Systemic sclerosis (SSc) is a rare autoimmune disease characterized by fibroproliferative alterations of the microvasculature leading to fibrosis and loss of function of the skin and internal organs. Gastrointestinal manifestations of SSc are the most commonly encountered complications of the disease affecting nearly 90% of the SSc population. Among these complications, the esophagus and the anorectum are the most commonly affected. However, this devastating disorder does not spare any part of the gastrointestinal tract (GIT), and includes the oral cavity, esophagus, stomach, small and large bowels as well as the liver and pancreas. In this review, we present the current understanding of the pathophysiologic mechanisms of SSc including vasculopathy, endothelial to mesenchymal transformation as well as the autoimmune pathogenetic pathways. We also discuss the clinical presentation and diagnosis of each part of the GIT affected by SSc. Finally, we highlight the latest developments in the management of this disease, addressing the severe malnutrition that affects this vulnerable patient population and ways to assess and improve the nutritional status of the patients.

Red Man syndrome (RMS) occurs with the rapid infusion of intravenous (IV) vancomycin. RMS induced by oral vancomycin has been the focus of a limited number of case reports. We present a case of a 75-year-old female admitted with severe Clostridium difficile colitis who received oral vancomycin and by the second day of therapy, she developed flushing, erythema, and pruritus involving the face, neck and upper torso. Oral vancomycin was immediately withheld, and diphenhydramine was initiated. Clinical improvement was apparent 24 hours after discontinuation of oral vancomycin. Our case adds to the published literature on this rare clinical entity that should be considered when severe colitis patients prescribed oral vancomycin, as part of the standard of care, develop the typical signs and symptoms of RMS.

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ObjectiveThere is a lack of literature on postendoscopic retrograde cholangiopancreatography (ERCP) complications in predominantly black urban populations of low socioeconomic status. The aim of this study was to determine the incidence and predictors of post-ERCP complications in this patient population.DesignRetrospective review of ERCP cases performed at two hospitals from 2007 to 2017 was performed. The categories of complications evaluated were overall complications, severe or fatal complications, pancreatitis, bleeding, infection, perforation and cardiopulmonary events. Predictors of complications were determined by univariate analysis.ResultsA total of 1079 ERCP procedures were reviewed. There were 106 complications (9.8%). Twenty-one were severe (1.9%) and 20 were fatal (1.9%). Both post-ERCP pancreatitis (PEP) and post-ERCP bleeding occurred in 18 patients (1.7%) each. Risk factors for overall complications were male sex (OR 1.54), ASA grade IV or V (OR 2.19), prior history of PEP (OR 6.98) and pancreatic duct stent placement (OR 2.75). Those who were ASA grade III or lower (OR 0.4) or who underwent biliary stone extraction (OR 0.62) had fewer complications. PEP was more likely in those with a prior history of PEP (OR 37.6). Those with a suspected or known biliary duct stone had less frequent pancreatitis (OR 0.32). Post-ERCP bleeding was more likely in the presence of cholangitis (OR 8.72).ConclusionOutcomes of ERCP in a predominantly black urban population demonstrate a lower incidence of PEP and all-cause mortality compared with historical data reported in the general population. Potential risk factors for post-ERCP complications were identified but require larger studies for validation.

Rheumatoid arthritis (RA) patients have nearly twice the risk of cardiovascular disease (CVD) compared to the general population. We aimed to assess, in a predominantly Black population, the prevalence of traditional and RA-specific CVD risk factors and therapeutic patterns. Utilizing ICD codes, we identified 503 RA patients ≥18 years old who were seen from 2010 to 2017. Of them, 88.5% were Black, 87.9% were women and 29.4% were smokers. CVD risk factors (obesity, diabetes, hypertension, dyslipidemia) were higher than in previously reported White RA cohorts. Eighty-seven percent of the patients had at least one traditional CVD risk factor, 37% had three or more traditional CVD risk factors and 58% had RA-specific risk factors (seropositive RA, >10 years of disease, joint erosions, elevated inflammatory markers, extra-articular disease, body mass index (BMI) < 20). CV outcomes (coronary artery disease/myocardial infarction, heart failure, atrial fibrillation and stroke) were comparable to published reports. Higher steroid use, which increases CVD risk, and lesser utilization of biologics (decrease CV risk) were also observed. Our Black RA cohort had higher rates of traditional CVD risk factors, in addition to chronic inflammation from aggressive RA, which places our patients at a higher risk for CVD outcomes, calling for revised risk stratification strategies and effective interventions to address comorbidities in this vulnerable population.

INTRODUCTION: Accumulating evidence indicates an association between CD4 count and Ulcerative colitis (UC) flares in patients with Human Immunodeficiency Virus (HIV)[1,4], whereby patients who have low CD4 counts are less likely to experience UC flares compared to those who have normal CD4 counts. While the exact mechanism is unknown, it is hypothesized that an immunosuppressed state allows for the remission of UC; this idea has been deemed the “Remission Hypothesis” [1]. CASE DESCRIPTION/METHODS: Objective: To present a case series of 3 patients with concomitant HIV and Ulcerative Colitis (UC) and examine the association between UC flares, CD4 counts and viral load over time. METHODS: Patient records at two urban university-affiliated medical centers were queried for patients with concomitant HIV and UC. ICD 9 and ICD 10 diagnostic codes for HIV and UC were used to identify patients. Inclusion criteria were confirmed UC via endoscopy, outpatient follow up, viral load and CD4 count documentation. CD4 counts and viral loads levels were compared during hospitalizations and outpatient follow-ups. RESULTS: 7 patients with UC and HIV were identified; 3 of these 7 patients had sufficient data available for further analysis. Our three patients lived with HIV for an average of 10 years. Patient 1 experienced 4 UC flares requiring inpatient hospitalizations while maintaining CD4 counts above 250 cells/µL and undetectable viral loads (Table 1). Patient 2 had five UC flares with CD4 counts above 250 cells/µL; an undetectable viral load was noted during 4 of the UC flares (Table 2). Patient 1 had two flares with CD4 counts above 250 cells/µL; the viral load was undetectable during flares (Table 3). DISCUSSION: The remission hypothesis suggests that patients who have concomitant HIV and UC can experience remission of their inflammatory bowel disease as their CD4 count declines [1]. HIV viral load is a more accurate and more important marker of HIV disease progression, and therefore, a relationship between viral load and UC flares need to be further studied. Our patients continued to experience flares despite suppressed viral load, and CD4 counts above 250 cells/µL. This case series is the first study that considers viral load and CD4 counts when considering IBD flares and disease progression. These findings raise the question of whether IBD flares occurs as a consequence of CD4 count above 250 or low viral load. Further studies with larger populations are needed to elucidate the pathophysiology of IBD and HIV coexistence.

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