Prolonged Gastrointestinal Manifestations After Recovery From COVID-19.

BACKGROUND & AIMS: Acute enteric infections are well known to result in long-term gastrointestinal (GI) disorders. Although COVID-19 is principally a respiratory illness, it demonstrates significant GI tropism, possibly predisposing to prolonged gut manifestations. We aimed to examine the long-term GI impact of hospitalization with COVID-19. METHODS: Nested within a large-scale observational cohort study of patients hospitalized with COVID-19 across North America, we performed a follow-up survey of 530 survivors 12-18 months later to assess for persistent GI symptoms and their severity, and for the development of disorders of gut-brain interaction (DGBIs). Eligible patients were identified at the study site level and surveyed electronically. The survey instrument included the Rome IV Diagnostic Questionnaire for DGBI, a rating scale of 24 COVID-related symptoms, the Gastrointestinal Symptoms Rating Scale, and the Impact of Events-Revised trauma symptom questionnaire (a measure of posttraumatic stress associated with the illness experience). A regression analysis was performed to explore the factors associated with GI symptom severity at follow-up. RESULTS: Of the 530 invited patients, 116 responded (52.6% females; mean age, 55.2 years), and 73 of those (60.3%) met criteria for 1 or more Rome IV DGBI at follow-up, higher than the prevalence in the US general population (P < .0001). Among patients who experienced COVID-related GI symptoms during the index hospitalization (abdominal pain, nausea, vomiting, or diarrhea), 42.1% retained at least 1 of these symptoms at follow-up; in comparison, 89.8% of respondents retained any (GI or non-GI) COVID-related symptom. The number of moderate or severe GI symptoms experienced during the initial COVID-19 illness by self-report correlated with the development of DGBI and severity of GI symptoms at follow-up. Posttraumatic stress disorder (Impact of Events-Revised score ≥33) related to the COVID-19 illness experience was identified in 41.4% of respondents and those individuals had higher DGBI prevalence and GI symptom severity. Regression analysis revealed that higher psychological trauma score (Impact of Events-Revised) was the strongest predictor of GI symptom severity at follow-up. CONCLUSIONS: In this follow-up survey of patients 12-18 months after hospitalization with COVID-19, there was a high prevalence of DGBIs and persistent GI symptoms. Prolonged GI manifestations were associated with the severity of GI symptoms during hospitalization and with the degree of psychological trauma related to the illness experience.

The 2022 top 10 list of endoscopy topics in medical publishing: an annual review by the American Society for Gastrointestinal Endoscopy Editorial Board.

Using a systematic literature search of original articles published during 2022 in Gastrointestinal Endoscopy and other high-impact medical and gastroenterology journals, the 10-member Editorial Board of the American Society for Gastrointestinal Endoscopy composed a list of the 10 most significant topic areas in GI endoscopy during the study year. Each Editorial Board member was directed to consider 3 criteria in generating candidate lists-significance, novelty, and global impact on clinical practice-and subject matter consensus was facilitated by the Chair through electronic voting. The 10 identified areas collectively represent advances in the following endoscopic spheres: artificial intelligence, endoscopic submucosal dissection, Barrett's esophagus, interventional EUS, endoscopic resection techniques, pancreaticobiliary endoscopy, management of acute pancreatitis, endoscopic environmental sustainability, the NordICC trial, and spiral enteroscopy. Each board member was assigned a consensus topic area around which to summarize relevant important articles, thereby generating this précis of the "top 10" endoscopic advances of 2022.

Characteristics and Outcomes of Black and White Patients Hospitalized With Nonalcoholic Steatohepatitis: A Nationwide Analysis.

BACKGROUND: Nonalcoholic steatohepatitis (NASH) is an increasingly common etiology for liver-related hospitalizations in the United States. The aim of this study was to examine the differences of disease characteristics and outcomes between hospitalized Black and White patients with NASH. MATERIALS AND METHODS: We used the National Inpatient Sample (NIS) to identify all adult hospitalizations with NASH (ICD-10 code: K75.81) from 2016 to 2018. We compared demographic and clinical characteristics between Black and White patients. Multivariable models were computed to compare all-cause mortality, length of stay (LOS), and total hospital costs between the groups. RESULTS: There were 43,409 hospitalizations with NASH (41,143 White, 2266 Black). Black patients were less likely to have cirrhosis (33.6%) compared with Whites (56.4%), P <0.0001. Black patients were less likely to have esophageal variceal bleeding (1.2% vs. 3.5%), ascites (17.1% vs. 28.8%), and acute liver failure (16.2% vs. 28.9%) compared with Whites (all P <0.0001). These findings were consistent among patients with cirrhosis. Mortality was higher among Blacks compared with Whites (3.9% vs. 3.7%, adjusted odds ratio=1.34; 95% confidence interval: 1.05-1.71, P =0.018). Compared with Whites, Blacks had a longer LOS (6.3 vs. 5.6, P <0.001), and higher hospital costs ($18,602 vs. $17,467; P =0.03). CONCLUSION: In this large population of inpatients with NASH, Black patients were less likely to have cirrhosis and liver disease-related complications, but had overall worse hospital mortality, longer LOS, and higher hospital costs. Further research is warranted to elaborate on factors that generate the health inequities in NASH outcomes between Black and White patients.

