Pyloric Stenosis: A Rare Manifestation of Crohn's Disease.

We are presenting a rare case of pyloric stenosis due to Crohn's disease. A 53-year-old woman with prior history of colonic Crohn's disease was admitted to the hospital with gastric outlet obstruction. Esophagogastroduodenoscopy demonstrated pyloric stenosis and biopsy was consistent with Crohn's disease. She was treated with corticosteroids and her condition improved.

COVID-19-Associated Ischemic Colitis: A Rare Manifestation of COVID-19 Infection-Case Report and Review.

Following the first report of COVID-19 infection in December 2019 as a respiratory illness, it has proven to be a multisystem disease. There are few reported cases of ischemic colitis with COVID-19 infection in the medical literature to date and we have limited understanding of its pathophysiology. We report 2 cases of ischemic colitis as the only manifestation of COVID-19. In addition, we review the current limited literature regarding COVID-19-associated ischemic colitis.

An Exceedingly Rare Case of Liraglutide-Induced Liver Injury.

Liraglutide is a glucagon-like peptide-1 (GLP-1) receptor agonist used for the treatment of type 2 diabetes mellitus. We are reporting the second case of liraglutide-induced liver injury, with complete resolution of liver injury after discontinuation of the drug.

Metastatic Gastric Cancer to the Colon.

Gastric cancer is one of the most common and deadly cancers worldwide, especially amongst older males. Current data suggest gastric cancer is the fifth most common neoplasm and the third most deadly cancer, with an estimated 783,000 deaths in 2018. Risk factors associated with the development of gastric cancer include obesity, gastroesophageal reflux disease, Helicobacter pylori infection, and low socioeconomic status. Diagnosis of gastric cancer can be accomplished by endoscopy, which allows the clinician to obtain a biopsy specimen. Endoscopic ultrasound is also an important modality that is helpful in assessing tumor invasion. The most common sites of metastatic gastric cancer in descending order are the liver, peritoneum, lung and bone. Rarely will gastric cancer metastasize to the colon. Here we present a rare case of colonic metastasis of a primary gastric adenocarcinoma.

The Impact of Human Immunodeficiency Virus (HIV) on Inflammatory Bowel Disease (IBD): A Retrospective Nationwide Study.

BACKGROUND: The "remission theory" is an emerging concept that suggests the presence of human immunodeficiency virus (HIV) results in decreased disease severity in patients with inflammatory bowel disease. This theory is based upon evidence that implicates CD4 T-lymphocytes in the pathogenesis of both Crohn's disease and ulcerative colitis. This study sought to elucidate the legitimacy of this theory. METHODS: A retrospective cohort analysis of all adult inpatient hospitalizations for inflammatory bowel disease (IBD) using the 2016 National Inpatient Sample (NIS) was conducted. Our study population included patients admitted with IBD who were infected with HIV. We compared our study group to patients who also had IBD but were not infected with HIV. Baseline demographic characteristics, resource utilization, and in-hospital mortality rates were extracted for both groups. RESULTS: A total of 58,979 patients were admitted for IBD in 2016. Of those patients, we identified 145 who also had the presence of HIV. We found that patients with ulcerative colitis and HIV had a shorter length of hospital stay (4.1 vs. 5.9 days, p-value < 0.01), lower hospital charge ($35,716 vs $52,893, p-value < 0.01), and lower hospital cost ($7,814 vs. $13,395, p-value < 0.01) than those who did not have HIV. In patients with Crohn's disease, the presence of HIV resulted in decreased colonoscopy rates (0% vs. 17.4%, p-value < 0.01); however, the rate of esophagogastroduodenoscopies was not statistically significant (7.1% vs. 14.7%, p-value 0.106). CONCLUSION: In this retrospective population-based study, we found that patients with ulcerative colitis and concurrent HIV had a milder course of the disease when compared to ulcerative colitis patients that were not infected with HIV. These findings support the remission theory in that HIV may play a role in inflammatory bowel disease.

Chronic obstructive pulmonary disease is associated with worse outcomes in ischemic colitis: a nationwide retrospective study.

