Introduction: Over-the-scope clips (OTSC) were initially developed for closure of gastrointestinal leaks, but have been increasingly used in cases of refractory or difficult to control upper gastrointestinal bleeding (UGIB). For UGIB, there is limited data comparing the use of OTSC to conventional hemostatic methods, such as epinephrine injection, bipolar cautery, or through the scope clips (TTSC). We present the case of an acute massive UGIB due to an esophageal ulcer that was treated successfully with an OTSC. Case Description/Methods: A 75 year-old man with a past medical history of atrial fibrillation on rivaroxaban and schizoaffective disorder presented for olecranon bursitis requiring bursectomy and oxacillin. On hospital day 11, he had acute onset hematemesis. He rapidly progressed to hemorrhagic shock and was intubated for airway protection. He required five units of packed red blood cells and high dose vasopressors. His rivaroxaban had been held since admission, but the day prior to hematemesis he was started on therapeutic dose enoxaparin for atrial fibrillation. Emergent endoscopy was performed bedside which revealed blood throughout the upper GI tract and a large adherent clot in the distal esophagus. The region surrounding the clot was injected with 5 mL of 1:10,000 epinephrine and the clot was removed with Roth net and biopsy forceps. Beneath the clot, there was a 6mm esophageal ulcer with a visible vessel. Positioning with TTSC was difficult, so an OTSC was utilized with successful hemostasis. Biopsies of the ulcer revealed gastric cardiac type mucosa with focal intestinal metaplasia, negative for dysplasia. The ulcer was thought most likely to be related to pill esophagitis. The patient was later discharged, and repeat endoscopy two months later revealed 14 centimeters of Barrett’s Esophagus. Discussion: OTSC are a useful tool in difficult to control UGIB. One study randomized patients with recurrent bleeding from peptic ulcers to conventional therapy versus OTSC, and there was a significantly lower rate of re-bleeding in patients treated with OTSC. Another study assessed the role of OTSC as the initial hemostatic tool in UGIB from ulcers and Dieulaofy lesions. This study also demonstrated a significantly lower rate of re-bleeding with OTSC as compared to conventional hemostatic methods. In UGIB, the role of OTSC are evolving, and they should be considered for hemostasis in recurrent UGIB or for initial hemostasis for lesions that are at high-risk for re-bleeding.Figure 1.: A: Distal esophageal ulcer with adherent clot B: Esophageal ulcer after epinephrine injection and clot removal C: Esophageal ulcer after over-the-scope clip deployment.
INTRODUCTION: Hospital admissions for patients with cirrhosis continue to increase. In New York City, 25-30% of hospitalized cirrhotics are readmitted within 30 days. Re-hospitalization is associated with increased mortality, poor quality of life, and financial burden to patients, hospitals, and payers. Preventable readmissions are partially accounted for by a well documented quality gap between evidence based guidelines for cirrhosis management and real world adherence to these recommendations. METHODS: We performed a prospective cohort study that compared outcomes among cirrhotic patients admitted to four internal medicine teams over a 6-month period. An electronic medical record (EMR) note template that outlined best practice measures for cirrhotics was developed. Inpatient providers on two teams were instructed to include it in daily progress notes and discharge summaries. The recommended practices included diagnostic paracentesis and diuretics for ascites, rifaximin and lactulose for hepatic encephalopathy, beta blockers for esophageal varices, and antibiotic prophylaxis for spontaneous bacterial peritonitis. The remaining two teams continued standard of care of cirrhotic patients. The primary outcome was 30-day readmissions. Secondary outcomes included in-hospital mortality, 30-day mortality, length of stay, and adherence to best practice guidelines. RESULTS: Over a 6-month period, 108 cirrhotic patients were admitted, 83 in the interventional group and 25 in the control group. MELD-Na scores on admission did not differ between the groups (20.1 v 21.1, P = 0.57). Thirty-day readmissions were not significantly different between the interventional and control groups (19.3% v 24%, P = 0.61). However, 30-day mortality was significantly lower in the interventional group (7.2% v 24%, P = 0.02). There was no difference between the two groups in in-hospital mortality (3.6% v 0%, P = 0.34) or length of stay (10.2 days v 12.6 days, P = 0.34). Adherence to best practice metrics was similar between the groups, except for rates of diagnostic paracentesis, which were higher in the interventional group (98% v 80%, P = 0.01). CONCLUSION: Implementation of an EMR note template with cirrhosis best practices was associated with lower 30-day mortality and higher rates of diagnostic paracentesis among admitted patients with cirrhosis. These findings suggest that integration of best practice measures into the EMR may improve outcomes in hospitalized cirrhotic patients. Larger studies are required to validate these findings.
