Background Hemorrhage is a common complication associated with endoscopic retrograde cholangiopancreatography (ERCP), usually following sphincterotomy. Studies investigating risk factors for hemorrhage including ERCP indication have been conflicting. Therefore, we conducted a systematic review and meta-analysis to characterize the association between the ERCP indication and hemorrhage.Methods Database searches of MEDLINE, EMBASE, and CENTRAL were conducted to identify articles up to December 12, 2022. Randomized trials or observational studies of adult patients undergoing ERCP were included. Quality assessment using the Cochrane Risk of Bias 2.0 and Newcastle-Ottawa Scales for randomized trials and observational studies respectively was conducted. A random effects meta-analysis generating pooled odds ratios with 95% confidence intervals was conducted.Results A total of 1323 articles were identified of which 26 were included with up to 25 121 subjects in each meta-analysis. Rates of sphincterotomy (median 96.1%; IQR 60.5-100), biliary stent placement (median 17.2%; IQR 10.6-34.4), antiplatelet use (median 6.0%; IQR 0-10.1), and anticoagulant use (median 1.9%; IQR 0%-3.2%) varied among included studies. No specific indication was associated with hemorrhage in the meta-analyses including cholangitis (OR 1.50; 95% CI 0.97-2.32), choledocholithiasis/biliary stone (OR 1.28; 95% CI 0.95-1.73), malignancy (OR 0.97; 95% CI 0.66-1.42), sphincter of Oddi dysfunction (OR 1.32; 95% CI 0.72-2.40), and acute pancreatitis (OR 0.81; 95% CI 0.44-1.49).Conclusions Overall, no indication was significantly associated with increased hemorrhage following ERCP. However, given limitations in the included studies (ie, significant heterogeneity between studies), additional research to better characterize these associations is needed.Protocol Registration Number PROSPERO (CRD42021283978). Bleeding is common after endoscopic retrograde cholangiopancreatography (ERCP). We asked if the reason for ERCP may affect bleeding risk. We answered this with a systematic review of the literature. When we looked at specific reasons for doing ERCP, such as cholangitis or cancer, we did not find any clear link to bleeding. However, there were limitations in the included studies. Overall, our study suggests that there is no clear connection between why ERCP is done and bleeding. More research is needed to investigate this question further.

This study documents prevalence of positive depression screens at the first prenatal visit in an urban, low-income, and primarily Black population as part of initiatives to strengthen mental health services in a region with high rates of race disparities in infant and maternal mortality. We conducted a cross-sectional chart review of 500 patients, collecting demographics, medical histories, and scores of the Edinburgh Postnatal Depression Scale (EPDS), the instrument recommended for use during pregnancy by national United States organizations. Of those with a completed EPDS (n=414), 32% screened positive (n=131). These women were more likely to have smoked (p=.02), used illicit drugs (p=.01), or had depression (p<.0001), anxiety (p=.0004), bipolar disorder (p=.02), or postpartum depression for the subgroup with prior pregnancies (p<.0001). A high percentage of patients had positive EPDS screens, highlighting the need for better integration of mental health services into prenatal care for vulnerable populations.

Chronic intestinal pseudo-obstruction (CIPO) is a disruption of the enteric nervous system characterized by chronic intestinal dysmotility and dilation. It has many underlying causes. We present a 52-year-old woman with 53 kg unintentional weight loss, abdominal pain, and vomiting. She had dilated small bowel loops with air fluid levels and no transition point on CT. Esophagogastroduodenoscopy (EGD) revealed aperistalsis and undigested duodenal food. The secondary cause was found to be Undifferentiated Connective Tissue Disorder (UCTD), a rheumatologic disorder that does not meet criteria for any single disease. This is the first reported case of UCTD being presented by CIPO.

Peptic ulcer disease (PUD) develops in approximately 25% of chronic users of non-steroidal anti-inflammatory drugs (NSAIDs). The incidence of uncomplicated PUD has been declining over the past 3 decades unlike that of complicated PUD in the elderly. An expert consensus document published jointly in 2008 by the American College of Gastroenterology (ACG), the American College of Cardiology Foundation (ACCF), and the American Heart Association (AHA) provided recommendations on prevention of PUD among users of antiplatelets and anticoagulants. This work aimed to evaluate physicians’ compliance with these guidelines in a tertiary academic setting. We examined our medical record database for the 9 month period extending from April 2018 until December 2018. Using this database, we identified elderly patients (> 64 years old) who were chronic (> 3 months) users of low dose aspirin (81 mg once daily) and had an indication for PUD prophylaxis as per the ACG–ACCF–AHA guideline document. We performed a retrospective chart review of patients included in this study. Descriptive statistics were compared using χ2 and independent sample t tests. A total of 852 patients were included in this study. The mean age was 75 years old, and 43% of patients were females. In addition to aspirin, patients were prescribed P2Y12 inhibitors (45.5%), direct oral anticoagulants (DOACs) (23%), warfarin (12%), steroids (9%) or enoxaparin (1%). Users of DOACs were most commonly prescribed apixaban (16%), followed by rivaroxaban (6%) and dabigatran (1%). Overall, only 40% of patients with an indication for PUD prophylaxis received a proton pump inhibitor. PUD prophylaxis may be underutilized in elderly patients. This finding, along with increasing rates of NSAID use and an aging population, may help explain the increased incidence of complicated PUD in the elderly. Efforts are needed to raise physician awareness of PUD prophylaxis guidelines.

BACKGROUND:Immunosuppressed women with inflammatory bowel disease (IBD) are at elevated risk of cervical cancer yet have lower screening rates. The objective of this study was to assess the familiarity with cervical cancer screening recommendations, and the perceived responsibility for implementing screening among three physician groups involved in the clinical care of women with IBD: primary care physicians (PCP), gastroenterologists (GI) and gynecologists (GYN).METHODS:We anonymously surveyed a sample of 117 PCP, 52 GYN and 35 GI physicians affiliated with Saint Louis University, Saint Louis, MO, USA, from April 2018 to January 2019. The physicians completed a questionnaire adressing essential aspects of cervical cancer screening such as screening age, screening frequency, human papillomavirus (HPV) vaccination, comfort level in performing Papanicolaou (Pap) smears, perception of physician responsibility in terms of which physicians should perform Pap smears.RESULTS:A total of 2.6% of PCPs, 37% of GIs and 29% of GYNs reported familiarity with cervical cancer screening recommendations. In addition, PCP and GI had no definite opinions regarding which physicians should be in charge of cervical cancer screening and performing Pap smears. However, 94% of GYNs felt that they should be in charge of cervical cancer screening and performing Pap smears.CONCLUSIONS:An apparent lack of familiarity exists among all three physician groups regarding cervical cancer screening recommendations in immunosuppressed patients with IBD. Similarly, there is no consensus regarding which specialty should be responsible for cervical cancer screening in this patient population.

ABSTRACT Porphyria cutanea tarda (PCT) is a skin disorder characterized by abnormal heme synthesis. We present a 45-year-old man with intermittent skin lesions recurring annually for years. Skin biopsy and measurement of serum heme precursors confirmed a diagnosis of PCT. He had persistently elevated alanine and aspartate transferase. He was referred to hematology and had genetic testing with iron studies which also revealed hereditary hemochromatosis (HH). Therapeutic phlebotomy was initiated, which led to resolution of iron overload and skin lesions. We highlight the associated conditions of PCT and HH, their common therapy of phlebotomy, and initial manifestations of HH.