BACKGROUND: Ischemic colitis (IC) occurs when the blood supply of the large intestine becomes compromised. Several cardiovascular conditions, such as coronary artery disease, congestive heart failure, and atrial fibrillation, are well-established risk factors for the development of IC. The effects of pulmonary conditions, namely chronic obstructive pulmonary disease (COPD), on IC have not been well studied. AIMS: Our aim was to elucidate if the presence of COPD worsened outcomes in patients with IC. METHODS: Retrospective analysis of patients hospitalized with IC in 2016 was evaluated using the National Inpatient Sample database. Baseline demographic data, length of hospital stay (LOS), total hospital cost/charge, rates of colectomy, and in-hospital mortality were extracted from the database. Categorical variables were compared using the chi-square test and continuous variables were compared using the t-test. RESULTS: A total of 25,035 patients with IC were identified while 4482 of these patients also had COPD. We found that IC patients with COPD had a longer LOS (5.8 days vs 4.4 days; P<0.01), higher total hospital charge ($56,682 vs $42,365; P<0.01), higher total hospital cost ($13,603 vs $10,238; P<0.01), higher mortality rate (6.5% vs 3.1%; P<0.01), and higher colectomy rate (5.1% vs 3.7%; P<0.01). CONCLUSIONS: The presence of COPD portends poor outcomes in patients with IC. This was evidenced by increased risk of death and increased risk of undergoing colectomy. Given these findings, patients with COPD warrant closer observation. We advocate that COPD be considered as part of the risk assessment of patients with acute IC who need surgical intervention.

Esophagitis Dissecans Superficialis (EDS) Secondary to Hair Dye Ingestion: Case Report and Literature Review.

Esophagitis dissecans superficialis (EDS) is a rare and underdiagnosed esophageal lesion characterized by sloughing of the esophageal mucosa that has been associated with medications, various autoimmune disorders, and exposure to some chemical irritants. Anatomically, EDS is most commonly seen in the middle and distal thirds of the esophagus. When present, EDS is best treated by discontinuing the offending agent and initiating pharmacologic therapy with proton pump inhibitors. Steroids may also be effective if the etiology is autoimmune in nature. Our case highlights a 65-year-old female diagnosed with EDS after incidental ingestion of hair dye containing resorcinol and para-phenylenediamine (PPD).

In-hospital mortality in gastroparesis population and its predictors: A United States-based population study.

BACKGROUND AND AIM: To determine the United States-based in-hospital gastroparesis mortality rate and independent predictors associated with it. METHODS: A retrospective study was conducted using the deidentified National Inpatient Sample and Healthcare Cost and Utilization Project database between the years 2012 and 2014. The in-hospital gastroparesis mortality rate was calculated. Patients' demographics, including age, gender, race, comorbid conditions, and hospital characteristics, were examined as potential predictors of mortality. RESULTS: The gastroparesis mortality rate was 3.19 per 1000 gastroparesis patients for the years 2012-2014. Caucasians had the highest mortality rate, with odds ratio (OR) = 2.27; 95% confidence interval (CI) 1.52-3.38, and P = 0.0001. Rural hospitals had higher mortality, with OR = 1.51, 95% CI 1.10-2.10, and P = 0.01, whereas urban nonteaching and teaching hospitals showed no statistically significant mortality difference, with OR = 0.83, 95% CI 0.6-1.15, and P = 0.27 and OR = 0.82, 95% CI 0.59-1.15, and P = 0.25, respectively. In hospitals in the south region, mortality was the highest at 65.6%, with OR = 2.05, 95% CI 1.48-2.84, and P < 0.0001. Patients with diabetes mellitus had 39% lower probability in the mortality group. CONCLUSION: Being of advanced age; being White; and being in a rural, southern U.S. hospital were predictors of in-hospital mortality in gastroparesis patients.

End-stage renal disease and lower gastrointestinal bleeding-A propensity-matched analysis of nationwide inpatient sample.