GIE Editorial Board Top 10: advances in GI endoscopy in 2021.

The 9-member Editorial Board of the American Society for Gastrointestinal Endoscopy performed a systematic literature search of original articles published during 2021 in Gastrointestinal Endoscopy and 10 other high-impact medical and gastroenterology journals on endoscopy-related topics. Votes from each editorial board member were tallied to identify a consensus list of the 10 most significant topic areas in GI endoscopy over the calendar year of study, with a focus on 3 criteria: significance, novelty, and global impact on clinical practice. The 10 areas identified collectively represent advances in the following endoscopic topics: colonoscopy optimization, bariatric endoscopy, endoscopic needle sampling and drainage, peroral endoscopic myotomy, endoscopic defect closure, meeting systemic challenges in endoscopic training and practice, endohepatology, FNA versus fine-needle biopsy sampling, endoscopic mucosal and submucosal procedures, and cold snare polypectomy. Each board member contributed a summary of important articles relevant to 1 to 2 of the consensus topic areas, leading to a collective summary that is presented in this document of the "top 10" endoscopic advances of 2021.

Digestive Manifestations in Patients Hospitalized With Coronavirus Disease 2019.

BACKGROUND & AIMS: The prevalence and significance of digestive manifestations in coronavirus disease 2019 (COVID-19) remain uncertain. We aimed to assess the prevalence, spectrum, severity, and significance of digestive manifestations in patients hospitalized with COVID-19. METHODS: Consecutive patients hospitalized with COVID-19 were identified across a geographically diverse alliance of medical centers in North America. Data pertaining to baseline characteristics, symptomatology, laboratory assessment, imaging, and endoscopic findings from the time of symptom onset until discharge or death were abstracted manually from electronic health records to characterize the prevalence, spectrum, and severity of digestive manifestations. Regression analyses were performed to evaluate the association between digestive manifestations and severe outcomes related to COVID-19. RESULTS: A total of 1992 patients across 36 centers met eligibility criteria and were included. Overall, 53% of patients experienced at least 1 gastrointestinal symptom at any time during their illness, most commonly diarrhea (34%), nausea (27%), vomiting (16%), and abdominal pain (11%). In 74% of cases, gastrointestinal symptoms were judged to be mild. In total, 35% of patients developed an abnormal alanine aminotransferase or total bilirubin level; these were increased to less than 5 times the upper limit of normal in 77% of cases. After adjusting for potential confounders, the presence of gastrointestinal symptoms at any time (odds ratio, 0.93; 95% CI, 0.76-1.15) or liver test abnormalities on admission (odds ratio, 1.31; 95% CI, 0.80-2.12) were not associated independently with mechanical ventilation or death. CONCLUSIONS: Among patients hospitalized with COVID-19, gastrointestinal symptoms and liver test abnormalities were common, but the majority were mild and their presence was not associated with a more severe clinical course.

Advanced endoscopy fellowship training in the United States: recent trends in American Society for Gastrointestinal Endoscopy advanced endoscopy fellowship match, trainee experience, and postfellowship employment.

BACKGROUND AND AIMS: The American Society for Gastrointestinal Endoscopy (ASGE) advanced endoscopy fellowship (AEF) match offers a structured application process for AEF training in the United States. Our aim was to describe recent trends in AEF match, trainee experience, and postfellowship employment. METHODS: ASGE AEF match data from 2012 to 2020 were reviewed. Online surveys were sent to advanced endoscopy trainees in 2019 and 2020 to explore their perceptions about AEF training and postfellowship jobs. RESULTS: Data for 2020 showed 19% of matched applicants were women, 55% foreign medical graduates, and 17.5% U.S. visa holders. The number of AEF match applicants increased by 15.6% (90 in 2012 to 104 in 2020) and number of AEF programs increased by 23.5% (51 in 2012 to 63 in 2020). The average applicant match rate was 57% (range, 52.8%-60.6%) and position match rate 87.9% (range, 79.1%-94.6%). Ninety-one percent of trainees (n = 58) rated the quality of their training as very good/excellent; 75% of trainees participated in >300 ERCPs and 64.1% in >300 EUS cases. Seventy percent of trainees reported that advanced endoscopic procedures comprised ≤50% of their procedure volume in their first job, and 71.9% believed it was not easy to find a job after fellowship; however, 97% believed they would make the same decision to pursue AEF training again. CONCLUSIONS: There has been a steady increase in the number of advanced endoscopy applicants and training positions over recent years. Most graduating fellows reported 50% or less of their upcoming clinical practice would involve advanced endoscopic procedures. Future studies are needed to further clarify employment opportunities and personnel needs for advanced endoscopists.

