Long-term aspirin use in patients hospitalized with ischemic colitis.

Background: Ischemic colitis is a form of mesenteric ischemia that often presents in patients with vascular disease. Long-term aspirin use has been shown to improve the outcomes in patients with cardiovascular or cerebrovascular disease. However, the relationship between aspirin use and ischemic colitis is unclear. Methods: Patients with a diagnosis of ischemic colitis were identified using the 2020 Nationwide Inpatient Sample. Patients were stratified by long-term aspirin use at the time of hospitalization. Data were collected regarding mortality, bowel perforation, peritonitis, shock, blood transfusion, length of stay in days (LOS), hospital charges, age, sex, race, primary insurance, median income, hospital region, hospital size, and comorbidities. The relationship between aspirin use and outcomes was analyzed using multivariate regression analysis. Results: A total of 67,685 patients were included. Aspirin users had a mean age of 72.8 years compared to 66.8 years for non-aspirin users. Long-term aspirin use was associated with a lower risk of in-hospital mortality (P<0.001), bowel perforation (P<0.001), peritonitis (P=0.01), shock (P<0.001), and blood transfusion (P<0.001). The mean LOS was 6.1 days in the aspirin group compared to 9.4 days in the non-aspirin group. Ischemic colitis patients taking aspirin had a mean hospitalization charge of $87,123 compared to $161,610 for those not using aspirin. Conclusions: Our study examined the impact of aspirin use in ischemic colitis patients. Among patients hospitalized with ischemic colitis, we found that long-term aspirin use was associated with a lower risk of in-hospital mortality and adverse events.

The impact of aspirin use on outcomes in patients with inflammatory bowel disease: Insights from a national database.

BACKGROUND: Inflammatory bowel disease (IBD) is an inflammatory disorder that can increase the risk of mortality. Aspirin is an anti-inflammatory drug used for primary prevention of cardiovascular events. A single center analysis previously reported that aspirin use did not impact major outcomes in IBD. In this study, we aim to assess the impact of aspirin use on mortality and other outcomes in patients with IBD using national data. METHODS: National inpatient sample (NIS) 2016-2020 was used to identify adult patients with IBD. Data were collected on patient demographics, hospital characteristics, and comorbidities. The outcomes studied were in-hospital mortality, sepsis, shock, Intensive Care Unit (ICU) admission, and need for surgery. Multivariate logistic regression analysis was performed. RESULTS: A total of 1,524,820 IBD hospitalizations were included. Of these, 137,430 (9%) were long-term aspirin users. The majority of the patients in the aspirin group were aged > 65 years (34.11%), female (56.37%), White (78.83%) and had Medicare insurance (36.77%). Aspirin users had a lower incidence of in-hospital mortality (1.6% vs 1.4%, P = 0.06), sepsis (2.5% vs 2.9%, P < 0.001), shock (2.9% vs 3.4%, P < 0.001), ICU admission (2.6% vs 2.9%, P < 0.001), need for surgery (2.1% vs 4.2%, P < 0.001). After adjusting for confounders, aspirin was associated with a reduction in mortality (adjusted odds ratio: 0.49, 95%CI 0.45-0.55, P < 0.001). CONCLUSION: Our study reports that aspirin use among patients with IBD was associated with a lower risk of death, sepsis, and shock. Aspirin use may have a protective effect in patients with IBD. Further studies are needed to confirm these results.

The Impact of COVID-19 on Outcomes of Ischemic Colitis: A Nationwide Retrospective Analysis.

