Bleeding Risk With Cold Snare Polypectomy of ≤10 mm Pedunculated Colon Polyps.

OBJECTIVES: Pedunculated polyps (PPs) in the colon are usually resected with hot snare polypectomy to prevent immediate postpolypectomy bleeding (IPPB). This study aimed to evaluate the safety of CSP of <10 mm PPs. MATERIALS AND METHODS: Patients undergoing colonoscopy from February 18, 2019, to April 24, 2020, and were found to have at least 1 ≤10 mm PP resected with CSP were included prospectively in a continuous quality improvement project to assess the risk of IPPB and delayed postpolypectomy bleeding. Polyp location, size, and pathology, as well as the method of resection, were recorded. In addition, we assessed the occurrence and severity of IPPB and the need for intervention. RESULTS: We found 239 eligible polyps in 182 patients. The mean (SD) age was 58.8 (8.3) years, and 61% were males. IPPB occurred in 72 of 239 polyps, corresponding to a per-polyp bleeding percentage of 30.1% and in 65 of 182 patients, equating to a per-patient bleeding rate of 35.7%. We successfully treated bleeding by endoscopic hemostasis in 57%; the remaining 31 polyps (43%) did not require endoscopic intervention. There was no association between IPPB with age, gender, or use of aspirin or antithrombotic agents. In the bivariate model, polyp size and pathology were not associated with the risk of IPPB. Right-sided polyps were associated with a reduced risk of IPPB in the bivariate model by 61% (odds ratio=0.39; 95% confidence interval, 0.21-0.74; P =0.0057). In the multivariate model, choking the polyp base decreased the likelihood of IPPB by 97% (odds ratio=0.03; 95% confidence interval, 0.00-0.86; P =0.0459). There were no instances of delayed bleeding, perforation, or postpolypectomy syndrome. CONCLUSIONS: CSP can be used for resection of ≤10 mm PPs. It is associated with a lower risk of immediate bleeding than the common perception among gastroenterologists.

Ogilvie Syndrome and COVID-19 Infection.

Coronavirus disease 2019 (COVID-19) is an airborne infection transmitted via respiratory droplets and aerosolized material; however, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) uses the same angiotensin-converting enzyme type 2 receptor present in the respiratory epithelial cells to bind surface epithelial cells in the gastrointestinal tract. Here we report a case of Ogilvie syndrome in a patient who tested positive for SARS-CoV-2 a month prior to hospital admission. Quick recognition of Ogilvie syndrome as a potential complication of COVID-19 infection, prompt treatment with conservative measures, and prevention of possible fecal-oral transmission of the virus are crucial steps.

Atezolizumab, a PD-L1 Inhibitor: An Association of Bleeding Gastric Ulcer With Its Use.

Atezolizumab is a programmed death-ligand 1 inhibitor, an immune checkpoint inhibitor (ICI), useful in various advanced solid malignancies. As atezolizumab is more commonly used nowadays, physicians should be aware of the rare associated adverse events (AEs). Most of the AEs associated with the ICIs are immune-related, and the common gastrointestinal (GI) manifestations are colitis and diarrhea. Upper GI manifestations are rare with atezolizumab, and bleeding gastric ulcer is even rarer. We report here a case of a 62-year-old male with hepatocellular carcinoma who presented with upper GI bleed after atezolizumab therapy. Esophagogastroduodenoscopy showed multiple gastric ulcers, which are likely the cause of his bleeding.

Portal vein thrombosis as an initial presentation of Crohn's disease.

Inflammatory bowel diseases (IBD) are chronic and progressive conditions that can increase the risk of thromboembolism, including that of portal vein thrombosis (PVT). Overall, PVT is a serious complication with a significant associated mortality. PVTs are exclusively described in cases with confirmed IBD diagnosis. This report highlights a case of PVT as an initial manifestation of Crohn's disease.

Ethnic differences in out-of-hospital cardiac arrest among Middle Eastern Arabs and North African populations living in Qatar.

