Conor G. Loftus

Update on the incidence and prevalence of Crohn's disease and ulcerative colitis in Olmsted County, Minnesota, 1940-2000.

Background We previously reported that the prevalence of Crohns disease (CD) and ulcerative colitis (UC) in Olmsted County, Minnesota, had risen significantly between 1940 and 1993. We sought to update the incidence and prevalence of these conditions in our region through 2000. Methods The Rochester Epidemiology Project allows population‐based studies of disease in county residents. CD and UC were defined by previously used criteria. County residents newly diagnosed between 1990 and 2000 were identified as incidence cases, and persons with these conditions alive and residing in the county on January 1, 2001, were identified as prevalence cases. All rates were adjusted to 2000 US Census figures for whites. Results In 1990–2000 the adjusted annual incidence rates for UC and CD were 8.8 cases per 100,000 (95% confidence interval [CI], 7.2–10.5) and 7.9 per 100,000 (95% CI, 6.3–9.5), respectively, not significantly different from rates observed in 1970–1979. On January 1, 2001, there were 220 residents with CD, for an adjusted prevalence of 174 per 100,000 (95% CI, 151–197), and 269 residents with UC, for an adjusted prevalence of 214 per 100,000 (95% CI, 188–240). Conclusion Although incidence rates of CD and UC increased after 1940, they have remained stable over the past 30 years. Since 1991 the prevalence of UC decreased by 7%, and the prevalence of CD increased about 31%. Extrapolating these figures to US Census data, there were ≈1.1 million people with inflammatory bowel disease in the US in 2000. (Inflamm Bowel Dis 2007)

PSC-IBD: a unique form of inflammatory bowel disease associated with primary sclerosing cholangitis

Background: Inflammatory bowel disease associated with primary sclerosing cholangitis (PSC-IBD) may have a high prevalence of rectal sparing, backwash ileitis, and colorectal neoplasia. Aims: To describe the clinical features and outcomes of PSC-IBD and compare these to a group of chronic ulcerative colitis (CUC) patients. Methods: The medical records of all patients with PSC-IBD evaluated at the Mayo Clinic Rochester between 1987 and 1992 were abstracted for information on endoscopic and histological features, colorectal neoplasia, surgery, and other clinical outcomes. Patients referred for colorectal neoplasia and those who did not undergo colonoscopy with biopsies were excluded. A control group of CUC patients matched for sex, duration of IBD at first clinic visit, and calendar year of first clinic visit was identified, and similar information was abstracted. Results: Seventy one PSC-IBD patients and 142 CUC patients without PSC were identified. Rectal sparing and backwash ileitis were more common in the PSC-IBD group (52% and 51%, respectively) than in controls (6% and 7%, respectively). Overall, colorectal neoplasia developed in 18 cases and 15 controls, including 11 cancers (seven cases and four controls). An increased risk of colorectal neoplasia or death was not detected in a matched analysis. Although the cumulative incidence of colorectal neoplasia was higher in cases (33%) than in controls (13%) at five years, this was of borderline statistical significance (p = 0.054, unmatched log rank test). Overall survival from first clinic visit was significantly worse among cases (79% v 97%) at five years (p<0.001, unmatched log rank test). Conclusion: PSC-IBD is frequently characterised by rectal sparing and backwash ileitis. Colorectal neoplasia develops in a substantial fraction and overall survival is worse. PSC-IBD may represent a distinct IBD phenotype.

Effect of 16-Hour Duty Periods on Patient Care and Resident Education

OBJECTIVE To measure the effect of duty periods no longer than 16 hours on patient care and resident education. PATIENTS AND METHODS As part of our Educational Innovations Project, we piloted a novel resident schedule for an inpatient service that eliminated shifts longer than 16 hours without increased staffing or decreased patient admissions on 2 gastroenterology services from August 29 to November 27, 2009. Patient care variables were obtained through medical record review. Resident well-being and educational variables were collected by weekly surveys, end of rotation evaluations, and an electronic card-swipe system. RESULTS Patient care metrics, including 30-day mortality, 30-day readmission rate, and length of stay, were unchanged for the 196 patient care episodes in the 5-week intervention month compared with the 274 episodes in the 8 weeks of control months. However, residents felt less prepared to manage cross-cover of patients (P = .006). There was a nonsignificant trend toward decreased perception of quality of education and balance of personal and professional life during the intervention month. Residents reported working fewer weekly hours overall during the intervention (64.3 vs 68.9 hours; P = .40), but they had significantly more episodes with fewer than 10 hours off between shifts (24 vs 2 episodes; P = .004). CONCLUSION Inpatient hospital services can be staffed with residents working shifts less than 16 hours without additional residents. However, cross-cover of care, quality of education, and time off between shifts may be adversely affected.

Clinical features of patients with novel Yersinia species.

