Safety and indications for endoscopic retrograde cholangiopancreatography in liver transplant patients: an analysis of the United States' National Inpatient Sample database.

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is performed to treat biliary complications after a liver transplantation; however, the previously available literature on the safety of ERCP in liver transplant patients is limited. We aimed to study the safety of ERCP in liver transplant patients. Methods: We used a National Inpatient Sample database from 2016-2019 to identify patients who underwent ERCP and had a history of a liver transplantation, using the international classification of diseases, 10th revision. Multivariate logistic regression analysis was conducted to determine the odds of post-ERCP complications in liver transplant recipients. Results: Liver transplant patients who underwent ERCP had a higher rate of post-ERCP pancreatitis and bleeding compared to the general adult population (11.39% vs. 9.19%, 0.83% vs. 0.53%, respectively). However, the adjusted odds of post-ERCP pancreatitis (adjusted odds ratio [aOR] 1.13, 95% confidence interval [CI] 0.86-1.49; P=0.36) and bleeding (aOR 1.41, 95%CI 0.58-3.46; P=0.45) were similar in both the liver transplant and no-transplant groups. There was no difference in the odds of post-ERCP cholangitis (aOR 1.26, 95%CI 0.80-2.01; P=0.32), and sepsis (aOR 0.94, 95%CI 0.66-1.34; P=0.76) between liver transplant and no transplant groups. Biliary stricture was the most common indication for ERCP in the liver transplant group, whereas choledocholithiasis was the main reason for ERCP in the general adult population. Conclusions: ERCP is a safe procedure for treating biliary complications in liver transplant patients. The odds of post-ERCP complications (pancreatitis, bleeding, sepsis, cholangitis) in liver transplant patients are comparable to those in patients with no transplantation.

Effect of acute kidney injury on hospital-based outcomes in patients admitted for variceal hemorrhage. Analysis of national inpatient sample database.

Introduction: Acute kidney injury (AKI) is known to be a marker of mortality in patients with cirrhosis and variceal hemorrhage. Aim: To study the effect of AKI on hospital-based outcomes in patients with variceal hemorrhage. Material and methods: We obtained data from the National Inpatient Sample for the years 2016-2018. Study inclusion criteria comprised adult variceal hemorrhage patients who also had AKI. The primary outcome of interest was in-hospital mortality. Secondary outcomes were length of stay, hospital charge, shock, blood transfusion, and ICU admission. We also determined the independent predictors of mortality in variceal hemorrhage patients using multivariate regression analysis. We used 2 different methods: multivariate logistic regression and propensity matching to adjust for confounders. Results: The number of people included in this study was 124,430, of whom 32,315 (26%) had AKI. Mortality in variceal hemorrhage patients with AKI was 30.4% in comparison to 4.8% without AKI. The presence of AKI was associated with increased odds of mortality (AOR = 8.28, 95% CI: 7.45-9.20, p < 0.01), ICU admissions (AOR = 4.76, 95% CI: 4.42-5.13, p < 0.01), blood transfusion (AOR = 1.24, 95% CI: 1.15-1.32, p < 0.01), and shock (AOR = 3.41, 95% CI 3.07-3.79, p < 0.01). The patients with AKI also had increased length of stay and hospital charges. Higher Charlson co-morbidity index, African American race, and being admitted to large sized hospital were independently associated with increased mortality. Conclusions: After analyzing the combined NIS dataset of 2016-2018, we concluded that patients admitted with variceal hemorrhage who has AKI are prone to adverse hospital outcomes.

A national study of pregnancy-related maternal and fetal outcomes in women with inflammatory bowel disease.

