Clinical Manifestations of Micronutrient Deficiencies in Short Bowel Syndrome: A Case Report.

The etiologies of short bowel syndrome (SBS) can be stratified into congenital or acquired etiologies, with the latter being more prevalent. Small intestinal surgical resection is the most common acquired etiology, employed in settings including mesenteric ischemia, intestinal injury, radiation enteritis, and inflammatory bowel disease (IBD) complicated by internal fistulas. We describe a case of a 55-year-old Caucasian male with a history of idiopathic superior mesenteric artery (SMA) ischemia post-SMA placement complicated by recurrent small bowel obstructions. He presented with SMA stent occlusion and infarction, leaving him with 75 cm of post-duodenal small bowel after emergent surgical resection. He was trialed on enteral nutrition and progressed to parenteral nutrition (PN) after failure to thrive. With intensive counseling, his compliance improved, and he was able to briefly maintain adequate nutrition status with supplemental total parenteral nutrition. After a period of being lost to follow-up, he succumbed to complications from untreated SBS. This case highlights the need for intensive nutritional support for patients with short bowel syndrome and awareness of clinical complications.

Adherence to guideline-directed hepatocellular carcinoma screening: A single-center US experience.

BACKGROUND: The American Association for the Study of Liver Disease recommends screening patients with cirrhosis for hepatocellular carcinoma (HCC) using imaging with or without alpha-fetoprotein every six months. Unfortunately, screening rates remain inadequate. AIM: To assess root causes of screening failure in a subspecialty hepatology clinic. METHODS: The authors identified patients with cirrhosis seen in a subspecialty hepatology clinic and determined whether they underwent appropriate screening, defined as two cross-sectional images between five and seven months apart. The authors characterized the primary driver of screening failure. Finally, other hepatologists were surveyed to determine provider perceptions of screening failure causes. RESULTS: 1034 patients were identified with an average age of 61 years and a mean MELD of 8.1 ± 3.8. Hepatitis C virus was the most common cirrhosis etiology. 489 (47%) underwent appropriate screening. No demographic or clinical differences were detected between those who underwent appropriate screening and those who did not. The most common etiologies of screening failure, in descending order, were: radiology unable to schedule timely imaging, provider did not order imaging, patient canceled follow up appointment, appointments scheduled too far apart, lost to follow up, no-show to radiology appointment, and provider canceled appointment. Hepatologists surveyed believed the most common cause of screening failure was no-show to radiology. CONCLUSION: Rates of screening were poor even in a subspecialty hepatology clinic. Screening failure was mostly due to systemic factors such as radiology availability and time between hepatology appointments rather than individual error.

Carnitine Deficiency in an Adult With Short Bowel Syndrome After Surgical Resection.

Carnitine is an essential cofactor for fatty acid metabolism. Deficiencies can be associated with muscle weakness, fatigue, weight loss, and cardiomyopathies. A 27-year-old woman with short bowel syndrome (SBS) presented with significant weight loss, fatigue, and muscle wasting despite adequate parenteral nutrition. Her laboratory test results revealed carnitine deficiency secondary to malnutrition. Levocarnitine supplementation was initiated with normalization of her carnitine levels. Her fatigue improved, and her weight returned to baseline. Carnitine deficiencies are seldomly reported in adults, particularly those with SBS. Carnitine deficiency should be suspected and corrected in patients with SBS and malabsorptive capacity due to surgical resection.

Nonocclusive mesenteric ischemia: A rare but lethal complication of enteral nutrition in critically ill patients.