Background: Ischemic colitis is the most common presentation of mesenteric ischemia and is associated with significant morbidity and mortality. Coagulopathy has been associated with the development of ischemic colitis. Coronavirus disease 2019 (COVID-19) infection can lead to a variety of pathology and physiological derangements, including coagulopathy. Some case reports have described severe ischemic colitis in patients with COVID-19 infection. Our study aimed to elucidate the impact of COVID-19 infection on ischemic colitis outcomes. Methods: Patients with a diagnosis of ischemic colitis were identified using the 2020 Nationwide Inpatient Sample (NIS). Patients were stratified based on the presence of COVID-19 infection. Data were collected regarding mortality, shock, blood transfusion, length of stay, hospital charges, age, gender, race, primary insurance, median income, hospital region, hospital bed size, and comorbidities. The relationship between COVID-19 and outcomes was analyzed using multivariate regression analysis. Results: A total of 67,685 patients were included in the final analysis. COVID-19 was associated with an increased risk of in-hospital mortality (adjusted odds ratio (aOR): 4.006, P < 0.001), shock (aOR: 1.62, P = 0.002), and blood transfusion (aOR: 1.49, P = 0.007). COVID-19 was also associated with an increased length of stay (16.2 days vs. 8.7 days) and higher total hospital charges ($268,884.1 vs. $145,805.9). Conclusions: Among hospitalized patients with ischemic colitis, COVID-19 infection was associated with worse outcomes and higher resource utilization. Further studies are needed to investigate the mechanisms underlying this association.

Baseline Features and Reasons for Nonparticipation in the Colonoscopy Versus Fecal Immunochemical Test in Reducing Mortality From Colorectal Cancer (CONFIRM) Study, a Colorectal Cancer Screening Trial.

Importance: The Colonoscopy Versus Fecal Immunochemical Test in Reducing Mortality From Colorectal Cancer (CONFIRM) randomized clinical trial sought to recruit 50 000 adults into a study comparing colorectal cancer (CRC) mortality outcomes after randomization to either an annual fecal immunochemical test (FIT) or colonoscopy. Objective: To (1) describe study participant characteristics and (2) examine who declined participation because of a preference for colonoscopy or stool testing (ie, fecal occult blood test [FOBT]/FIT) and assess that preference's association with geographic and temporal factors. Design, Setting, and Participants: This cross-sectional study within CONFIRM, which completed enrollment through 46 Department of Veterans Affairs medical centers between May 22, 2012, and December 1, 2017, with follow-up planned through 2028, comprised veterans aged 50 to 75 years with an average CRC risk and due for screening. Data were analyzed between March 7 and December 5, 2022. Exposure: Case report forms were used to capture enrolled participant data and reasons for declining participation among otherwise eligible individuals. Main Outcomes and Measures: Descriptive statistics were used to characterize the cohort overall and by intervention. Among individuals declining participation, logistic regression was used to compare preference for FOBT/FIT or colonoscopy by recruitment region and year. Results: A total of 50 126 participants were recruited (mean [SD] age, 59.1 [6.9] years; 46 618 [93.0%] male and 3508 [7.0%] female). The cohort was racially and ethnically diverse, with 748 (1.5%) identifying as Asian, 12 021 (24.0%) as Black, 415 (0.8%) as Native American or Alaska Native, 34 629 (69.1%) as White, and 1877 (3.7%) as other race, including multiracial; and 5734 (11.4%) as having Hispanic ethnicity. Of the 11 109 eligible individuals who declined participation (18.0%), 4824 (43.4%) declined due to a stated preference for a specific screening test, with FOBT/FIT being the most preferred method (2820 [58.5%]) vs colonoscopy (1958 [40.6%]; P < .001) or other screening tests (46 [1.0%] P < .001). Preference for FOBT/FIT was strongest in the West (963 of 1472 [65.4%]) and modest elsewhere, ranging from 199 of 371 (53.6%) in the Northeast to 884 of 1543 (57.3%) in the Midwest (P = .001). Adjusting for region, the preference for FOBT/FIT increased by 19% per recruitment year (odds ratio, 1.19; 95% CI, 1.14-1.25). Conclusions and Relevance: In this cross-sectional analysis of veterans choosing nonenrollment in the CONFIRM study, those who declined participation more often preferred FOBT or FIT over colonoscopy. This preference increased over time and was strongest in the western US and may provide insight into trends in CRC screening preferences.

McKittrick-Wheelock syndrome: A rare cause of chronic diarrhea treated with endoscopic polypectomy.