BACKGROUND AND AIMS: The incidence of inflammatory bowel disease (IBD) among women is highest during their reproductive years and current estimates suggest that the rate of conception is low in female IBD patients. The aim of our study was to assess the burden of adverse maternal and perinatal outcomes among female IBD patients. METHODS: Using the national inpatient sample database from 2016 to 2018, we recruited all female patients above the age of 15 years admitted with a primary diagnosis of pregnancy and a secondary diagnosis of IBD. We adjusted our results for hospital and patient level variables including age, race, socioeconomic status, hypertension, diabetes mellitus, obesity, smoking, hyperlipidemia, alcohol use, and malnutrition. Multivariable regression analysis was used for analysis. RESULTS: Pregnant women with IBD had greater odds of gestational diabetes (adjusted odds ratio [AOR] 1.55, 95% confidence interval [CI] 1.04-2.3, p 0.02), hypertensive complications (AOR 1.35, 95% CI 1.06-1.72, p 0.01), and pre-term delivery (AOR, 1.41 95% CI 1.13-1.76, p 0.003). Pregnancies with co-existent IBD were associated with fetal growth restriction (AOR 1.27, 95% CI 1-1.63, p 0.04) and fetal death (AOR 3.21, 95% CI 1.72-6.00, p < 0.01). Odds of experiencing postpartum hemorrhage or large for gestational age infant were comparable to general population. Crohn's disease was independently associated with increased odds of worse maternal and fetal outcome. IBD patients had increased mean length of stay by 0.14 days and increased mean hospital charges of $2741. CONCLUSIONS: Women with IBD had greater likelihood of poor maternal and fetal outcomes and increased hospital resource utilization.

Burden of depression and anxiety among patients with inflammatory bowel disease: results of a nationwide analysis.

PURPOSE: The burden of psychiatric disorders is on a rise in inflammatory bowel disease (IBD) patients which has shown to effect medication compliance and overall clinical outcomes. We studied the prevalence of depression and anxiety in IBD patients when compared to individuals with other chronic medical conditions. METHODS: This is a retrospective cohort study using the United States national inpatient sample of 2016 to 2018. We identified patient encounters with a diagnosis of IBD. Our primary outcome was prevalence of depression and anxiety in IBD patients when compared to general adult population with other chronic medical conditions. We further studied these outcomes in subgroups of patients with ulcerative colitis and Crohn's disease. RESULTS: A total of 963,619 patient encounters were identified with the diagnosis of IBD between 2016 and 2018, of them 162,850 (16.9%) had depression and 201,685 (20.9%) had anxiety. The prevalence of depression and anxiety was significantly higher in IBD patients in comparison to general population, (16.9% vs 12.3%) and (20.9% vs 15%) respectively (p < 0.001). Association of depression and anxiety was also higher in IBD patients when compared to patients with other chronic conditions like diabetes, metastatic cancer, and coronary artery disease. Crohn's disease and ulcerative colitis were independently associated with increased odds of depression and anxiety and these results were statistically significant (p < 0.001). CONCLUSIONS: IBD is associated with increased prevalence of depression and anxiety when compared to general population. Association of these psychiatric illnesses with IBD is significantly higher when compared to other chronic medical conditions.

Does the Route of Cocaine Use Affect the Mortality and Outcomes of Cocaine-Induced Intestinal Ischemia? A Systematic Review.

Intestinal ischemia results from diminished perfusion of the colon resulting in tissue hypoxia. Anecdotal reports suggest that cocaine-induced intestinal ischemia has the highest mortality and longer length of stay among the vasoconstrictors. The present study aimed to summarize the available studies in the literature to assess the effect of routes of consumption on the outcomes of cocaine-induced intestinal ischemia. We conducted a systematic search of MEDLINE from inception through October 2019. Studies of cocaine-induced intestinal ischemia were included if data were available on comorbidities, mortality, and hospital length of stay (LOS). The study's primary outcomes were mortality and need for surgery, while secondary outcomes included the hospital length of stay, LACE index, and hospital score. Statistical tests used included linear and binary logistic regression. STATA 2015 was used, and P < 0.05 was statistically significant. Of the 304 studies, 8 case series and 45 case reports (n = 69 patients) met the inclusion criteria. Different routes of cocaine use had similar mortality odds and the need for surgery for intestinal ischemia. Hospital LOS showed significant difference among the subgroups. Readmission scores (LACE and hospital score) were higher for intravenous and smoking than ingestion and intranasal use (P < 0.05). In conclusion, different routes of cocaine use appear to have similar mortality odds for intestinal ischemia, which vary significantly among the different routes of cocaine consumption for the length of stay and readmission scores. Prompt recognition of the route of cocaine use is vital to improve the outcome. Large-scale and well-designed observational studies are needed to investigate this topic further.

