Faculty Bibliography

INTRODUCTION: Meckel's diverticulum (MD) is the most common congenital malformation of the gastrointestinal (GI) tract, present in 2-4% of the population. Typically, it presents as GI bleeding and is usually diagnosed in childhood. However, some patients may remain asymptomatic through adulthood or present later in life with complications. We describe an unusual case of an adult male presenting with abdominal pain and maroon stools, who underwent an extensive workup and was eventually diagnosed with MD only after a double-balloon enteroscopy (

INTRODUCTION: Iron deficiency anemia is a common condition that often leads to evaluation of the gastrointestinal tract for sources of blood loss. Parasitic infections are uncommon causes of gastrointestinal blood loss. Here we present a case of progressive iron deficiency anemia due to Trichuris trichiura (whipworm) infection. CASE DESCRIPTION/METHODS: A 65-year-old male, originally from the Philippines, with a past medical history of hypertension and coronary artery disease (on aspirin and clopidogrel) presented with progressive worsening fatigue for four weeks with new onset small volume rectal bleeding for three days. Travel history was notable for a recent trip to Mexico complicated by a self-limited diarrheal illness six weeks prior to presentation as well as frequent travel to the Philippines. Physical exam was notable for pallor and a rectal exam with no evidence of external hemorrhoids and brown stool. Labs were notable for hemoglobin of 7.5 g/dL from a baseline of 14 g/dL one year prior to presentation. Other pertinent labs included a mean corpuscular volume of 80 fL, iron saturation of 4% with a ferritin of 7 ng/mL. An upper endoscopy and colonoscopy was performed. The upper endoscopy was unremarkable with no source of blood loss anemia. The colonoscopy was notable for internal hemorrhoids and evidence of worms found in the cecum. A worm was obtained and sent for microscopic evaluation with final speciation revealing T. trichiura (whipworm). The patient also underwent a video capsule endoscopy as an outpatient two weeks after discharge which was unremarkable. The patient was treated with a three day course of mebendazole and initiated on iron supplementation with interval outpatient follow up revealing resolution of iron deficiency anemia within 6 weeks post-treatment with subsequent hemoglobin of 13.7 g/dL. DISCUSSION: Parasitic infections, especially those without significant concurrent gastrointestinal symptoms, can lead to a diagnostic delay as a potential cause of iron deficiency anemia. Whipworm infections occurs through ingestion of whipworm eggs that are then passed in the feces of infected individuals. Many cases of T. trichiura infection are asymptomatic however a high worm burden can lead to diarrhea and anemia. The pathophysiology of resulting iron deficiency anemia from T. trichiura is thought to be from worm consumption of blood and possible colonic lesions leading to occult gastrointestinal bleeding. A thorough history, including travel history, remains crucial for diagnosis. (Figure Presented)

INTRODUCTION: Gastrointestinal (GI) complications in patients undergoing orthopedic surgery are common but underreported. Prolonged immobility and the use of post-operative narcotics can increase the risk of GI complications which include: constipation, ileus, bowel obstruction, stercoral colitis, perforation, and death. In 2017 we observed an increase in GI complications among patients undergoing orthopedic surgery at our orthopedic hospital. This prompted a multidisciplinary quality improvement (QI) initiative to reduce GI complications among patients admitted after joint or spine surgery.
METHOD(S): Following a surge of GI complications at our university-affiliated tertiary referral orthopedic satellite hospital in early 2018 we created a multidisciplinary QI program. The first component was a didactic lecture delivered by a GI attending to the orthopedic trainees, attendings, physician extenders, nurses and staff. The 1 hour lecture discussed an effective GI history, exam and reviewed the symptoms and treatment of common GI conditions affecting post-operative patients. The second component was the development of a post-operative constipation and bowel assessment algorithm focused on early identification, escalation and treatment of GI conditions (Figure 1). The third component was a redesign of the electronic medical record post-operative constipation order sets in order to facilitate implementation of the aforementioned bowel algorithm. This new order set changed laxative orders from ?as needed? to standing with an option to be held for diarrhea. These QI initiatives were implemented on a rolling basis from 1/31/2018 to 5/31/2018. Cases of ileus, obstruction and perforation were determined based on coding for admitted orthopedic patients.
RESULT(S): The proportion of patients admitted with each diagnosis was compared from the first quarter (1/1 to 3/31) of 2018 to 2019 corresponding to 6 months after the implementation of all QI components (Figure 2). We achieved a 71% reduction in overall bowel complications (P<0.05). The greatest reduction was achieved in post-operative ileus by 81% (P<0.05). Following the QI initiative there was only 1 perforation corresponding to a 50% reduction.
CONCLUSION(S): We created a multidisciplinary QI program that successfully reduced GI complications in patients hospitalized following orthopedic surgery. The greatest impact was in the reduction of post-operative ileus and serious adverse events such as perforation. (Figure Presented)

Background: Good colon preparation is critical for ensuring high quality optical colonoscopy (OC). Hospitalized patients are at high risk for inadequate colon preparation for OC due to comorbidities, medication use and debilitated status. Inadequate colon preparation leads to delayed, aborted and rescheduled procedures resulting in prolonged hospitalizations and increased costs. The Pure Vu System is a novel device intended to fit over existing colonoscopes to facilitate intraprocedural cleansing of the colon by simultaneously irrigating and evacuating bowel content.
Method(s): This multicenter, prospective, single-arm study (sponsored by Motus GI)anticipates enrolling up to 100 hospitalized patients to evaluate the Pure-Vu System following standard bowel preparation. This interim analysis summarizes the results of the initial 45 patients enrolled. Upon consenting, patients were consecutively enrolled regardless of the bowel preparation condition and the procedure was performed with the Pure-Vu System. The primary endpoint was improvement of colon cleansing from baseline to post procedure as assessed by the improvement in Boston Bowel Preparation Scale (BBPS)following cleansing with Pure-Vu System Secondary endpoints were rate of patients with successful colonoscopy for the intended indication in the first attempt and safety.
Result(s): Forty-five hospitalized patients (62% males), mean age 63.1 years and mean BMI of 27.1 kg/m² were included in the analysis. The predominate indication for OC was GI bleeding (62%)(Table 1). In 36 (80%)patients, the physician was able to successfully diagnose in the first attempt per the patients' indication. In these patients, adequate bowel cleansing (BBPS>=2 in each segment that were visualized)was improved from 39% at baseline to 100% after cleansing with the Pure-Vu System. There was one procedure related perforation which required surgical repair, the patient was discharged 48 hours post operatively and fully recovered.
Conclusion(s): Bowel preparation for hospitalized patients remain a significant challenge resulting in delayed/cancelled procedures, missed pathology and increased costs of care. Although a small subset, this first U.S. multicenter study investigates a population that poses the most challenging medical circumstances. One of the limitations of this study is unavailability of the Pure-Vu system compatible with Slim (pediatric)colonoscopes; in 4 of the 9 cases where a conclusive diagnosis could not be obtained, a Slim scope was used to complete the procedure. The Pure-Vu system cleanses the colon intraprocedurally and may improve the efficacy and prevent a delayed or repeat OC procedure. This preliminary analysis demonstrates an increase in the BBPS score following the use of the Pure-Vu System, but more importantly, it demonstrates an increase in colon cleansing adequacy to reach successful diagnosis. [Figure presented][Figure presented]
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