Gastrointestinal Source Research Articles

Eggerthella lenta Bloodstream Infections Are Associated With Increased Mortality Following Empiric Piperacillin-Tazobactam (TZP) Monotherapy: A Population-based Cohort Study.

Eggerthella lenta is a anaerobic gram-positive bacilli associated with polymicrobial intraabdominal infections. Recently, E. lenta was recognized as an important cause of anaerobic bloodstream infections (BSIs) associated with high mortality. Eggerthella lenta has been reported to have high minimal inhibitory concentrations (MICs) to piperacillin-tazobactam (TZP), a broad-spectrum antibiotic with anaerobic coverage commonly used in multiple centers for empiric treatment of abdominal sepsis. We describe a retrospective population-based analysis of invasive E. lenta infections from 2009 through 2015. A logistic regression analysis for 30-day mortality risk factors was conducted. We identified 107 E. lenta infections, 95 (89%) were BSIs, 11 (10%) skin and soft tissue infections, and 1 intraabdominal abscess. Polymicrobial infections were found in 40%; 72% of isolates were from a gastrointestinal source, most commonly appendicitis (33%) of which two-thirds were perforated. TZP MIC50 and MIC90 for E. lenta isolates were 32 μg/mL and 64 μg/mL, respectively. The overall 30-day mortality for BSI was 23% and was independently associated with empiric TZP monotherapy (odds ratio [OR], 4.4; 95% confidence interval [CI], 1.2-16; P = .02) and intensive care unit stay (OR, 6.2; 95% CI, 1.4-27.3; P = .01). Thirty-day mortality rates were significantly influenced by the use of different TZP MIC breakpoints. Our results demonstrate the increased recognition of E. lenta as an anaerobic opportunistic pathogen and highlight the need for improved empiric antimicrobial guidelines and TZP MIC breakpoints with better correlation to clinical outcomes to guide appropriate management of invasive E. lenta infections.

MRSA in the Blood From MRSA in the Gut: A Rare Presentation of MRSA Bacteremia From a Gastrointestinal Source

MRSA causes a wide variety of diseases in humans ranging from benign skin infections to life-threatening sepsis. Blood stream infections (BSI) secondary to MRSA have high mortality rates of 20-40%. Immunocompromised patients are at risk of acquiring health care associated MRSA BSI. Most common sources for MRSA BSI are intravascular inoculation, urinary tract infection and pneumonia. We report a case of MRSA BSI originated from gastrointestinal tract. A 23-year-old African-American male with a history of HIV presented with odynophagia, weight loss and hematochezia. Subsequently, he developed septic shock due to MRSA bacteremia. The initial physical examination was significant for cachexia, oral thrush, grade III systolic murmur in mitral area, perianal ulcers, painful digital rectal exam with few stains of blood on the gloved finger. Laboratory data was significant for CD4 count of 21 cell/mm3, hemoglobin of 9.9 g/dl, creatinine of 1.53 mg/dl. Bactrim and Azithromycin was started for HIV prophylaxis. Upper GI Endoscopy was positive for severe candida esophagitis. Colonoscopy showed multiple superficial ulcers in the transverse colon and terminal ileum with the biopsy negative for IBD. Subsequently he developed fever and watery diarrhea. Stool cultures were positive for MRSA. Blood cultures were obtained which grew MRSA with similar sensitivity pattern as of the gut MRSA. He was successfully treated with IV Vancomycin for MRSA bacteremia. TEE did not show any evidence of endocarditis. Repeat blood and stool cultures were negative. The patient was subsequently discharged with initiation of HAART therapy. HIV/AIDS patients are at increased risk for infections and MRSA is one of the most common pathogens in hospital settings. The common sites of MRSA carriage are nose, throat and rectum. There have not been convincing case reports of gastrointestinal origin of MRSA BSI in the past. However, it has been demonstrated in an immunocompromised mice model that MRSA BSI could be originated from the gut derived bacteria and the proposed mechanism was the migration of bacteria from the intestinal lumen to blood stream. MRSA in the blood from MRSA in the gut could account for a portion of 10-20% of cases when the sources remain unidentified. Early diagnosis and treatment of MRSA infection of GI tract may prevent serious complications including MRSA bacteremia and septic shock in severely immunocompromised patients.

THE WAY OF RECONSTRUCTIVE SURGERY IN CHRONIC DUODENAL ULCER, COMPLICATED BY BLEEDING WITH SEVERE BLOOD LOSS AFTER RETROCOLIC GASTROJEJUNOSTOMY

Currently, surgical treatment of gastrointestinal bleeding is based primarily on topical preoperative identification of their source. In this regard, the treatment of patients with bleeding from unknown sources is a difficult task and is accompanied by a high mortality rate. In such cases, in the absence of confirmation of gastrointestinal bleeding source, treatment should base on the clinical pic- ture. A successful case of surgical treatment of patient with chronic duodenal ulcer, complicated with bleeding after retrocolic gastroenteroanastomy is described.