AIMS: We aim to determine the influence of lower gastrointestinal bleeding (LGIB) on mortality, morbidity, length of hospital stay and resource utilisation in end-stage renal disease (ESRD) patients. MATERIAL AND METHODS: The National Inpatient Sample database (2016 &2017) was used for data analysis using the International Classification of Diseases, Tenth Revision codes to identify the patients with the principal diagnosis of ESRD and LGIB. We assessed the all-cause in-hospital mortality, morbidity, predictors of mortality, length of hospital stay (LOS) and total costs between propensity-matched groups of ESRD patients with LGIB versus ESRD patients. RESULTS: We identified 2 187 954 ESRD patients, of whom 242 075 has LGIB, and 1 945 879 were ESRD patients. The in-hospital mortality was higher in ESRD with LGIB (OR 2.5, 95% CI 1.5-2.2; P = .00). ESRD with LGIB has higher odds of mechanical ventilation (OR 1.4, 95% CI 6.4-16.4; P = .00), and shock requiring vasopressor (OR 1.2, 95% CI 4.9-5.4; P = .002). Advanced age (OR 1.02 CI 1.02-1.03 P = .00), anaemia (OR 1.04 CI 1.59-1.91 P = .006), acute coronary syndrome (OR 1.8 CI 1.6-2.1, P = .00), acute respiratory failure (OR 1.29 CI 2.0-2.6, P = .00), mechanical ventilation (OR 1.9, CI 3.5-4.4, P = .00) and sepsis (OR 1.5, CI 4.1-5.08, P = .00) were identified as predictors of mortality in ESRD with LGIB. Mean LOS (10.8 ± 14.9 vs 6.3 ± 8.5, P < .01) and mean total charges (37 054 $ vs 18 080 $, P < .01) were also higher. CONCLUSIONS: In this propensity-matched analysis, ESRD with LGIB was associated with higher odds of in-hospital mortality, mechanical ventilation and shock requiring vasopressor. Mean LOS and resource utilisation were also higher.

Epidemiology of esophageal cancer: update in global trends, etiology and risk factors.

Esophageal cancer is the eighth most common type of cancer worldwide and constitutes the sixth leading cause of cancer deaths. It is characterized by its high mortality rate, poor prognosis at time of diagnosis and variability based on geographic location. Present day, the prevalence of esophageal cancer is in transition. Although esophageal squamous cell carcinoma continues to be the most prevalent type worldwide, esophageal adenocarcinoma is quickly becoming the most prevalent type in developed countries. Risk factors for the development of esophageal squamous cell carcinoma include low socioeconomic status, consumption of tobacco, alcohol, hot beverages, and nitrosamines. Additionally, micronutrient deficiencies have also been linked to the development of esophageal squamous cell cancer. These include vitamin C, vitamin E, and folate. With respect to esophageal adenocarcinoma, risk factors include Barrett's esophagus, gastroesophageal reflux disease, obesity, and tobacco consumption. Screening for esophageal cancer will likely play an essential role in prevention, and consequently, mortality in the future. Present day, there are no established guidelines for esophageal squamous cell cancer screening. Guidelines for esophageal adenocarcinoma are more well established but lack concrete evidence in the form of randomized controlled trials. This review will discuss the epidemiology, risk factors, and current prevention strategies for esophageal cancer in depth. It is our aim to raise awareness on the aforementioned topics to increase public health efforts in eradicating this disease.

Implementing visual cues to improve the efficacy of screening colonoscopy: exploiting the Hawthorne effect.

BACKGROUND: Colonoscopy is the gold standard for colon cancer screening. Adenoma detection rate and a withdrawal time of 6 min are quality metrics to measure the efficacy of colonoscopy in colon cancer screening. The aim of our study was to exploit the Hawthorne effect in an effort to ensure adherence to a minimum 6-min withdrawal time and subsequently increase adenoma detection rate. METHODS: This was a retrospective single-center study where we reviewed the records of patients who underwent screening colonoscopy in 2015 and 2017. We divided our patient population into 2 groups. The first group of patients from 2015 underwent screening colonoscopy with no visual cues on the colonoscopy monitor. The second group of patients from 2017 had visual cues indicating withdrawal time on the colonoscopy monitor. RESULTS: Screening colonoscopy had a statistically significantly higher adenoma detection rate when performed with visual cues compared to without visual cues (25.3% vs. 19.45, P=0.04). Polyp detection rate was also higher in the group where visual cueing was used (52.9% vs. 22.9%, P<0.001). There were no statistically significant differences in actual withdrawal time or cecal intubation rates. CONCLUSIONS: Visual cues indicating withdrawal time are a useful intervention that results in an increased adenoma detection rate. Given its practicality and cost effectiveness, we recommend universally implementing visual cues to ensure adherence to a minimum 6-min withdrawal time.

Esophageal Cancer: An Updated Surveillance Epidemiology and End Results Database Analysis.