Aims: There are very few studies comparing epidemiology and outcomes of out-of-hospital cardiac arrest (OHCA) in different ethnic groups. Previous ethnicity studies have mostly determined OHCA differences between African American and Caucasian populations. The aim of this study was to compare epidemiology, clinical presentation, and outcomes of OHCA between the local Middle Eastern Gulf Cooperation Council (GCC) Arab and the migrant North African populations living in Qatar.Methods: This was a retrospective cohort study of Middle Eastern GCC Arabs and migrant North African patients with presumed cardiac origin OHCA resuscitated by Emergency Medical Services (EMS) in Qatar, between June 2012 and May 2015.Results: There were 285 Middle Eastern GCC Arabs and 112 North African OHCA patients enrolled during the study period. Compared with the local GCC Arabs, univariate analysis showed that the migrant North African OHCA patients were younger and had higher odds of initial shockable rhythm, pre-hospital interventions (defibrillation and amioderone), pre-hospital scene time, and decreased odds of risk factors (hypertension, respiratory disease, and diabetes) and pre-hospital response time. The survival to hospital discharge had greater odds for North African OHCA patients which did not persist after adjustment. Multivariable logistic regression showed that North Africans were associated with lower odds of diabetes (OR 0.48, 95% CI 0.25-0.91, p = 0.03), and higher odds of initial shockable rhythm (OR 2.86, 95% CI 1.30-6.33, p = 0.01) and greater scene time (OR 1.02 95% CI 1.0-1.04, p = 0.02).Conclusions: North African migrant OHCA patients were younger, had decreased risk factors and favourable OHCA rhythm and received greater ACLS interventions with shorter pre-hospital response times and longer scene times leading to better survival.

National Trends and Outcomes of Nonautoimmune Hemolytic Anemia in Alcoholic Liver Disease: Analysis of the Nationwide Inpatient Sample.

GOAL: The aim of this study was to determine the burden of nonautoimmune hemolytic anemia (NAHA) in hospitalized patients with coexisting alcoholic liver disease (ALD), identify risk factors for NAHA in ALD and describe the hospitalization outcomes. BACKGROUND: ALD can result in structural and metabolic alterations in the red-blood cell membrane leading to premature destruction of erythrocytes and hemolytic anemia of varying severity. STUDY: Hospitalized ALD patients with concomitant NAHA were identified in the Nationwide Inpatient Sample database using International Classification of Diseases-9 codes from 2009 to 2014. The primary outcome was to determine the nationwide prevalence and risk factors of NAHA in patients hospitalized with ALD. RESULTS: The prevalence of NAHA was 0.17% (n=3585) among all ALD patients (n=2,125,311) that were hospitalized. Multivariate analysis indicated higher odds of NAHA in ALD patients in the following groups: female gender [adjusted odds ratio (AOR) AOR 1.80, P<0.0001]; highest quartile of median household income (AOR 1.88, P<0.0001); increasing Charlson-Deyo Comorbidity Index (3 to 4 vs. 0, AOR 2.16, P=0.0042) and cirrhosis (AOR 2.74, P<0.0001). Discharges of ALD with anemia had a significantly longer average length of stay (8.8 vs. 6.0 d, P<0.0001), increased hospital charges ($38,961 vs. $25,244, P<0.0001) and higher mortality (9.0% vs. 5.6%, P<0.0001) when compared with ALD with no anemia. CONCLUSION: NAHA in patients with ALD is an important prognostic marker, predicting a longer, costlier hospitalization and increased inpatient mortality in ALD.

Secondary angiodysplasia-associated gastrointestinal bleeding in end-stage renal disease: Results from the nationwide inpatient sample.