BACKGROUND: The American Society for Parenteral and Enteral Nutrition (ASPEN)/ Society of Critical Care Medicine and the European Society for Clinical Nutrition and Metabolism guidelines recognize that critically ill patients receiving stable, low doses of vasopressors have experienced the advantages of early initiation of enteral nutrition (EN). However, clinical questions remained unanswered including vasopressor combinations associated with complications, the advent of other therapies during hypotensive states, as well as the volume and content of EN that might contribute to the development of a nonocclusive mesenteric ischemia (NOMI). PRESENTATION: A 68-year old male with a history of hypertension, hyperlipidemia, atrial fibrillation, coronary artery disease with two-vessel bypass grafting, and peripheral vascular disease underwent subtotal excision of an infected right axillofemoral-femoral bypass graft. Postoperatively, EN was held because of hemodynamic instability and postsurgical complications. A fiber-free, high-protein, and low-residue formula was started at 10 ml/h while the patient was receiving stable doses of midodrine, norepinephrine, and vasopressin. Despite advancement of tube-feed rates to goal, nasogastric output never exceeded 300 ml. Computerized tomography of the abdomen showed diffuse bowel distention with pneumatosis, concerning for bowel ischemia. No surgical interventions were pursued, and the patient died. CONCLUSIONS: Our patient developed NOMI postoperatively while receiving EN. Further studies addressing EN route, trophic vs full EN, recommended formula, the safety of vasoactive agents, the addition of fiber to EN, and continuous venovenous hemodiafiltration in relation to NOMI are needed, as there continues to be clinical controversy regarding these topics.

Failure to thrive: A severe manifestation of interleukin 10 receptor A mutation in adult inflammatory bowel disease.

BACKGROUND: Very early-onset inflammatory bowel disease (VEO-IBD) secondary to interleukin 10 receptor A (IL-10RA) mutations has aggressive disease courses with increased nutrition needs compared with those in other monogenic forms of IBD. PRESENTATION: A male patient was hospitalized when he was 18 days old for bloody diarrhea, which was diagnosed as Crohn's disease at 6 months old. He showed failure to thrive (FTT) and worsening inflammation while receiving enteral nutrition (EN) and standard IBD treatment. He was hospitalized in 2016, at 28 years old, for a Crohn's flare when sequencing confirmed a heterozygous mutation in IL10-RA. His weight and plasma micronutrient levels improved when he transitioned to parenteral nutrition (PN). He was initiated on anakinra while awaiting hematopoietic stem cell transplant, with substantial decrease in inflammation. He was able to gain weight, initiate an oral diet, and decrease his PN requirement. CONCLUSION: Our patient experienced progressive FTT while receiving EN. VEO-IBD incidence is rising, and its diagnosis is often delayed. Therefore, prompt recognition with treatment initiation is essential to improving nutrition outcomes in this patient population. Further investigation is warranted to determine whether these patients would benefit from early initiation of PN.

Margin marking before colorectal endoscopic mucosal resection and its impact on neoplasia recurrence (with video).

BACKGROUND AND AIMS: Ablation of resection margins after EMR of large nonpedunculated colorectal polyps decreases recurrence. Margin marking before EMR (EMR-MM) may represent an alternative method to achieve a healthy resection margin. We aimed to determine the efficacy of EMR-MM in reducing neoplasia recurrence. METHODS: We conducted a single-center historical control study of EMR cases (EMR-MM vs conventional EMR) for nonpedunculated polyps ≥20 mm between 2016 and 2021. For EMR-MM, cautery marks were placed along the lateral margins of the polyp with the snare tip. EMR was then performed to include resection of the healthy mucosa containing the marks. We compared recurrence at surveillance colonoscopy after EMR-MM versus historical control subjects. Multivariable logistic regression was performed to identify factors associated with recurrence. RESULTS: Two hundred ten patients with 210 polyps (median size, 30 mm; interquartile range: 25-40) underwent EMR-MM (n = 74) or conventional EMR (n = 136). Patient and lesion characteristics were similar between the groups. At a median follow-up of 6 months, the recurrence rate was lower with EMR-MM (6/74; 8%) compared with historical control subjects (39/136; 29%) (P < .001). EMR-MM was not associated with an increased rate of adverse events. On multivariable analysis, EMR-MM remained the strongest predictor of recurrence (odds ratio, .20; 95% confidence interval, .13-.64; P = .003) aside from polyp size (odds ratio, 2.81; 95% confidence interval, 1.35-6.01; P = .008). CONCLUSIONS: In this single-center historical control study, EMR-MM of large nonpedunculated colorectal polyps reduced the recurrence risk by 80% when compared with conventional EMR. This simple technique may provide an alternative to margin ablation.