Late-Onset Biallelic Mismatch Repair Deficiency Syndrome

A 33-year-old man with a history of successfully treated low-grade follicular lymphoma 2-years prior was evaluated for recurrent aching upper abdominal pain, early satiety, and fatigue. He denied overt gastrointestinal bleeding, but reported occasional night sweats, chills, and weight loss. His family history was notable for esophageal cancer in his father and gastric cancer in his mother. Physical examination showed 2 café-au-lait macules on the lower abdomen but no lymphadenopathy, abdominal tenderness, or mass was appreciated. Laboratory tests showed mild normocytic anemia and normal liver enzyme levels. An abdominal computed tomographic (CT) enterography showed bowel-wall thickening and luminal narrowing extending over the proximal jejunum (Figure A, arrow). Positron emission tomography showed corresponding activity, highlighting the small bowel as the primary source (Figure B). A CT-guided biopsy showed metastatic adenocarcinoma of an unknown primary favoring a gastrointestinal source. Upper endoscopy was unremarkable. Colonoscopy showed multiple large adenomas in the proximal colon (Figure C). The patient underwent small-bowel surgical excision. Histologic examination of the specimen showed a biphasic tumor containing both mucinous and gland-forming parts (Figure D, top, H&E). Immunohistochemistry testing of the adenocarcinoma showed intact MLH1, MSH2, and PMS2 nuclear staining but abnormal (absent) MSH6 nuclear staining in both normal and tumor mucosa (Figure D, bottom). The diagnosis of biallelic mismatch repair deficiency (BMMRD) syndrome (also known as constitutional mismatch repair deficiency) was made, which is a rare autosomal-recessive hereditary cancer syndrome that results from biallelic germline mutations in 1 of the 4 mismatch repair genes: MLH1, MSH2, MSH6, and PMS2. The combination of café-au-lait macules, small-bowel adenocarcinoma, adenomatous colon polyps, and a history of lymphoma was highly suggestive of BMMRD. The absence of MSH6 expression in the tumor and normal tissue indicated biallelic MSH6 mutations. The tumor spectrum of BMMRD is broad, including hematologic, brain, and gastrointestinal tract tumors.1Wimmer K. Kratz C.P. Vasen H.F. et al.Diagnostic criteria for constitutional mismatch repair deficiency syndrome: suggestions of the European consortium ‘care for CMMRD' (C4CMMRD).J Med Genet. 2014; 51: 355-365Google Scholar These individuals often have dermatologic findings of neurofibromatosis type 1, such as café-au-lait macules. Although most often a childhood cancer syndrome, BMMRD has a less-penetrant phenotype in which individuals remain unaffected until the third or fourth decade of life (as in our patient). In addition, tumor immunohistochemistry testing often is difficult to interpret in BMMRD cases because the control (normal tissue) has absent MMR staining. Unlike the autosomal-dominant mutation of a MMR gene in Lynch syndrome, BMMRD is much less understood.2Vasen H. Ghorbanoghli Z. Bourdeaut F. et al.Guidelines for surveillance of individuals with constitutional mismatch repair-deficiency proposed by the European Consortium ‘Care for CMMR-D’(C4CMMR-D).J Med Genet. 2014; 51: 283-293Google Scholar, 3Durno C. Boland C.R. Cohen S. et al.Recommendations on surveillance and management of Biallelic Mismatch Repair Deficiency (BMMRD) syndrome: a consensus statement by the US Multi-Society Task Force on colorectal cancer.Gastroenterology. 2017; 152: 1605-1614Google Scholar Although BMMRD recommendations for screening young persons have been formulated, the surveillance and tumor spectrum in adults remains less clear.3Durno C. Boland C.R. Cohen S. et al.Recommendations on surveillance and management of Biallelic Mismatch Repair Deficiency (BMMRD) syndrome: a consensus statement by the US Multi-Society Task Force on colorectal cancer.Gastroenterology. 2017; 152: 1605-1614Google Scholar This case illustrates several important points. First, one should maintain a high suspicion for hereditary cancer syndromes. Second, the finding of café-au-lait macules can be an important clue to BMMRD. Third, BMMRD has a broad tumor spectrum that includes multiple polyps and should be in the differential diagnosis of colonic adenomatous polyposis. Finally, the syndrome most often presents in childhood but may have a late-onset presentation, highlighting the need for increased awareness of this condition by adult gastroenterologists.