BACKGROUND: Chronic kidney disease is associated with angiodysplasia of gastrointestinal tract leading to increased risk of gastrointestinal bleeding. AIM: To determine the nationwide prevalence, trends, predictors and resource utilization of angiodysplasia-associated gastrointestinal bleeding in end-stage renal disease hospitalizations. METHODS: The Nationwide Inpatient Sample database from 2009 to 2014, was utilized to conduct a retrospective study on patients with angiodysplasia associated- gastrointestinal bleeding and end-stage renal disease. Hospitalizations with end-stage renal disease were included in the Nationwide Inpatient Sample database and a subset of hospitalizations with end-stage renal disease and angiodysplasia-associated gastrointestinal bleeding were identified with International Classification of Diseases, 9th revision, Clinical Modification codes for both end-stage renal disease (585.6) and Angiodysplasia (569.85, 537.83). RESULTS: The prevalence of angiodysplasia-associated gastrointestinal bleeding was 0.45% (n = 24709) among all end-stage renal disease patients (n = 5505252) that were hospitalized. Multivariate analysis indicated that the following were significant factors associated with higher odds of angiodysplasia associated-gastrointestinal bleeding in end-stage renal disease patients: an increasing trend from 2009-2014 (P < 0.01), increasing age (P < 0.0001); African American race (P = 0.0206); increasing Charlson-Deyo Comorbidity Index (P < 0.01); hypertension (P < 0.0001); and tobacco use (P < 0.0001). Diabetes mellitus (P < 0.0001) was associated with lower odds of angiodysplasia associated-gastrointestinal bleeding in end-stage renal disease patients. In comparison with urban teaching hospitals, rural and urban nonteaching hospitals were associated with decreased odds of angiodysplasia associated-gastrointestinal hemorrhage. CONCLUSION: Angiodysplasia-associated gastrointestinal bleeding in end-stage renal disease patients showed an increasing trend from 2009-2014. Advanced age, African American race, overall high comorbidities, hypertension and smoking were significant factors for angiodysplasia-associated gastrointestinal bleeding in end-stage renal disease hospitalized patients.

Blocked by a Ring: A Case of Gastric Linitis Plastica Presenting as Large Bowel Obstruction Secondary to Rectal Stenosis.

Metastatic gut lesions from primary gastric carcinoma occur via hematogenous, lymphatic, or peritoneal seeding. We report an unusual case of large bowel obstruction secondary to rectal stenosis due to metastatic signet ring cell gastric cancer. A 61-year-old woman with a history of 8 weeks' duration of alternation in bowel movements presented with symptoms of bowel obstruction. Computed tomography revealed rectal wall thickening, and sigmoidoscopy demonstrated edematous and fibrotic rectal mucosa. Superficial biopsies were negative for malignant disease. Because of worsening of obstructive symptoms, an emergent surgical diversion was performed. Surgical biopsies were consistent with poorly differentiated adenocarcinoma. Gastroscopy established diagnosis of gastric adenocarcinoma with signet ring type cells. Rectal stenosis on examination and demonstration of rectal wall thickening on imaging should raise suspicion for Schnitzler's metastasis, and an upper endoscopy should be performed.

Varicella Zoster Virus Esophagitis in an Immunocompetent Patient.

The varicella zoster virus is highly infectious, spreading via direct contact or respiratory droplets, and can lead to life-threatening complications. Although disseminated disease tends to occur most commonly in immunocompromised patients, we present a peculiar case of varicella zoster esophagitis in a healthy, immunocompetent adult. To provide prompt treatment, clinicians should be aware that the varicella zoster virus could cause severe esophagitis, even in immunocompetent patients.

Hepatic Sinusoidal Obstruction Syndrome in a Patient With Multiple Myeloma Treated With CyBorD.

Hepatic sinusoidal obstruction syndrome (SOS) is a life-threatening state generally occurring as a complication of conditioning regimens used for hematopoietic stem cell transplant. Hepatic SOS after a standard dose of chemotherapy in malignancies is rare, and there are only a few cases in pediatric literature. We report a 56-year-old man with multiple myeloma who experienced SOS after being initiated on chemotherapy including cyclophosphamide, dexamethasone, and bortezomib and who experienced a delay in treatment with defibrotide, because it is currently approved by the Food and Drug Administration for only patients who develop SOS after hematopoietic stem cell transplant.

