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A common complication of antibiotic use is the development of diarrheal illness. The pathogenesis of antibiotic associated diarrhea (AAD) may be mediated through alteration of intestinal microbiota, overgrowth of opportunistic pathogens, and direct drug toxicity on the gut. Alterations in the intestinal microbiota result in metabolic imbalances, loss of colonization resistance and in turn allow proliferation of opportunistic pathogens. Currently fewer than 33% of AAD cases can be attributable toClostridioides difficileleaving a large number of cases undiagnosed and poorly treated. Although the pathogenesis ofClostridioides difficileinfection (CDI) has been well documented, the role of other putative microbial etiologies (Clostridium perfringens,Staphylococcus aureus,Klebsiella oxytoca,Candida species) and their pathogenic mechanisms in AAD has been unclear. This review provides a comprehensive and systematic approach to the existing data on AAD and includes concise descriptions of the pathogenesis of CDI and non-CDI AAD in the form of figures.

Magnesium Citrate (MC) is not FDA approved as a colonoscopy preparation. Advantages include low cost, small volume and accessibility without prescription. We retrospectively evaluated bowel preparations used in a private gastroenterology practice. The sample size is the largest for any similar studies (n =19,173).Electronic Medical Records were queried for colonoscopies between 2010-2016. Bowel preps, indications (screening vs. other) and preparation adequacy were all recorded. Adequacy rates were calculated and compared using generalized linear modeling. Data were analyzed using SAS.The most common prep used was MC 2 bottles; screening (n=6,064, with 98.94% adequacy) and non-screening (n=3,251, with 99.29% adequacy), followed by MC 3 bottles; screening (n=2,757 with 90.35% adequacy), and non-screening (n=1,925 with 92.92% adequacy).MC bowel preparation is adequate, well tolerated, and inexpensive. In a large retrospective analysis, it compares favorably to other preparations.

BACKGROUND AND AIM: There is wide variation in choice of sedation and airway management for endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to perform a systematic review and meta-analysis to investigate safety outcomes of deep sedation with monitored anesthesia care (MAC) versus general endotracheal anesthesia (GETA). METHODS: Individualized search strategies were performed in accordance with PRISMA and MOOSE guidelines. This meta-analysis was performed by calculating pooled proportions using random effects models. Measured outcomes included procedure success, all-cause and anesthesia-associated adverse events, and post-procedure recovery time. Heterogeneity was assessed with I(2) statistics and publication bias by funnel plot and Egger regression testing. RESULTS: Five studies (MAC:n=1284 vs GETA:n=615) were included. Patients in the GETA group were younger, had higher body mass index (BMI), and higher mean ASA scores (all P

Inferior vena cava filters (IVCF) are associated with many long-term complications. Often, these complications manifest as acute events, such as shock. However, we report a case of a patient who presented with chronic hypotension and dizziness due to a thrombosed IVCF filter.

BACKGROUND Gastrointestinal hemorrhage (GIH) is a common complication with gastrointestinal cancers (GIC). There is no comprehensive research that examines GIH in different types of GIC. AIM To study the prevalence, predictors, and interventions of GIH based on the anatomical location of GIC. METHODS This is a retrospective analysis of the 2016-2018 National Inpatient Sample database, the largest inpatient care database in the United States. All adult inpatients (≥ 18-year-old) were included. ICD-10-CM codes were used to identify patients with GIH and GIC. Prevalence of GIH was obtained based on the anatomical location of GIC. Predictors of GIH in the GIC population were studied using multivariate analysis. Interventions including endoscopy were compared to the non-intervention group to determine the differences in inpatient mortality. RESULTS Out of a total of 18173885 inpatients, 321622 (1.77%) cases had a diagnosis of GIC. Within GIC patients, 30507 (9.5%) inpatients had GIH, which was significantly (P < 0.001) more than the prevalence of GIH in patients without GIC (3.4%). The highest to lowest GIH rates are listed in the following order: Stomach cancer (15.7%), liver cancer (13.0%), small bowel cancer (12.7%), esophageal cancer (9.1%), colorectal cancer (9.1%), pancreatic cancer (7.2%), bile duct cancer (6.0%), and gallbladder cancer (5.1%). Within gastric cancer, the GIH rate ranged from 14.8% in cardia cancer to 25.5% in fundus cancer. Within small bowel cancers, duodenal cancers had a higher GIH rate (15.6%) than jejunal (11.1%) and ileal cancers (5.7%). Within esophageal cancers, lower third cancers had higher GIH (10.7%) than the middle third (8.0%) or upper third cancers (6.2%). When studying the predictors of GIH in GIC, socioeconomic factors such as minority race and less favorable insurances (Medicaid and self-pay) were associated with significantly higher GIH on multivariate analysis (P < 0.01). Chemotherapy and immunotherapy were also identified to have a lower risk for GIH [odds ratios (OR) = 0.74 (0.72-0.77), P < 0.001]. Out of 30507 GIC inpatients who also had GIH, 16267 (53.3%) underwent an endoscopic procedure, i.e., upper endoscopy or colonoscopy. Inpatient mortality was significantly lower in patients who underwent endoscopy compared to no endoscopy [5.5% vs 14.9%, OR = 0.42 (0.38-0.46), P < 0.001]. CONCLUSION The prevalence of GIH in patients with GIC varies significantly based on the tumor’s anatomical location. Endoscopy, which appears to be associated with a substantial reduction in inpatient mortality, should be offered to GIC patients with GIH. Nevertheless, the decision on intervention in the GIC population should be tailored to individual patient's goals of care, the benefit on overall care, and long-term survival.

