Introduction: Colonoscopy using a standard diameter adult colonoscope (AC) can be difficult where there is a fixed, narrow or angulated colonic segment or, a redundant colon. Such encounters are more common in a subgroup of patients which includes females, adults with small statures, history of abdominal surgeries especially a hysterectomy, or colonic diverticular disease. Such segments are often traversed by switching from an AC to the smaller-diameter, more flexible pediatric colonoscope (PC). In addition to this back-up role, PCs are suitable for routine colonoscopies and via less colonic stretch, may decrease patients’ discomfort. Despite their utility, whether there are specific subgroups of patients in whom the use of a PC at the onset of procedure, as opposed to a back-up, leads to superior colonoscopy outcomes remains largely understudied. Nonetheless, given this background, some experts initiate a colonoscopy with the PC. This study aimed to examine the current practices among endoscopists and investigate whether there are subgroups of patients in whom the use of a PC at the onset of procedure is preferable. Methods: An Institutional Review Board (IRB)-approved 14-question survey developed by a panel of endoscopists was emailed to all 36 gastroenterologists who perform colonoscopies at the endoscopy unit of Thomas Jefferson University Hospital. The survey questions included the colonoscope preference (AC vs PC) at the onset of procedure in 10 subgroups of patients often encountered at colonoscopy. Results: A total of 33 out of 36 (91.7%) endoscopists responded; 81.8% (n = 27) were males and 18.2% (n = 6) were females. A total of 45.5% (n = 15) have been in practice for more than 20 years; 72.7% (n = 24) perform more than 500 colonoscopies each year. Respondent’s colonoscope preference at the onset of procedure for the cases surveyed are shown in Table 1 and Figure 1. There was a notable difference in respondents’ preference for PC in male and female patients with BMI <23 (30.3% and 75% respectively) and those with a history of abdominal surgeries (21.2% and 51.5% respectively). Conclusion: The results of this survey affirm that the use of an AC is preferred in most patients, except in females that are of small stature and females with a history of multiple abdominal surgeries. In addition, female gender and a history of abdominal surgeries is the feature that mostly prompts the use of a PC. Comparison of colonoscopy outcomes with ACs and PCs in patient subgroups is worthy of a robust further study.Table 1.: Responses regarding colonoscope preference at the onset of procedureFigure 1.: Graphical representation of responses regarding colonoscope preference at the onset of a colonoscopy in the patient subgroups surveyed (A, B, C, D, E)*. *Letter Key can be found in the accompanying tabular representation of the results in Table 1.
A 58-year-old woman with a history of morbid obesity, asthma, and prior warfarin use presented to the hospital with shortness of breath and a three-month history of painful, ulcerated ulcers with retiform purpura of her bilateral distal extremities. A punch biopsy specimen demonstrated focal necrosis and hyalinization of the adipose tissue with subtle arteriolar calcium deposition, findings consistent with calciphylaxis. We discuss the presentation of non-uremic calciphylaxis and review the risk factors, pathophysiology, and interdisciplinary management approach of this rare disease.
Introduction: Cytomegalovirus (CMV) colitis is a rare disease among immunocompetent patients presenting with inflammatory bowel disease (IBD). CMV can cause steroid-refractory IBD, which may require antiviral and infliximab (IFX) combination therapy. Case Description/Methods: A 23-year-old woman was admitted for dehydration and poor oral intake in the setting of eight bloody bowel movements per day, tenesmus, and weight loss. She presented to an outside hospital 5-weeks prior with abdominal cramps and bright red blood per rectum. The CT scan showed bowel wall thickening and mucosal enhancement in the rectosigmoid and descending colon. A colonoscopy 2-weeks prior to admission was suggestive of severe ulcerative colitis (UC) and she was started on mesalamine/budesonide. Due to poor clinical response, she was switched to prednisone 40 mg for 5 days. Outpatient medical management failed and, upon admission, she was converted to methylprednisolone 20 mg every eight hours. Serum CMV PCR was positive at 1,758 IU/mL and colonic biopsies showed scattered CMV inclusions by immunohistochemical staining. She was started on ganciclovir 5mg/kg/dose IV in addition to the steroid regimen and IFX infusions were deferred. By day 2 of ganciclovir IV and day 7 of methylprednisolone IV, IBD symptoms began to resolve. On discharge at hospital day 12, patient was transitioned to twice daily oral valganciclovir 900 mg for a 3-week course and an oral prednisone taper. CMV PCR was 1,185 IU/mL on discharge and < 100 IU/mL at one week follow up. IFX therapy was initiated 45 days post discharge with improved symptoms, as characterized by a 17-lb weight gain at 3-month follow-up. (Figure) Discussion: CMV colitis is a rare diagnosis in immunocompetent patients with early, steroid naïve IBD. Serum PCR positive infection has been reported more commonly after 2-3 weeks of steroid therapy. CMV infection is a recognized complication and marker of poor prognosis in moderate to severe UC, especially those who present with steroid refractory disease. It is believed that the inflammatory mediators associated with UC play a synergistic role in CMV reactivation and subsequent disease. In addition, local corticosteroid induced immunosuppression may further facilitate CMV gene transcription, resulting in disease progression and poor steroid response. There remains no consensus for management of UC with concomitant CMV colitis however, in our patient the use of antiviral and biologic therapy (IFX) promoted disease regression and clinical improvement.Figure 1.: H&E Stain (20x) demonstrating active chronic colitis (left). Immunohistochemical staining (40x) showing CMV immunoreactivity (right).