Spontaneous fungal peritonitis: Micro-organisms, management and mortality in liver cirrhosis-A systematic review.

BACKGROUND: Spontaneous peritonitis is an infection of ascitic fluid without a known intra-abdominal source of infection. spontaneous fungal peritonitis (SFP) is a potentially fatal complication of decompensated cirrhosis, defined as fungal infection of ascitic fluid in the presence of ascitic neutrophil count of greater than 250 cells/mL. AIM: To determine the prevalence of fungal pathogens, management and outcomes (mortality) of SFP in critically ill cirrhotic patients. METHODS: Studies were identified using PubMed, EMBASE, Cochrane Central Register of Controlled Trials and Scopus databases until February 2019. Inclusion criteria included intervention trials and observation studies describing the association between SFP and cirrhosis. The primary outcome was in-hospital, 1-mo, and 6-mo mortality rates of SFP in cirrhotic patients. Secondary outcomes were fungal microorganisms identified and in hospital management by anti-fungal medications. The National Heart, Lung and Blood Institute quality assessment tools were used to assess internal validity and risk of bias for each included study. RESULTS: Six observational studies were included in this systematic review. The overall quality of included studies was good. A meta-analysis of results could not be performed because of differences in reporting of outcomes and heterogeneity of the included studies. There were 82 patients with SFP described across all the included studies. Candida species, predominantly Candida albicans was the fungal pathogen in majority of the cases (48%-81.8%) followed by Candida krusei (15%-25%) and Candida glabrata (6.66%-20%). Cryptococcus neoformans (53.3%) was the other major fungal pathogen. Antifungal therapy in SFP patients was utilized in 33.3% to 81.8% cases. The prevalence of in hospital mortality ranged from 33.3% to 100%, whereas 1-mo mortality ranged between 50% to 73.3%. CONCLUSION: This systematic review suggests that SFP in end stage liver disease patient is associated with high mortality both in the hospital and at 1-mo, and that antifungal therapy is currently underutilized.

A rapid market survey on the availability of car seats in Qatar: Implications for child passenger safety.

Introduction: Despite the high income level in Arabian Gulf countries, people in the region need to improve their use of child restraint systems (CRSs) to reduce the incidence of preventable injuries to child automobile passengers. Anecdotal reports have attributed the resistance to using CRSs to the expense and unavailability of the systems, prompting car seat giveaway programs. Previous studies have not assessed the adoption of CRS. This study reports the results of a rapid market survey (RMS) to understand the availability, characteristics, and affordability of CRSs in Qatar and recommend future child restraint policies and legislation. Methods: The RMS identified all retail outlets that sell CRSs in Qatar and collected standard data on each restraint system: brand, model number, age/weight limits, compliance with standards, availability, and language of the owner's manual. A previously utilized metric for child safety devices was used to measure affordability. Results: The RMS showed a sufficient number (83) and variety (five types) of car seat models at 15 retail outlets, selling at a wide price range of $14-$1,399. All the car seats complied with the European standard. Only 2% showed a manufacturing or expiry date. A user manual was available for 71% of the seats and in different languages, but only 28% appeared in Arabic. The median CRS price was equivalent to the wages for less than one day of work. Conclusion: The RMS demonstrates the availability, variety, and affordability of CRSs in Qatar. Unavailability and expense cannot be cited as barriers to use CRS, and the market is prepared for legislation requiring car seats for children in Qatar. Areas for improvement include requiring user manuals for all seats, especially in Arabic; requiring that all car seats comply with globally accepted safety standards, especially for expiry/manufacturing dates, given the harsh local climate; and encouraging further varieties of CRSs in the local market.

Colorectal cancer screening in hospitalized patients: results from the Nationwide Inpatient Sample.