Background: Patients with atrial fibrillation undergoing percutaneous coronary intervention have indications for oral anticoagulation and dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor. The concurrent use of all three agents, termed triple oral antithrombotic therapy (TAT), increases the risk of bleeding. A number of prospective trials showed that the omission of aspirin mitigates the risk of bleeding without affecting major adverse cardiovascular event (MACE). Materials and Methods: The databases of PubMed, Embase, and Cochrane Central databases were searched from inception to October 2019. Relevant randomized control trials comparing dual antithrombotic therapy (DAT) versus TAT were identified and a metanalysis was performed using random-effect model. The safety endpoints of interest were thrombolysis in myocardial infarction criteria (TIMI) major and minor bleeding, TIMI major bleeding, and intracranial bleeding. The efficacy endpoints of interest were MACE and individual components of MACE. Results: Six trials with 11,722 patients were included. For safety endpoint, DAT was associated with significantly lower incidence of TIMI major and minor bleeding [RR: 0.58, 95% CI 0.44–0.77, P = 0.0001], TIMI major bleeding [RR: 0.55, 95% CI 0.42–0.73, P < 0.0001] as well as intracranial bleeding [RR: 0.35, 95% CI 0.16–0.73, P = 0.006] compared with TAT. No significant difference was observed for MACE [RR: 0.96 (0.79–1.17) P = 0.71] or any of the individual components of MACE between the two groups. Conclusion: Omission of aspirin from TAT in patients with Atrial Fibrillation (AF) after percutaneous coronary intervention is associated with lower risk of bleeding without compromising the efficacy in terms of mortality and cardiovascular thrombotic events.

Cholecystectomy is one of the most common surgical procedures in clinical practice. Laparoscopic cholecystectomy has become the gold standard for the management of symptomatic gallstone disease due to its minimally invasive nature and safety with quoted complication rates of under 5%. Surgical clip migration into the bile duct with resultant stone formation is a rare complication of laparoscopic cholecystectomy. Here we present a case of cholangitis in addition to gallstone pancreatitis as a result of surgical clip migration into the bile duct leading to stone formation.

Peutz-Jeghers syndrome (PJS) is a rare autosomal dominant disorder characterized by hamartomatous polyps throughout the gastrointestinal tract, mostly causing gastrointestinal bleeding and recurrent intestinal obstructions. Few intussusception related to PJS occurs reportedly in adults. Unlike pediatric cases almost all reported cases end up with surgical resection. Here we present a case of PSJ-related intussusception in an adult patient treated successfully with endoscopic approach, with no surgical intervention required.