Abstract: Thrombocytopenia is a frequent complication in patients with cirrhosis. As many as 84% of patients with cirrhosis have thrombocytopenia, and it is an independent variable indicative of advanced disease and poor prognosis. Although there is great concern that it may aggravate bleeding during surgical procedures, there is limited evidence to inform decisions regarding the treatment of cirrhotic patients with thrombocytopenia undergoing invasive procedures. Finally, there is evidence that platelets play a significant role in liver regeneration. In this report, the clinical implications of thrombocytopenia in cirrhotic patients are reviewed. The utility of platelet counts in the prognosis of cirrhosis and relationship to complications of advanced liver disease, including portal hypertension, esophageal varices, and hepatocellular carcinoma. The impact of low platelet counts on bleeding complications during invasive procedures is outlined. Finally, the role of platelets and potential adverse impact in liver regeneration is reviewed. Keywords: thrombocytopenia, prognosis, invasive procedures, liver regeneration
Background: Acupuncture has been widely studied, and theories regarding its analgesic mechanism of action have been proposed. It has been used for procedural analgesia; however, no reports of its use in urologic surgery have been reported. In this case report, we demonstrate how acupuncture can be used as an alternative to general anesthesia for transurethral resection of bladder tumor (TURBT). This may serve as an attractive option for bladder cancer patients with medical comorbidities, which predispose them to high risk for general anesthesia. Case Presentation: A 65-year-old Caucasian female with toxicant-induced loss of tolerance (TILT) was found to have a bladder mass. TURBT was discussed, and in light of her TILT syndrome, she elected to undergo the procedure with acupuncture in lieu of general anesthesia for fear of an adverse reaction. Acupuncture was performed by a trained practitioner with therapeutic needles placed in the ears, hands, abdomen, and lower extremities bilaterally. She was subsequently taken to the operating room where we performed a TURBT of a bladder tumor overlying the left ureteral orifice. The procedure was generally well tolerated and the patient experienced mild pain. There were no perioperative complications. The tumor was estimated to be 3 cm in largest diameter, and a total of 8 g of aggregate tissue was sent to our pathologists. Pathology analysis demonstrated adequate resection with detrusor muscle present in the sample. The bladder tumor was low-grade papillary urothelial cell carcinoma (Stage Ta). She has had tumor recurrence and has undergone repeat TURBT, but to date, she is 22 months free of bladder cancer. Conclusion: In this case report, we demonstrate that acupuncture is a safe and effective alternative to general anesthesia for patients undergoing TURBT. Since tobacco use is prevalent among bladder cancer patients, many of these individuals have associated medical comorbidities, which predispose them to high risk with general anesthesia. Therefore, acupuncture may serve as an attractive alternative for certain patients in this population.