The Progression of Celiac Disease, Diagnostic Modalities, and Treatment Options.

Celiac disease (CD) is an autoimmune disorder that affects genetically predisposed individuals who are sensitive to gluten and related proteins. It affects children and adults with increasing prevalence in the older age groups. Both adaptive and innate immune responses play role in CD pathogenesis which results in damage of lamina propria and deposition of intraepithelial lymphocytes. There are other proposed mechanisms of CD pathogenesis like gastrointestinal infections, intestinal microbiota, and early introduction of gluten. The diagnosis of CD is based on clinical symptoms and serological testing, though a majority of cases are asymptomatic, and small intestinal biopsies are required to confirm the diagnosis. Celiac disease is generally associated with other autoimmune diseases, and it is advisable to test these patients for diseases like type 1 diabetes mellitus, Addison's disease, thyroid diseases, inflammatory bowel disease, and autoimmune hepatitis. The patient with a new diagnosis of CD requires close follow-up after starting treatment to see symptom improvement and check dietary compliance. A newly diagnosed patient is advised to follow with a dietitian to better understand the dietary restrictions as about 20% of patients stay symptomatic even after starting treatment due to noncompliance or poor understanding of diet restrictions. The most effective treatment for CD is a gluten-free diet, but work on non-dietary therapy is in process and few medications are in the clinical trial phase.

Does Performing Endoscopy Sooner Have an Impact on Outcomes in Patients With Acute Nonvariceal Upper Gastrointestinal Hemorrhage? A Systematic Review.

Background Endoscopy is the cornerstone for the diagnosis and treatment of nonvariceal upper gastrointestinal bleeding. Regarding the management of nonvariceal bleeding, the administration of crystalloid solution and proton pump inhibitors before endoscopy is well established, but the optimal timing of endoscopy has been a matter of debate and a subject of many investigational studies. The need for urgent endoscopy arises to provide prompt redress to acute bleeding, decrease the length of stay, and lower mortality from ongoing bleeding. Objective This study aimed to determine if endoscopy performed within 24 hours of presentation improves outcomes in terms of mortality, hospital length of stay, and rebleeding in individuals presenting with nonvariceal upper gastrointestinal bleed with any risk. Methodology We performed a systematic review of two large databases (PubMed and Google Scholar) to incorporate all studies published after 2000. We included studies with nonvariceal upper gastrointestinal bleeding and excluded those reporting variceal gastrointestinal hemorrhage. Results We reviewed eight studies that qualified after meeting our inclusion and exclusion criteria. We divided these studies into three separate groups based on the timing of endoscopy. Only two studies found a difference in mortality that was statistically significant in patients who underwent endoscopy within 24 hours of presentation. One study showed lower mortality in a patient who underwent urgent endoscopy, but it did not reach statistical significance. Other studies did not show any statistical difference in mortality, hospital length of stay, and rebleeding rates. The studies showed conflicting evidence on the amount of blood transfusion, though urgent endoscopy was found to be difficult in few studies due to blood obscuring the lesion. Conclusions While data suggest that there is a potential benefit in performing endoscopy sooner, there is no concrete evidence to point to a particular time range. Before performing endoscopy, the American Society for Gastrointestinal Endoscopy (2012) recommends adequate resuscitation with crystalloid solutions, blood transfusions, and antisecretory and prokinetic agent therapy. More investigational studies are needed to formulate a time-sensitive flow sheet to approach endoscopy in patients with nonvariceal upper gastrointestinal bleeding. A strict criterion is also needed to delineate patients into low-risk and high-risk groups. Doing so would provide a systematic approach to help with mortality, rebleeding, and healthcare resource utilization.