Effect of Dysphagia on Hospital Outcomes and Readmissions in Patients with Human Immunodeficiency Virus.

OBJECTIVES: Dysphagia is a common symptom in patients hospitalized with human immunodeficiency virus (HIV). There are limited data on the relation between dysphagia and important hospital outcomes. The aim of our study was to assess the impact of dysphagia on hospital costs, length of stay (LOS), mortality, and 30-day readmission rates in HIV patients hospitalized with dysphagia. METHODS: We used the Nationwide Readmissions Database to identify all adult hospitalizations with HIV between January 2010 and September 2015. We stratified cases according to the presence of dysphagia (International Classification of Diseases, Ninth Revision, Clinical Modification code 787.2) as a primary or secondary diagnosis, and compared clinical and hospital characteristics between the two groups. Multivariable regression models were used to compare LOS, total hospital costs, in-hospital mortality, 30-day mortality, and 30-day readmission rates between the two groups. RESULTS: A total of 206,332 hospitalized patients with HIV were included in the study. Of these, 8699 (4.2%) patients had dysphagia. Patients with dysphagia were more likely to have Candida esophagitis (26.8% vs 3.6%), esophageal strictures (3.1% vs 0.2%), and malnutrition (41.6% vs 17.6%); and they were more likely to undergo upper endoscopy (23.2% vs 3.8%) and percutaneous feeding tube placement (9.2% vs 0.7%), all P < 0.0001. On multivariate analysis, dysphagia was associated with longer LOS (12 vs 7.4 days; P < 0.0001), higher hospitalization cost ($32,993 vs $21,813, P < 0.0001), and increased 30-day readmissions (24% vs 20.8%, adjusted odds ratio 1.19; 95% confidence interval 1.12-1.25; P < 0.0001). Patients with dysphagia had higher in-hospital mortality (4.7% vs 3.5%) but this did not reach statistical significance (adjusted odds ratio 1.01; 95% confidence interval 0.91-1.12; P = 0.86). CONCLUSION: In hospitalized patients with HIV, dysphagia is a significant independent predictor of longer LOS, higher costs, and higher rates of 30-day readmissions. These findings highlight the importance of optimizing treatment of dysphagia in patients with HIV to mitigate its negative impact on patient and hospital outcomes.

Frequency of Care Fragmentation and Its Impact on Outcomes in Acute and Chronic Pancreatitis in a Nationally Representative Sample.

OBJECTIVES: Hospitalized patients with acute and chronic pancreatitis (AP and CP) are prone to frequent readmissions to different hospitals. The rate of care fragmentation and its impact on important outcomes are unknown. The aims of this study were to evaluate the rate and predictors of care fragmentation in patients hospitalized with AP and CP using a nationally representative sample, and to analyze the impact of care fragmentation on mortality, cost, and hospital readmissions. METHODS: We identified all adult hospitalizations with a primary diagnosis of AP or CP in the 2010-2014 National Readmissions Database, which captures statewide readmissions. We calculated 30- and 90-day readmission and care fragmentation rates. Readmission to a nonindex hospital was considered care fragmentation. Logistic regression was used to determine hospital and patient factors independently associated with 30-day care fragmentation. Patients readmitted within 30 days were followed for 60 days postdischarge from the first readmission. Mortality during the first readmission, hospitalization costs, and rates of 60-day readmission were compared between those with and without care fragmentation. RESULTS: There were 479,427 admissions with AP and 25,513 with CP. The rates of 30- and 90-day readmissions were 13.5% and 22.9% for AP and 26.9% and 44.7%% for CP. The rates of 30- and 90-day care fragmentation were 28% and 32% for AP and 33% and 38% for CP. Younger age (younger than 45 y), male patients, length of stay <5 days, ≥4 Elixhauser comorbidities, and self-pay or Medicaid insurance were associated with increased risk of 30-day care fragmentation. Large hospital size, routine discharge, and metropolitan location were associated with lower risk. Patients who had the first readmission to a nonindex hospital had a higher mortality (2% vs 1.6%, P = 0.005), length of stay (6.5 vs 5.6 days, P < 0.0001), mean hospitalization cost ($16,731 vs $13,368, P < 0.0001), and 60-day readmission (48.4% vs 42.9%) compared with those readmitted to the index hospital. CONCLUSIONS: In patients with AP and CP, one-third of 90-day readmissions occur at a nonindex hospital. Care fragmentation is associated with increased mortality, readmissions, and cost of care.