Abstract The science of mountainous hydrology spans the atmosphere through the bedrock and inherently crosses physical and disciplinary boundaries: land–atmosphere interactions in complex terrain enhance clouds and precipitation, while watersheds retain and release water over a large range of spatial and temporal scales. Limited observations in complex terrain challenge efforts to improve predictive models of the hydrology in the face of rapid changes. The Upper Colorado River exemplifies these challenges, especially with ongoing mismatches between precipitation, snowpack, and discharge. Consequently, the U.S. Department of Energy’s (DOE) Atmospheric Radiation Measurement (ARM) user facility has deployed an observatory to the East River Watershed near Crested Butte, Colorado, between September 2021 and June 2023 to measure the main atmospheric drivers of water resources, including precipitation, clouds, winds, aerosols, radiation, temperature, and humidity. This effort, called the Surface Atmosphere Integrated Field Laboratory (SAIL), is also working in tandem with DOE-sponsored surface and subsurface hydrologists and other federal, state, and local partners. SAIL data can be benchmarks for model development by producing a wide range of observational information on precipitation and its associated processes, including those processes that impact snowpack sublimation and redistribution, aerosol direct radiative effects in the atmosphere and in the snowpack, aerosol impacts on clouds and precipitation, and processes controlling surface fluxes of energy and mass. Preliminary data from SAIL’s first year showcase the rich information content in SAIL’s many datastreams and support testing hypotheses that will ultimately improve scientific understanding and predictability of Upper Colorado River hydrology in 2023 and beyond.
Introduction: Metastases to the stomach are rare and typically seen in advanced stages of cancer. They commonly originate from primary breast cancer, esophageal cancer, lung cancer, or melanoma. Only a few cases of gastric metastasis from ovarian cancer exist in the literature because ovarian tumors commonly disseminate within the peritoneal cavity. It is crucial to differentiate between a primary gastric cancer and metastatic disease to guide appropriate treatment. Here we present a case of metastatic serous ovarian adenocarcinoma with gastric metastasis that presented as anemia and a GI bleed. Case Description/Methods: A 67-year-old woman with a history of metastatic serous ovarian adenocarcinoma status post surgical debulking, multiple lines of chemotherapy, and radiotherapy to the brain presented with a chief complaint of generalized weakness and dark stools. As an outpatient, she was found to be severely anemic with a hemoglobin of 4.4 two weeks before her admission. She transfused 4 units of packed red blood cells and was told to have endoscopic evaluation. She was not on blood thinners or aspirin. On admission, her Hemoglobin was 6.5, BUN was 86, and creatinine was 1.26, with a BUN/Cr ratio of ∼68. Endoscopy revealed one actively oozing cratered gastric ulcer found at the incisura (figure 1a). The lesion was 8 mm in largest dimension. For hemostasis, one through-the-scope clip was successfully placed, and argon plasma coagulation was also used (figure 1b). Biopsies were obtained and showed metastatic serous carcinoma. Discussion: Gastric metastatic disease is an infrequent finding with an incidence under 1%. Clinical manifestations of metastasis to the stomach include nonspecific symptoms of abdominal pain, nausea, vomiting, symptomatic anemia and melena. Although the most common diagnostic approach to metastatic gastric carcinoma is endoscopy with biopsy, results of the biopsy may be negative for tumor cells due to the localization of tumor cells within the deep layers of the mucosa, which are inaccessible to biopsy forceps. In such cases, endoscopy with ultrasound can be utilized. Management of GI tumor bleeds may be challenging due to the high rates of rebleeding, and several treatment modalities may be required. If conventional hemostatic methods such as through-the-scope clips and cautery are ineffective, hemostatic sprays can be considered, but they typically only provide short-term relief. Additionally, over-the-scope clips can be considered for refractory GI bleeding due underlying malignancy.Figure 1.: Figure 1 1a: Ulcer in the incisura of the stomach 1b: Ulcer status post hemostatic clip and argon plasma coagulation (APC).