Duodenal ulcers are a major cause of gastrointestinal bleeding after cardiac surgery

ObjectiveTo determine the incidence of gastrointestinal (GI) bleeding in patients after cardiac surgery, assess the perioperative risk factors, and determine the type of GI tract pathology associated with bleeding events. MethodsAt a tertiary referral hospital, all cardiac surgery patients having a postoperative GI bleed from April 2002 to March 2012 were identified. To determine bleeding etiology, only patients requiring endoscopy were included in the analysis. By retrospective review of 3 prospectively maintained databases, the incidence and independent predictors of GI bleeding, as well as endoscopic findings, were determined. ResultsNinety-one GI bleeding events that required endoscopy were identified in 9017 patients. Those that bled were aged 71 ± 12 years, and 76% were men. Sixty-three percent of these patients had valve surgery and 37% had an isolated coronary artery bypass grafting. The overall incidence of GI bleeding was 1.01%, with an upper GI source accounting for 78%. Endoscopy data found a duodenal ulcer as the bleeding source in 71%, whereas stress gastritis accounted for 8%. Preoperative risk factors for bleeding included age ≥70 years, ejection fraction <35%, congestive heart failure, cerebrovascular disease, chronic kidney disease, and gastrointestinal disease. A preoperative history of atrial fibrillation and anticoagulation with Coumadin also was associated with bleeding. Patients that bled had a 30-day mortality rate of 8.8%, which was significantly greater than patients who did not bleed (4.3%; P = .03). ConclusionsClinical variables can be used to identify patients at high risk for GI bleeding after cardiac surgery. When GI bleeding occurs, the most common cause is duodenal ulceration, which has an association with Helicobacter pylori infection. These findings may provide an opportunity to initiate preoperative preventative strategies.

Identifying the Portal of Entry in Bacterial Endocarditis: A Quest to the Source

Background: Infective endocarditis (IE) results from bacterial seeding of the heart valves. Causative bacteria can be grouped according to the likely source such as skin, oral cavity or bowel. This allows for screening of a portal of entry (POE) to prevent recurrent IE and to identify underlying pathologies such as colonic malignancies or oral lesions. Rates of routine screening for POE are largely unknown. Methods: At our tertiary hospital, a retrospective analysis identified 86 patients over 18 months with a new diagnosis of infective endocarditis. We assessed if a POE was identified and if screening for POE was performed appropriate to the causative bacteria. Results: The POE was identified in 51 (59%) of patients. Intravenous drug use was present in 28% of identified POEs. Cutaneous infection was the most common POE (67%) followed by oral and gastrointestinal sources. Over 50% of infections with gastrointestinal and oral flora arose from an unknown POE. In 5 patients with gastrointestinal POEs identified, 2 had pre-malignant polyps and 1 had a malignant tumour. 48% of patients requiring inpatient valve surgery had an unknown POE with 4 cases of recurrent-prosthetic IE. Conclusions: In the absence of a protocol for identifying the POE in infective endocarditis, the source of infection remains unknown in a significant number of patients. Without identifying the source of the initial insult, these patients are at future risks of re-infection, which carries significant morbidity and mortality, especially in those with prosthetic heart valves. Our results highlight the need to standardise POE investigation to reduce the incidence of recurrent infective endocarditis.

Approach to the Patient with Abdominal Pain

Abdominal pain is the most common presenting complaint in the emergency department (ED), accounting for nearly 8% of ED visits. Although many chronic conditions may cause pain in the abdomen, acute abdominal pain, defined as undiagnosed pain present for less than 1 week, is of greatest concern to the emergency practitioner. For many reasons, acute abdominal pain is often diagnostically challenging. Abdominal pain may be due to numerous causes, including gastrointestinal, genitourinary, cardiovascular, pulmonary, and other sources. Symptoms may fluctuate or change in nature, and the quality of pain can be difficult for the patient to describe. Physical examination findings, although important, are variable and can even be misleading. Despite being such a common presenting complaint, misdiagnosis is not uncommon and results in a high percentage of medicolegal actions in both and adult and pediatric populations. Key words: abdominal computed tomography, abdominal pain, abdominal ultrasonography, pain management, point-of-care ultrasonography

Origin, Clinical Characteristics and 30-Day Outcomes of Severe Hematochezia in Cirrhotics and Non-cirrhotics.

