Christine S. Choi

Chronic use of PPI and H2 antagonists decreases the risk of pouchitis after IPAA for ulcerative colitis.

IntroductionBacteria have been implicated in the development of pouchitis after ileal pouch anal anastomosis. The change in gastric pH with the use of proton pump inhibitors and H2 antagonists may lead to alteration of enteric bacteria. We hypothesized that chronic use of these medications would decrease the incidence of pouchitis.MethodsPatients who had undergone ileal pouch anal anastomosis for ulcerative colitis were classified by history of pouchitis. Patients were further classified by their use of proton pump inhibitors, H2 blockers, antacids, and other known risk factors for pouchitis.ResultsEighty-five patients were identified. There was a statistically significant increase in the use of daily acid suppression in patients without pouchitis. There was also a statistically significant increase in the use of antacids in patients without pouchitis. Occasional use of acid suppression did not alter the rate of pouchitis.ConclusionsOur data suggest that the daily use of proton pump inhibitors, H2 antagonists, or antacids is associated with a decreased risk of pouchitis in ulcerative colitis. Occasional use of these agents did not seem to afford the same protection. These data suggest that altering the pH of the gastrointestinal tract may influence the development of pouchitis.

Liposomal Bupivacaine Use in Transversus Abdominis Plane Blocks Reduces Pain and Postoperative Intravenous Opioid Requirement After Colorectal Surgery.

BACKGROUND: Enhanced recovery protocols frequently use multimodal postoperative analgesia to improve postoperative outcomes in patients undergoing colorectal surgery. OBJECTIVE: The purpose of this study was to evaluate liposomal bupivacaine use in transversus abdominis plane blocks on postoperative pain scores and opioid use after colorectal surgery. DESIGN: This was a retrospective cohort study comparing outcomes between patients receiving nonliposomal anesthetic (n = 104) and liposomal bupivacaine (n = 303) blocks. SETTINGS: The study was conducted at a single tertiary care center. PATIENTS: Patients included those identified within an institutional database as inpatients undergoing colorectal procedures between 2013 and 2015 who underwent transversus abdominis plane block for perioperative analgesia. MAIN OUTCOME MEASURES: The study measured postoperative pain scores and opioid requirements. RESULTS: Patients receiving liposomal bupivacaine had significantly lower pain scores for the first 24 to 36 postoperative hours. Pain scores were similar after 36 hours. The use of intravenous opioids among the liposomal bupivacaine group decreased by more than one third during the hospitalization (99.1 vs 64.5 mg; p = 0.040). The use of ketorolac was also decreased (49.0 vs 18.3 mg; p < 0.001). In subgroup analysis, the decrease in opioid use was observed between laparoscopic and robotic procedures but not with laparotomies. No significant differences were noted in the use of oral opioids, acetaminophen, or ibuprofen. Postoperative length of stay and total cost were decreased in the liposomal bupivacaine group but did not achieve statistical significance. LIMITATIONS: The study was limited by its retrospective, single-center design and heterogeneity of block administration. CONCLUSIONS: Attenuated pain scores observed with liposomal bupivacaine use were associated with significantly lower intravenous opioid and ketorolac use, suggesting that liposomal bupivacaine-containing transversus abdominis plane blocks are well aligned with the opioid-reducing goals of many enhanced recovery protocols.

RNA-seq implicates deregulation of the immune system in the pathogenesis of diverticulitis

Individuals with diverticula or outpouchings of the colonic mucosa and submucosa through the colonic wall have diverticulosis, which is usually asymptomatic. In 10-25% of individuals, the diverticula become inflamed, resulting in diverticulitis. Very little is known about the pathophysiology or gene regulatory pathways involved in the development of diverticulitis. To identify these pathways, we deep sequenced RNAs isolated from full-thickness sections of sigmoid colon from diverticulitis patients and control individuals. Specifically for diverticulitis cases, we analyzed tissue adjacent to areas affected by chronic disease. Since the tissue was collected during elective sigmoid resection, the disease was in a quiescent state. A comparison of differentially expressed genes found that gene ontology (GO) pathways associated with the immune response were upregulated in diverticulitis patients compared with nondiverticulosis controls. Next, weighted gene coexpression network analysis was performed to identify the interaction among coexpressed genes. This analysis revealed RASAL3, SASH3, PTPRC, and INPP5D as hub genes within the brown module eigengene, which highly correlated (r = 0.67, P = 0.0004) with diverticulitis. Additionally, we identified elevated expression of downstream interacting genes. In summary, transcripts associated with the immune response were upregulated in adjacent tissue from the sigmoid colons of chronic, recurrent diverticulitis patients. Further elucidating the genetic or epigenetic mechanisms associated with these alterations can help identify those at risk for chronic disease and may assist in clinical decision management.NEW & NOTEWORTHY By using an unbiased approach to analyze transcripts expressed in unaffected colonic tissues adjacent to those affected by chronic diverticulitis, our study implicates that a defect in the immune response may be involved in the development of the disease. This finding expands on the current data that suggest the pathophysiology of diverticulitis is mediated by dietary, age, and obesity-related factors. Further characterizing the immunologic differences in diverticulitis may better inform clinical decision-making.

Higher Mortality in Surgically Managed Diverticulitis is Associated with Asian Ethnicity and Right-Sided Disease.

BACKGROUND: Although right-sided diverticulitis is perceived to have a higher incidence among Asians and infrequently requires surgical management in comparison with sigmoid diverticulitis, it is unknown whether differences in outcomes are due to ethnic disparity or disease pathophysiology. OBJECTIVE: The aim of this study was to determine the surgical outcomes for Asian and non-Asian patients with diverticulitis who underwent colectomy. DESIGN: Patients identifiable by ethnicity in the Nationwide Inpatient Sample with diverticulitis and colectomy between 2004 and 2010 were included. Univariate comparisons were made between Asian and non-Asian patients by using t tests for continuous variables and &khgr;2 tests for categorical variables. Propensity score matching analysis was performed to compare Asian patients with otherwise similar non-Asian patients. PATIENTS: Included were 58,142 non-Asian and 335 Asian patients with diverticulitis who underwent a colectomy. MAIN OUTCOME MEASURES: The primary outcomes were in-hospital mortality, hospital length of stay, and total costs. RESULTS: Asian patients were younger (56.1 vs 59.2 years, p < 0.0001), were more likely to undergo a right colectomy (22.7% vs 4.1%, p < 0.0001), and were more likely to have emergent/urgent surgery than the non-Asian patients (67.1% vs 49.8%, p < 0.0001). Without controlling for patient/disease factors, there were statistically significant differences in mortality (non-Asian 2.2% vs Asian 4.2%; p = 0.014), length of stay (non-Asian 8.9 vs Asian 9.8 days; p = 0.0166), and costs (non-Asian

Combined Medical and Surgical Approach Improves Healing of Septic Perianal Crohn's Disease

18,783 vs Asian

Diverticulitis and Crohn's disease have distinct but overlapping tumor necrosis superfamily 15 haplotypes

21,901; p = 0.001). Propensity score matching comparing 333 non-Asian patients with 333 similar Asian patients showed that, whereas differences in cost and length of stay became insignificant, the difference in mortality remained statistically significant. LIMITATIONS: The ethnicity variable was not uniformly collected by all states within the Nationwide Inpatient Sample database. CONCLUSIONS: Among patients undergoing a colectomy for diverticulitis, a higher mortality was observed in Asian patients and right-sided disease. Future longitudinal studies comparing the natural history and outcomes of management between right- and left-sided diverticulitis are necessary to investigate whether a true ethnic disparity exists.