Clinical Features of Ischemic Enteritis Diagnosed by Double-Balloon Endoscopy

Introduction. Ischemic enteritis (IE) is a relatively rare small bowel disease that is diagnosed via double-balloon endoscopy (DBE), although the lack of established diagnostic criteria can make it difficult to confirm the diagnosis. This study aimed to describe the clinical characteristics, endoscopic imaging features, and treatments for IE at our center. Patients and Methods. We retrospectively searched the DBE database (1,521 patients) at Nagoya University Hospital for patients with IE and collected data regarding endoscopic findings, clinical background, and histological findings. The cases were categorized according to whether they involved transient or stenotic IE. Results. The DBE database included 24 patients (14 men) with IE. Transient IE was identified in 9 patients, and stenotic IE was identified in 15. Half of the patients had a history of cerebrovascular and cardiovascular disease. A granular structure at the ulcer base was the most frequently observed DBE finding at the stenotic site. Enterography using the contrast medium revealed that transient IE had a similar stenotic lesion length, relative to stenotic IE, although stenotic IE had a significantly higher stenosis ratio (81% vs. 63%, P = 0.033 ). Small bowel enteroclysis revealed the “lead pipe” sign (11 patients), thumbprinting (3 patients), and the serrated lumen sign (1 patient). Only 1 patient with stenotic IE experienced recurrence after conservative treatment. Conclusion. During DBE, IE was characterized by cannular stenosis with extended and variable ulceration types, which spread over the edge of the stenosis, and a granular appearance at the ulcer base. These findings may help guide the diagnosis of IE.

Diagnosis and Management of Osteomyelitis Associated With Stage 4 Pressure Ulcers: Report of a Query to the Emerging Infections Network of the Infectious Diseases Society of America

Background Few studies exist to guide the management of patients with stage 4 pressure ulcers with possible underlying osteomyelitis. We hypothesized that infectious disease (ID) physicians would vary widely in their approach to such patients. Methods The Emerging Infections Network distributed a 10-question electronic survey in 2018 to 1332 adult ID physicians in different practice settings to determine their approach to such patients. Results Of the 558 respondents (response rate: 42%), 17% had managed no such patient in the past year. Of the remaining 464 respondents, 60% usually felt confident in diagnosing osteomyelitis; the strongest clinical indicator of osteomyelitis reported was palpable or visible bone at the ulcer base. Approaches to diagnosing osteomyelitis in patients with visible and palpable bone varied: 41% of respondents would assume osteomyelitis, 27% would attempt pressure off-loading first, and 22% would perform diagnostic testing immediately. Preferred tests for osteomyelitis were bone biopsy (for culture and histopathology) and magnetic resonance imaging. Respondents differed widely on favored route(s) (intravenous, oral, or both) and duration of antimicrobial therapy but would treat longer in the absence, vs presence, of full surgical debridement (P < .001). Overall, 62% of respondents opined that osteomyelitis under stage 4 pressure ulcers is usually or almost always treated excessively, and most (59%) suggested multiple topics for future research. Conclusions Regarding osteomyelitis underlying stage 4 pressure ulcers, ID physicians reported widely divergent diagnostic and treatment approaches. Most of the reported practice is not supported by the available evidence, which is quite limited and of low quality.

1429. Diagnosis and Management of Osteomyelitis Associated with Stage IV Pressure Ulcers: Report of a Query to the Emerging Infections Network of the Infectious Diseases Society of America

Background Despite the high prevalence and morbidity of stage IV pressure ulcers, there are few clinical studies to guide diagnosis and treatment of osteomyelitis in such patients. Methods The Emerging Infections Network conducted an electronic survey of adult ID physicians in 2018 to determine their approach to managing patients with stage IV pressure ulcers (exposed bone, tendon, or muscle) and osteomyelitis. Results The overall response rate was 42% (558/1,332). Of the respondents, 94/558 (17%) had not seen such patients in the last year, so opted out. Of the remaining 464 respondents, 276 (60%) usually felt confident in diagnosing osteomyelitis by physical examination, and laboratory or imaging test results; the strongest indicator of osteomyelitis was thought to be palpable or visible bone at the ulcer base (Figure 1). Approaches to diagnosing osteomyelitis in patients with visible and palpable bone varied: 41% would assume osteomyelitis was present, 27% would try local wound care and pressure-offloading before doing tests, 22% would do diagnostic tests immediately, and 10% would follow another strategy. The preferred tests for osteomyelitis were bone biopsy (for culture or histopathology) and MRI (Figure 2). Regarding treatment, respondents differed widely regarding favored route(s) of antimicrobial therapy (all IV, partly IV and partly oral, or all oral), regardless of presumed pathogen (Figure 3). Respondents also differed widely regarding preferred duration of antimicrobial therapy, but generally would treat longer in the absence of full surgical debridement (P < 0.001 overall) (Figure 4). Overall, 62% of respondents believed that osteomyelitis under stage IV pressure ulcers usually or almost always is treated excessively. Most respondents (59%) had multiple suggestions for future research, primarily regarding the duration and utility of antimicrobial therapy in this context. Conclusion ID physicians (i) report significant practice variability in their approach to diagnosing and treating osteomyelitis underlying stage IV pressure ulcers, (ii) are concerned about excessive antibiotic use in such patients, and (iii) perceive a critical need for additional research in this area. Disclosures All authors: No reported disclosures.