Hemorrhagic Shock from a Duodenal Ulcer Eroding into an Ectopic Varix.

Ectopic varices are an infrequent yet fatal complication resulting from the progression of liver cirrhosis. Duodenal varices pose a significant challenge to clinicians as they are not easily visualized on endoscopy due to their submucosal location and lack of red color signs. Identification of duodenal varices is important given the risk of massive and life-threatening bleeding that is difficult to control. Patients may present in hemorrhagic shock requiring immediate resuscitation; however, confirmation of the bleeding source as variceal or non-variceal is critical in determining the optimal therapeutic intervention. Here, we report an unusual case of a duodenal ulcer that eroded into an ectopic varix resulting in hemorrhagic shock.

Prevalence and clinical risk factors for esophageal candidiasis in non-human immunodeficiency virus patients: A multicenter retrospective case-control study.

BACKGROUND: Although esophageal candidiasis (EC) may manifest in immunocompetent individuals, there is a lack of consensus in the current literature about predisposing conditions that increase the risk of infection. AIM: To determine the prevalence of EC in patients without human immunodeficiency virus (HIV) and identify risk factors for infection. METHODS: We retrospectively reviewed inpatient and outpatient encounters from 5 regional hospitals within the United States (US) from 2015 to 2020. International Classification of Diseases, Ninth and Tenth Revisions were used to identify patients with endoscopic biopsies of the esophagus and EC. Patients with HIV were excluded. Adults with EC were compared to age, gender, and encounter-matched controls without EC. Patient demographics, symptoms, diagnoses, medications, and laboratory data were obtained from chart extraction. Differences in medians for continuous variables were compared using the Kruskal-Wallis test and categorical variables using chi-square analyses. Multivariable logistic regression was used to identify independent risk factors for EC, after adjusting for potential confounding factors. RESULTS: Of the 1969 patients who had endoscopic biopsies of the esophagus performed from 2015 to 2020, 295 patients had the diagnosis of EC. 177 of 1969 patients (8.99%) had pathology confirming the diagnosis of EC and were included in the study for data collection and further analysis. In comparison to controls, patients with EC had significantly higher rates of gastroesophageal reflux disease (40.10% vs 27.50%; P = 0.006), prior organ transplant (10.70% vs 2%; P < 0.001), immunosuppressive medication (18.10% vs 8.10%; P = 0.002), proton pump inhibitor (48% vs 30%; P < 0.001), corticosteroid (35% vs 17%; P < 0.001), Tylenol (25.40% vs 16.20%; P = 0.019), and aspirin use (39% vs 27.50%; P = 0.013). On multivariable logistic regression analysis, patients with a prior organ transplant had increased odds of EC (OR = 5.81; P = 0.009), as did patients taking a proton pump inhibitor (OR = 1.66; P = 0.03) or corticosteroids (OR = 2.05; P = 0.007). Patients with gastroesophageal reflux disease or medication use, including immunosuppressive medications, Tylenol, and aspirin, did not have a significantly increased odds of EC. CONCLUSION: Prevalence of EC in non-HIV patients was approximately 9% in the US from 2015-2020. Prior organ transplant, proton pump inhibitors, and corticosteroids were identified as independent risk factors for EC.

Trends in inflammatory bowel disease and pancreatic cancer: an analysis of the National Inpatient Sample database.

Background: An association between inflammatory bowel disease (IBD) and pancreatic cancer has been suggested in the literature. We aimed to determine the trend in prevalence of pancreatic cancer amongst patients hospitalized for Crohn's disease (CD) or ulcerative colitis (UC) in the United States. Methods: An analysis of the National Inpatient Sample database was performed to identify adults diagnosed with pancreatic cancer and CD or UC, using validated ICD-9 and ICD-10 codes, from 2003-2017. Age, sex, and racial demographics were also collected. Surveillance, Epidemiology and End Results registry (SEER) data were analyzed for trends in the incidence and mortality of pancreatic cancer amongst the general population in the United States. Results: From 2003-2017, there was a significant increase in the hospitalizations related to pancreatic cancer, from 0.11% to 0.19% (PTrend<0.001), representing a 72.73% increase, in CD patients, and from 0.08% to 0.38% (PTrend<0.001), representing a 375.00% increase, in UC patients. According to the SEER 13 data on pancreatic cancer in the general population, the incidence of pancreatic cancer increased from 11.34 per 100,000 cases in 2003 to 12.74 per 100,000 cases in 2017, thus representing only a 12.35% increase over the study period. Conclusions: Our study indicates a trend for increasing prevalence of pancreatic cancer in patients hospitalized with CD and UC from 2003-2017 in the United States. This increasing trend observed in the IBD population parallels the increase in the incidence of pancreatic cancer reported among the general population, but at a much greater rate.