The sites of origin, causes and outcomes of severe hematochezia have not been compared between cirrhotics and non-cirrhotics. In cirrhotics versus non-cirrhotics presenting with severe hematochezia, we aimed at (1) identifying the site and etiology of gastro-intestinal bleeding and independent predictors of bleeding from the upper gastrointestinal tract versus small bowel or the colon, (2) comparing 30-day clinical outcomes, and (3) proposing an algorithm for management of severe hematochezia. In this cohort study from two university-based medical centers, 860 consecutive patients with severe hematochezia admitted from 1995 to 2011 were prospectively enrolled with 160 (18.6%) cirrhotics. We studied (a) general clinical and laboratory characteristics of cirrhotics versus non-cirrhotics, (b) predictors of bleeding sites in each patient group by multiple variable regression analysis, and compared (c) 30-day outcomes, including rebleeding, surgery and deaths. Cirrhosis independently predicted an upper gastrointestinal source of bleeding (OR 3.47; 95% CI 2.01-5.96) as well as history of hematemesis, melena in the past 30days, positive nasogastric aspirate, prior upper gastrointestinal bleeding or use of aspirin or non-steroidal anti-inflammatory. The most prevalent diagnoses were esophageal varices (20%) in cirrhotics and colon diverticular bleeding (27.1%) in non-cirrhotics. Thirty-day rates of rebleeding, surgical interventions and deaths were 23.1 versus 15% (P=0.01), 14.4 versus 6.4% (P<0.001), and 17.5 versus 4.1% (P<0.001), in cirrhotics versus non-cirrhotics, respectively. Cirrhosis predicted an upper gastrointestinal site of bleeding in patients presenting with severe hematochezia. The 30-day rates of rebleeding, surgery, and death were significantly higher in cirrhotics than in non-cirrhotics.

Intra-Abdominal Candidiasis: The Importance of Early Source Control and Antifungal Treatment.

Intra-abdominal candidiasis (IAC) is poorly understood compared to candidemia. We described the clinical characteristics, microbiology, treatment and outcomes of IAC, and identified risk factors for mortality. We performed a retrospective study of adults diagnosed with IAC at our center in 2012–2013. Risk factors for mortality were evaluated using multivariable logistic regression. We identified 163 patients with IAC, compared to 161 with candidemia. Types of IAC were intra-abdominal abscesses (55%), secondary peritonitis (33%), primary peritonitis (5%), infected pancreatic necrosis (5%), and cholecystitis/cholangitis (3%). Eighty-three percent and 66% of secondary peritonitis and abscesses, respectively, stemmed from gastrointestinal (GI) tract sources. C. albicans (56%) and C. glabrata (24%) were the most common species. Bacterial co-infections and candidemia occurred in 67% and 6% of patients, respectively. Seventy-two percent of patients underwent an early source control intervention (within 5 days) and 72% received early antifungal treatment. 100-day mortality was 28%, and highest with primary (88%) or secondary (40%) peritonitis. Younger age, abscesses and early source control were independent predictors of survival. Younger age, abscesses and early antifungal treatment were independently associated with survival for IAC stemming from GI tract sources. Infectious diseases (ID) consultations were obtained in only 48% of patients. Consulted patients were significantly more likely to receive antifungal treatment. IAC is a common disease associated with heterogeneous manifestations, which result in poor outcomes. All patients should undergo source control interventions and receive antifungal treatment promptly. It is important for the ID community to become more engaged in treating IAC.

A clinical practical approach to the surveillance definition of central line–associated bloodstream infection in cancer patients with mucosal barrier injury

The Centers for Disease Control and Prevention recently introduced the concept of mucosal barrier injury (MBI) in an attempt to recognize the possibility of a gastrointestinal source for certain bloodstream infections. This could underestimate the central venous catheter (CVC) as the source of central line-associated bloodstream infection (CLABSI) in cancer. The definition of catheter-related bloodstream infection (CRBSI) by the Infectious Diseases Society of America is a more specific and stringent definition that identifies the CVC as the source of infection. In our study, we compared the 2 definitions in cancer patients. We retrospectively reviewed 149 CLABSI cases that occurred at our center between January 2013 and March 2014 who had 2 simultaneously positive blood cultures drawn from the CVC and peripheral site or concurrent paired tip and blood cultures. Of the 149 patients with CLABSI, only 70 (47%) had definite CRBSI. CRBSI was identified more commonly in non-MBI CLABSI cases than MBI CLABSI (69% vs 18%, P < .0001). The CRBSI definition may be more accurate in identifying the catheter as the source of bloodstream infection in patients with MBI. Because CRBSI continues to occur in patients with MBI, we caution against excluding all MBI patients from CLABSI surveillance.

ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding.