BACKGROUND: Esophageal cancer is the sixth leading cause of cancer-related deaths and the eighth most common cancer worldwide with a 5-year survival rate of less than 25%. Here we report the incidence, risk factors and treatment options that are available currently, and moving into the future. METHODS: We retrospectively analyzed the Surveillance Epidemiology and End Results (SEER) database made available by the National Cancer Institute in the USA. Specifically we extracted data from the years 2004 - 2015. RESULTS: In total we identified 23,804 patients with esophageal adenocarcinoma and 13,919 patients with esophageal squamous cell carcinoma. Males were at an increased risk of developing both types of esophageal cancer when compared to females. Most cases of adenocarcinoma were diagnosed as poorly differentiated grade III (42%), and most cases of squamous cell carcinoma were diagnosed as moderately differentiated grade II (39.5%). The most common stage of presentation for both adenocarcinoma (36.9%) and squamous cell (26.8%) carcinoma was stage IV. The worst outcomes for adenocarcinoma were noted with grade III tumors (hazard ratio (HR): 1.56, 95% confidence interval (CI): 1.44 - 1.68, P value: < 0.01), stage IV tumors (HR: 3.58, 95% CI: 3.33 - 3.85, P value: < 0.01) and those not treated with surgery (HR: 2.54, 95% CI: 2.44 - 2.65, P value: < 0.01). For squamous cell carcinoma, the worst outcomes were noted with grade III tumors (HR: 1.35, 95% CI: 1.23 - 1.49, P value: < 0.01), stage IV tumors (HR: 2.12, 95% CI: 1.94 - 2.32, P value: <0.01). CONCLUSIONS: The incidence of esophageal adenocarcinoma in the USA is steadily on the rise. Conversely, the incidence of squamous cell carcinoma has been continually declining. While white males had an increased incidence of both types of esophageal cancer, a higher proportion of African Americans suffered from squamous cell carcinoma. Despite the wide spread use of proton pump inhibitors, adenocarcinoma continues to be a major public health concern.

Cirrhosis Is Associated With Worse Outcomes in Ischemic Colitis: A Nationwide Retrospective Study.

BACKGROUND: Ischemic colitis (IC) occurs when the blood supply of the large intestine becomes compromised. Cirrhosis is a disease entity in which there is a delicate balance between pro-coagulant and anti-coagulant states. Our aim was to examine the impact cirrhosis has on outcomes in patients with ischemic colitis. METHODS: A retrospective analysis of patients hospitalized with IC in 2017 was evaluated using the National Inpatient Sample database. Baseline demographic data, length of hospital stay (LOS), total hospital charge, rates of colectomy and in-hospital mortality were extracted from the database. Categorical variables were compared using the Chi-square test and continuous variables were compared using t-test. RESULTS: A total of 29,035 patients with IC were identified, while 420 of these patients also had cirrhosis. Patients with IC and cirrhosis were noted to be younger age at presentation when compared to patients with IC and no cirrhosis (mean 63.9 years vs. 70.4 years; P < 0.001). When comparing both groups, IC patients with cirrhosis were more likely to be male (50% vs. 26.1%; P < 0.001), Black (10.9% vs. 7.6%; P = 0.013) and Hispanic (18% vs. 6.1%; P < 0.001). We found that IC patients with cirrhosis had a longer LOS (7.3 days vs. 4.8 days; P < 0.001), higher total hospital charge ($84,769 vs. $48,347; P < 0.001) and higher mortality rate (10.7% vs. 3.6%; P < 0.001); however, the presence of cirrhosis was not associated with increased odds of undergoing colectomy (odds ratio: 0.31; 95% confidence interval: 0.07 - 1.27; P = 0.104). CONCLUSIONS: The presence of cirrhosis is associated with increased odds of in-hospital mortality in those presenting with IC. This compounds the already high rates of mortality in patients that undergo surgery for IC and could reflect lack of reserve to withstand the ischemic episode in the setting of cirrhosis. Though odds of undergoing colectomy is not increased, patients with cirrhosis warrant closer observation.

National Trends and Hospitalizations Related to Pancreatic Cancer in Acute Pancreatitis Patients: A Nationwide Inpatient Sample Study.