Background and Aims Transoral outlet reduction (TORe) is a common endoscopic treatment for patients with weight regain after Roux-en-Y gastric bypass (RYGB) with a dilated gastrojejunal anastomosis (GJA). This study aims to assess long-term efficacy of TORe. Methods This was a retrospective review of prospectively collected data on RYGB patients who underwent TORe for weight regain or inadequate weight loss. The primary outcome was efficacy of TORe at 1, 3, and 5 years. Secondary outcomes were procedure details, safety profile, and predictors of long-term weight loss after TORe. Results Three hundred thirty-one RYGB patients underwent 342 TORe procedures and met inclusion criteria. Of these, 331, 258, and 123 patients were eligible for 1-, 3- and 5-year follow-ups, respectively. Mean body mass index was 40 ± 9 kg/m2. Pre-TORe GJA size was 23.4 ± 6.0 mm, which decreased to 8.4 ± 1.6 mm after TORe. Patients experienced 8.5% ± 8.5%, 6.9% ± 10.1%, and 8.8% ± 12.5% total weight loss (TWL) at 1, 3, and 5 years with follow-up rates of 83.3%, 81.8%, and 82.9%, respectively. Of 342 TORe procedures, 76%, 17.5%, 4.4%, and 2.1% were performed using single purse-string, interrupted, double purse-string, and running suture patterns, respectively, with an average of 9 ± 4 stitches per GJA. Pouch reinforcement suturing was performed in 57.3%, with an average of 3 ± 2 stitches per pouch. There were no severe adverse events. Some patients (39.3%) had additional weight loss therapy (pharmacotherapy or procedure), with 3.6% getting repeat TORe. Amount of weight loss at 1 year (β = .43, P = .01) and an additional endoscopic weight loss procedure (β = 8.52, P = .01) were predictors of percentage of TWL at 5 years. Conclusions TORe appears to be safe, effective, and durable at treating weight regain after RYGB.

OBJECTIVE Pericardial effusion is not an uncommon finding in hospitalized patients. Many pericardial effusions are found incidentally through computed tomography (CT) performed for other indications. Echocardiography is usually ordered when an incidentally discovered pericardial effusion is found on the CT to examine the effect of the effusion on hemodynamics and to detect early signs of tamponade. However, in clinical practice, the discrepancy between CT and echocardiography regarding the size of pericardial effusions is common. The accuracy of CT in the evaluation of the size of pericardial effusions is not well-studied. Our study aims to evaluate the accuracy of CT in assessing the size of a pericardial effusion compared with the gold standard echocardiography. METHODS This is a retrospective study examining patients presenting to the University of Toledo Medical Center (UTMC) with pericardial effusions. One hundred and forty-one patient charts were reviewed and 45 subjects were excluded. Ninety-six patients in whom both CT and echocardiography were performed were enrolled in the final analysis. The time interval between both imaging modalities was limited to less than 14 days and no interventions on the effusion (e.g., pericardiocentesis) occurred in the time interval between the two imaging modalities. RESULTS The size of the pericardial effusion was assessed similarly between CT and echocardiography in 50% of the cases (48/96). In the other half of the study population, the results were discrepant; CT was found to overestimate the size of pericardial effusion in 44% of the cases (42/96). The agreement rate between the two modalities is significantly low kappa = 0.111, P = 0.028. The independent variables age, gender, body mass index (BMI), use of anticoagulants, and renal function had no effect on the agreement between CT and echocardiography. CONCLUSION Computerized tomography tends to overestimate the size of the pericardial effusion compared to echocardiography. Based on an incidental finding of pericardial effusion on CT scan, this discrepancy should be recognized prior to ordering an echocardiogram. Echocardiography can be considered in relevant clinical settings.

