Edward J. Levine

Acute hemorrhagic Crohn's disease controlled with infliximab.

To the Editor: A 19-year-old female with a 6-year history of ileocolonic Crohn’s disease (CD) presented with acute recurrent hematochezia. She had recently been hospitalized 1 month prior for an exacerbation of Crohn’s ileocolitis. Mesalamine and prednisone helped induce her remission and she otherwise felt well. On presentation to the emergency department, she demonstrated mild tachycardia and hypotension and was subsequently admitted for further evaluation. An admission hemoglobin of 9.1 g/dL dropped to 6.8 g/dL after ongoing hematochezia. The patient required 4 units of packed red blood cells for resuscitation. Serial stool collections ruled out infectious etiologies and abdominopelvic computed tomography with enteric and intravenous contrast demonstrated terminal ileitis. The patient was placed on intravenous steroids but continued to demonstrate hematochezia. Upper endoscopy showed Los Angeles Grade A esophagitis and no other acute findings. Colonoscopy revealed numerous ulcers in the terminal ileum with fresh blood. In addition, clotted blood filled the entire colon. No active disease was visualized 10 cm proximal to the terminal ileal ulcers. General Surgery evaluated the patient, given the extent of the hemorrhage. A small bowel follow-through demonstrated terminal ileum irregularity consistent with active CD and no other diseased segments. After a nonreactive tuberculin skin test and normal chest film, a 5 mg/kg infliximab infusion was given. The patient’s bleeding promptly ceased and she did not require surgical intervention or additional blood transfusions. She was discharged 4 days after infliximab infusion with repeat doses given at 2 and 6 weeks. The patient successfully responded to infliximab and has demonstrated no further hemorrhage 6 months since initiating this therapy.

Republication: Examination of financial charges associated with intentional foreign body ingestions by prisoners: A pattern of escalation

Introduction: Intentional ingestions of foreign objects (IIFO) continue to be prevalent among prisoners. Our previous research examined determinants of hospital admission, endoscopy, and surgery among prisoners who ingest foreign objects. However, little is known about the financial impact of these events on healthcare facilities that service the prisoner population. This study aims to fill this gap by examining hospital charges attributable to 435 prisoner episodes of IIFO. Methods: A retrospective review of all prisoners who presented to our medical center with the complaint of IIFO was conducted. Both Institutional Review Board and Bureau of Prisons approvals were obtained before data collection. All prisoners ages 18–75 were included between the dates of January 2004 and December 2011. Episodes were divided into three categories: (a) Unverified IIFO wherein ingested object was claimed by the patient but never identified; (b) verified IIFO wherein ingested object was clearly identified; (c) secondary events due to direct complications of previous IIFO episode (s). The temporal occurrence of IIFO was organized by increasing the number of episodes and grouped accordingly. Detailed list of hospital charges was obtained for every IIFO episode including: (a) emergency services, (b) procedures, (c) laboratory, (d) surgical supplies, (e) allied health services, (f) radiology studies, (g) anesthesiology charges, (h) pharmacy, and (h) intensive care costs. Descriptive statistics were used to analyze basic data. Kruskal–Wallis test was used to examine differences among nonnormally distributed variables and sub-groups. Statistical significance set at alpha = 0.05. Results: A total of 435 IIFO episodes occurred during the study period in a population of 125 patients (mean age 33.8 ± 11.7 years, median age 34 [range 19–75] years, 92.8% male). Hospital charges associated with these episodes totaled

A Common Finding in an Uncommon Location

6,209,557. There were 94 unverified IIFOs, 332 verified IIFOs, and 9 secondary events. Verified IIFOs were associated with significantly greater median charges (

Cricopharyngeal Intramural Hematoma: An Unusual Complication of Orthopedic Intervention