Chronic diarrhea is a commonly encountered complaint and a principal cause of health care utilization worldwide. Although there are various etiologies of chronic diarrhea, McKittrick-Wheelock syndrome is a rare syndrome defined as a large villous adenoma with secretory diarrhea causing severe fluid imbalances. We report a case of a patient with McKittrick-Wheelock syndrome who was successfully treated with endoscopic resection. Our case aims to add information to the current literature supporting the endoscopic management of McKittrick-Wheelock syndrome.

Does use of long-term aspirin impact outcomes in patients with acute pancreatitis?

INTRODUCTION: Although the effect of rectal indomethacin in post-endoscopic retrograde cholangiopancreatography pancreatitis is well established, the effect of aspirin on acute pancreatitis (AP) is not well studied. We investigate the effect of aspirin on AP. METHODS: We collected data from the National Inpatient Sample database from 2016 to 2020, to identify adult patients with acute pancreatitis. Patients were stratified into 2 groups, based on the presence of aspirin use. The primary outcome was mortality, while other outcomes were sepsis, shock, acute kidney injury (AKI), ICU admission, deep venous thrombosis (DVT), pulmonary embolism (PE), portal vein thrombosis (PVT), pseudocyst and ileus. RESULTS: A total of 2.09 million patients met the inclusion criteria, of which 197 170 (9.41%) had long-term aspirin use. The majority of the patients with aspirin use were aged >65 years, male, White and had Medicare insurance. There was a higher incidence of biliary pancreatitis while rates of alcohol-induced pancreatitis were lower in patients with aspirin use. There was a lower incidence of mortality, sepsis, shock, PE, DVT, PVT and pseudocyst in patients with aspirin use. There was no difference in the incidence of ileus, while the incidence of AKI was higher. After adjusting for confounding factors, patients with aspirin use had a 23.6% lower risk of mortality. DISCUSSION: Our results reveal a significant finding of aspirin's protective effect on AP in the US population. Our study is the largest study revealing an association between aspirin and AP. Further studies assessing the role of aspirin use in AP are warranted.

The burden of acute pancreatitis on COVID-19 in the United States.

Background: Although SARS-CoV-2 primarily affects the respiratory system, gastrointestinal symptoms were also seen. Our study analyzed the prevalence and impact of acute pancreatitis (AP) on COVID-19 hospitalizations in the United States. Methods: The 2020 National Inpatient Sample database was used to identify patients with COVID-19. The patients were stratified into 2 groups based on the presence of AP. AP as well as its impact on COVID-19 outcomes were evaluated. The primary outcome was in-hospital mortality. Secondary outcomes were intensive care unit (ICU) admissions, shock, acute kidney injury (AKI), sepsis, length of stay, and total hospitalization charges. Univariate and multivariate logistic/linear regression analyses were performed. Results: The study population comprised 1,581,585 patients with COVID-19, from which 0.61% of people had AP. Patients with COVID-19 and AP had a higher incidence of sepsis, shock, ICU admissions, and AKI. On multivariate analysis, patients with AP had higher mortality (adjusted odds ratio [aOR] 1.19, 95% confidence interval [CI] 1.03-1.38; P=0.02). We also noted a higher risk of sepsis (aOR 1.22, 95%CI 1.01-1.48; P=0.04), shock (aOR 2.09, 95%CI 1.83-2.40; P<0.001), AKI (aOR 1.79, 95%CI 1.61-1.99; P<0.001), and ICU admissions (aOR 1.56, 95%CI 1.38-1.77; P<0.001). Patients with AP also had a longer length of stay (+2.03 days, 95%CI 1.45-2.60; P<0.001), and higher hospitalization charges ($44,088.41, 95%CI $33,198.41-54,978.41; P<0.001). Conclusions: Our study revealed that the prevalence of AP in patients with COVID-19 was 0.61%. Although this was not strikingly high, the presence of AP is associated with worse outcomes and higher resource utilization.

The burden of Clostridioides difficile on COVID-19 hospitalizations in the USA.

