entered into medical records were used to identify GC patients. For each study year, the patients were evaluated for age, ethnicity, and gender, and each patient was counted only once throughout the study. Subsequent patient encounters were counted as visits and separated by inpatient and clinic visits. Complex or severe disease may require more frequent and intensive clinical management; therefore, we evaluated annual clinic visits as "surrogate markers" of disease severity. Finally, we studied the primary diagnosis for Helicobacter pylori (H. pylori) infection (ICD-9 code 41.86) as an additional factor that might increase the risk of GC. RESULTS: A total of 285 patients were diagnosed with GC at LSUHSC-S between 2005 and 2011. African Americans (181 patients, 89 males and 92 females, 63.5% of total patients) had significantly higher frequencies of GC diagnosis compared with non-Hispanic whites (104 patients, 54 males and 50 females, 36.5% of total patients), at a ratio of 1.74 (P = 0.002). Within each ethnic group, men and women were diagnosed at approximately equal annual rates. Our findings differed significantly from United States national trends, which found that African American females and white females had lower risks for GC than their corresponding male counterparts. The United States national trend between 2005 and 2011 showed that African Americans males had a higher incidence of GC, with an annual mean (per 100000) of 16.31 ± 0.76 compared with white males (9 ± 0.1, P < 0.001), African American females (8.7 ± 0.34, P < 0.001) and white females (4.05 ± 0.07, P < 0.001). Among the GC patients, the number of clinic visits was highest among African American males (195.1 ± 28.1), who had significantly more clinic visits than African Americans females (123 ± 13.02, P < 0.05), white males (41.57 ± 4.74, P < 0.001) and white females (35 ± 8.9, P < 0.001). Similar trends were found for inpatient visits, with an annual mean of 11.43 ± 1.5 for African American males, followed by African American females (7.29 ± 1.36), white males (2.57 ± 0.69) and white females (1.57 ± 0.612). African American males had significantly more inpatient visits than white males (P < 0.001), and African American females had more inpatient visits than white females (P < 0.01). African American patients showed the highest frequency of H. pylori positive status, with approximately 72% vs 28% for the white patients. CONCLUSION: Increase in GC diagnoses among women at LSUHSC-S is significantly higher than United States national averages, suggesting local geographic and socioeconomic influences may alter GC disease course.

Diabetic Ketoacidosis-induced Hypertriglyceridemic Acute Pancreatitis Treated with Plasmapheresis-Recipe for Biochemical Disaster Management.

Diabetic ketoacidosis (DKA)-induced hypertriglyceridemia causing pancreatitis is an interesting phenomenon that has rarely been reported in literature. Plasmapharesis is a well known treatment modality for hypertriglyceridemia-induced pancreatitis. We report a patient with DKA-induced hypertriglyceridemic acute pancreatitis treated successfully with plasmapharesis.

Laboratory markers as predictors of mortality in patients with Clostridium difficile infection.

Previous studies have identified laboratory markers for severe Clostridium difficile infection (CDI). The most consistent of these markers is the presence of marked leukocytosis. We examined the validity of these markers as predictors of mortality in patients with CDI. We excluded patients with preexisting hematologic conditions that would be expected to impair their ability to demonstrate leukocytosis. On univariate analysis, marked leukocytosis (P = 0.02), thrombocytopenia (P = 0.008), and increased blood urea nitrogen (P < 0.001) and creatinine (P = 0.001) levels were found to be significantly associated with mortality in patients with CDI. However, on logistic regression analysis, only renal impairment was found to be an independent predictor (odds ratio, 5.07). Importantly, in our study, leukocytosis was not an independent predictor after adjustment for other variables, which may be due to our selection criteria when adjusting for confounding variables. We are therefore of the opinion that in immunocompromised hosts who are leukopenic at the time of CDI diagnosis, other laboratory markers should be identified to serve as indicators for severe disease.

Eosinophilic gastroenteritis of the pancreas: an unusual cause of obstructive jaundice.

Eosinophilic gastroenteritis (EG) is a rare gastrointestinal disorder of undetermined etiology and is manifest by eosinophilic infiltration of any area of gastrointestinal tract, most frequently stomach and small intestine. Peripheral eosinophilia is present in about 80% of patients. Definitive diagnosis requires histologic evidence of eosinophilic infiltration; which is usually patchy in distribution. Steroids are the mainstay of treatment. We present a case of 47-year-old man with abdominal pain, jaundice, and marked eosinophilia. Endoscopic retrograde cholangio-pancreatogram revealed a dilated common bile duct. There was biopsy proven eosinophilic infiltration in stomach, duodenum, gall bladder, and pancreas. Obstructive jaundice is an extremely rare manifestation of EG. This unusual case illustrates the wide variety of gastrointestinal manifestations caused by EG and emphasizes the importance of clinical suspicion and endoscopic mucosal biopsies in diagnosis of EG. This entity should be considered in the patients with chronic and relapsing gastrointestinal symptoms.

The 3-hydroxy-3-methylglutaryl-CoA reductase inhibitor pravastatin reduces disease activity and inflammation in dextran-sulfate induced colitis.

The dextran sulfate (DSS) model of colitis causes intestinal injury sharing many characteristics with inflammatory bowel disease, e.g., leukocyte infiltration, loss of gut epithelial barrier, and cachexia. These symptoms are partly mediated by entrapped leukocytes binding to multiple endothelial adhesion molecules (MAdCAM-1, VCAM-1, ICAM-1, and E-selectin). Pravastatin, an 3-hydroxy-3-methylglutaryl (HMG)-CoA reductase inhibitor, has anti-inflammatory potency in certain inflammation models; therefore, in this study, we measured the effects of pravastatin in DSS-induced colitis. The administration of pravastatin (1 mg/kg) relieved DSS-induced cachexia, hematochezia, and intestinal epithelial permeability, with no effect on serum cholesterol. Histopathologically, pravastatin prevented leukocyte infiltration and gut injury. Pravastatin also blocked the mucosal expression of MAdCAM-1. DSS treatment promoted mucosal endothelial nitric-oxide synthase (eNOS) mRNA degradation, an effect that was blocked by pravastatin. Importantly, the protective effects of pravastatin in DSS-induced colitis were not found in eNOS-deficient mice. Our results demonstrate that HMG-CoA reductase inhibitors preserve intestinal integrity in colitis, most likely via increased eNOS expression and activity, independent of cholesterol metabolism.