Hospitalization for variceal hemorrhage in an era with more prevalent cirrhosis

AIM: To examine hospitalization rates for variceal hemorrhage and relation to cause of cirrhosis during an era of increased cirrhosis prevalence.

Impact on 30-d readmissions for cirrhotic patients with ascites after an educational intervention: A pilot study

BACKGROUND A low proportion of patients admitted to hospital with cirrhosis receive quality care with timely paracentesis an important target for improvement.We hypothesized that a medical educational intervention,delivered to medical residents caring for patients with cirrhosis,would improve quality of care.AIM To determine if an educational intervention can improve quality of care in cirrhotic patients admitted to hospital with ascites.METHODS We performed a pilot prospective cohort study with time-based randomization over six months at a large teaching hospital.Residents rotating on hospital medicine teams received an educational intervention while residents rotating on hospital medicine teams on alternate months comprised the control group.The primary outcome was provision of quality care-defined as adherence to all quality-based indicators derived from evidence-based practice guidelines-in admissions for patients with cirrhosis and ascites.Patient clinical outcomesincluding length of hospital stay(LOS);30-d readmission;in-hospital mortality and overall mortality-and resident educational outcomes were also evaluated.RESULTS Eighty-five admissions(60 unique patients)met inclusion criteria over the study period-46 admissions in the intervention group and 39 admissions in the control group.Thirty-seven admissions were female patients,and 44 admissions were for alcoholic liver disease.Mean model for end-stage liver disease(MELD)-Na score at admission was 25.8.Forty-seven(55.3%)admissions received quality care.There was no difference in the provision of quality care(56.41%vs 54.35%,P=0.9)between the two groups.30-d readmission was lower in the intervention group(35%vs 52.78%,P=0.1)and after correction for age,gender and MELD-Na score[RR=0.62(0.39,1.00),P=0.05].No significant differences were seen for LOS,complications,in-hospital mortality or overall mortality between the two groups.Resident medical knowledge and self-efficacy with paracentesis improved after the educational intervention.CONCLUSION Medical education has the potential to improve clinical outcomes in patients admitted to hospital with cirrhosis and ascites.

Lymphangitic spread from appendiceal adenocarcinoma to ileocecal valve, mimicking Crohn's disease

Due to the anatomical peculiarity of the appendix,diagnosis of tumors arising from this area can be challenging by clinicoradiologic means.We report a case of a rare primary appendiceal signet ring carcinoma with an uncommon presentation.An 86-year-old woman was admitted toour hospital with subacute epigastric pain.Computed tomography demonstrated bowel wall thickening with fat stranding in the ileocecal region.The leading diagnostic consideration was inflammatory bowel disease.Upon colonoscopy,a swollen,distorted ileocecal valve was identified.The remaining colon was otherwise unremarkable.Extensive biopsy sampling of the ileocecal region and colon was performed.A lymphangitic signet ring carcinoma within the ileocecal region was diagnosed on biopsy;there was no dysplasia or carcinoma of the remaining biopsies.By cytomorphology and immunoprofile,a lymphangitic signet ring carcinoma of appendiceal origin was the primary consideration,further confirmed upon subsequent laparotomy.This case represents an unusual pattern of appendiceal tumor spread with localized,lymphangitic involvement,creating a milieu which closely simulates Crohn’s disease on imaging modalities.