A Novel Case of Metformin-Induced Pancreatitis in an Individual With Normal Dosing and No Underlying Chronic Kidney Disease.

It is well known that most medications have side effects, and many of them have gone through years of testing with thousands of test subjects before entering the market. However, as physicians it is important to assess how patients react to the initiation of new medications not only looking for known side effects but also rare ones. Our case highlights a rare presentation of metformin-induced pancreatitis in the setting of normal renal function and appropriate dosing. We are hoping our case will create more awareness and inspire future research in exploring the pathophysiology and causes of metformin-induced pancreatitis. Moreover, we aim to make healthcare professionals mindful so that they may recognize acute pancreatitis as a side effect of metformin even in a healthy patient.

Role of Bowel Preparation in Adenoma Detection Rate and Follow-up Recommendations in African American Dominant Patient Population.

INTRODUCTION: Bowel preparation quality in colonoscopy is one of the most essential components of quality assessment. According to the latest guidelines, inadequate bowel preparation warrants repeat colonoscopy in less than a year. Our aim was to investigate the role of bowel preparation in adenoma detection rate (ADR), its relationship with patients' demographics, and compliance with subsequent surveillance recommendations with guidelines. METHODS: This is a retrospective chart review study. Bowel preparation quality was divided into three categories: high, intermediate, and low. ADR and polyp detection rates (PDR) were calculated as the number of patients with adenoma or polyp divided by the total number of patients. RESULTS: Among 1,062 patients (934 African American and 128 non-African American) 81%, 11%, and 8% had high, intermediate, and low-quality bowel preparations, respectively. Race, gender, age, type of endoscopist, and body mass index did not play any role in bowel preparation quality. ADR and PDR were significantly higher in African Americans as compared to non-African Americans. ADR was significantly lower in the low-quality as compared to the high- and intermediate-quality bowel preparations (OR=2.13; p=0.0032). Bowel preparation quality was not correlated with subsequent follow-up recommendations. Academic gastroenterologists and surgeons had the highest and lowest compliance with surveillance guidelines, respectively. CONCLUSIONS: Racial and gender disparity appears to have no meaningful effect on the quality of bowel preparation. Only two categories (adequate [high/intermediate] or inadequate [low-quality]) may be used for follow-up recommendations. Non-compliance with surveillance guidelines is concerning and may inadvertently increase the interval risk of colorectal cancer.

Rectal Invasion by Metastatic Prostate Adenocarcinoma.

In men, prostate cancer is the second most diagnosed cancer worldwide. Typical sites for metastasis include bone, lung, and liver. Prostate cancer with gastrointestinal involvement, particularly rectal, has been rarely reported in the literature. As patients with prostate cancer with rectal invasion may present with symptoms similar to those of other gastrointestinal pathologies, such as anal fissures and rectal carcinoma itself, misdiagnosis and delays in care can result. Direct visualization of the rectum via endoscopy, along with biopsy, allows clinicians to make an accurate and timely diagnosis in patients with prostate cancer with rectal involvement, which in turn leads to broader available treatment options.

Atypical Hemolytic Uremic Syndrome in the Setting of Acute Clostridium difficile Colitis.

Hemolytic uremic syndrome (HUS) is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure. HUS can be secondary to multiple etiologies such as infections, medications, and immune processes. A rare, yet significant, etiology of HUS includes acute Clostridium difficile colitis. Here, we present a case of atypical HUS secondary to acute C. difficile colitis, successfully treated with hemodialysis and systemic corticosteroids. It is imperative that clinicians are cognizant of C. difficile-associated HUS given the overall rising incidence of acute C. difficile infections.

Evaluating the Improvement in Colonoscopy Quality Indicators Subsequent to Publication of Professional Society Guidelines.

Introduction  Quality metrics of colonoscopy should be routinely monitored with a focus on optimizing the patient's subsequent risk of colorectal cancer development. Documentation of bowel preparation, adenoma detection rate (ADR), and post-colonoscopy follow-up recommendations are three of the most important quality indicators for colonoscopy, but significant improvement has been challenging to achieve. The goal of this study is to determine whether the publication of colonoscopy quality indicator guidelines in 2015 resulted in an improvement in quality measures of physicians in our endoscopy suite as compared to before. Methods  We reviewed the electronic medical records of patients who underwent a screening or surveillance colonoscopy in 2014 and 2017. Colonoscopies were performed in an open-access medical center endoscopy suite, staffed by three groups of physicians (academic gastroenterologists (AGs), non-academic gastroenterologists (non-AGs), and surgeons). We gathered demographic data, bowel preparation reports, follow-up recommendations, and notice to patient's primary care physician, and calculated ADR for patients. Age- and gender-matched patients in both years were analyzed for ADR. These data were further subcategorized for each group of physicians. Results  There were 553 patients in 2014 and 1,095 in 2017. Overall, male gender and African American race constituted the majority of patients in both years. Among age- and gender-matched patients in 2014 and 2017 (412 and 243 patients, respectively), ADR within each group of endoscopists was not significantly different between these two years (AGs 44% vs. 50%; non-AGs 32% vs. 27%; surgeons 25% vs. 21%; p>0.05 for all). However, in 2014 and 2017, ADR was significantly higher in the AG group as compared to the non-AG group and surgeons (p<0.006 and p<0.0004, respectively). Reporting of bowel preparation quality (82% vs. 87%) and documenting the recommended period for follow-up surveillance colonoscopy in the report (68% vs. 78%) improved between 2014 and 2017 (p=0.002 and p=0.0001, respectively). Correct recommendations for follow-up surveillance colonoscopy only improved significantly in the AG group (74% in 2014 as compared with 82% in 2017, p=0.003). Conclusion  Based on the current guidelines, AG physicians are far exceeding the target ADR goals, and are superior compared to other groups of endoscopists. Although improvements were noted after guideline publications, areas of needed improvement with respect to meeting gastroenterology society guidelines for quality remained. The fact that individual physicians are performing and billing in an endoscopy suite staffed and equipped by a medical center creates an environment where responsibility for improvement in quality cannot be readily assigned.

Rapidly Progressive Acute Liver Failure in Relapsed Multiple Myeloma.

Multiple myeloma affects upwards of 30,000 people every year and has significant morbidity and mortality. Common complications of the disease involve lytic bone lesions, hypercalcemia, anemia, and acute renal failure. A rare, yet serious, complication includes acute liver failure secondary to hepatic plasma cell infiltration. While this is reported seldom in living patients, it is found in upwards of 40% of patients incidentally on imaging or during autopsy. Conscientious and meticulous monitoring of liver function tests allows for early detection of liver failure in multiple myeloma; thus, allowing for broader therapeutic options overall.