Fungal Peptic Ulcer Disease in an Immunocompetent Patient.

The lifetime prevalence of peptic ulcer disease (PUD) is 5-10%. While PUD in immunocompetent patients is most commonly associated with Helicobacter pylori infection or the use of non-steroidal anti-inflammatory drugs (NSAIDs), other common causes of PUD must also be considered in the differential diagnosis. We describe a case of endoscopic and histological resolution of PUD related to Candida infection in a healthy, immunocompetent woman. LEARNING POINTS: Peptic ulcer disease (PUD) can be secondary to fungal infections, even in immunocompetent patients.A higher index of suspicion needs to be maintained for fungal causes of PUD, particularly if symptoms do not improve.Recognizing fungal causes of PUD may lead to faster diagnosis and treatment.

Temporal Trends and Predictors of Pancreatitis Patients Who Leave Against Medical Advice: A Nationwide Analysis.

BACKGROUND: Acute pancreatitis is the leading gastrointestinal cause of hospital admissions. Our study aims to determine the trends and predictors of discharge against medical advice (AMA). METHODS: We utilized the Nationwide Inpatient Sample (2003 - 2016) to identify patients admitted with pancreatitis. We compared in-hospital complications and determined predictors of discharge AMA using a multivariate logistic regression. RESULTS: A total of 7,158,894 patients were admitted with pancreatitis. Of those, 199,351 left AMA. Discharge AMA increased over time from 2.3% to 3.2%. Patients who left AMA were more likely to be younger, male, black, and a lower socioeconomic status (SES). They had a greater prevalence of depression, cirrhosis, smoking, drug abuse, and human immunodeficiency virus (HIV) infection. Alcohol use was the most likely etiology of pancreatitis among those leaving AMA. In a multivariate regression, patients more likely to leave AMA included: age 18 - 44, male, and black. Patients with a history of depression, drug abuse, and HIV infection were also more likely to be discharged AMA. CONCLUSIONS: Discharges AMA increased over time. Predictors of AMA include patients who are younger, male, black, lower socioeconomic status, and have a history of depression, HIV infection, alcohol and drug use. Future studies are necessary to examine the reasons for discharge AMA among this population.

Temporal trends in the utilization and outcomes of percutaneous coronary interventions in patients with liver cirrhosis.

OBJECTIVES: We sought to assess the national trends in the utilization and outcomes of percutaneous coronary interventions (PCI) in patients with cirrhosis. BACKGROUND: Contemporary data on PCI in patients with liver cirrhosis are limited. METHODS: The National-Inpatient-Sample was used to identify patients who underwent PCI between 2003 and 2016. We examined the annual PCI rate, and compared the in-hospital morbidity, mortality, resource utilization, and cost following PCI in patients with and without cirrhosis. RESULTS: A total of 8,860,178 PCI hospitalizations were identified, of those, 20,339 (0.2%) were performed in patients with cirrhosis. Annual PCI rates decreased overtime in patients without liver cirrhosis but increased in those with cirrhosis (Ptrend < .001). Patients with cirrhosis had a characteristic clinical, demographic, and socioeconomic profile compared with those without cirrhosis. The use of bare-metal stents decreased from 69.1 to 11.4% in the noncirrhosis group, and from 81.9 to 21.3% in the cirrhosis group. Compared with propensity-matched patients without cirrhosis, PCI in cirrhotic patients was associated with higher in-hospital mortality across all indications (STEMI 19.1 vs. 11.5%, p = .002; NSTEMI 8.7 vs. 5.6%, p = .002; and UA/SIHD 7.7 vs. 4.3%, p < .001). Cirrhotic patients also had significantly higher rates of acute kidney injury, but similar rates of vascular complications and stroke. Additionally, cirrhotic patients had longer hospitalizations, were less likely to be discharged home, and accrued higher cost across all PCI indications. CONCLUSIONS: Patients with cirrhosis who are deemed "suitable PCI candidates" in current practice remain at high-risk for worse short-term morbidity and mortality, and higher cost of care.

Detection of hiatal hernias: comparison of high-resolution manometry and physician reported in an obese-predominant population.

BACKGROUND: The diagnosis of a hiatal hernia (HH) can be made by barium oesophagram or upper endoscopy. Data regarding the ability of high-resolution manometry (HRM) with oesophageal pressure topography (OPT) to identify HH remains limited. We aim to assess the diagnostic accuracy of the automated localisation on high-resolution manometry compared with physician visual interpretation on the detection of HH. METHODS: Patients (n=181) from West Virginia, Pennsylvania, Maryland, Virginia and Ohio, undergoing HRM with OPT from 1 January 2015 to 1 December 2017 were reviewed. The BMIs of this patient population are of the highest in the USA. Demographics, presenting symptoms, laboratory data, endoscopic findings, radiographic findings, and HRM findings were collected. Diagnosis of HH through HRM automated identification of oesophageal landmarks were compared with diagnosis by physician visual interpretation of OPT. RESULTS: Automated identification of HH using HRM had high specificity (99.1%), but low sensitivity (11.4%). Physician visual interpretation of OPT similarly had high specificity (82.9%, 83.8%), but low sensitivity (30.0%, 28.6%). Automated identification of HH had a greater positive predictive value (88.9%) compared with physician visual interpretation (52.5%, 52.6%) but was found to have a similar negative predictive value (63.9%) as physician visual interpretation (65.3%, 65.0%). CONCLUSION: Compared with physician visual interpretation of OPT, automated identification of HH was more specific, but less sensitive in the diagnosis of HH. Use of automated identification of HH using HRM alone may lead to an increased number of false negatives, and subsequent underdiagnosis of this condition.

Incidence, Predictors, and Outcomes of Gastrointestinal Bleeding in Patients Admitted With ST-Elevation Myocardial Infarction.

Gastrointestinal bleeding (GIB) complicating ST-elevation myocardial infarction (STEMI) poses significant management challenges and may be associated with poor outcomes. We sought to evaluate the incidence and outcomes of GIB in STEMI patients using a nationwide database. We identified adults admitted with STEMI between in the National Inpatient Sample (2003 to 2016), and compared the morbidity, mortality, resource utilization, and cost in patients with and without GIB. We assessed rates of endoscopy referral and its associated with mortality. Among 1,450,696 weighted STEMI hospitalizations, 32,624 (2.2%) were complicated with GIB. Patients with GIB were older, and had distinctive characteristics compared to those without GIB. Older age, cardiogenic shock; history of peptic ulcer disease, cirrhosis, anemia, or alcohol use disorder were the strongest predictors of GIB during STEMI hospitalizations. In-hospital mortality was higher in the GIB group (28.2% vs 11.1%, p <0.001). The excess mortality associated with GIB persisted after propensity-score matching, and in sensitivity analyses excluding patients who underwent coronary intervention >24-hours after admission, and those transferred to another hospital. Post-STEMI GIB was associated with more strokes and acute kidney injury, longer hospitalizations, and higher cost. In a logistic regression analysis, GIB was independently associated with mortality (odds ratios [OR] 1.91, 95% confidence interval [CI] 1.85 to 1.97, p <0.001). There was a correlation between undergoing endoscopy and lower in-hospital mortality (unadjusted OR 0.27; 95% CI, 0.24 to 0.29; adjusted-OR 0.30; 95% CI, 0.27 to 0.33; p <0.001). In conclusion, GIB complicating STEMI is uncommon but is associated with excess morbidity, mortality, resource utilization and cost. Referral to endoscopy in this cohort may be associated with reduced in-hospital mortality.