Incidence and predictors of 30-day readmissions in patients hospitalized with chronic pancreatitis: A nationwide analysis.

BACKGROUND: Patients with chronic pancreatitis are prone to frequent readmissions. The aim of this study is to evaluate the rate and predictors of 30-day readmissions in patients with chronic pancreatitis using the Nationwide Readmission Database (NRD). METHODS: We performed a retrospective analysis of all adult patients with the principal discharge diagnosis of chronic pancreatitis from 2010 through 2014. We excluded patients who died during the hospitalization. Multivariate Cox proportional hazard regression was performed to identify demographic, clinical, and hospital factors that associated with 30-day unplanned readmissions. RESULTS: During the study period, 25,259 patients had the principal discharge diagnosis of chronic pancreatitis and survived the index hospitalization. Of these, 6477 (26.7%) were readmitted within 30 days. Younger age group, males, length of stay >5 days, admission to a large, metropolitan hospital, and several comorbidities (renal failure, rheumatic disease, chronic anemia, heart failure, depression, drug abuse, psychosis, and diabetes) were independently associated with increased risk of 30-day readmission. ERCP, pancreatic surgery, and obesity were associated with lower risk. The most common reasons for readmissions were acute pancreatitis (30%), chronic pancreatitis (17%), pseudocyst (2%), and abdominal pain (6%). CONCLUSIONS: One in four patients with chronic pancreatitis is readmitted within 30 days (26.7%). Pancreatic disease accounts for at least half of all readmissions. Several baseline comorbidities and characteristics are associated with 30-day readmission risk after index admission. Knowledge of these predictors can help design interventions to target high-risk patients and reduce readmissions and costs of care.

Outcomes and Predictors of Readmissions with GI Bleeding in Patients with Left Ventricular Assist Devices.

OBJECTIVES: Gastrointestinal (GI) bleeding is a major comorbidity in patients with left ventricular assist devices (LVADs). The study aim was to estimate the rate of hospital readmissions for GI bleeding in patients with LVADs using a nationally representative database. Additionally, we evaluated the etiologies, costs, endoscopy utilization, mortality, and predictors of GI bleeding readmissions in these patients. METHODS: We analyzed data from the National Readmissions Database (NRD) from 2010 through 2014. We compared hospitalized adult patients with congestive heart failure (CHF) who underwent LVAD implantation (cases) with CHF patients without LVAD or heart transplant (controls). Three age- and sex-matched controls were randomly selected per single case. A multivariate Cox regression model was used to compare the hazards of 60-day all-cause and GI bleeding readmission between the groups, controlling for significant confounders. RESULTS: A total of 3293 hospitalized patients with CHF who had LVAD placement (cases) and 9879 who did not have LVADs (controls) were included in the study. At 60 days, patients with LVAD had a significantly higher readmission rate with GI bleeding (8.7% vs 2.3%, adjusted hazard ratio [aHR] 4.45, 95% confidence interval 3.71-5.33, P < 0.0001). The all-cause readmission rate also was higher (43.3% vs 35.7%, aHR 1.23, 95% confidence interval 1.12-1.34, P < 0.0001). The most common etiologies of bleeding in patients with LVADs were gastroduodenal and small intestinal arteriovenous malformations (28.6%). During bleeding readmissions, patients with LVAD were more likely to undergo endoscopy (72.1% vs 33.5%, P < 0.0001) and receive packed red blood cell transfusions (62% vs 36.6%, P< 0.0001) compared with controls. GI bleeding readmissions were more costly ($40,936 vs $35,313, P< 0.0001), and longer (12 vs 10.9 days, P< 0.0001) in patients with LVADs compared with controls. Independent risk factors for 60-day GI bleeding readmission were increasing age (aHR 1.04, P< 0.0001) and GI bleeding during index admission (aHR 2.68, P< 0.0001). In those without bleeding during index admission, increasing age and chronic anemia were associated with 60-day GI bleeding readmission. Mortality during bleeding readmission was similarly low in patients with LVADs compared with CHF controls (0.2% vs 0.3%, P = 0.14). CONCLUSIONS: After LVAD implantation, there is a fivefold increased risk of readmission with GI bleeding within 60 days. Gastroduodenal and small intestinal arteriovenous malformations are the most common culprit lesions. These findings suggest that small bowel enteroscopy should be considered as the initial test of choice in patients with suspected upper gastroduodenal bleeding. Readmissions with bleeding in patients with LVADs increase morbidity and cost of care but not mortality. Older patients and those with a history of bleeding during LVAD implantation are at higher risk of bleeding readmission and may benefit from close monitoring and cautious anticoagulation to prevent rebleeding.