Background and GoalsHepatitis A (HAV) and hepatitis B (HBV) vaccination in patients with chronic liver disease is an accepted standard of care. We determined HAV and HBV vaccination rates in a tertiary care referral hepatology clinic and the impact of electronic health record (EHR)-based reminders on adherence to vaccination guidelines.MethodsWe reviewed the records of 705 patients with chronic liver disease referred to our liver clinic in 2008 with at least two follow-up visits during the subsequent year. Demographics, referral source, etiology, and hepatitis serology were recorded. We determined whether eligible patients were offered vaccination and whether patients received vaccination. Barriers to vaccination were determined by a follow-up telephone interview.ResultsHAV and HBV serologic testing prior to referral and at the liver clinic were performed in 14.5% and 17.7%; and 76.7% and 74% patients, respectively. Hepatologists recommended vaccination for HAV in 63% and for HBV in 59.7% of eligible patients. Patient demographics or disease etiology did not influence recommendation rates. Significant variability was observed in vaccination recommendation amongst individual providers (30–98.6%), which did not correlate with the number of patients seen by each physician. Vaccination recommendation rates were not different for Medicare patients with hepatitis C infection for whom a vaccination reminder was automatically generated by the EHR. Most patients who failed to get vaccination after recommendation offered no specific reason for noncompliance; insurance was a barrier in a minority.ConclusionsHepatitis vaccination rates were suboptimal even in an academic, sub-speciality setting, with wide-variability in provider adherence to vaccination guidelines.

Tubo-ovarian abscess (TOA) is a potentially lethal condition, often requiring a combination of medical and surgical interventions. Endoscopic ultrasound (EUS)-guided drainage is a known modality for safe and effective management of pelvic fluid collections, but its role for the treatment of TOA is not well documented. We report the first known case of successful treatment of a large TOA with EUS-guided transrectal drainage using a lumen-apposing metal stent.

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INTRODUCTION: Tubo-ovarian abscess (TOA) is a potentially lethal condition requiring a combination of medical and surgical intervention. Endoscopic ultrasound (EUS)-guided drainage is a known modality for safe and effective management of pelvic collections, but its role in TOA drainage is not well documented. We present a case of a TOA treated successfully with EUS-guided transrectal drainage using a lumen apposing metal stent (LAMS). CASE DESCRIPTION/METHODS: A 45-year-old woman presented to the hospital with a 4-day history of left lower quadrant abdominal pain. Her medical history included a right-sided TOA treated with antibiotics one year ago, type II diabetes mellitus, and obesity. She was tachycardic and tachypneic on arrival with a leukocytosis and elevated inflammatory markers. Computed tomography (CT) revealed a 11.3 × 10.3 × 9.4 cm complex cystic structure within the left adnexa consistent with a TOA (Image 1). Due to worsening leukocytosis and abdominal pain, interventional radiology was consulted but could not find a safe window for percutaneous drainage. A rectal EUS subsequently revealed a 50 × 45 mm abscess 20 cm from the anal verge (Image 2). A 19-gauge EZ-Shot 3 FNA needle was advanced with return of purulent fluid. After injection of 15 cc ionic contrast to delineate the abscess and confirm positioning, EUS-guided transrectal drainage of the TOA with placement of a 15 × 10 mm AXIOS stent (Boston Scientific, Marlborough, MA, USA) was successfully performed. The distal flange was deployed within the abscess cavity and the proximal flange was deployed within the rectal lumen with copious amounts of purulent drainage through the AXIOS stent (Image 3). Repeat CT performed one week later revealed significant interval decrease in the size of the TOA. DISCUSSION: EUS-guided drainage of pelvic collections has been established as a lower-risk alternative to surgical interventions, especially for collections greater than 4 cm and within a 1-2 cm reach of the EUS transducer. Furthermore, use of LAMS can facilitate drainage through a wider conduit, promoting rapid evacuation and source control. To our knowledge, this is the first reported case of successful EUS-guided transrectal drainage of a TOA using a LAMS.