Introduction: Data on the outcomes of inflammatory bowel disease (IBD) post liver transplant (LT) for primary sclerosing cholangitis (PSC) have been reported in small studies in the past. We explored the MarketScan database to investigate the outcomes of IBD in post-LT patients with PSC. Methods: Adult patients older than 18 years with IBD and PSC who underwent LT between 1/1/2013 and 11/23/2020 were analyzed in the Marketscan claims database. Patients were excluded if they were in the database for less than 3 months pre-LT, had less than 6 months enrollment post-LT, or had HIV/AIDS. IBD outcomes were based on immunosuppresive medications, IBD-related surgery, and IBD-related hospitalizations. McNemar’s tests and signed rank test were used. Results: A total of 178 patients with IBD and PSC with mean age at LT of 46.5±12.5 years, 29.2% female were studied. Median follow up was 29.86 months. Pre-LT 94 (52.8%) patients were on steroids, 90 (50.5%) were on 5-ASA, 35 (19.6%) were on antimetabolites, 20 (11.2%) were on biologics, 1 (0.5%) was on small molecules for IBD and 26 (14.61%) were on transplant medications. Post-LT 159 (89.3%) patients were on steroids, 76 (42.7%) on 5-ASA, 27 (15.1%) on antimetabolites, 11 (6.2%) on biologics, none on small molecules for IBD and 164 (92.13%) were on transplant medications. As expected, more patients were prescribed transplant medications (P< 0.0001) and steroids (P < 0.001) post-LT as compared to pre-LT. There was a trend toward less 5-ASA and biologics used post-LT (P=0.06) for IBD. Eleven (6.2%) patients had IBD-related surgeries pre-LT compared to 7 (3.9%) post-LT (P=0.45). The cohort had a median of 1 hospitalization (IQR: 0-3) for IBD pre-LT and a median of 1 hospitalization (IQR: 0-2) post-LT (P=0.02, Table 1). Conclusion: We found that IBD course in the post-LT setting in patients with IBD and PSC may not be as severe as pre-LT, as reflected by a trend in less use of 5-ASA and biologics and less IBD-related hospitalizations. We were unable to tease out the impact of biologics and small molecule medications in these patients due to their limited use in this cohort. This information is useful in management of patients with IBD who are post-LT for PSC in the real-world setting. Table 1. - Comparison of inflammatory bowel disease (IBD) severity as indicated by immunosuppressive medications, IBD-related surgeries and IBD-related hospitalizations pre and post liver transplant (LT), n=178 Variable Pre-LT Post-LT P-value Transplant Medications 26 (14.61%) 164 (92.13%) < 0.0001* Steroids 94 (52.81%) 159 (89.33%) < 0.001* Biologics 20 (11.24%) 11 (6.18%) 0.06** 5-ASA 90 (50.56%) 76 (42.70%) 0.06* Antimetabolite 35 (19.66%) 27 (15.17%) 0.22* Small molecules 1 (0.56%) 0 (0.00%) N/A IBD surgery (at least one) 11 (6.18%) 7 (3.93%) 0.45** Strictureplasty 1 (0.56%) 0 (0.00%) N/A Colectomy 9 (5.06%) 5 (2.81%) 0.42** Enterostomy 4 (2.25%) 3 (1.69%) 1.00** Anal Fistula Surgery 0 (0.00%) 1 (0.56%) N/A Incision and Drainage 1 (0.56%) 1 (0.56%) 1.00** Proctectomy 1 (0.56%) 2 (1.12%) 1.00** IBD Hospitalizations 0.02*** Median (IQR) 1 (0-3) 1 (0-2) Range 0-13 0-18 *McNemar’s Test was used.**Exact McNemar’s Test was used.***Signed Rank Test was used.
