The Institute of Medicine's guidelines for weight gain in pregnancy are based on women's pre-pregnancy body mass index (BMI). Data suggests that BMI may not be the best indicator for nutritional status in patients with inflammatory bowel disease (IBD) due to discordance among BMI, percentage of ideal body weight, and micronutrient deficiencies. The goal of this study was to determine the frequency with which nutritional data is obtained in pregnant women with IBD and the prevalence of abnormal nutritional parameters among these women based on pre-pregnancy BMI. We retrospectively reviewed the medical records of women with IBD with confirmed pregnancy at the University of Wisconsin School of Medicine and Public Health between January 2008 and October 2014. Subjects were identified using ICD-9 codes for Crohn's disease (CD), ulcerative colitis (UC), indeterminate colitis (IC) and for normal or abnormal pregnancy. Subject demographics, disease characteristics, pregnancy course, and nutritional data were abstracted from electronic health record (Epic Systems 2014 IU1). Descriptive statistics were calculated. Comparison between groups was performed with the student's t test and chi square test where P < 0.05 was considered significant. One hundred and thirty-six eligible patients were identified (CD = 66 [49%], UC = 66 [49%], IC = 4 [3%]). Seventy-nine patients (58%) had normal pre-pregnancy BMI, 36% were overweight or obese, and 5% were underweight. Of the 130 patients with available data, only 18% gained the recommended amount of weight during pregnancy based on pre-pregnancy BMI; 30% gained insufficient weight and 45% gained excessive weight. One hundred 3 patients (76%) saw a gastroenterology provider during pregnancy. Fifty-four patients (40%) had no nutritional parameters checked during pregnancy. Among the patients who had nutritional testing, protein stores were most frequently assessed (40%) followed by vitamin B12 (37%), vitamin D (35%), and iron studies (17%). Thirty-seven (45%) of these patients had at least one abnormal parameter. No difference was found in the prevalence of abnormal nutritional lab testing based on pre-pregnancy BMI. Of the 30 patients with active disease during pregnancy, 10 patients (33%) did not have any nutritional parameters checked. Fifty-nine (43%) patients had pregnancy complications. No difference was found in the proportion of patients with inappropriate weight gain between those with and without a pregnancy complication (P = 0.06). Thirty-five (60%) patients with a complication underwent nutritional assessment. Within this group 68% of women had at least one abnormal nutritional parameter. In our cohort of IBD patients 75% of women did not gain weight appropriately during pregnancy and many women experienced a pregnancy complication. Nutritional testing was not performed on a large number of patients despite follow-up by both obstetric and gastroenterology providers. Abnormal nutritional values were not associated with a single pre-pregnancy BMI category. Among patients with inappropriate weight gain, many patients were not nutritionally assessed using laboratory assessments or nutrition consultation. Further prospective studies are needed to determine the optimal means of assessing the nutritional status of pregnant women with IBD as nutritional deficiencies may increase the risk for a pregnancy complication and their prevalence may not be adequately reflected by pre-pregnancy BMI.
Introduction: Recent studies suggest low alanine aminotransferase (ALT) levels are associated with increased mortality, especially in elderly patients over the age of 70, as well as patients with coronary artery disease and patients requiring hemodialysis. Prior studies have postulated that low ALT levels are associated with increased frailty, a difficult parameter to objectively quantify, resulting in the associated increased mortality. To our knowledge, there has not been prior inquiry into low ALT in patients with chronic liver disease undergoing orthotopic liver transplantation (OLT). The aim of our current study was to determine if low ALT levels prior to OLT are associated with higher post-transplant morbidity/mortality, and could be used as a marker of frailty in pre-transplant patient selection. Methods: A retrospective chart review was performed of 485 consecutive liver transplants from January 2012 to December 2017 at the University of Cincinnati Medical Center. Based on prior studies, low ALT was defined as 15 U/L in women and 17 U/L in men. Baseline clinical characteristics and laboratory parameters by ALT groups were compared. Logistic regression modeling was carried out to evaluate baseline factors independently associated with all-cause mortality. Differences in survival between subjects according to ALT were assessed using the Kaplan-Meier method. Results: Of the 485 cases, 149 (39%) had low ALT prior to OLT. There were 37 simultaneous liver-kidney transplants included in the cohort, 8 of which had low ALT (5%). Patients with low ALT were older compared to the patients without low ALT (57.4 vs 55.4, p=0.05), but otherwise the groups were similar amongst baseline characteristics tested. After a median follow-up of 32.5 months, there were 72 deaths after OLT in the cohort, 25 with low ALT (14%) compared to 47 (16.7%) without low ALT (p=0.452). The secondary outcomes of 30 day and 1-year readmission were not significantly different between the two groups. The median overall survival with low ALT was 4.92 months (CI 2.13-14.7) compared to 8.46 months without low ALT (CI 2.07-16.3), however this difference was not statistically significant. Conclusion: Low ALT prior to orthotopic liver transplantation did not predict increased mortality or other complications such as readmissions in our study population.979_A Figure 1. Kaplan-Meier curve of mortality based on ALT levels979_B Figure 2. Kaplan-Meier curve of overall mortality after OLT
