Chemoprophylaxis to Prevent Deep Venous Thrombosis in Patients Hospitalized for Pancreatitis: Beneficial or Harmful?

INTRODUCTION:  Vascular complications in pancreatitis generally occur in the form of hemorrhage or thrombosis. Pancreatitis resulting in splanchnic thrombosis has been well studied, but the cause of this correlation has not been studied in the current era of increasing anticoagulant use for deep venous thrombosis (DVT) prophylaxis. Hemorrhagic pancreatitis and peri-pancreatic bleeding are also known phenomena encountered in relation to pancreatitis, but these risks are not well established in the setting of chemical prophylaxis for DVT. OBJECTIVES:  Our objective was to identify whether chemical DVT prophylaxis in pancreatitis harms the patient by increasing the risk of hemorrhagic conversion of pancreatitis or peri-pancreatic hemorrhage or if it is beneficial by preventing splanchnic venous thrombosis in the abdominal vasculature that surrounds the pancreas. METHODS:  We undertook a retrospective chart review with approval from the Institutional Review Board on patients who were hospitalized for or developed pancreatitis during their hospital stay from April 2014 to July 2015. We reviewed the charts for imaging suggestive of venous thrombosis or the development of intra-abdominal hemorrhage at admission during hospitalization and within 30 days after hospitalization. We also reviewed the methods of DVT prophylaxis to identify any correlation with the risk of hemorrhage or thrombosis. A bedside index of severity in acute pancreatitis score was used within 24 hours of admission to calculate the severity of the patients' pancreatitis. The data collected were analyzed for descriptive statistics, correlation using Pearson's coefficient, and multivariate regression analysis using Microsoft Excel and SPSS Inc. Released 2009. PASW Statistics for Windows, Version 18.0. Chicago: SPSS Inc. RESULTS:  This study included 389 patients who met the inclusion criteria. Of these, 74.6% of patients received chemical prophylaxis, mostly low molecular weight heparin, and 18.5% of patients were not on chemical or mechanical means of DVT prophylaxis. Only 12 patients (3%) had complications related to thrombosis and hemorrhage. Seven patients had splanchnic venous thrombosis, one had a hemorrhagic conversion of pancreatitis, three had a peri-pancreatic hemorrhage, and one had both the hemorrhagic conversion of pancreatitis and peri-pancreatic hemorrhage. Ten patients out of 12 patients had complications before admission, and nine of the 12 patients were on chemical prophylaxis. Pearson's coefficient showed no statistically significant correlation between the incidence of complications and the use of chemical DVT prophylaxis. Multivariate analysis showed no specific variable that increased the risk of complications. CONCLUSIONS:  Our study showed that chemoprophylaxis for DVT in patients hospitalized for acute pancreatitis is neither harmful by causing hemorrhagic conversion of pancreatitis, peri-pancreatic hemorrhage nor beneficial by preventing splanchnic venous thrombosis.

Differential risk of disease progression between isolated anastomotic ulcers and mild ileal recurrence after ileocolonic resection in patients with Crohn's disease.

BACKGROUND AND AIMS: It is standard of care to perform ileocolonoscopy within a year of ileocolonic resection for Crohn's disease (CD) and to guide management decisions based on the Rutgeert score (RS). The modified RS subdivides i2 into lesions confined to the anastomosis (i2a) or >5 aphthous lesions in the neoterminal ileum (i2b). There is uncertainty, however, if i2a lesions incur an increased risk of disease recurrence. The primary aim of this study was to compare the rates of endoscopic progression between i2a and i2b when compared with i0-i1. METHODS: This was a retrospective, single-center study including patients with CD who had an ileocolonoscopy ≤12 months after ileocolonic resection with primary anastomosis and who had >1 year of documented clinical follow-up after the index endoscopic evaluation. All consecutive eligible patients between 2004 and 2014 were included in the study. Demographic, disease, and treatment data were collected. Patients with i3 or i4 at index colonoscopy were excluded from further analyses. Outcomes included endoscopic progression and recurrent surgery. For patients with RS of i0 to i2, endoscopic progression was predefined as progression of the RS in subsequent colonoscopies to i3 or i4. Recurrent surgical interventions were defined as re-resection or stricturoplasty of the previous ileocolonic anastomosis. RESULTS: Two hundred seven CD patients (median age, 36 years [interquartile range, 26-48]) had an ileocolonoscopy ≤12 months after ileocolonic resection. At index colonoscopy, 95 patients (45.9%) had an RS of i0, 31 (14.9%) i1, 40 (19.3%) i2a, 25 (12.1%) i2b, 10 (4.8%) i3, and 6 (2.9%) i4. One hundred ninety-one patients had an RS of i0 to i2 and were included in the analyses for recurrent surgery. One hundred forty-nine patients had a second endoscopic evaluation and were included in the analysis for the primary outcome of endoscopic disease progression. Kaplan-Meier analyses were performed and found the hazard ratio (HR) of endoscopic progression to be significantly higher with i2b lesions when compared with i0 or i1 (HR, 6.22; 95% confidence interval [CI], 2.38-16.2; P = .0008). Patients with i2a did not have significantly higher rates of endoscopic progression when compared with i0 or i1 (HR, 2.30; 95% CI, .80-6.66; P = .12). Likewise, patients with i2b lesions had higher risk of needing recurrent surgery when compared with i0 or i1 (HR, 3.64; 95% CI, 1.10-12.1; P = .034), whereas patients with i2a lesions were not found to have a significantly elevated risk of recurrent surgery (HR, 1.43; 95% CI, .35-5.77; P = .62). CONCLUSION: Endoscopic lesions limited to the ileocolonic anastomosis (RS i2a) in patients with CD undergoing colonoscopy within 1 year of their resection were not associated with a significantly higher rate of progression to more severe disease, whereas those in the neoileum (RS i2b) were. Prospective studies are needed to confirm these findings.

A rare case of infectious colitis.

Methicillin-resistant Staphylococcus aureus (MRSA) is responsible for numerous infectious processes. Gastrointestinal tract involvement is rather rare and only a handful of cases of MRSA colitis have been reported in North America. We present a case of MRSA colitis in an adult without apparent risk factors. Abdominal computed tomography (CT) showed thickening of the sigmoid colon, indicative of colitis, and empiric therapy with ciprofloxacin and metronidazole was started. Initial work-up for infection-including blood and stool cultures, and stool Clostridium difficile toxin assay-was negative. The patient's clinical status improved but his diarrhea did not abate. Repetition of stool culture demonstrated luxuriant growth of MRSA sensitive to vancomycin. Oral vancomycin was administered and the patient's symptoms promptly ceased.

Cytomegalovirus Colitis Mimicking Rectal Carcinoma in a Young Immunocompetent Patient.

Cytomegalovirus (CMV) infection is often seen in immunocompromised patients. Rarely, immunocompetent patients may present with CMV as a self-limiting, flu-like illness, though a few cases of significant organ-specific complications have been reported in these patients. We report a case in which a previously healthy man presented with hematochezia and an obstructing rectal mass thought to be rectal adenocarcinoma. Biopsy was positive for CMV, which was treated with full resolution of rectal mass confirmed with colonoscopy and barium contrast enema. This is the first reported case of CMV colitis mimicking rectal adenocarcinoma in an immunocompetent patient.