BACKGROUND AND AIM: Clostridioides difficile infection (CDI) is the leading cause of hospital acquired-infectious diarrhea in the USA. In this study, we assess the prevalence and impact of CDI in COVID-19 hospitalizations in the USA. METHODS: We used the 2020 National Inpatient Sample database to identify adult patients with COVID-19. The patients were stratified into two groups based on the presence of CDI. The impact of CDI on outcomes such as in-hospital mortality, ICU admission, shock, acute kidney injury (AKI), and sepsis rates. Multivariate regression analysis was performed to assess the effects of CDI on outcomes. RESULTS: The study population comprised 1581 585 patients with COVID-19. Among these, 0.65% of people had a CDI. There was a higher incidence of mortality in patients with COVID-19 and CDI compared with patients without COVID-19 (23.25% vs 13.33%, P < 0.001). The patients with COVID-19 and CDI had a higher incidence of sepsis (7.69% vs 5%, P < 0.001), shock (23.59% vs 8.59%, P < 0.001), ICU admission (25.54% vs 12.28%, P < 0.001), and AKI (47.71% vs 28.52%, P < 0.001). On multivariate analysis, patients with CDI had a statistically significant higher risk of mortality than those without (aOR = 1.47, P < 0.001). We also noted a statistically significant higher risk of sepsis (aOR = 1.47, P < 0.001), shock (aOR = 2.7, P < 0.001), AKI (aOR = 1.55, P < 0.001), and ICU admission (aOR = 2.16, P < 0.001) in the study population. CONCLUSIONS: Our study revealed the prevalence of CDI in COVID-19 patients was 0.65%. Although the prevalence was low, its presence is associated with worse outcomes and higher resource utilization.

Iron Man: Non-HFE Hemochromatosis Without Significant Fibrosis.

Hemochromatosis is a genetic disorder marked by abnormally high levels of intestinal iron absorption leading to severe end-organ damage. It is classically associated with HFE gene mutations, including C282Y and H63D, but in recent years, many non-HFE mutations along with novel variants have been discovered, particularly among non-Whites. We describe a case of an elderly Japanese patient who was evaluated for markedly elevated ferritin found to have hemochromatosis, with no hepatic fibrosis while being negative for HFE and common non-HFE gene mutations.

Hospital frailty risk score predicts worse outcomes in patients with chronic pancreatitis.

Background: Chronic pancreatitis (CP) is a pathological fibroinflammatory response to persistent inflammation or stress to the pancreas. The effect of frailty on outcomes in patients with CP has not been previously examined. In this study, we examined the effect of frailty on outcomes in hospitalized patients with CP. Methods: Records of patients with a primary or secondary discharge diagnosis of CP (ICD10-CM codes K86.0, K86.1) between January 2016 and December 2019 were obtained from the National Inpatient Sample database. Data were collected on patient demographics, hospital characteristics, comorbidities, and etiology of CP. The relationship between frailty and outcomes, including mortality, intensive care unit (ICU) admission, sepsis, shock, length of stay (LOS), and total hospitalization charges (THC), were analyzed using multivariate analysis. Results: 722,160 patients were included in the analysis. Patients with a high hospital frailty risk score had a higher mortality risk (adjusted odds ratio [aOR] 12.57, 95% confidence interval [CI] 10.42-15.16; P<0.001) compared to patients with low frailty scores. Patients with high frailty scores also had a higher risk of sepsis (aOR 5.75, 95%CI 4.97-6.66; P<0.001), shock (aOR- 26.25, 95%CI-22.83-30.19; P<0.001), ICU admission (aOR 25.86, 95% CI-22.58-29.62; P<0.001), and acute kidney injury (aOR 24.4, 95%CI 22.39-26.66; P<0.001). They also had a longer LOS (7.04 days, 95%CI 6.57-7.52; P<0.001) and higher THC ($72,200, 95%CI 65,904.52-78,496.66; P<0.001). Conclusions: Frail patients, as determined by their hospital frailty risk score, are at high risk of worse outcomes. This data suggests opportunities for physicians to risk-stratify patients and predict outcomes.

A Rare Case of Rectal Squamous Cell Carcinoma Treated with Nigro Protocol.

Squamous cell carcinoma (SCC) of the rectum is a rare malignancy, and the optimal treatment strategy remains unknown. Cases are limited in the literature, and although historically treated with surgical resection, more recent cases have suggested success with chemotherapy. Although Nigro protocol was initially developed for anal SCC, we present a case of rectal SCC successfully treated with the Nigro protocol. Our case supports the use of chemoradiotherapy as initial treatment for rectal SCC over surgery.