Hepatic artery pseudoaneurysm is an uncommon but serious complication that can occur after liver transplantation. Overall incidence is estimated to be around 2% but risk factors remain poorly defined. We present the case of a patient who presented with hemobilia due to hepatic artery pseudoaneurysm eroding into the bile duct within a few weeks of liver transplantation. The patient is a 65 year old male who underwent orthotopic liver transplantation (LT) for Hepatitis C cirrhosis and hepatocellular carcinoma. Post-transplant immunosuppression consisted of tacrolimus and mycophenolate mofetil. Medical co-morbidities included hypertension and type 2 diabetes. Duplex Ultrasonogram in immediate post-transplant period revealed mild parvus et tardus hepatic artery waveforms that remained stable. One week post-LT, patient underwent endoscopic retrograde cholangiopancreatography (ERCP) for evaluation of abnormal liver tests (aspartate aminotransferase (AST) 294 IU/L, alanine aminotransferase (ALT) 263 IU/L, Alkaline phosphatase 757 IU/L, total bilirubin 2.4 mg/dl, direct bilirubin 1.4 mg/dl). A tight anastomotic stricture was found, and biliary sphincterotomy was performed with placement of 2 biliary stents. Post-procedural course was complicated by mild pancreatitis, which resolved with conservative measures. Liver enzymes remained persistently elevated, and a percutaneous liver biopsy was performed 2 weeks after ERCP. Histologic findings were consistent with large duct obstruction. A week later, patient presented with abdominal pain and hematochezia. Computed tomographic angiogram was suggestive of hepatic artery pseudoaneurysm as well as occlusion of right portal vein. Repeat ERCP was performed that showed hemobilia and a pseudoaneurysm with hepatic artery to common bile duct fistula. The patient underwent surgical resection of pseudoaneurysm and bile duct, hepaticojejunostomy and revascularization of hepatic artery. Patient is alive and doing well after a 2 week follow up. Extension of a pseudoaneurysm into the common bile duct is a rare but potentially fatal complication. Although surgical technique is the most cited etiology for hepatic artery complications, percutaneous liver biopsy might have contributed in our case. This case demonstrates the criticality of early detection and appropriate management.
A patient with recurrent Clostridium difficile infection (CDI) as well as inflammatory bowel disease (IBD) comes in with worsening diarrhea - which disease process do you focus on treating - the infection with antibiotics or conversely the IBD with immunosuppression? This case highlights an instance where the development of erythema nodosum (EN) helped aid in the diagnosis of ulcerative colitis (UC) flare in the setting of active Clostridium difficile infection (CDI). A 38-year-old female with a 14-year history of UC maintained on mesalamine with recurrent episodes of CDI presented with increasing abdominal pain and bloody diarrhea. Six weeks prior, the patient had completed treatment for CDI with oral vancomycin. There were no other new medications, travel, or dietary changes. Vital signs were normal and physical exam was notable for mild abdominal tenderness in the right lower quadrant and epigastrium. Laboratory evaluation revealed creatinine of 0.5 mg/dl and albumin of 3.5 g/dl. C. difficile toxin PCR was positive. All other lab work was unremarkable. Mesalamine was continued for maintenance of UC and the patient was started on oral vancomycin and intravenous metronidazole for CDI. Despite treatment, there was no clinical improvement. On hospital day 3 the patient developed painful, erythematous, blanching nodules on bilateral lower extremities with concern for erythema nodosum—a finding that the patient had never experienced before. Given the lack of clinical improvement with the treatment of CDI and development of EN, a known sequela of IBD, the focus was shifted to treatment of her UC flare with intravenous hydrocortisone. She was also switched to fidaxomicin from vancomycin and metronidazole for more aggressive CDI treatment. Within 24 hours, the patient's diarrhea and skin lesions had improved. The case above describes how EN helped aid in identifying the main culprit for the patient's worsening diarrhea and abdominal pain. The initial management was focused toward treating the CDI; however, the patient then developed EN, known to be associated with IBD, which appropriately helped guide treatment for UC flare. While EN is a rare finding (seen in up to 10-15% of patients with IBD)1, when present it can differentiate the cause of symptoms when that cause is unclear. 1. Farhi et al. Significance of erythema nodosum and pyoderma gangrenosum in inflammatory bowel diseases: a cohort study of 2402 patients. 2008. 281-93.