The predictive value of liver tests for the presence of liver metastases.

Aim: To analyze the predictive value of biochemical liver tests in patients with malignant melanoma, breast, colorectal or lung cancers at the time of diagnosis of liver metastases. Methods: A retrospective review of patients with the above-mentioned solid tumors at MedStar Georgetown University Hospital from 2016-2020. Results: The highest optimal cutoff according to sensitivity and specificity for the presence of liver metastases was for AST ≥1.5 × ULN for melanoma, lung, and breast cancers and ≥2 × ULN for colorectal cancer, ALT ≥1.25 × ULN for melanoma, breast and colorectal cancers and ≥1.5 × ULN for lung cancer, and ALP ≥1.5 × ULN for melanoma, breast and colorectal cancers. Conclusion: Using thresholds of liver enzymes above the ULN may improve the diagnostic accuracy for the presence of liver metastases.

Breast Cancer Metastasis to the Gastrointestinal Tract With Unusual Endoscopic and Histologic Presentations.

The gastrointestinal (GI) tract is an infrequent site of breast cancer metastasis, but it often poses a diagnostic challenge when it occurs. The symptoms of GI metastases are often nonspecific, and the endoscopic manifestations are variable, requiring tissue biopsies for histologic examination. We report 2 cases of breast cancer metastasizing to the GI tract: a case of human epidermal growth factor receptor 2-positive invasive ductal carcinoma that metastasized to the stomach, a rare location for this histologic subtype, and another case of invasive lobular cell carcinoma that metastasized to the colon with unusual findings of mucosal pallor and edema on colonoscopy.

Immunotherapy Use Prior to Liver Transplant in Patients with Hepatocellular Carcinoma.

Hepatocellular carcinoma (HCC) is the fourth leading cause of cancer-related mortality worldwide, and its incidence has increased rapidly in the United States over the past two decades. Liver transplant is considered curative, but is not always possible, and pre-transplant immunotherapy is of great interest as a modality for downstaging the tumor burden. We present a review of the literature on pre-liver transplant immunotherapy use in patients with HCC. Our literature search queried publications in Ovid MEDLINE, Ovid Embase, and Web of Science, and ultimately identified 24 original research publications to be included for analysis. We found that the role of PD-1 and PD-L1 in risk stratification for rejection is of special interest to researchers, and ongoing randomized clinical trials PLENTY and Dulect 2020-1 will provide insight into the role of PD-1 and PD-L1 in liver transplant management in the future. This literature search and the resulting review represents the most thorough collection, analysis, and presentation of the literature on the subject to date.

A screen for F1 hybrid male rescue reveals no major-effect hybrid lethality loci in the Drosophila melanogaster autosomal genome.

Hybrid sons between Drosophila melanogaster females and D. simulans males die as 3rd instar larvae. Two genes, D. melanogaster Hybrid male rescue (Hmr) on the X chromosome, and D. simulans Lethal hybrid rescue (Lhr) on chromosome II, interact to cause this lethality. Loss-of-function mutations in either gene suppress lethality, but several pieces of evidence suggest that additional factors are required for hybrid lethality. Here we screen the D. melanogaster autosomal genome by using the Bloomington Stock Center Deficiency kit to search for additional regions that can rescue hybrid male lethality. Our screen is designed to identify putative hybrid incompatibility (HI) genes similar to Hmr and Lhr which, when removed, are dominant suppressors of lethality. After screening 89% of the autosomal genome, we found no regions that rescue males to the adult stage. We did, however, identify several regions that rescue up to 13% of males to the pharate adult stage. This weak rescue suggests the presence of multiple minor-effect HI loci, but we were unable to map these loci to high resolution, presumably because weak rescue can be masked by genetic background effects. We attempted to test one candidate, the dosage compensation gene male specific lethal-3 (msl-3), by using RNA interference with short hairpin microRNA constructs targeted specifically against D. simulans msl-3 but failed to achieve knockdown, in part due to off-target effects. We conclude that the D. melanogaster autosomal genome likely does not contain additional major-effect HI loci. We also show that Hmr is insufficient to fully account for the lethality associated with the D. melanogaster X chromosome, suggesting that additional X-linked genes contribute to hybrid lethality.