Salmonella typhimurium as a Rare Cause of Small Bowel Obstruction.

Small bowel obstruction (SBO) is an extremely common condition for hospitalization throughout the world. Although most causes of are due to post-operative adhesions, there are much less common causes which remain important to consider as differentials due to diagnostic and treatment implications. To the best of our knowledge, we are presenting the first case of SBO caused by Salmonella typhimurium induced terminal ileitis. We discuss how certain characteristics on CT imaging along with culture data led to our diagnosis and successful treatment.

Role of endoscopic evaluation prior to diagnostic transesophageal echocardiography: Is it necessary?

Background and Aim: Esophagogastroduodenoscopy (EGD) is often performed prior to transesophageal echocardiogram (TEE) to evaluate for esophageal pathologies. Although TEE is a safe procedure, some contraindications exist, such as esophageal varices. The incidence of bleeding with TEE is <0.01%, which questions the need for this routine invasive procedure prior to TEE. We sought to characterize patients in whom pre-TEE endoscopy was requested to determine its clinical utility and identify those that would most benefit. Methods: We retrospectively studied patients who underwent EGD for TEE clearance between January 2014 and October 2019. We assessed how often EGD changed management and complications after TEE in those with EGD abnormalities. Results: Eighty-three patients were included. Twenty-three percent had prior GI bleed, 63% had cirrhosis, 18% had known varices, and 7% had prior variceal bleed. The most common EGD findings were varices (33%). Eighty-one percent proceeded with TEE. Reasons for TEE deferral included varices (12.5%), high-risk bleeding lesion (12.5%), and mechanical abnormality (12.5%). In the majority (37.5%), TEE was deemed no longer indicated. No patient undergoing TEE had significant hemoglobin drop or overt bleeding. The most common reason for not performing TEE was unrelated to EGD findings: lack of ongoing indication for TEE. Conclusion: Based on our study, EGD is likely not needed for TEE clearance in patients with varices or prior GI bleed. Given that data are limited in patients with abnormalities such as strictures, EGD may still be warranted for these patients. Further studies to identify which patients will benefit from pre-TEE endoscopy are warranted.

Gender differences in esophageal variceal bleeding in the United States.

BACKGROUND AND AIMS: Esophageal variceal bleeding is a common reason for hospitalization in patients with cirrhosis. The main objective of this study was to analyze the effects of gender differences on outcomes in hospitalizations related to Esophageal variceal bleeding in the United States. METHODS: A retrospective observational cohort study was performed using the National Inpatient Sample (NIS) database for all hospitalizations with a discharge diagnosis of esophageal varices with hemorrhage from 2016 to 2019. The primary outcome was in-hospital mortality, while secondary outcomes included rate of early endoscopy (defined as less than 1 day), AKI, blood transfusion, sepsis, ICU admission and TIPS (Transjugular Intrahepatic Portosystemic Shunt). We also compared the length of stay and total hospitalization charges. RESULTS: We identified a total of 166,760 patients with variceal bleeding of which 32.7% were females. In-hospital mortality was higher in males, 9.91%, compared to females, 8.31% (adjusted odds ratio (aOR): 0.88, p-value=.008, when adjusted for confounding factors). The odds of undergoing an EGD, length of stay, or total hospitalization charges did not differ between the two groups. Compared to men, women had lower odds of receiving TIPS (aOR = 0.83, p-value=.002). CONCLUSION: Women hospitalised with esophageal variceal bleeding are at a lower risk of death compared to males. Further research is needed to elucidate the factors associated with this lower risk.

Marked Hyperbilirubinemia Associated with Primary Myelofibrosis Responsive to Ruxolitinib.

Primary myelofibrosis (PMF) is a chronic myeloproliferative disorder seen in older adults which can present both with hepatosplenomegaly as well as mild nonspecific liver enzyme abnormalities. Mild elevations in bilirubin can occasionally be seen due to both intravascular hemolysis as well as extramedullary hematopoiesis. Marked hyperbilirubinemia as a presenting sign of PMF progression, however, has not been reported. We present the case of a patient with a remote diagnosis of PMF, who presented with marked hyperbilirubinemia with a notable response to ruxolitinib.