Factors Associated With Inpatient Endoscopy Delay and its Impact on Hospital Length-of-Stay and 30-Day Readmission.

BACKGROUNDS AND AIMS: Inpatient endoscopy delay (IED) negatively impacts the delivery of high-quality care. We aimed to identify factors associated with IED and evaluate its effect on hospital length-of-stay (LOS) and readmission. METHODS: This was a retrospective analysis of all inpatient endoscopies performed between November 2017 and November 2019 at a tertiary care center. IED was defined as the number of days elapsed between anticipated versus actual procedure day. Data were extracted from the endoscopy documentation software and via electronic chart review. Multivariate logistic regressions were modeled to determine variables associated with IED and hospital readmission. RESULTS: A total of 4239 inpatients (mean age, 58.3 years; 50.3% women) underwent endoscopic procedures during the study period of which 819 patients (19.3%) experienced a delay. IED resulted in a median prolonged LOS of 2 days (interquartile range, 1-2 days). Patients with IED were less likely to have an etiology identified on endoscopy (odds ratio [OR], 0.73; 95% confidence interval [CI], 0.63-0.86; P < .001). The 2 most common causes for delays were poor bowel preparation (n = 218; 27%) and lack of endoscopy personnel/unit availability (n = 197; 24.4%). Independent predictors of IED included: older age (OR, 1.1; 95% CI, 1.01-1.03; P = .03), female sex (OR, 1.20; 95% CI, 1.03-1.40; P = .02), use of antithrombotics (OR, 1.30; 95% CI, 1.08-1.57; P = .006), opioids (OR, 1.23; 95% CI, 1.04-1.44; P = .012), being on contact isolation (OR, 1.38; 95% CI, 1.09-1.75; P = .008), and colonoscopy (OR, 1.50; 95% CI, 1.27-1.77; P < .001). Conversely, inpatients admitted to a dedicated GI medicine service were less likely to have IED (OR, 0.79; 95% CI, 0.65-0.96; P = .02). IED was the only independent predictor of 30-day readmission (OR, 1.22; 95% CI, 1.02-1.47; P = .03). CONCLUSIONS: IED occurred frequently, unfavorably prolonged LOS, and was an independent risk factor for 30-day readmission. We provide a comprehensive analysis of actionable variables associated with IED that can be targeted to improve inpatient endoscopy delivery.

Effect of referral pattern and histopathology grade on surgery for nonmalignant colorectal polyps.

BACKGROUND AND AIMS: The incidence of surgery for nonmalignant colorectal polyps is rising. The aims of this study were to evaluate referral patterns to surgery for nonmalignant polyps, to compare outcomes between surgery and endoscopic resection (ER), and to identify factors associated with surgery in a university-based, tertiary care center. METHODS: Patients referred to colorectal surgery (CRS) for nonmalignant colorectal polyps between 2014 and 2019 were selected from the institution's integrated data repository. Clinical characteristics were obtained through chart review. Multivariate analysis was performed to identify factors associated with surgery for nonmalignant polyps. RESULTS: Six hundred sixty-four patients with colorectal lesions were referred to CRS, of which 315 were for nonmalignant polyps. Most referrals (69%) came from gastroenterologists. Of the 315 cases, 136 underwent surgery and 117 were referred for attempt at ER. Complete ER was achieved in 87.2% (n = 102), with polyp recurrence in 27.2% at a median of 14 months (range, 0-72). When compared with surgery, ER was associated with a lower hospitalization rate (22.2% vs 95.6%; P < .0001), shorter hospital stay (mean, .5 ± .9 vs 2.23 ± 1 days; P < .0001), and fewer adverse events (5.9% vs 22.8%; P = .0002). Intramucosal adenocarcinoma on baseline pathology (odds ratio, 5.7; 95% confidence interval, 1.2-28.2) and referrals by academic gastroenterologists (odds ratio, 2.5; 95% confidence interval, 1.11-5.72) were associated with a higher likelihood of surgery on multivariate analysis. CONCLUSIONS: Gastroenterologists commonly refer nonmalignant colorectal polyps to surgery, even though ER is effective and associated with lower morbidity. Both referrals from academic gastroenterologists and baseline pathology of intramucosal adenocarcinoma were factors associated with surgery. All colorectal polyps should be evaluated in a multidisciplinary approach to identify lesions suitable for ER before embarking in surgery.

