Lukens, Frank

Abstract Background and study aims Anticoagulation (AC) and antiplatelet (AP) therapy may increase the risk of gastrointestinal bleeding after double balloon enteroscopy (DBE); however, limited data are currently available regarding the incidence. The aim of this study was to assess the incidence and clinical characteristics of post-DBE bleeding in patients on AC and AP therapy. Patients and methods The medical records of patients who underwent DBE between 2009 and 2013 at Mayo Clinic, Florida, were retrospectively reviewed. Patients were divided into three groups: 1) continued AP therapy; 2) AC therapy; and 3) neither AP nor AC at the time of DBE. Follow-up data were collected at 60 days and 1 year. Results A total of 683 patients were identified; 43 on AC, 183 on AP and 457 not on AP or AC therapy. The most common indication for DBE was obscure gastrointestinal bleeding in the groups on and not on AP (85.3 % vs 70.9 %, P < 0.0001). There was no statistical difference in post-DBE bleeding rates in patients on AP vs not on AP at 60 days (11.5 % vs 7.5 %, P = 0.12) or 1 year (19.9 % vs 15.7 %, P = 0.23). Rates of bleeding in patients on AC were 11.6 % within 60 days and 22.5 % within 1 year. Multivariate analysis reflected American Society of Anesthesiologist > 3 and indication for DBE of GI bleeding were independent risk factors for post-DBE bleeding within 1 year. Conclusions Continued antiplatelet use at the time of DBE was not an independent risk factor for bleeding post-DBE at 60 days or 1 year of follow up.

ABSTRACT Insulinomas are rare, with an annual incidence of 1–4 people per mission. Insulinomas are the most common functioning endocrine neoplams of the pancreas. Endoscopic ultrasound has both diagnostic and therapeutic yield in undifferentiated pancreatic tumors. We present a case of a recurrent insulinoma, refractory to surgical and medical management diagnosed with endoscopic ultrasound. Our case uniquely conveys a successful, alternative approach to addressing symptomatic insulinomas refractory to surgical or medical management through computed tomography–guided percutaneous ethanol-lipiodol injection.

ObjectivesStudies suggest that adults diagnosed with celiac disease (CD) are at higher risk of developing acute pancreatitis (AP). The aim of this study is to explore the relationship between CD and AP in terms of inpatient prevalence, mortality, morbidity, and resource utilization in the past decade.MethodsRetrospective cohort study using the Nationwide Inpatient Sample (2007–2016). The primary outcome was the occurrence of AP in CD patients. Secondary outcomes were the trend in AP cases in CD patients, and mortality, morbidity, length of stay, and total hospital charges and costs.ResultsOf 337,201 CD patients identified, 7372 also had AP. The mean age was 53 years, 71% were women. The inpatient prevalence of AP in CD was 2.2% versus 1.2% in non-CD cohort (P< 0.01). Patients with CD displayed increased odds of having AP (adjusted odds ratio, 1.92;P< 0.01). Patients with AP and CD displayed lower odds of morbidity and mortality than non-CD patients with AP.ConclusionsThe inpatient prevalence of AP is higher in CD patients, and increased from 2007 to 2016. Patients with CD and AP displayed lower morbidity and mortality, which may suggest that they have a less severe form of AP or lower baseline comorbidity.

Background/objectives Liver transplant recipients have an increased risk of Clostridioides difficile infection (CDI) which associated with higher morbidity and mortality. CDI in liver transplant has been argued to increase hospital costs, charges, and length of stay (LOS) in small studies. However, no recent nationwide analysis determines these outcomes. Methods This is a retrospective cohort study using the National Inpatient Sample 2016. All patients with ICD10CM diagnostic codes for CDI were included. The cohort was stratified for the history of liver transplant and liver transplant index admission. The primary outcome was the odds of CDI in both patient cohorts to patients without liver transplant. Secondary outcomes were inpatient morbidity, mortality, resource utilization, colectomy rates, LOS, and total hospital costs and charges. Results A total of 360 364 patients with CDI were identified, 1665 had a history of liver transplant and 155 had liver transplant during that admission. Patients with a history of liver transplant had increased odds of CDI compared to patients with no history of liver transplant (adjusted odds ratio 2.78; 95% confidence interval, 2.44–3.16). Patients with CDI had greater odds of shock, acute kidney injury, ICU stay, organ failure and significantly higher costs, charges and LOS. Conclusions Patients with a history of liver transplant increased odds of CDI. CDI with history of liver transplant and the index admission for liver transplant had higher odds of morbidity and resource utilization. Clinicians must maintain a high index of suspicion for CDI for early diagnosis and appropriate initiation of treatment.