This guideline provides recommendations for the management of patients with acute overt lower gastrointestinal bleeding. Hemodynamic status should be initially assessed with intravascular volume resuscitation started as needed. Risk stratification based on clinical parameters should be performed to help distinguish patients at high- and low-risk of adverse outcomes. Hematochezia associated with hemodynamic instability may be indicative of an upper gastrointestinal (GI) bleeding source and thus warrants an upper endoscopy. In the majority of patients, colonoscopy should be the initial diagnostic procedure and should be performed within 24 h of patient presentation after adequate colon preparation. Endoscopic hemostasis therapy should be provided to patients with high-risk endoscopic stigmata of bleeding including active bleeding, non-bleeding visible vessel, or adherent clot. The endoscopic hemostasis modality used (mechanical, thermal, injection, or combination) is most often guided by the etiology of bleeding, access to the bleeding site, and endoscopist experience with the various hemostasis modalities. Repeat colonoscopy, with endoscopic hemostasis performed if indicated, should be considered for patients with evidence of recurrent bleeding. Radiographic interventions (tagged red blood cell scintigraphy, computed tomographic angiography, and angiography) should be considered in high-risk patients with ongoing bleeding who do not respond adequately to resuscitation and who are unlikely to tolerate bowel preparation and colonoscopy. Strategies to prevent recurrent bleeding should be considered. Nonsteroidal anti-inflammatory drug use should be avoided in patients with a history of acute lower GI bleeding, particularly if secondary to diverticulosis or angioectasia. Patients with established high-risk cardiovascular disease should not stop aspirin therapy (secondary prophylaxis) in the setting of lower GI bleeding. [corrected]. The exact timing depends on the severity of bleeding, perceived adequacy of hemostasis, and the risk of a thromboembolic event. Surgery for the prevention of recurrent lower gastrointestinal bleeding should be individualized, and the source of bleeding should be carefully localized before resection.

Severe Sepsis due toClostridium perfringensBacteremia of Urinary Origin: A Case Report and Systematic Review

Clostridium perfringens bacteremia is an uncommon yet serious clinical syndrome that typically arises from a gastrointestinal source. However, clinicians should consider nongastrointestinal sources as well. We present a rare case of C. perfringens bacteremia of urinary origin that required surgical intervention for definitive treatment. A 61-year-old male presented with acute nausea and vomiting, altered mental status, and chronic diarrhea. His physical exam revealed right costovertebral tenderness and his laboratory work-up revealed acute renal failure. Percutaneous blood cultures grew C. perfringens. Cross-sectional imaging revealed a right-sided ureteral stone with hydronephrosis, which required nephrostomy placement. On placement of the nephrostomy tube, purulent drainage was identified and Gram stain of the drainage revealed Gram-variable rods. A urinary source of C. perfringens was clinically supported. Although it is not a common presentation, nongastrointestinal sources such as a urinary source should be considered in C. perfringens bacteremia because failure to recognize a nongastrointestinal source can delay appropriate treatment, which may include surgical intervention.

Abstract 17598: More Than One in Five Older Veterans are Hospitalized for Bleeding Following Initiation of Warfarin for Atrial Fibrillation

Introduction: Clinicians are hesitant to prescribe oral anticoagulants to older adults with atrial fibrillation (AF) due to concerns over bleeding risk. Hypothesis: As many data on bleeding events are from trials of rigorously selected patients, we hypothesized that major bleeding events (requiring hospitalization) would be more common than previously reported. Methods: We created a retrospective cohort of 31,951 Veterans with AF aged ≥75 years who were new referrals to VA anticoagulation clinics (warfarin) from 1/1/02 - 12/31/12. Patients with comorbid conditions requiring warfarin (e.g. pulmonary embolus) were excluded. Data were extracted from the VA electronic medical record and linked with Medicare claims data for subsequent hospitalizations. The primary outcome was any hospitalization for bleeding. We identified bleeding subtypes by source, and compared characteristics of patients with and without bleeding hospitalizations. Results: Mean population age was 81.1 years, 98.1% were male, and 8.4% were nonwhite. Over a median follow-up period of 2.62 years, 7288 patients (22.8%) were hospitalized for bleeding. There were 12,004 total bleeding events; overall, 980 (13.4%) patients experienced multiple events. The most common bleeding sources (first event) were gastrointestinal (50.8%), genitourinary (21.6%), and intracranial (9.4%) (Figure). The median time to first bleeding event was 1.59 years. Patients hospitalized for bleeding were more likely to have coronary disease (48.4% vs. 40.9%, P&lt;0.01); COPD (28.4% vs. 24.7%, P&lt;0.01); chronic kidney disease (17.8% vs. 16.0%, P&lt;0.01); CHF (34.7% vs. 29.5%, P&lt;0.01), and labile INR (63.3% vs. 53.7%, P&lt;0.01). The rate of hospitalization for stroke over the same time period was 5.0%. Conclusions: After initiating warfarin, over one in five older Veterans are hospitalized for bleeding, most commonly from a gastrointestinal source. Comorbidity burden and labile INR place these patients at increased risk.

