Ulcerated intussuscepted jejunal lipoma-uncommon cause of obscure gastrointestinal bleeding: A case report

BACKGROUND Intestinal lipomas are rare benign gastrointestinal(GI)tumors,usually asymptomatic,but may become symptomatic as the result of some complications such as intussusception,intestinal obstruction,volvulus or bleeding.They can occur at any site along the entire GI tract,more frequent in colon and rarely in small intestine.The patient reported here is a very rare case of jejunal lipoma,ulcerated and intussuscepted,diagnosed in an adult investigated for a chronic iron deficiency anemia(IDA),and successfully managed by segmental jejunal resection.CASE SUMMARY A 63-year-old male was referred to“St.Spiridon”Hospital,Institute of Gastroenterology and Hepatology,Iasi,to investigate an obscure GI bleeding with an IDA.After upper GI endoscopy and colonoscopy were performed,excluding potentially bleeding lesions,videocapsule endoscopy was then carried out,revealing fresh blood and a protruding lesion in proximal jejunum,findings confirmed by a single-balloon enteroscopy.Multiple biopsies were taken from the lesion,but histological results were inconclusive.Then,contrast-enhanced computed tomography was performed showing jejunal polypoid mass with homogenous fat density,suggestive for lipoma.A week later a laparotomy was performed revealing the intussuscepted jejunal segment which was resected enbloc,and sent for further histopathologic analysis.The patient made an uneventful recovery and was discharged seven days later,and at six months follow-up he had no complains and his hemoglobin returned to normal value.CONCLUSION Lipomas are very rarely located in the jejunum,usually asymptomatic,but they may lead to complications such as intussusception and bleeding.Surgical resection remains the treatment of choice.

Role of ammonia in predicting the outcome of patients with acuteon- chronic liver failure

BACKGROUND High venous ammonia(VA)values have been proven to be a part of the mechanism of hepatic encephalopathy in patients with liver cirrhosis(LC)as well as acute hepatitis.Moreover,VA has been associated with poor prognosis and high mortality in these clinical settings.However,the role of ammonia in acuteon-chronic liver failure(ACLF)has not yet been clearly established.AIM To assess the role of VA in predicting the outcome of cirrhotic patients with ACLF in a tertiary care center.METHODS We performed a retrospective observational study including consecutive patients with LC hospitalized for acute non-elective indications such as ascites,hepatic encephalopathy(HE),upper gastrointestinal bleeding,or bacterial infections that fulfilled the Asian Pacific Association for the Study of the Liver(APASL)criteria for ACLF.The study was conducted in“St.Spiridon”University Hospital,Iasi,Romania,a tertiary care center,between January 2017 and January 2019.The APASL ACLF Research Consortium(AARC)score was calculated and ACLF grade was established accordingly.West-haven classification was used for HE.Statistical analysis was performed using IBM SPSS version 22.0.RESULTS Four hundred and forty-six patients were included,aged 59(50-65)years,57.4%men.Child-Pugh,model for end-stage liver disease(MELD)and AARC scores were 11(10-12),19.13±6.79,and 7(6-8),respectively.66.4%had ACLF grade I,31.2%ACLF grade II,and 2.5%ACLF grade III.HE was diagnosed in 83.9%,34%grade I,37.2%grade II,23.5%grade III,and 5.3%grade IV.Overall mortality was 7.8%.VA was 103(78-148)μmol/L.Receiver operating characteristic analysis showed good accuracy for the prediction of in-hospital mortality for the AARC score[Area under the curve(AUC)=0.886],MELD score(AUC=0.816),VA(AUC=0.812)and a fair accuracy for the Child-Pugh score(AUC=0.799).Subsequently,a cut-off value for the prediction of mortality was identified for VA(152.5μmol/L,sensitivity=0.706,1-specificity=0.190).Univariate analysis found acute kidney injury,severe HE(grade III or IV),VA≥152.5μmol/L,MELD score≥22.5,Child-Pugh score≥12.5,and AARC score≥8.5 to be associated with inhospital mortality.Multivariate analysis identified AARC score≥8.5 and venous ammonia≥152μmol/L to be independent predictors of in-hospital mortality.CONCLUSION VA could be used as an inexpensive predictor of in-hospital mortality in patients with ACLF.Patients with both ACLF and VA>152.5μmol/L have a high risk for a poor outcome.

Did the severe acute respiratory syndrome-coronavirus 2 pandemic cause an endemic Clostridium difficile infection?

BACKGROUND Clostridium difficile infection(CDI)has increased in prevalence during the last years.The coronavirus disease 2019(COVID-19)pandemic has negatively influenced patient outcomes.The majority of the severe acute respiratory syndrome-coronavirus 2(SARS-CoV-2)-infected patients received antibiotics during hospitalization.AIM To analyze the factors that influenced CDI development after SARS-CoV-2 infection.METHODS Between March 2020 to December 2020,we performed a prospective observational study including 447 patients diagnosed with CDI who were admitted to our tertiary referral university hospital.The diagnosis of CDI was based on the presence of diarrhea(≥3 watery stools within 24 h)associated with Clostridium difficile toxins A or B.We excluded patients with other etiology of acute diarrhea.RESULTS Among the total 447(12.5%)patients with CDI,most were male(54.3%)and mean age was 59.7±10.8 years.Seventy-six(17.0%)had history of COVID-19,most being elderly(COVID-19:62.6±14.6 years vs non-COVID-19:56.8±17.6 years,P=0.007),with history of alcohol consumption(43.4%vs 29.4%,P=0.017),previous hospitalizations(81.6%vs 54.9%,P<0.001)and antibiotic treatments(60.5%vs 35.5%,P<0.001),requiring higher doses of vancomycin and prone to recurrent disease(25.0%vs 13.1%,P=0.011).Age over 60 years[odds ratio(OR):2.591,95%confidence interval(CI):1.452-4.624,P=0.001],urban residence(OR:2.330,95%CI:1.286-4.221,P=0.005),previous antibiotic treatments(OR:1.909,95%CI:1.083-3.365,P=0.025),previous hospitalizations(OR:2.509,95%CI:1.263-4.986,P=0.009)and alcohol consumption(OR:2.550,95%CI:1.459-4.459,P=0.001)were risk factors of CDI in COVID-19.CONCLUSION CDI risk is unrelated to history of SARS-CoV-2 infection.However,previous COVID-19 may necessitate higher doses of vancomycin for CDI.