Abstract Background and study aims With newer imaging modalities, indications for use of endoscopic retrograde cholangiopancreatography (ERCP) have changed in the last decade. Despite advances in ERCP, paucity in recent literature regarding utilization and outcomes of ERCP exists. Thus, the aim of this study was to assess the inpatient use of ERCP, outcomes, and most common indications. Patients and methods Retrospective-cohort study using the Nationwide Inpatient Sample 2007–2016. All patients with ICD9–10CM procedural codes for ERCP were included. The primary outcome was the use of ERCP. Secondary outcomes included determining procedural specifics (stenting, sphincterotomy and dilation), complications (post-ERCP pancreatitis [PEP], bile duct perforation), hospital length of stay, total hospital costs and charges. Multivariate regression analysis was used to adjust for confounders. Results A total of 1,606,850 patients underwent inpatient ERCP. The mean age was 59 years (60 % female). The total number of ERCPs increased over the last decade. Patients undergoing ERCP in 2016 had greater odds of undergoing bile duct stent placement, pancreatic duct (PD) stenting, biliary dilation, pancreatic sphincterotomy, PEP and biliary perforation. Inpatient mortality decreased. Hospital charges increased, while length of stay (LOS) decreased. Conclusions The number of ERCPs increased in the past decade. Odds of therapeutic interventions and complications increased. The most common principal diagnoses were choledocholithiasis and gallstone-related AP. Hence, physicians must be aware to promptly diagnose and treat complications. These findings may reflect the increased case complexity and fact that ERCP continues to evolve into an increasingly interventional tool, contrasting from its former role as a predominantly diagnostic and gallstone extraction tool.

Objective Cholangiocarcinoma (CCA) affects all ethnicities worldwide. The Hispanic population being the leading ethnic minority in the United States, its importance to the healthcare system cannot be understated. This study aims to assess the occurrence and outcomes of CCA in Hispanic patients in the United States. Methods This is a case-control study using the National Inpatient Sample 2014. All patients with ICD-9 CM codes for CCA were included. Hispanic patients were identified from the ethnic categories within the database. The primary outcomes were the occurrence and odds of CCA in the Hispanic population when compared with other ethnicities. Secondary outcomes were inpatient mortality, morbidity, ICU stay, multiorgan failure, and resource utilization. Results A total of 13 965 patients with CCA were identified, of which 2750 were propensity-matched to controls (1480 Hispanic). The inpatient occurrence of CCA in Hispanics relative to the national population was 2.73/100 000 persons, compared to 4.82/100 000 persons (39.9/100 000 relative to inpatient population) of all other ethnicities. After adjusting for confounders on multivariate analysis, Hispanic patients displayed adjusted propensity-matched odds of 1.28 (P < 0.01) of having CCA when compared with other ethnicities. Hispanics did not display different propensity-matched odds of inpatient mortality, morbidity, hospital length of stay, or resource utilization compared to non-Hispanic patients. Conclusion This study demonstrated that the odds of CCA in admitted patients are higher for the Hispanic population. This difference with the prevalence potentially suggests the presence of social factors such as disparities in cancer prevention or detection in this group.

INTRODUCTION: Gender in ulcerative colitis (UC) is a well-studied topic with contradicting results with a slight male predominance seen in large population based studies in Olmsted County, Minnesota, while other studies have shown a slight female predominance. Yet, the relationship between UC and gender is not well-understood. Hence, it is unclear what is responsible for differences in gender. The aim of this study is to assess the inpatient prevalence and inpatients outcomes of UC by gender. METHODS: Case-control study using the NIS 2016, the largest public inpatient database in the US. All patients with ICD9-10CM codes for UC were included. None were excluded. Female patients were identified within the database using the female gender indicator. The primary outcome was determining the odds of UC in female patients compared to males. Secondary outcomes included determining inpatient morbidity, mortality, resource utilization, colectomy rates, hospital length of stay (LOS), and inflation-adjusted total hospital costs and charges. Propensity score matching was used to create a matching population for Charlson Comorbidity Index and age. Multivariate regression analyses were used to adjust for income in patient zip code, hospital region, location, size and teaching status. RESULTS: A total of 38, 950 patients with UC were identified and propensity matched for selected covariates. The mean patient age was 45, and 47.2% were female. For the primary outcome, females had decreased adjusted odds (aOR: 0.92, P < 0.01) of being admitted for UC. For secondary outcomes, female patients displayed lower adjusted odds of multi-organ failure, being placed on TPN, and undergoing colectomy. Females also had lower adjusted mean hospital costs, charges, and length of stay (LOS). All adjusted odds and means are displayed in Table 1. CONCLUSION: Females have lower inpatient prevalence of UC, complications, and economic burden compared to males. This reinforces the slight male predominance that was seen in the older Olmstead County population-based studies. One can speculate that the difference in complications, costs, charges, and LOS indicate that females have less severe disease at hospital admission. Numerous studies have examined the effect of gender on disease severity and outcomes, and there continues to be conflicting data. Thus, future studies are needed to determine what contributes to the variation in disease prevalence and course by gender, and possibly better tailor treatment regimens by gender.