Introduction: While the link between Streptococcus (S.) gallolyticus bacteremia and colorectal adenocarcinomas is well-established, bacteremia due to other viridans streptococci species, such as Streptococcus mitis and Streptococcus anginosus, can also be found in the setting of colorectal cancers and precursor lesions. Colonoscopy is the standard of care in evaluating S. gallolyticus bacteremia and it is occasionally recommended in the setting of viridans streptococci bacteremia. Data underlying these associations and recommendations are based on case reports and epidemiologic studies. We present a single-center retrospective study to evaluate the diagnostic yield of colonoscopy in the setting of viridans streptococci bacteremia. Methods: IRB exemption was obtained from TJUH. The laboratory was queried for all patients who had viridans streptococcus bacteremia between April 2017 and March 2021. The medical records of patients with S. gallolyticus, S. anginosus, and S. mitis bacteremia were evaluated for colonoscopy findings within 1 year of the positive cultures. Exclusion criteria included patients with polymicrobial bacteremia (>3 strains). The proportion of colorectal adenocarcinomas and multiple polyps (defined as >2 polyps) among these groups were analyzed with the Fischer’s exact test. Results: The number of patients found to have S. gallolyticus, S. anginosus, and S. mitis bacteremia are shown (Table 1). Of note, 6 of the 9 patients who underwent colonoscopy within a year of S. gallolyticus bacteremia were found to have either multiple polyps or colorectal cancer. Patients with S. gallolyticus bacteremia were more likely to have colorectal cancer found on colonoscopy compared to those with S. mitis (P=0.015), but were not more likely to have multiple polyps identified (P=0.309). There was no statistical difference in the proportion of colorectal cancer or multiple polyps on colonoscopy when comparing patients with S. gallolyticus and S. anginosus bacteremia. Conclusion: The known association between S. gallolyticus and colorectal cancer is affirmed based on this first-ever retrospective study of its kind. There is a relatively high proportion of colorectal cancer in the setting of S. gallolyticus bacteremia, which substantiates the recommendation for colonoscopy. Comparatively, the diagnostic yield of colonoscopy in the setting of S. anginosus or S. mitis bacteremia is questionable. Further characterization of the patient populations is necessary to elucidate the confounding variables.Table 1.: Table shows the number of patients found to have S. gallolyticus, S. anginosus, and S. mitis bacteremia followed by the number of these patients that underwent colonoscopy within 1 year of the bacteremia and the findings on the colonoscopy (categorized as multiple polyps or colorectal cancer). Multiple polyps are defined as more than 2 polyps on colonoscopy for which pathology shows tubular or villous adenomas.
Introduction: Cecal bascule is a rare type of colonic volvulus. It is believed that its pathogenesis involves a congenital predisposition and a physiologic stressor, such as ischemia. Consequently, it is a source of morbidity and mortality among patients with cardiac diseases. Case Description/Methods: A 55-year-old man with ischemic cardiomyopathy presented to the hospital with cardiogenic shock. He received an intra-aortic balloon pump for hemodynamic support while awaiting heart transplant evaluation. His hospital course was complicated by intra-aortic balloon pump thrombosis and stroke. On hospital day 170, he developed new-onset abdominal pain and distension. CT of the abdomen showed that the cecum had shifted toward the midline. Serial abdominal x-rays showed worsening colonic dilation and repeat CT confirmed a mobile cecal bascule. After a multi-disciplinary discussion, he underwent open ileocectomy on hospital day 177. His post-operative course was uneventful, and he underwent heart transplant on hospital day 249 (Figure 1). Discussion: Cecal volvulus is classified into 3 different types: Type 1 develops from clockwise axial torsion of the cecum, Type 2 arises from torsion of the cecum and terminal ileum that is usually in the counterclockwise rotation, and Type 3, known as a cecal bascule, results from upward angulation of the cecum. The incidence of cecal volvulus is increasing yearly and continues to be associated with high mortality rates. It is believed that a predisposition to cecal volvuli requires mobility of the ascending colon, which can be congenital or acquired, and occurs in up to 25% of the population. Multiple case reports of cecal volvulus in patients with recent cardiothoracic surgery, cardiomyopathy, or coronary artery disease suggest a possible ischemic or cardiac predilection. While the overall incidence of GI complications in cardiac surgery is low (1.1%), mortality due to such complications is high (33%). Likewise, cecal volvulus is associated with a mortality of 10% to 40%. The diagnosis of cecal volvulus involves abdominal radiography and/or cross-sectional imaging. Surgical options for management include cecopexy, cecostomy, colectomy, or manual detorsion; these options must be considered case-by-case, as recurrence rate is high without resection, but resection can carry higher mortality. While successful colonic decompression of cecal bascule has been described, most cases of cecal volvulus are treated with surgical resection.Figure 1.: Coronal CT image of cecal bascule.