Watch a video presentation of this article Watch an interview with the author Despite the development of evidence-based quality metrics for cirrhosis care, the in-hospital mortality rate among patients with decompensated cirrhosis remains high at approximately 10%.1 Many critical diagnostic and therapeutic interventions for hospitalized patients with cirrhosis have time-dependent efficacy (Table 1). This article reviews these interventions and the data that support their importance. Given the high risk for spontaneous bacterial peritonitis (SBP), diagnostic paracentesis is recommended in all hospitalized patients with cirrhosis and ascites, even in the absence of symptoms. Retrospective analyses of the Nationwide Inpatient Sample revealed that only 51% to 61% of hospitalized patients with cirrhosis underwent paracentesis, but for those who did, the in-hospital mortality rate was reduced by 24% to 29%.2, 3 Multicenter retrospective analysis of patients with cirrhosis and ascites demonstrated that delays in paracentesis (>12 hours) after admission accounted for a 2.7-fold increase in in-hospital mortality.4 Furthermore, each hour delay in paracentesis was associated with a 3.3% inpatient mortality rate increase. These findings support the prioritization of early (<12 hours) diagnostic paracentesis in any hospitalized patient with cirrhosis and ascites. SBP in patients with cirrhosis is extremely concerning given the significant risk for development of hepatorenal syndrome (HRS) and associated mortality rates as high as 40%. Once diagnosed (by ascites fluid neutrophils >250 cells/mm3 and/or positive culture), appropriate SBP therapy consists of broad-spectrum antibiotics in all patients, as well as high-dose albumin at days 1 and 3, particularly in those with creatinine concentration >1 mg/dL, blood urea nitrogen level >30 mg/dL, or total bilirubin level >4.0 mg/dL.5 Although no prospective studies have investigated the timing of initiation of antibiotics in SBP, a retrospective cohort study of 126 patients with cirrhosis with SBP-associated septic shock demonstrated that those who survived were more likely to have been administered antibiotics earlier (median [range] 1.8 [1.1-5.2] versus 9.5 [3.9-14.3] hours; P < 0.001], with each hour delay in antibiotic treatment increasing mortality by 1.86 times.6 Both national and international consensus guidelines recommend prompt initiation of empiric antibiotic therapy at diagnosis of SBP by ascites cell count without waiting for culture data.5, 7 Development of rapidly progressive type 1 HRS is associated with potentially irreversible acute kidney injury and poor short-term survival in the absence of liver transplantation. Once identified, pharmacological treatment with vasoconstrictor therapy and albumin infusion is essential to maximize the likelihood of reversing type 1 HRS. Where available, terlipressin is the vasoconstrictor of choice given its efficacy in reversing HRS.7 If terlipressin is unavailable, a combination of midodrine and octreotide is recommended.5 However, if there is no clinical response or if intensive care unit (ICU) care is accessible, norepinephrine infusion is preferred because it exhibits similar efficacy to terlipressin.8 No prospective studies have examined the relationship between timing of HRS therapy initiation and outcomes. In a post hoc analysis of 56 patients treated for type 1 HRS with terlipressin, the only variable that predicted HRS reversal was baseline serum creatinine.9 A similar analysis demonstrated that lower creatinine and higher urine output at baseline correlated with increased rates of HRS reversal in patients receiving terlipressin.10 In addition, there have been several small studies that have shown that transjugular intrahepatic portosystemic shunt (TIPS) may improve renal function and possibly reduce mortality in HRS.11 Earlier initiation of HRS therapy, prior to the development of severe renal dysfunction, and consideration of TIPS may improve the likelihood of HRS reversal. The objective of care in acute upper gastrointestinal (GI) hemorrhage in patients with cirrhosis is to control bleeding and prevent early rebleeding and 6-week mortality.12 In addition to assessing for adequate respiratory function and circulation, evaluation for ICU admission is advised. The in-hospital mortality rate from variceal bleeding is as high as 20%, related to the risks for hemorrhagic shock and infection, both at presentation and later during the hospitalization.12 Vasoactive medications, such as octreotide, have been shown to reduce both transfusion requirements and all-cause mortality.13 Prophylactic antibiotics have been shown to reduce the risk for infection, rebleeding, and death.14 For these reasons, consensus guidelines recommend both vasoactive medications and an antibiotic, such as ceftriaxone, be administered immediately in the patient with cirrhosis and upper GI bleed.12 Esophagogastroduodenoscopy (EGD) should