Encephalitis Associated With Hemophagocytic Lymphohistiocytosis Secondary to Immune Checkpoint Inhibitors: An Unfamiliar Spin-Off.

Checkpoint inhibitors (CPI) have become mainstream in standard therapy in various tumors, especially in malignant melanoma. Despite their widespread beneficial effects, these inhibitors are also notorious for immune-related adverse events (irAEs). Hemophagocytic lymphohistiocytosis (HLH) is an aggressive and life-threatening syndrome of excessive immune activation. We report a case of a 33-year-old male having a history of metastatic melanoma on immunotherapy (status post two cycles of ipilimumab/nivolumab) admitted for persistent fever and elevated liver enzymes. Additional work showed anemia, thrombocytopenia, hypertriglyceridemia, and hyperferritinemia which meet the diagnostic criteria of histiocyte society HLH-2004. The patient was effectively treated with oral prednisone. Moreover, further complications encompassed slurred speech, word-finding difficulties, ataxia, and lower extremity hyperreflexia concerning for autoimmune encephalitis. He was treated with high-dose IV methylprednisolone (1 gram/day for 3 days) with improvement in symptoms. Autoimmune encephalitis associated with HLH can be fatal - high-dose IV methylprednisolone should be considered, but this avenue still needs to be explored.

Pravastatin-Induced Acute Pancreatitis: A Case Report and Literature Review.

Pancreatitis is inflammation of pancreas associated most commonly with chronic alcoholism and gallstones. Other less common causes of pancreatitis are hyperlipidemia, infections, surgery, trauma, post endoscopic retrograde cholangiopancreatography, and drugs. Drugs are now increasingly recognized as a cause of pancreatitis, and high suspicion and exclusion of other most common causes is required before considering drug-induced pancreatitis. There are few case reports of acute pancreatitis in the literature after statin use, but out of these, only 3 are after starting pravastatin. We are reporting a case of 49-year-old male who presented with nausea, vomiting, and abdominal pain. His laboratory findings were significant for lipase more than 10 000 on admission, and computed tomography scan of abdomen was showing peripancreatic fat stranding and inflammation. After exclusion of most common causes of pancreatitis, pravastatin was found probable culprit for his symptoms, which he started taking 2 weeks ago. We also reviewed the literature on statins-induced acute pancreatitis. With increased uses of statins, physician need to be vigilant to suspect statins as a culprit in cases of pancreatitis with unknown etiology. Prompt discontinuation of statins is required in these cases.

Thrombotic Thrombocytopenic Purpura Induced by Immune Checkpoint Inhibitiors: A Case Report and Review of the Literature.

In recent years, the role of immune checkpoint inhibitors (ICI) in cancer treatment has rapidly expanded. In randomized clinical trials, these agents have demonstrated clinical efficacy in extending survival and increasing response rates. Immune-related adverse effects (irAEs) involving various organs have been frequently narrated. Herein, we present a case report of thrombotic thrombocytopenic purpura (TTP) as a rare side effect of nivolumab, plus ipilimumab, in the treatment of metastatic renal cell carcinoma (RCC). A review of the literature for other case reports of TTP during treatment with ICIs was also performed. Our aim is to elucidate the significance of early recognition of this rare adverse effect in patients being treated with this relatively newer class of medications.

Spontaneous Bacterial Peritonitis in Cardiogenic Ascites.