Introduction Intensive Care Units (ICUs) are among the most expensive components of hospital care. Experts believe that ICUs are overused; however, hospitals vary in their ICU admission rate. Our hypothesis is based on clinical observations that many patients with diabetic ketoacidosis (DKA), stroke, and gastrointestinal (GI) bleeding admitted to the ICU don't really need it and could be managed safely in a non-ICU level of care. Reducing inappropriate admissions would reduce healthcare costs and improve outcomes. Our primary objective was to determine the frequency of inappropriate ICU admissions. Secondary objectives were to evaluate which diagnoses were more unnecessarily admitted to the ICU, evaluate different variables and comorbidities, and determine the mortality rates during ICU admissions. Methods Patients admitted to the ICU, from the Emergency Department (ED) or transferred from the floor, during a one-year period were evaluated in this retrospective study. Patients 18-years old and above who had an admitting diagnosis of DKA, GI bleed, ischemic stroke, or hemorrhagic stroke were included. Patients in a comatose state, intubated, on vasopressors, hemodynamically unstable or had an unstable comorbid disease, subarachnoid hemorrhage, surgery during hospitalization prior to the ICU admission were excluded. Patients were categorized as having an appropriate or inappropriate ICU admission based on our institutional ICU admission criteria and data from available literature and guidelines. Results A total of 95 patients were included in our cohort. Seventy-two out of 95 (76%) were considered as inappropriate ICU admissions. When comparing each of the four admitting diagnoses, a significantly higher proportion of DKA patients were considered inappropriate ICU admissions when compared to the other diagnoses (P = 0.001). The overall mortality rate of ICU admissions was 16%, 15 patients out of 95 study population. When comparing each of the four admitting diagnoses, there was a significant difference in mortality rate with DKA having the lowest mortality (3%) and GI bleed having the highest mortality (43%). Out of the 15 patients who died, only 1 patient was categorized as an inappropriate ICU admission. Conclusions More than three-quarters of our study population was admitted to the ICU inappropriately. Incorporating severity scores in ICU admission criteria could improve the appropriateness of ICU admission and financial feasibility. This article is based on a poster: Alsamman S, Alsamman MA, Castro M, Koselka H, Steinbrunner J: ICU admission patterns in patients with DKA, stroke and GI bleed: do they all need ICU? J Hosp Med. March 2015.

BACKGROUND: The optimal approach at treating infected biliary stents at the time of cholangitis remains unknown. This study aims to compare the efficacy of stent exchange versus stent sweeping/stent-in-stent approaches at treating cholangitis. METHODS: The study was a retrospective cohort study. Patients with biliary stents and cholangitis were included. Outcomes were rate of recurrent cholangitis and time to recurrent cholangitis in those whose stents were left in place (stent sweeping and stent-in-stent) compared to those whose stents were removed (stent exchange). Primary analysis included patients with metal biliary stents only. Secondary analysis included those with metal and plastic biliary stents. RESULTS: A total of 182 patients (age 64±12;89F) with a metal biliary stent(s) at index cholangitis were included. Of these, 40 (22%) had stents removed, i.e. stent exchange. The remaining 142 (78%) did not have stent removal (97 with stent-in-stent and 45 with stent sweeping). Recurrent cholangitis occurred in 22.5% and 42.3% in the stent removal and non-removal groups, respectively (p=0.02). Stent removal remained a negative predictor of recurrent cholangitis after controlling for age, sex, history of diabetes and chemotherapy (OR=0.39, p=0.03). Median time from index cholangitis to recurrent cholangitis was shorter for patients whose stents were not removed compared to those whose stents were removed (182 versus 450 days, p=0.011). On Cox regression model, stent removal remained a negative predictor of recurrent cholangitis after controlling for age, sex, history of diabetes and chemotherapy (HR=0.41, p=0.01). The findings persisted in the secondary analysis including both metal and plastic biliary stents (303 patients). CONCLUSION: Biliary stent removal with stent exchange at the time of cholangitis appears to be more effective at preventing recurrent cholangitis than leaving an infected stent in the biliary system.

Spinal epidural abscess (SEA) is uncommon with an incidence reported as 0.33–1.96 abscesses per 10,000 hospital admissions per year. Two-thirds of the cases were caused by Staphylococcus aureus. Escherichia coli (E. coli) is a less common cause of SEA, and it is usually after urinary tract infection in patient with preexisting risk factor. A 69-year-old male with a past medical history significant for prostatitis was admitted with fever, altered mental status, neck pain, progressive lower extremities weakness, and frequent falls for 7 days. Both blood and urine cultures grew E. coli. Lumbar puncture showed 94 RBCs, 24 WBCs (16% neutrophils and 46% lymphocytes), and elevated protein level at 1140 mg/dl with no bacteria. C-spine MRI showed epidural abscess along the anterior and right lateral margin of the cord causing cord compression from C5 through C7, anterior perivertebral abscess from C4 through T2, marrow edema involving C6 and C7 vertebral bodies with increased signal in the intervertebral disc space at C6-C7, and consistent with osteomyelitis and discitis. Anterior cervical decompression with evacuation of anterior epidural abscess with fusion was done. The culture from the epidural abscess grew E coli. A diagnosis of SEA should be considered in patients presenting with progressive weakness and neurological deficits following UTI and is to be confirmed by MRI. E. coli could be the culprit for epidural abscess and spine osteomyelitis even in immunocompetent patients.