Colorectal cancer (CRC) is preventable with regular screening. This study aims to determine estimates and predictors of inpatient CRC screening during hospitalization in the USA. This nationwide population-based study utilized data from the National Inpatient Sample database from 2005 to 2014 to examine rates of CRC screening among hospitalized patients. There were 6470 inpatient CRC screening nationwide from 129 645 394 inpatient hospitalizations. Multivariable analysis showed that higher rates of inpatient CRC screening were associated with: females compared to males [odds ratio (OR): 0.87; 95% confidence interval (CI): 0.78-0.97]; 50-59 years age group compared to 70-79 years (OR: 0.76; 95% CI: 0.62-0.94) and more than 80 years (OR: 0.47; 95% CI: 0.35-0.64); Charlson Comorbidity Index score of 0 compared to scores of 1-2 (OR: 0.79; 95% CI: 0.64-0.98), 3-4 (OR: 0.61; 95% CI: 0.49-0.76), more than 5 (OR: 0.61; 95% CI: 0.47-0.79); rural hospitals rather than urban teaching hospital (OR: 0.50; 95% CI: 0.39-0.63) and urban nonteaching hospitals (OR: 0.64; 95% CI: 0.49-0.82); hospitals in the Midwest region (OR: 1.56; 95% CI: 1.14-2.12) compared to the Northeast region; recent years of 2011/2012 (OR: 1.89; 95% CI: 1.44-2.49) and 2013/2014 (OR: 2.70; 95% CI: 2.14-3.41) compared to the period 2005/2006. The CRC screening rate among hospitalized patients admitted in US hospitals is low. There were no association of differences in racial, household income or health insurance status with inpatient CRC screening. Noninvasive screening methods in hospitalized patients like stool-based fecal immunochemical test provide a unique method of increasing cancer screening rates.

Blind After a Binge: Purtscher-like Retinopathy in Acute Alcoholic Pancreatitis.

Purtscher-like retinopathy is an occlusive microvasculopathy that causes sudden onset vision loss of varying severity. The condition is a rare complication of acute pancreatitis and is scarcely documented in the literature. In addition, it is vision-threatening, and there are no evidence-based therapies available. We report a 37-year-old woman presenting with abdominal pain and nausea in the setting of heavy alcohol use. She was diagnosed with acute pancreatitis. During hospitalization, she developed acute visual disturbance and was found to have significantly diminished visual acuity. A dilated funduscopic examination demonstrated multiple retinal cotton wool spots bilaterally and macular edema. The patient was diagnosed with Purtscher-like retinopathy in the setting of acute pancreatitis. Although the prognosis for her vision was guarded, given the ischemic nature of the insult, she had subjective improvement in visual acuity during the remainder of the hospital course with symptomatic management.

Systematic review of histological remission criteria in eosinophilic esophagitis.

Elemental diets, dietary elimination, and steroid therapies are the most common therapies in the clinical trials for eosinophilic esophagitis (EoE). Histological findings (usually reported as eosinophils per microscopic high-powered field [hpf]) remain the most common end-point used to define response. Yet, the threshold for defining "response" and "remission" are ill-defined among consensus guidelines and may vary from study to study. We conducted a systematic literature review of articles on eosinophilic esophagitis, published between January 2007 and November 2017, considering histological remission as the primary outcome. We abstracted treatment information and definitions of histological remission or response. A comparison of definitions of histological remission across and within institutions was performed. A total of 61 articles were included in this review, with approximately 60% of the studies published from centers in the United States. Histological definitions of remission of EoE ranged from 0 to ≤20 eosinophils/hpf. The most stringent criteria, ranging from 0 to ≤5 eosinophils/hpf, were commonly used in interventional trial studies that examined the effects of new treatments. We found remarkable variability in definitions between studies, treatment types, and regions. Age or epidemiological distribution of study subjects did not influence the criteria for histological remission. Clinical and histological improvements are important measures of the effects of treatment. Histological findings, the most objective measure of treatment, should provide an optimal method for comparing the effectiveness of various treatments. Yet, our findings suggest a lack of consistent remission criteria in published studies. Considering these inconsistencies, it is difficult to compare the effectiveness of various treatments.