The most common cause of ascites is liver cirrhosis. Additional causes such as heart failure, cancer, and pancreatitis among others can also precipitate this abnormality. Spontaneous bacterial peritonitis (SBP) is an infection of ascitic fluid that happens without any evidence of an intra-abdominal surgically-treatable cause. Ascites of cardiac origin can also be complicated by SBP. Here we present a case of a 62-year-old male with extensive cardiac history who presented to our service with ongoing dyspnea and orthopnea. He also had significant abdominal distention and pitting edema. The patient was found to have constrictive pericarditis and was admitted for pericardiectomy. Ascitic fluid was consistent with a transudative process. Lab and imaging did not show evidence of liver or kidney disease. Ascitic fluid was indicative of ascites of cardiac origin. Postoperatively patient developed intermittent fevers initially thought to be due to pericarditis but later found to be due to SBP complicating his recurrent ascites. Such a temporal association of SBP that complicates ascites after pericardiectomy has not been discussed frequently in literature.

A Review of Interstitial Pneumonitis Caused by Elotuzumab Through Case Discussions and Academic Writings.

Patients with relapsed or refractory multiple myeloma have undergone two or three previous therapies are now being treated with a humanized IgG1 monoclonal antibody elotuzumab (HuLuc63) that targets F7 signalling lymphocytic activation molecule F7 (SLAMF7)- a signalling lymphocytic activation molecule. It is combined with dexamethasone and lenalidomide/pomalidomide for therapy. Adverse effects associated with elotuzumab consists of peripheral neuropathy, fever, constitutional symptoms (fatigue, headache, decreased appetite), and infections. A rare side effect of interstitial lung disease has only been observed in a single case. There are two case studies presented below of hypoxic respiratory failure upon this monoclonal antibody treatment both were successfully treated with steroid therapy. This article brings forth the hypothesis that elotuzumab can cause pneumonitis, and discontinuation of elotuzumab along with high-dose corticosteroids helps reverse the pneumonitis.

Association of resolvin level in pregnant women with preeclampsia and metabolic syndrome.

OBJECTIVE: Preeclampsia (PE) and Metabolic syndrome (MetS) are multifactorial conditions and are major causes of maternal and neonatal morbidity and mortality worldwide. Both conditions are pro-inflammatory and can be causative factor for vascular damage. Anti-inflammatory mediators such as Resolvin also called resolution-phase interaction products may help to reduce the effect. Therefore, this study aimed to measure the serum Resolvin level in mild pre-eclamptic women with and without metabolic syndrome. MATERIAL AND METHODS: A total of 293 pregnant females were recruited in this case control study. They were grouped as: Group A [pre-eclamptic patients with MetS (n = 140)] and Group B [pre-eclamptic patients without MetS (n = 153)]. Preeclampsia was diagnosed according to the ACOG criteria and metabolic syndrome according the NCEP-ATP III guidelines. Anthropometric data, lipid profile, Resolvin, VEGFR and PlGF levels were tested as per manufacturer's guidelines. Data was analyzed by using SPSS version 23. In all instances, a p value of <0.05 was considered significant. RESULTS: All females were aged matched so no difference was observed in any group. Blood pressure and triglyceride levels were significantly higher in Group A; whereas VEGFR and PlGF were lower as compared to Group B. Higher Resolvin levels were observed in Group A subjects as compared to Group B [105.19 ± 42.29 pg/ml; 46.74 ± 20.16 pg/ml; p < 0.01 respectively]. Resolvin levels were found to have a weak correlation with BMI (r = 0.264; p = 0.11), while a positive strong correlation with systolic BP (r = 0.722; p < 0.001), diastolic BP (r = 0.664; p < 0.001) and a negative correlation with VEGFR (r = -0.639; p < 0.01) and PlGF (r = -0.523; p < 0.01). CONCLUSION: Higher resolvin levels were observed in PE subjects with metabolic syndrome and showed a significant strong positive correlation with blood pressure. Further longitudinal studies are required to identify the causal link.