Yield of colonoscopy with special reference to lower gastrointestinal bleeding in a tertiary referral center in Eastern India

Abstract Background: Little data exist on the yield of colonoscopy in its different indications, especially gastrointestinal (GI) bleeding. Furthermore, there are no formal guidelines regarding the timing of its performance in the work up for lower GI bleeding. Methods: In a retrospective study, spanning from January 2007 to December 2013, the clinical data of all the patients undergoing colonoscopy were retrieved from the hospital records including the predominant symptom which mandated colonoscopy and results of the other tests done before colonoscopy including upper GI endoscopy (esophagogastroduodenoscopy [EGD]). The type of GI bleed (overt or occult) along with the presence or absence of iron deficiency anemia (IDA) was noted. The yield of EGD in the corresponding years in those having a presentation with lower GI bleed and/or IDA was also noted for comparison. Results: Overall yield of colonoscopy was low (25.7%) like for all its indications except lower GI bleed where its yield was highest (45.2%). 81.2% of the cases with a diagnosis presented with lower GI bleed, highest for colon cancer (90%), and polyps (86.1%). Cases of occult bleed more often had a positive diagnosis than overt bleed (P = 0.02). EGD yielded positive findings in more cases (43.2%, P = 0.00) than colonoscopy (except piles). Colonic cancers and polyps were presented with hematochezia when compared to gastric cancer which presented more often with occult bleed and other clinical symptoms. Conclusion: EGD should be done first in lower GI bleeding to exclude upper GI source and select subsequent colonoscopy. For hematochezia and occult bleed, colonoscopy is important whether IDA is present or not.

PTU-051 Diagnostic yield of oesophago-gastro-duodenoscopy as the initial investigation for patients presenting with haematochezia

<h3>Introduction</h3> It is suggested that 15% of patients presenting with haematochezia will have an upper gastrointestinal (UGI) source of bleeding.¹Current surgical school of thought recommends oesophago-gastro-duodenoscopy (OGD) as first-line investigation for patients with haematochezia.²More recent thinking suggests that a nasogastric lavage should be undertaken in this patient group to identify an UGI source of bleed.²We aimed to investigate whether the reported figure was an accurate representation and whether OGD should be undertaken primarily. <h3>Method</h3> Patients who presented with haematochezia were identified between January 2010 and June 2014, using clinical coding. Data collected included demographics, presentation, initial haemoglobin and urea serum levels, OGD findings and results from further endoscopic investigation. <h3>Results</h3> A total of 231 patients were identified (mean age 68 years, 55% male). Of these, 42 underwent OGD as first-line investigation. The majority of these (73%) had a normal endoscopy. The following pathologies where identified in the remaining endoscopies; duodenitis (7%), gastric ulcer (4%), gastritis (2.3%), oesophagitis (2.3%), oesophageal telangiectasia (2.3%), gastric erosions (2.3%), oesophageal ulcer (2.3%) and oesophageal varices (2.3%) Of those with a normal OGD, 80% had a further lower GI endoscopy. 60% of these patients had a clear LGI pathology accounting for their presentation. These findings demonstrate that of the patients who underwent OGD first line, only 7% had significant UGI pathology at OGD (peptic ulcer, oesophageal varices) with 2% actively bleeding (oesophageal varices). The mean haemaglobin for this population was 98 g/L (range 32–142 g/L). The median serum urea level was 9.2 mmol/L (range 1–13.2 mmol/L). In those with a normal OGD, 35% had a raised serum urea (mean 8.3 mmol/L, range 1.0–46.2 mmol/L). Whilst in those with an identified attributable UGI pathology, serum urea was raised in 100% of the cases (mean 8.8 mg/dl, range 7.9–9.9 mg/dl.) <h3>Conclusion</h3> We suggest an incidence of UGI pathology leading to haematochezia of 7%, which is far lower that the quoted figure of 15%. We therefore challenge surgical recommendation that OGD should be the first line investigation in this patient group unless haemodynamic instability or clinical suspicion is suggestive. <h3>Disclosure of interest</h3> None Declared. <h3>References</h3> Jensen DM, Machicado GA. Diagnosis and treatment of severe hematochezia. The role of urgent colonoscopy after purge. Gastroenterology 1988;95(6):1569–74 Jensen DM, Ghassemi KA. Lower GI Bleeding: epidemiology and management. Curr Gastroenterol Rep. 2013;15(7):333

Transfusion-free management of gastrointestinal bleeding: the experience of a bloodless institute.

The Institute for Patient Blood Management and Bloodless Medicine at the Englewood Hospital has considerable experience in managing patients with gastrointestinal bleeding who do not accept blood-derived products. We present our data and experience over the last 8 years in managing such patients. There is paucity of data on management and outcomes of gastrointestinal bleeding in patients who do not accept blood-derived products. We performed a retrospective study of patients from 2003 to 2011 presenting with gastrointestinal bleeding who do not accept blood-derived products. Inclusion criteria were either overt bleeding with a presenting hemoglobin (Hb) of <12 g/dL or a decrease in Hb of >1.5 g/dL. Ninety-six patients who met the inclusion criteria were included. Forty-one upper and 48 lower gastrointestinal bleeding sources were identified. Mean Hb was 8.8 g/dL and mean nadir was 6.9 g/dL. Among 37 patients (80.5%) with Hb ≤6.0 g/dL, 30 (81%) survived. Four of 7 patients (57%) with a Hb <3 g/dL survived. The overall mortality rate was 10.4%. In unadjusted logistic regression models, age [1.06 (1.01-1.12 y)], admission to ICU [6.37(1.27-31.9)], and anticoagulation use [6.95 (1.57-30.6)] were associated with increased mortality. Initial Hb [0.68 (0.51-0.92)] and nadir Hb [0.48 (0.29-0.78)] inversely predicted mortality. These results suggest that transfusion-free management of gastrointestinal hemorrhage can be effective with mortality comparable with the general population accepting medically indicated transfusion. Management of these patients is challenging and requires a dedicated multidisciplinary team approach knowledgeable in techniques of blood conservation.