Spontaneous Intramural Esophageal Rupture: An Uncommon Presentation of Eosinophilic Esophagitis Requiring Endoscopic Clipping.

Spontaneous intramural esophageal rupture (SIER) is a form of acute esophageal trauma defined as an injury deeper than a Mallory-Weiss tear but not extending completely through the muscular propria as in Boerhaave syndrome. SIER is a rare complication of eosinophilic esophagitis (EoE); after extensive literature review, we found 7 case reports of SIER complicating EoE. We present a case of SIER complicating EoE in a 46-year-old man with an atypical presentation requiring endoscopic clipping to achieve successful hemostasis.

A Case of Concomitant Emphysematous Cystitis and Clostridium difficile Colitis with Pneumoperitoneum.

Emphysematous cystitis (EC) is a rare condition described as air within the wall and lumen of the urinary bladder. It is a complicated form of urinary tract infection caused by gas-forming bacteria. Pneumoperitoneum described as gas in the peritoneum is usually seen with abdominal hollow organ perforation, and approximately 10% of cases have been reported that are not associated with abdominal hollow viscus perforation. To the best of our knowledge, no case of EC with pneumoperitoneum in the setting of concurrent Klebsiella urinary tract infection and Clostridiumdifficile (C. difficile) colitis have been reported. Here we present a unique case of EC with pneumoperitoneum, in a patient with recurrent C. difficile infection and Klebsiella pneumonia-urinary tract infection, treated conservatively with a favorable outcome.

Dapagliflozin-Associated Euglycemic Diabetic Ketoacidosis in a Patient Presenting with Acute Pancreatitis.

Sodium-glucose cotransporter 2 (SGLT-2) inhibitors are a class of medications used for glycemic control in type II diabetes mellitus. Their mechanism of action involves preventing resorption of glucose at the proximal kidney, thereby promoting glucosuria and weight loss. However, they have also been found to be associated with euglycemic diabetic ketoacidosis (euDKA). This case describes a 25-year-old male with a history of type II diabetes on metformin, sitagliptin, and dapagliflozin who was admitted with his third episode of pancreatitis secondary to hypertriglyceridemia. His home oral glycemic agents were continued as inpatient. Despite tight euglycemic control, the patient developed profound metabolic acidosis and was found to have an elevated beta-hydroxybutyrate level and normal lactic acid level. He was admitted into the intensive care unit and started on an insulin drip, and after resolution of his acidosis he was transitioned to basal insulin successfully. He was discharged with an insulin regimen while his oral glycemic agents were discontinued indefinitely. SGLT-2 inhibitors are associated with euDKA, most likely as a result of their non-insulin-dependent glucose clearance, hyperglucagonemia, and decreased ketone clearance. The aim of this case report is to inform the physician about the possibility of euDKA in a patient with type II diabetes on a SGLT-2 inhibitor presenting with an acute illness.

Health System Response and Adaptation to the Largest Sandstorm in the Middle East.

The State of Qatar experienced a sandstorm on the night of April 1, 2015, lasting approximately 12 hours, with winds of more than 100 km/h and average particulate matter of approximately 10 µm in diameter. The emergency department (ED) of the main tertiary hospital in Qatar managed 62% of the total emergency calls and those of higher triage order. The peak load of patients during the event manifested approximately 6 hours after the onset. The Major Emergency Command Centre of the hospital ensured the department was maximally organized in terms of disaster management, and established protocols were brought into action. Multiple timely meetings were convened in efforts to effectively execute plans that included rapid emergency medical services handover time, resourcing staff, maximizing bed space, preventing dust entry in the ED, bypassing certain administrative processes, canceling day-surgeries that did not affect inpatient morbidity, and procuring additional respiratory equipment. Patients arrived mainly with exacerbations of asthma and respiratory distress, ophthalmic emergencies, and vehicular trauma; surprisingly, the incidence of pedestrian injuries did not vary. (Disaster Med Public Health Preparedness. 2017;11:227-238).