then be performed as soon as possible within 12 hours of presentation.12 In patients presenting with hematemesis, early EGD in less than 12 hours was associated with lower 6-week rebleeding rates and mortality.15 In addition, patients who are at high risk for treatment failure may benefit from TIPS within 72 hours, because this has been shown to reduce rebleeding and mortality.16 Early vasoactive medications, antibiotics, EGD, and consideration of TIPS have all been shown to reduce in-hospital mortality from variceal bleeding and should be implemented as soon as possible. Overt hepatic encephalopathy (OHE) is among the most common reasons for admission in patients with decompensated cirrhosis. Consensus guidelines recommend a four-pronged approach at presentation that consists of: (1) initiation of care for patients with altered consciousness; (2) exclusion of alternative causes of altered mental status; (3) identification of precipitating factors and their correction; and (4) commencement of empirical hepatic encephalopathy treatment.17 Patients with high-grade OHE who are unable to protect their airway might require endotracheal intubation and ICU transfer. Early exclusion of precipitating factors, such as infection, bleeding, and electrolyte disturbances, is of the utmost importance because most episodes of OHE are attributable to a precipitant, and many of these can be life-threatening. Data regarding time-sensitive interventions for OHE are lacking. One study showed that administration of six or more cups of lactulose within the first 24 hours of admission was associated with a significantly shorter length of stay by 2.36 days.18 The addition of rifaximin to lactulose is indicated for the prevention of recurrent episodes of OHE.17 Further research is needed to fully elucidate the relationship between timing of initiation of OHE therapy and clinical outcomes. Hospitalized patients with cirrhosis are a vulnerable population at high risk for complications and death. We have reviewed several interventions that, when done expeditiously, have been shown to improve outcomes in this population (Fig. 1). Despite this, multiple studies demonstrate that adherence to these consensus recommendations and best practices for inpatient cirrhosis care remains suboptimal. We recommend institutions invest in the educational and operations infrastructure necessary to adhere to these evidence-based guidelines to optimize the care of these patients.
Introduction: Ischemic colitis is an inflammatory condition caused by a reduction in blood flow to the colon. It is most often seen in older adults presenting with acute lower abdominal pain and hematochezia. Its appearance on endoscopy can range from erythematous, friable mucosa, to cyanotic mucosa with ulcerations. We present a case of ischemic colitis that mimicked colorectal cancer. Case Description/Methods: A 73-year-old woman with coronary artery disease, peripheral vascular disease, and a 30-pack-year smoking history presented with one day of intense right lower quadrant abdominal pain and diarrhea. Prior to her presentation, she had had several years of intermittent post-prandial abdominal pain and a 20-lb unintentional weight loss. The patient underwent computed tomography (CT) of the abdomen and pelvis which showed circumferential wall thickening in the cecum and proximal ascending colon with pericolonic mesenteric nodes concerning for cecal neoplasm or segmental colitis. During colonoscopy, a frond-like, ulcerated, partially-obstructing mass was found in the cecum (Figure 1a). Gross appearance was concerning for an atypical-appearing adenocarcinoma. Biopsies of the mass revealed acute ischemic colitis with no underlying neoplasm, and CT angiography showed severe atherosclerosis at the origins of the celiac and superior mesenteric arteries. The patient’s symptoms improved with supportive care. Repeat colonoscopy one month later showed significant improvement with residual right-sided colonic erythema and scattered pale regions of mucosa thought to be due to hypoperfusion (Figure 1b). Repeat biopsies again confirmed ischemic colitis without evidence of malignancy. Discussion: The patient’s case was initially concerning for a colorectal cancer given significant weight loss and apparent mass. However, biopsies were consistent with acute ischemic colitis, which improved on repeat colonoscopy. CT scan can differentiate ischemic colitis from colon cancer in 75% of cases, but colonoscopy is preferred, as it allows for direct visualization and biopsies. In approximately 20% of ischemic colitis cases, there is a coexisting colonic carcinoma. Given an atypical appearance of a lesion with initial pathology read as ischemic colitis, a repeat colonoscopy with additional biopsies can be helpful in confirming the diagnosis.Figure 1.: Nodularity, necrosis, irregular margins, and scarring in the mid-transverse colon compatible with protrusion of surgical mesh into the colon.