Hospitalization Outcomes of Acute Pancreatitis in Hematopoietic Stem Cell Transplant Recipients.

Background: Acute pancreatitis (AP) carries a significant morbidity and mortality worldwide. AP is a potential complication of hematopoietic stem cell transplantation (HSCT) although its incidence remains unclear. HSCT recipients are at increased risk of AP due to various factors but the effect of AP on mortality and resource utilization in the adult population has not been studied. We investigated the impact of AP on hospitalization outcomes among patients following HSCT. Methods: We queried the National Inpatient Sample (NIS) database using the International Classification of Diseases (ICD)-10 codes. All adult patients with a diagnosis or procedure code of HSCT were included in the study. Patients were divided into those with a diagnosis of AP and those without. Sensitivity analysis was performed for patients with a length of stay greater than 28 days. The relationship between AP and mortality, length of stay, total hospitalization cost, and charges was assessed using univariate analysis followed by multivariate analysis. Results: Of the 140,130 adult patients with HSCT, 855 (0.61%) patients developed AP. There was 1.74 times higher risk of mortality in patients with AP as compared to controls (adjusted odds ratio (aOR): 1.74, P = 0.0055). There was no statistically significant difference in the length of stay, hospitalization charge, or cost before sensitivity analysis. After sensitivity analysis, 13,240 patients were included, from which 125 (0.94%) had AP. There was 3.85 times higher risk of mortality in patients who developed AP as compared to controls (aOR: 3.85, P = 0.003). There was a statistically significant increase noted in the length of stay (adj coeff: 20.3 days, P = 0.002), hospital charges (+$346,616, P = 0.017), and cost (+$121,932.4, P = 0.001) in patients with AP as compared to those who did not develop AP. Conclusion: Recipients of HSCT who develop AP have shown to have higher mortality on sensitivity analysis. This study highlights that AP in HSCT patients is associated with worse outcomes and higher resource utilization. Physicians should be aware of this association as the presence of pancreatitis portends a poor prognosis.

Emphysematous Pancreatitis Mimicking Bowel Perforation.

Emphysematous pancreatitis is a rare complication of acute necrotizing pancreatitis, which carries a mortality rate of up to 70%. It has only been described in isolated case reports. We report a patient who presented with suspected bowel perforation and was subsequently found to have emphysematous pancreatitis that was managed successfully with multidisciplinary team involvement.

Acute esophageal necrosis complicated by refractory stricture formation.

Acute esophageal necrosis (AEN) is a rare presentation of severe esophageal injury. The optimal long-term management of complications related to AEN, particularly stricture formation, are not well defined. We report a case of AEN in a patient who presented with diabetic ketoacidosis (DKA) and had dysphagia due to refractory stricture formation after mucosal healing occurred. A 62-year-old male with diabetes mellitus presented with altered mental status. He was admitted for hypovolemic shock secondary to DKA and treated with vasopressors, fluid resuscitation, and insulin. After resolution of DKA, he reported persistent dysphagia. Upper endoscopy showed circumferential black mucosal discoloration throughout the entire esophagus that spared the gastroesophageal junction. He was diagnosed with AEN and was continued on a proton pump inhibitor and sucralfate with improvement in symptoms. Repeat endoscopy 4 weeks later showed a 10-cm benign-appearing stricture in the mid esophagus. He underwent dilation with temporary symptomatic relief; however, recurrence in symptoms has thus far necessitated a total of 10 repeat upper endoscopies, including repeat dilations along with local steroid injection therapy. AEN is a rare presentation of severe esophageal injury and is typically associated with severe hemodynamic compromise. Although most cases resolve with supportive care and mucosal healing, there is little information regarding prognosis and optimal management of complications, such as refractory esophageal strictures. We describe a case of AEN complicated by refractory symptomatic esophageal stricture despite several dilations and intralesional steroid injections and discuss our approach to treatment.