Metabolic gene expression changes in the hippocampus of obese epileptic male rats in the pilocarpine model of temporal lobe epilepsy.

Chronically epileptic male adult rats in the pilocarpine model of temporal lobe epilepsy (TLE), exhibited gross expansion of abdominal fat mass and significant weight gain several months after induction of status epilepticus (SE) when compared to control rats. We hypothesized that epileptogenesis can induce molecular changes in the hippocampus that may be associated with metabolism. We determined the expression levels of genes Hsd11b1, Nr3c1, Abcc8, Kcnj11, Mc4r, Npy, Lepr, Bdnf, and Drd2 that are involved in regulation of energy metabolism, in the hippocampus of age-matched control and chronic epileptic animals. Taqman-based quantitative real time polymerase chain reaction (qPCR) and the delta-delta cycle threshold (CT) methods were used for the gene expression assays. Gene expression of Hsd11b1 (cortisol generating enzyme) was significantly higher in epileptic versus control rats at 24h and 2 months, after induction of SE. Nr3c1 (glucocorticoid receptor) mRNA levels on the other hand were down-regulated at 24h, 10 days and 2 months, post SE. Abcc8 (Sur1; subunit of ATP-sensitive potassium (K(ATP)) channel) was significantly down-regulated at 10 days post SE. Kcnj11 (Kir6.2; subunit of ATP-sensitive potassium (K(ATP)) channel) was significantly up-regulated at 24h, 1 month and 2 months post SE. Thus, we demonstrated development of obesity and changes in the expression of metabolic genes in the hippocampus during epileptogenesis in male rats in the pilocarpine model of TLE.

Association study of candidate gene polymorphisms and obesity in a young Mexican-American population from South Texas.

BACKGROUND AND AIMS: Obesity is increasingly a health problem and a risk factor for diabetes in young Mexican-American populations. Genetic association studies in older, mostly non-Hispanic populations have reported that polymorphisms in the candidate genes HSD11B1, CRP, ADIPOQ, PPARG, ANKK1, ABCC8 and SERPINF1 are associated with obesity or diabetes. We analyzed the polymorphisms rs846910, rs1205, rs1501299, rs1801282, rs1800497, rs757110 and rs1136287 in these candidate genes, for association with obesity and metabolic traits in a young Mexican-American population from south Texas. METHODS: Genotyping of the seven common SNPs were performed by allelic discrimination assays in 448 unrelated Mexican Americans (median age = 16 years) from south Texas. χ(2) tests and regression analyses using additive models were used for genetic association analyses adjusting for covariates; p values were corrected for multiple testing by permutation analyses. RESULTS: rs1800497 (ANKK1) shows association with waist circumference (p = 0.009) and retains the association (p = 0.03) after permutation testing. Analysis of metabolic quantitative traits shows that rs846910 (HSD11B1) was associated with HOMA-IR (p = 0.04) and triglycerides (p = 0.03), and rs1205 (CRP) with HOMA-IR (p = 0.03) and fasting glucose levels (p = 0.007). However, the quantitative traits associations are not maintained after permutation analysis. None of the other SNPs in this study showed associations with obesity or metabolic traits in this young Mexican-American population. CONCLUSIONS: We report a potential association between rs1800497 (linked to changes in brain dopamine receptor levels) and central obesity in a young Mexican-American population.