Difference in Prevalence of Small Bowel Video Capsule Endoscopy Findings Between Cardiac Versus Non-Cardiac Inpatient Cohorts

Introduction: Capsule endoscopy (CE) is a diagnostic tool used to investigate the small intestine for gastrointestinal bleeding sources (GIB) and mucosal abnormalities. It has been demonstrated that CE is safe to perform in cardiac patients with implantable electromechanical devices and left ventricular assist (LVAD) devices. Limited data is available comparing CE findings between inpatient (IP) cardiac vs. noncardiac cohorts. Our objective is to explore the relationship of small bowel (SB) CE findings among IP cardiac patients with and without LVAD and non-cardiac patients. Methods: A retrospective analysis was performed in adult IP that underwent CE at a single large tertiary medical center from November 2002 to December 2013. Data extraction included demographics (age, BMI, race, and gender), medical and antithrombotic history, and CE findings. IP were divided into 3 groups: LVAD patients, non-LVAD cardiac patients, and non-cardiac patients. Comparisons of dichotomous variables were performed using a Chi-squared test. A p-value of 0.05 was considered statistically significant. Results: Four hundred twenty-four consecutive IP adults (56% males) who underwent a CE were included in the analysis. Sixty-six percent were white, mean age 63 (SD=15.8), BMI 29.4 (SD=8.9), and 65% had GIB as indication for study. There was a trend toward a higher likelihood of finding a GIB source in the patients with cardiac history (LVAD and non-LVAD) compared to the non-cardiac group, 17.1% compared to 11.8%, p=0.06. The non-cardiac IP group was associated with a significantly higher likelihood of findings of SB ulcerations compared to the cardiac groups, 7.5% vs. 3.0% (p=0.030). A sub-analysis was performed for IP off anti-coagulation and no difference was present in CE findings between the 3 groups. Conclusion: Inpatients with a cardiac history referred for CE tend to have more GIB sources found on CE than non-cardiac patients, but not to a significant extent. Findings of ulcerations are significantly more common in non-cardiac patients undergoing CE. In this study, the yield of CE to evaluate for GIB source in the SB is higher in cardiac vs. non-cardiac IP, but useful for both groups diagnostically.

Clinical characteristics and outcomes of clostridial bacteraemia in cancer patients

Clostridial bacteraemia is usually associated with substantial morbidity and mortality in cancer patients. However, clinical characteristics and risk factors for early mortality in this population are poorly described. We retrospectively studied cancer patients with clostridial bacteraemia treated between January 1996 and December 2011. We compared clinical manifestations between patients with solid tumour and haematological malignancy and assessed risk factors for 7-day mortality. In all, 164 cancer patients developed clostridial bacteraemia during the study period—85 (52%) with solid tumour and 79 (48%) with haematological malignancy. Common isolates were Clostridium perfringens (27%), Clostridium septicum (19%) and Clostridium tertium (14%). Solid tumour malignancy patients were more likely to have a focal gastrointestinal source for bacteraemia and were more likely to undergo subsequent surgery. Haematological malignancy patients were more often neutropenic and more often had no focal source of bacteraemia. Seven-day mortality was 20% (33/164) and did not vary based on malignancy type. The adjusted odds ratio of dying within 7 days of clostridial bacteraemia among patients with hypotension (40/164) was 7.2 (95% CI, 2.9–18.1) and in patients with acute haemolysis (7/164) was 10.5 (95% CI, 1.3–85.2). Clostridial species also impacted mortality; no patient with C. tertium bacteraemia died within 7 days. In conclusion, clinical manifestations of clostridial bacteraemia differed between patients with solid tumour and haematological malignancy, but 7-day mortality was similar. Patients with hypotension and haemolysis at time of bacteraemia were at increased risk for early death.