5,860) than unverified IIFOs (

Hepatic Encephalopathy and Portosystemic Encephalopathy

3,997) and secondary events carried lower cost (

Intentional Foreign Object Ingestions: Need for Endoscopy and Surgery

3,501) than the former two (P < 0.01). We also observed a pattern of escalating costs associated with increasing number of sequential IIFO episodes, with the 1st episode carrying median charges of

Abdominal Pain and Colonic Obstruction From an Intra-Abdominal Desmoid Tumor

4,683 and episodes numbered 11+ carrying median charges of

Iatrogenic Esophageal Foreign Body After Motor Vehicle Accident

7,698 (P < 0.01). Conclusions: Hospital charges associated with the care of prisoners who ingest foreign objects tend to escalate over time. Although charges in most of the categories demonstrated increases with greater numbers of ingestions, the largest contributors to this pattern of escalating charges included radiology, pharmacy, hospital room charges, and surgical services. These findings suggest that early intervention in the destructive cycle of IIFO may not only improve patient outcomes but also result in savings to the healthcare system. The following core competencies are addressed in this article: Medical knowledge, Patient care, Practice based learning and improvement, Systems based practice. Republished with permission from: Otey AJ, Houser JS, Jones C, Evans DC, Dalal P, Whitmill ML, Levine E, McKimmie R, Papadimos TJ, Steinberg SM, Bergese SD, Stawicki SP. Examination of financial charges associated with intentional foreign body ingestion by prisoners: A pattern of escalation. OPUS 12 Scientist 2014;8(1):6-8.

Tu1121 Effectiveness of Weekly Board Review Conference in Improving Trainee in-Service Exam Scores

Question: A 52-year-old man with a history of end-stage renal disease secondary to focal segmental glomerulosclerosis status post renal transplant presented to the hospital with acute onset nausea, vomiting, and epigastric pain. The gastroenterology consult team was asked to evaluate him for these symptoms. Home medication list was notable for ferrous sulfide, hydralazine, clonidine, amlodipine, and as needed lactulose for opiate-induced constipation. Previous esophagogastroduodenoscopy from 6 years prior was normal. Physical examination was notable for only mild abdominal distention and tenderness. Abdominal x-ray on admission showed large and small intestinal distention suggestive of an ileus, felt to be related to his chronic opiate use. Admission chemistry was notable for a creatinine of 1.8 mg/dL, just below his baseline. His complete blood count was remarkable for a normocytic anemia with a hemoglobin of 8.3 g/dL. Iron studies revealed an iron level of 93 g/dL, iron saturation of 38%, total iron binding capacity of 244 g/dL, and ferritin of 1348 ng/mL. Esophagogastroduodenoscopy performed the following day for further evaluation of his nausea, vomiting, and abdominal pain exhibited dark, speckled mucosa covering the gastric fundus, prepylorus, and the entire examined duodenum (Figures A–C). Biopsies taken from the prepyloric area showed granular pigment deposition (Figure D). Biopsies from the duodenum showed granular pigment of the superficial villous tips (Figure E). Iron histochemical stain showed weak and partial positive staining on both the gastric and duodenal biopsies (Figure F). What is the diagnosis? See the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Mo1064 Colectomy in Adults With Ulcerative Colitis Varies by Race and Payer Status

Esophageal injuries typically present after direct intraluminal trauma by foodstuffs, the mechanical shearing forces caused by retching, ingested foreign bodies, or iatrogenesis. Injuries range from the mucosal tears of Mallory-Weiss syndrome to the transmural rupture of Boerhaave’s syndrome. Esophageal intramural hematomas (EIH) are exceedingly rare types of esophageal injury. These hematomas typically involve the distal esophagus [1]; thus, their discovery in the proximal esophagus deserves special mention. Uncommon causes of EIH include trauma induced by sclerotherapy [2, 3], mucosal biopsy [4], coagulopathy [5], antithrombotic therapy [6], or carcinoma [7]. We report a rare case of a cricopharyngeal intramural hematoma following anterior cervical decompression presenting only with dysphagia.