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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.
Abstract Recent advances in the treatment of inflammatory bowel disease (IBD) include the use of immune modifiers and monoclonal antibodies, such as tumor necrosis factor (TNF) alpha inhibitors, anti-integrin agents, janus kinase inhibitors, and interleukin-12/23 inhibitors. These agents achieve higher rates of clinical remission and mucosal healing than conventional therapy. However, these therapies increase the risk of infections, including some vaccine-preventable diseases. Infections are one of the most common adverse event of immunosuppressive therapy. Thus, providers should optimize immunization strategies to reduce the risk of vaccine-preventable infections in patients with IBD. There are several newly licensed vaccines recommended for adults by the US Advisory Committee on Immunization Practices. This review will focus on how gastroenterology providers can implement the adult immunization schedule approved by ACIP for patients with IBD.
Introduction: Spontaneous hyperinflation (SH) is a recognized but rare complication of intragastric balloon (IGB) placement. Urgent endoscopic removal is critical. Patients may present to centers unfamiliar with IGBs, so all gastroenterologists should be aware of this rare but dangerous complication. Specific removal kits are not always available, and in emergencies, IGBs may be removed with standard endoscopic tools. Case Description/Methods: A 44-year-old woman with obesity had an IGB placed in the Dominican Republic 6 months prior to presentation, with 60-pound weight loss. One week prior, she returned to the Dominican Republic. The IGB was inflated further for additional weight loss. She presents to the ED with 5 days of vomiting >10x/day, severe abdominal pain, and lack of bowel movements for 1 week. Vital signs were normal in the ED. Exam showed soft, distended abdomen, tender in the upper regions, without peritoneal signs. Labs were notable for leukocytosis of 12.0 and lipase of 422 (normal 13-60). CT abdomen/pelvis showed a large IGB (13 x 18 x 15 cm) with internal air-fluid level and no evidence of gastric outlet obstruction. Emergent dual channel upper endoscopy (EGD) was performed (Figure 1). The IGB external catheter was grasped with a snare and rat-tooth forceps and pulled out of the mouth. The internal fluid was suctioned out and cultured. The IGB surface suggested microbial colonization. IGB removal was attempted with the above tools, but there was significant breakdown of the IGB, complicating removal. Two snares were used to grasp each end of the catheter, allowing for completion of IGB removal. There was a large, deep ulcer where the IGB was sitting, likely due to ischemia from the IGB. Fluid culture was negative. Bacterial culture of the IGB showed skin microbiota, and fungal culture showed rare Candida krusei. Post-procedure recovery was unremarkable; she was discharged the next day. Discussion: SH rarely occurs post-IGB placement, and the mechanism of microbial overgrowth with hyperinflation is uncertain. Our patient had no gas-producing organisms cultured from the IGB or its fluid. If there is concern for SH, the IGB should be removed as soon as possible given risk of gastric or esophageal perforation. IGB removal is typically device-dependent and should be done following the manufacturer’s instructions, but in emergent cases, all IGBs can be aspirated with an endoscopic injection needle and removed with standard endoscopic tools.Figure 1.: A: Coronal view of patient’s CT of the abdomen/pelvis with IV and oral contrast, showing significant hyperinflation of intragastric balloon. B: Endoscopic image showing intragastric balloon with appearance of internal microbial colonies and adherence to the gastric wall. C: The intragastric balloon post-removal. The intragastric balloon appears to have internal microbial overgrowth. The balloon was broken during endoscopic removal, making both the internal and external catheters accessible to grasping with a snare. The entire balloon was sent for bacterial and fungal culture.
Liver transplantation (LT) in alcohol-associated hepatitis (AH) remains controversial, in part because spontaneous recovery (SR) can occur. There is a paucity of data on SR in patients with severe AH who undergo LT evaluation. The purpose of this study was to determine factors associated with SR and survival in patients with severe AH who undergo LT evaluation.This is a retrospective study of ALD patients with Model for End-Stage Liver Disease (MELD) >25 and <90 days abstinence who underwent LT evaluation at a single center between 2012 and 2018. One hundred forty-four patients (median age, 45.5 years; 68.1% male) were included. Forty-nine (34%) underwent LT and 95 (66%) patients did not undergo LT, and of those, 34 (23.6%) experienced SR. Factors associated with recovery were younger age (OR, 0.92; p = 0.004), lower index international normalized ratio (INR; 0.31; p = 0.03), and lower peak MELD (OR, 0.83; p = 0.02). Only 7 patients (20.6%) achieved a compensated state with a MELD <15 and absence of therapy for ascites or HE. Survival was improved in patients who underwent early LT when compared to SR. Survival was impaired in SR following relapse to alcohol use when compared to SR patients who abstained and LT recipients. Among all 6-month survivors of AH, alcohol use trended toward an association with mortality (HR, 2.05; p = 0.17), but only LT was associated with decreased mortality risk (HR, 0.20; p = 0.005).SR from AH after LT evaluation is associated with age, index INR, and lower peak MELD. Most recovered patients continue to experience end-stage complications. LT is the only factor associated with lower mortality.
Austrian syndrome is the clinical triad of endocarditis, meningitis, and pneumonia secondary to Streptococcus pneumoniae. It is an uncommon but serious illness that requires clinical suspicion in an at-risk population in order to guide further workup and treatment. Here we present a case of a Wisconsin resident who illustrates the severity of the disease and how certain elements of this triad may be delayed in clinical presentation.
