Delay in performing ERCP and adverse events increase the 30-day readmission risk in patients with acute cholangitis.

BACKGROUND: Readmission to the hospital within 30 days of discharge (30-day readmission rate) is used as a quality measure. OBJECTIVE: To investigate the incidence and factors that contribute to readmissions in patients with acute cholangitis. DESIGN: Retrospective cohort study. SETTING: Tertiary-care referral center. PATIENTS: Retrospective analysis of consecutive patients admitted to our center for acute cholangitis and ERCP. INTERVENTION ERCP MAIN OUTCOME MEASUREMENTS: Incidence and variables associated with 30-day readmission and 1-year mortality. RESULTS: ERCP was successful in 98.8% of patients during the index admission. The 30-day readmission rate was 22.0%. Recurrence of cholangitis was the most common etiology for readmissions (37.8%). Readmission within 30 days was independently associated with failed ERCP or ERCP delayed for >48 hours (odds ratio [OR] 2.47; 95% confidence interval [CI], 1.01-6.07), development of any after-ERCP adverse event (OR 11.0; 95% CI, 3.06-39.30), and the etiology of cholangitis (etiologies not related to stones) (OR 3.3; 95% CI, 1.17-9.18). Every 1-point increase in the Charlson Comorbidity Index score (OR, 1.33; 95% CI, 1.05-1.69) was associated significantly with 1-year mortality. In unadjusted analysis, 30-day readmission after ERCP was associated significantly with 1-year mortality (OR, 2.86; 95% CI, 1.16-7.07). This association, however, was not present after adjustment for other covariates. LIMITATIONS: Retrospective study. CONCLUSION: Delays in performing ERCP during the index admission, development of after-ERCP adverse events, and etiology of cholangitis not related to stones increased the risk of 30-day readmissions.

Lamotrigine-Induced Acute Pancreatitis.

Drug-induced pancreatitis is a rare phenomenon. Therefore, diagnosis requires ruling out more common etiologies of acute pancreatitis. The majority of research on drug-induced pancreatitis is from case reports. Only a limited number of drugs have been definitively established to induce pancreatitis. Lamotrigine is used in both bipolar and epilepsy. Lamotrigine is currently weakly identified to induce pancreatitis. We present a case of lamotrigine-induced pancreatitis. Extensive workup ruled out other major causes of pancreatitis-including alcohol. We aimed to show lamotrigine can be a causative drug of acute pancreatitis.

Jejunal Adenocarcinoma: A Rare Cause of Small Bowel Obstruction.

Jejunal adenocarcinoma (JA) is both a rare type of gastrointestinal malignancy and an uncommon cause of small bowel obstruction (SBO). It typically presents with vague symptoms, such as abdominal pain, nausea, vomiting, and, in some cases, weight loss. Due to this vague presentation as well as lack of definitive imaging techniques, diagnosis tends to be delayed and patients typically present at later stages. We present a case of a patient who presented with acute onset abdominal pain. Imaging revealed the presence of an SBO with the presence of a suspicious small bowel stricture. He eventually underwent upper endoscopy to find the mass, with subsequent biopsy indicating JA. We hope to bring greater awareness to jejunal carcinoma as a potent cause of SBO in adults.

Metastatic Jejunal Renal Cell Carcinoma Intussusception Presenting as Melena.

Renal cell carcinoma (RCC) most commonly metastasizes to the lungs, and it is uncommon for RCC to metastasize to the small bowel. Small bowel metastasis commonly presents with gastrointestinal (GI) bleeding. In rare cases, a metastatic small bowel mass can serve as a lead point for intussusception. In this report, we present the case of a male patient whose chief complaint was melena. The patient denied any abdominal pain or nausea. Investigation with push enteroscopy revealed a jejunal mass, and further evaluation with CT showed small bowel intussusception. The patient subsequently underwent small bowel resection and anastomosis. Histopathology confirmed that the jejunal mass was metastatic RCC. We present this case in order to showcase the utility of push enteroscopy in the diagnosis of small bowel metastasis in RCC.

Microscopic colitis: is it a spectrum of inflammatory bowel disease?

Lymphocytic and collagenous colitis are forms of microscopic colitis which typically presents in elderly patients as chronic watery diarrhea. The association between microscopic colitis and inflammatory bowel disease is weak and unclear. Lymphocytic colitis progressing to ulcerative colitis has been previously reported; however there is limited data on ulcerative colitis evolving into microscopic (lymphocytic or collagenous) colitis. We report a series of six patients with documented ulcerative colitis who subsequently were diagnosed with collagenous colitis or lymphocytic colitis suggesting microscopic colitis could be a part of the spectrum of inflammatory bowel disease. The median duration of ulcerative colitis prior to being diagnosed with microscopic colitis was 15 years. We noted complete histological and/or symptomatic remission in three out of six cases while the other three patients reverted back into ulcerative colitis suggesting lymphocytic or collagenous colitis could present as a continuum of ulcerative colitis. The exact molecular mechanism of this histological transformation or the prognostic implications is still unclear. Till then it might be prudent to follow up these patients to assess for the relapse of inflammatory bowel disease as well as for dysplasia surveillance.

Risk factors of non-alcoholic fatty liver disease in patients with inflammatory bowel disease.

BACKGROUND: Metabolic risk factors are associated with non-alcoholic fatty liver disease (NAFLD), but they are less frequent in inflammatory bowel disease (IBD). AIM: This study evaluates the frequency of NAFLD and its risk factors among IBD patients including anti-TNF-α therapy. METHODS: IBD patients who underwent abdominal imaging from January, 2009 to December, 2010 were analyzed in this nested, case-controlled study. IBD patients with NAFLD by imaging were compared with those who had no evidence of NAFLD (control). RESULTS: Among 928 IBD patients, 76 (8.2%) had evidence of NAFLD by imaging, and were compared to 141 patients without NAFLD evaluated (study: control ratio=~1:2). NAFLD patients were older (46.0 ± 13.3 vs. 42.0 ±14.1 years; p=0.018) and had a later onset of IBD compared to the control group (37.2 ± 15.3 vs. 28.7 ± 23.8 years; p=0.002). Metabolic syndrome was present in 29.0% of NAFLD patients, with a median Adult Treatment Panel risk factor of 2 [Interquartile range 1,3]. Patients not receiving anti-TNF-α therapy had a higher occurrence of NAFLD (p=0.048). In multivariate analysis, hypertension (OR=3.5), obesity (OR=2.1), small bowel surgeries (OR=3.7), and use of steroids at the time of imaging (OR=3.7) were independent factors associated with NAFLD. CONCLUSION: NAFLD occurred in 8.2% of the IBD population. NAFLD patients were older and had a later onset of IBD disease. IBD patients develop NAFLD with fewer metabolic risk factors than non-IBD NAFLD patients. It is also less common among patients who received anti-TNF-α therapy.