First Clostridioides difficile Recurrence Is Highest Following Concomitant Antimicrobial Administration During and Within 30 Days of Treatment.

BACKGROUND: Clostridioides difficile infection (CDI) is an epidemic with the strongest risk factor being antibiotic usage. Patients who get CDI frequently require concomitant antibiotics for other indications around the time of their infection. AIMS: To assess the recurrence of CDI (rCDI) in patients receiving concomitant antibiotics at the same time or shortly thereafter treatment of CDI. METHODS: We retrospectively reviewed records for patients with their first inpatient CDI episode. Patients were grouped into those who didn't receive concomitant antibiotics (noABx), those receiving antibiotics at the same time as treatment of CDI (ABxDURING), those receiving antibiotics within 30-days of completion of CDI therapy (ABxAFTER) and those who received antibiotics both during and after CDI treatment (ABxDuringAfter). Our primary outcome was recurrence within 14-90 days; other outcomes included ICU stay at the time of diagnosis, 30-day ICU transfer, 30-day colectomy, and readmission. RESULTS: 457 patients had CDI during admission (mean age: 66.4 years, 51.9% female). 64.1% were exposed to concomitant antibiotics. Recurrence rates were 4.3%, 6.1%, 13.8% and 19.1%, for noABx, ABxDURING, ABxAFTER and ABxDuringAfter, respectively. Patients with ABxDuringAfter had the highest rates of rCDI when compared to noABx [OR 5.67, 95% CI (2.18-14.72)]. CONCLUSIONS: There is a high rate of utilization of non-CDI antibiotics during or shortly after completing CDI treatment with high rates of recurrence within 90-days. Concomitant antimicrobials alter the opportunity for the microbiota to re-grow and worsens dysbiosis leading to increases in recurrence. Concomitant antimicrobial stewardship remains important in patients being treated for CDI and shortly after treatment.

An Entirely Atypical Presentation of Esophageal Squamous Cell Cancer with Pancreatic and Bone Metastases.

Few cases of solitary pancreatic metastases from esophageal cancer have been reported; however, these previous cases all describe a solid pancreatic mass. We present a unique case of a 67-year-old man with squamous cell carcinoma detected within a pancreatic cystic lesion that was sampled with endoscopic ultrasound-guided fine needle aspiration. Esophagogastroduodenoscopy identified a friable and fungating partially obstructing mass in the distal esophagus with features of fistulization into the lung. Pathology showed esophageal squamous cell cancer. An isolated bone lesion was also biopsied and revealed squamous cell cancer. The patient tolerated oral intake and a multidisciplinary decision was made for palliative care with home hospices given his comorbidities portending poor operative candidacy and overall poor prognosis secondary to multiple sites of metastases from his esophageal squamous cell cancer.

Older patients are significantly more likely to have colon ischaemia-associated conditions that are chronic and complex.

BACKGROUND: Colon ischaemia is a common disease which has been associated with various medications and comorbidities. AIM: To test the hypothesis that there are differences in the frequencies of these associations in older compared with younger patients. METHODS: A retrospective cohort study was performed of patients hospitalized with colon ischaemia at two major medical centres from 2005-2017. Clinical, colonoscopic and pathologic criteria were used to identify patients admitted with colon ischaemia; patients with other types of colitis were excluded. Demographic and medical data were extracted. Two cohorts were created: patients aged 18-64 years and patients > 65 years. These were compared using SAS 14.3. RESULTS: A total of 788 patients were included, of which 271 (34.4%) were of ages 18-64 years, and 517 (66.6%) were 65 years old or older. In the older cohort, constipation-inducing medications (83.8% vs 64.1%; P = <0.0001), diuretics (38.1% vs 25.1%; P = <0.001) and nonsteroidal anti-inflammatory drugs (58% vs 41.5%; P = <0.0001) were more common than in the younger cohort. Antipsychotic medication use was more common in the younger cohort (10.4% vs 5.4%; P = 0.01). There was a higher percentage of younger patients with a history of hypercoaguable state (1.9% vs 0.2%; P = 0.03) and dialysis dependence (22.9% vs 8.7%; P = <0.01), while a higher percentage of patients in the older cohort had a history of chronic obstructive pulmonary disease (12% vs 6.3%; P = 0.01) or atrial fibrillation (18.9% vs 10.3%; P = <0.01). CONCLUSIONS: Our study shows that older patients are more likely to have colon ischaemia-associated conditions that are chronic and complex, while younger patients are more likely to have acute colon ischaemia-associated conditions.