Answer to June 2014 Photo Quiz

Answer: Dysgonomonas capnocytophagoides. This isolate, which was nonmotile and catalase and oxidase negative, was identified by the Vitek 2 system (bioMerieux, Inc., Hazelwood, MO) as Rhizobium radiobacter, while RapID NF (Remel, Lenexa, KS) gave no identification. The isolate was submitted for identification by partial 16S rRNA gene sequencing as well as matrix-assisted laser desorption ionization–time of flight mass spectrometry (MALDI-TOF MS). Sequencing identified the isolate as Dygonomonas capnocytophagoides. Blood cultures remained positive for 13 days despite treatment with meropenem alone followed by dual therapy with piperacillin-tazobactam and levofloxacin. The MICs of ceftriaxone, erythromycin, ampicillin, clindamycin, and tetracycline for this organism were ≥256 μg/ml, 8 μg/ml, 32 μg/ml, 0.25 μg/ml, and 0.5 μg/ml, respectively. The addition of doxycycline based on these susceptibility results quickly sterilized the patient's bloodstream. Ultimately, the hepatic abscesses were excised en bloc on hospital day 48 with the explantation and reimplantation of the patient's second orthotopic liver. His postoperative course was uneventful, and he has since made a full recovery. The genus Dysgonomonas is subdivided into three major species, Dysgonomonas mossii, D. gadei, and D. capnocytophagoides (formerly designated CDC group DF-3), with a fourth species “Dysgonomonas hofstradii,” proposed (1,–3). Colonies measure 1 to 2 mm in diameter after 24 h of growth, have a distinct strawberry-like odor, and do not spread or adhere. Microscopically, Dysgonomonas spp. appear as small, Gram-negative rods or cocci. All members are oxidase negative, do not reduce nitrate or produce H2S, ferment glucose, lactose, and xylose, and produce alkaline phosphatase and β-galactosidase but not arginine dehydrolase. Although the species show few biochemical differences, the distinguishing features of D. capnocytophagoides include negative indole and catalase reactions (2, 3). The pathogenic potential of this uncommon bacterium seems to be limited to immunocompromised individuals. In 1988, D. capnocytophagoides was reported to have caused diarrhea in an immunocompromised host and later bacteremia in two leukemic patients, one of whom had the strain isolated from stool (1). When D. capnocytophagoides causes clinical disease, a gastrointestinal source should be strongly considered because most strains have been isolated from stool, although the organism has also been isolated from urine and skin abscesses (1, 3). Another alarming feature of Dysgonomonas spp. is their well-established resistance to beta-lactams, macrolides, aminoglycosides, and quinolones (4), a susceptibility profile similar to that of our patient's organism. Identification of this organism with conventional identification techniques can be difficult. MALDI-TOF MS misidentified the organism as D. gadei, an error previously documented in the medical literature because of gaps in the MALDI-TOF MS database. A negative catalase reaction in this situation would indicate that the correct identification is indeed D. capnocytophagoides (5). Though 16S rRNA gene sequencing correctly identified the pathogen as D. capnocytophagoides, this procedure is time-consuming and is also considerably more expensive to perform than MALDI-TOF MS. MALDI-TOF MS may replace such molecular techniques in identifying such rare pathogens as D. capnocytophagoides once the databases become more accurate and reliable (6). (See page 1811 in this issue [doi:10.1128/JCM.00349-13] for photo quiz case presentation.)

Escherichia coli bacteraemia: 2 years of prospective regional surveillance (2010-12)

To determine the prevalence of antibiotic resistance and the epidemiology of Escherichia coli bacteraemia isolates across the Yorkshire and Humber National Health Service region over 2 years. Ten percent of all E. coli blood culture isolates were collected per month from 14 laboratories across the Yorkshire and Humber region. Individual laboratories submitted antibiotic susceptibility data and isolates were re-tested centrally using the VITEK2(®) system (bioMérieux, France). Isolates were also characterized using PCR to test for the presence of sequences encoding extended-spectrum β-lactamases (ESBLs) and genotyped using amplified fragment length polymorphism (AFLP). Selected isolates were further characterized using multilocus sequence typing. Between July 2010 and June 2012, 770 isolates were examined: 63%, 40%, 14% and 7% of isolates were non-susceptible to ampicillin, trimethoprim, ciprofloxacin and gentamicin, respectively. Eight percent of isolates (n = 63) were ESBL positive; CTX-M group 1 enzymes were the most common (68%). There was a fluctuating trend in the prevalence of resistance to amoxicillin/clavulanic acid (MIC >8 mg/L): July-September 2010, 16%; July-September 2011, 38%; and April-June 2012, 22%. AFLP identified 106 types. The majority of isolates belonged to one of two AFLP types: AFLP 1 [sequence type (ST) 131; 17%] and AFLP 2 (ST73; 18%). ST131 and ST73 were both associated with hospital- and community-onset bacteraemia, and with urinary, hepatobiliary and gastrointestinal sources of infection. ESBL-positive isolates were predominantly ST131 (60%). Continued surveillance of antibiotic resistance among E. coli bacteraemia isolates is necessary to enhance these early baseline data. The variable prevalence of resistance to amoxicillin/clavulanic acid raises concerns, as both E. coli bacteraemia and empirical use of this antibiotic are common.