Background Pancreatic cancer (PC) is one of the common cancers in the United States (U.S.) and is associated with high mortality and morbidity. In spite of the modest improvement in survival, cancer care costs including PC continue to rise and inpatient costs contribute a significant chunk to cancer care, which is often ignored. Acute pancreatitis (AP) is a rare manifestation of PC. This study aims to determine the national trends and associated health care utilization of PC patients hospitalized with AP in the U.S. Methods We used National Inpatient Sample (NIS) to extract data for patients hospitalized with a primary diagnosis of PC in AP in 2016 using International Classification of Diseases, 10th revision, and Clinical Modification (ICD-10-CM) codes. The analysis included disease etiologies, age, race, sex, hospital region, hospital size, institution type, mortality, length of hospital stay (LOS), and commonly associated comorbidities were correlated. Results There were 250 patients with a discharge diagnosis of PC in patients admitted with AP. Most of the patients were whites (76.6%) with the mean age of 39.42 ± 2.51 years, had Medicare (63.26%) as primary insurance, were from Southern region (46%) and had higher Charlson comorbidity index (CCI) (76.00% with CCI > = 3). The mean hospital charges were $48,462.13, and mean LOS was 5.24 days. The LOS was significantly impacted by race, hospital region, endoscopic retrograde cholangiopancreatography (ERCP), and comorbidities such as dementia, smoking, and seizure. Out of the 250 patients admitted with PC, 245 patients (98%) were discharged alive. Conclusions Our study shows a downward trend in LOS, hospital charges, and in-hospital mortality as compared to other studies despite PC and AP presenting together versus PC with or without other etiologies.

Spontaneous Gastrojejunal Fistulization after Roux-en-Y Bypass Surgery: A Case Report and Review of Literature.

Fistula development is an uncommon but well-recognized complication following Roux-en-Y gastric bypass (RYGB). The broad spectrum of clinical presentation represents a challenge at the time of diagnosis. We present the case of a patient who developed gastrojejunal fistulization after gastric bypass surgery.

Bilateral Basal Ganglia Infarction After Intranasal Use of Cocaine: A Case Report.

We present a case of a young man who developed bilateral basal ganglia infarct after intranasal use of cocaine. Cerebral ischemic infarcts are a known complication of cocaine use. This complication is rare and has been reported in the past with cocaine and concomitant use of other drugs such as heroin and amphetamines.

Elevated International Normalized Ratio: A Risk Factor for Portal Vein Thrombosis in Cirrhotic Patients.

BACKGROUND: Portal vein thrombosis (PVT) is a complication that is commonly seen in patients with cirrhosis and an entity that leads to increased mortality in patients who undergo liver transplantation. This study aims to establish a link between an elevated international normalized ratio (INR) and the presence of PVT in a cohort of cirrhotic patients. METHODS: We retrospectively reviewed the electronic medical records of all patients diagnosed with cirrhosis in SBH Health System from 2013 to 2018. Among these patients we extracted baseline demographic data, laboratory results, co-morbidities and the presence of PVT. RESULTS: In total there were 268 patients who met our inclusion criteria. Twenty-two patients had PVT, while 246 patients did not. Of the 22 patients with PVT there was a statistically significant increase in INR when compared to patients without PVT. There was also a statistically significant increase in total bilirubin, alkaline phosphatase and platelet count. CONCLUSIONS: Elevated INR levels are associated with the presence of PVT in patients with cirrhosis. These findings suggest a hypercoagulable state and could assist clinicians in risk-stratifying patients when making the decision to initiate anti-coagulation therapy.

Herpes Simplex Virus Hepatitis: A Brief Review of an Oft-overlooked Pathology.

Herpes simplex virus (HSV) is a rarely reported cause of viral hepatitis. Aggressive in nature, most cases of HSV hepatitis rapidly progress to fulminant hepatic failure. Present day, its pathogenesis is yet to be elucidated, but its complications and associated high mortality rate are clear. Clinically, its symptoms mimic those of other causes of acute hepatic failure thus making the diagnosis of HSV hepatitis a precarious task. Although treatment in the form of acyclovir is readily available, most cases have a poor prognosis due to late initiation of therapy. This makes the early identification of HSV essential in improving outcomes and potentially preventing mortality.

An unexpected surprise: Delayed gastric outlet obstruction from coin ingestion.

Gastric outlet obstruction (GOO) is characterized by postprandial vomiting due to mechanical obstruction. Rarely it can occur due to ingestion of a foreign body. Most cases of foreign body ingestion are benign, with passage of the ingested object into the stool with no clinical sequelae. We describe a case of an 80-year-old woman with GOO occurring secondary to ingestion of two coins (American quarters). Rarely will such a small object cause a true gastric outlet obstruction. To our knowledge this makes the second such case reported in the medical literature.