Successful stent-in-stent dilatation of the common bile duct through a duodenal prosthesis, a novel technique for malignant obstruction: A case report and review of literature.

For patients suffering from both biliary and duodenal obstruction, endoscopic retrograde cholangiopancreatography (ERCP) with stent placement is the treatment of choice. ERCP through an already existing duodenal prosthesis is an uncommon procedure and furthermore no studies have reported installing a covered metal stent onto an already existing bare metal stent in the common bile duct (CBD). We describe a rare case of a stent-in-stent dilatation of the CBD through an already existing self-expanding metal stent in the second part of duodenum for the patient presenting with jaundice in setting of biliary and duodenal obstruction from pancreatic adenocarcinoma. The biliary obstruction was relieved with a decrease in bilirubin levels post-stenting.

Off label use of lumen-apposing metal stent for persistent gastro-jejunal anastomotic stricture.

We are reporting a novel "off-label" use of lumen apposing metal stent (LAMS) for management of refractory gastro-jejunal (GJ) anastomotic stricture after Roux-en-y gastric bypass (RYGB). With increasing prevalence of obesity, bariatric surgery is performed more frequently than ever. RYGB is one of the most commonly performed bariatric procedures. GJ anastomotic stricture is a late complication of this procedure. Our patient, seven years after RYGB developed GJ anastomotic ulcer and subsequently a stricture not amendable to repeated pneumatic dilations. Instead of using the conventional fully covered self-expanding metal stent (fcSEMS) we deployed the relatively new LAMS keeping in mind its novel dumbbell shaped design. Our patient's symptoms were controlled successfully and she remained asymptomatic on follow-up. Despite initial approval for pancreatic pseudocyst drainage, LAMS has been used with increased frequency at various locations within gastrointestinal tract including GJ anastomotic strictures. Future randomized control trials are warranted to compare the efficacy of fcSEMS to LAMS.

Dieulafoy's lesion: a rare cause of lower gastrointestinal bleeding.

The most common etiologies of lower gastrointestinal bleeding include ischemia, diverticulosis, and angiodysplasia. A Dieulafoy's lesion, an uncommon cause of upper gastrointestinal bleeding, is even more rare as an etiology of lower gastrointestinal bleeding. We report a case of an elderly patient with abrupt hematochezia requiring stabilization and blood transfusions. The presumptive diagnosis was diverticulosis or an arteriovenous malformation, but colonoscopy revealed that the source of bleeding was a Dieulafoy's lesion in the ascending colon. The lesion was injected with epinephrine, followed by placement of clips to achieve hemostasis. There were no subsequent interventions and the patient was safely discharged.

A case of cyclic neutropenia in adults.

A 22 years old patient presented with recurrent episodes of diarrhoea, pharyngitis, apthous ulcers and fever for the past 6 months. The episodes lasted a week each time. The patient was admitted and blood studies revealed neutropenia with increased number of Large Granular Lymphocytes. Later on it was found out that his neutrophil count dropped to less than 0.2 x 10(9)/L after every 3 weeks. Bone marrow study revealed decreases neutrophil precursors during these episodes. He was diagnosed with adult onset cyclic neutropenia and his episodes were treated with G-CSF and Ceftriaxone.

Spontaneous renal artery dissection: current perspective.

Spontaneous Renal artery dissection is a rare entity that may remain clinically silent or present with non-specific signs and symptoms, which makes it a diagnostic challenge. It may be associated with certain underlying vascular pathologies, but its occurrence remains idiopathic in the majority of cases. While there are no evidence-based guidelines for its management, blood pressure control and preservation of renal function remain the cardinal goals of therapy.