Our purpose was to describe the clinical features of patients with novel Yersinia species. Between 1985 and 1999; 194 patients had yersinia species isolated from stool specimens, 38 (20%) had non-Yersinia enterocolitica species; 12 (32%) had Yersinia intermedia, 7 (18%) Yersinia fredericksenii, 3 (8%) Yersinia kristensenii, and the remaining 16 (42%) were unclassified non-Yersinia enterocolitica species. The most common presenting symptom was diarrhea alone in 10 (26.3%) patients. Symptoms persisted for >1 month in 54% of cases; 21% had symptoms for <1 week; 18 (47%) patients were taking corticosteroids, acid suppressants, and/or antibiotics when Yersinia was isolated. An immunocompromised state was present in 11 (29%) patients. An immunocompromised host and administration of acid suppressants predicted persistence of symptoms for >1 month. Most [27 (71%)] patients received no treatment; 5 (13%) received antibiotics. In conclusion, novel non-Yersinia enterocolitica species, including Yersinia intermedia, Y. fredericksenii, and Y. kristensenii may represent up to 20% of all Yersinia isolates. Diarrhea is the most common symptom.

A case of IgG4-associated cholangitis and autoimmune pancreatitis responsive to corticosteroids

Background A 72-year-old male presented to the emergency department with epigastric pain, anorexia and progressive jaundice of 1 weeks duration. He had no prior history of gastrointestinal illness, diabetes or cancer. He did not smoke or consume alcohol. He did have a family history of colon and bone cancer.Investigations Biochemical and serologic studies, CT scan, abdominal ultrasound, endoscopic ultrasound, endoscopic retrograde cholangiopancreatography, biliary cytology, pancreas needle biopsies and immunohistochemical stainings.Diagnosis Autoimmune pancreatitis with IgG4-associated sclerosing cholangitis affecting the extrahepatic biliary ducts and mimicking primary sclerosing cholangitis and cholangiocarcinoma.Management Corticosteroids and immunomodulatory therapy.

Proton Pump Inhibitors: Review of Emerging Concerns

&NA; First introduced in 1989, proton pump inhibitors (PPIs) are among the most widely utilized medications worldwide, both in the ambulatory and inpatient clinical settings. The PPIs are currently approved by the US Food and Drug Administration for the management of a variety of gastrointestinal disorders including symptomatic peptic ulcer disease, gastroesophageal reflux disease, and nonulcer dyspepsia as well as for prevention of gastrointestinal bleeding in patients receiving antiplatelet therapy. PPIs inhibit gastric acid secretion, and the most commonly associated adverse effects include abdominal pain, diarrhea, and headache. Although PPIs have had an encouraging safety profile, recent studies regarding the long‐term use of PPI medications have noted potential adverse effects, including risk of fractures, pneumonia, Clostridium difficile diarrhea, hypomagnesemia, vitamin B12 deficiency, chronic kidney disease, and dementia. These emerging data have led to subsequent investigations to assess these potential risks in patients receiving long‐term PPI therapy. However, most of the published evidence is inadequate to establish a definite association between PPI use and the risk for development of serious adverse effects. Hence, when clinically indicated, PPIs can be prescribed at the lowest effective dose for symptom control.

Adult‐onset systemic Langerhans cell histiocytosis mimicking inflammatory bowel disease: the value of skin biopsy and review of cases of Langerhans cell histiocytosis with cutaneous involvement seen at the Mayo Clinic

Langerhans cell histiocytosis (LCH) is frequently known to involve multiple organ systems. However, gastrointestinal involvement by LCH is rare.

Buried bumper syndrome arising from a percutaneous endoscopic cecostomy tube

Buried bumper syndrome (BBS) is a well-recognized omplication of PEG placement caused by excessive utward traction on the tube. It can develop 1 to 50 onths after tube insertion and is manifested by diffiulty in feeding; peristomal leakage, bulging, and pain; nd skin breakdown.1,2 Treatment involves manual or ndoscopic removal of the tube with replacement, if eeded.1,3 To our knowledge, this is the first case of BBS rising in a patient with a percutaneous endoscopic ecostomy (PEC) tube.

Gas and Bloating—Controlling Emissions: A Case-Based Review for the Primary Care Provider

The evaluation of the patient with gas and bloating can be complex and the treatment extremely challenging. In this article, a simplified approach to the history and relevant physical examination is presented and applied in a case-oriented manner, suitable for application in the primary care setting.

The safety profile of Azathioprine (AZA)/6-Mercaptopurine (6-MP) in the treatment of inflammatory bowel disease (IBD): a population-based study in Olmsted County, Minnesota

The safety profile of Azathioprine (AZA)/6-Mercaptopurine (6-MP) in the treatment of inflammatory bowel disease (IBD): a population-based study in Olmsted County, Minnesota