Rates of inflammatory bowel disease in Hispanics comparable to non-Hispanic Whites: results of a cohort study.

PURPOSE: Previous studies have suggested that inflammatory bowel disease (IBD) occurs at higher rates among non-Hispanic Whites (NHWs) compared to other ethnicities; however, Hispanics as the largest minority in the United States remain underrepresented in IBD research and we hypothesize that they have similar rates of IBD. We examined the epidemiology, demographics, clinical presentation, and treatment of IBD in a predominantly Hispanic cohort in Los Angeles (LA) County. METHODS: This was a retrospective cohort study based at Olive View-UCLA Medical Center, one of the three major safety-net hospitals in LA County. Electronic medical records from 2015 to 2018 were queried, and biopsy-proven cases of IBD (n = 170) were identified. Outcomes included the incidence and prevalence of IBD, disease distribution, treatment, and IBD-related surgery. RESULTS: The incidence of IBD among Hispanics was 175 (95% confidence interval [CI] 127-240) and 113 (95% CI 62-200) for NHWs per 100,000 person-years. Prevalence of IBD per 100,000 people was 418 (95% CI 341-512) for Hispanics and 557 (95% CI 431-739) for NHWs. Notably, the proportion of Hispanic IBD patients with a history of smoking was 21.5% vs 50.8% in NHWs (p = 0.011). There were no significant differences between the two groups with regard to Montreal classification, pharmacotherapy, or IBD-related surgery. CONCLUSIONS: In one of the largest US studies of Hispanics with IBD, and the only one to have both clinical and histopathologic confirmation as inclusion criteria, we found the incidence and prevalence of IBD among Hispanics to be higher than previously recognized and comparable to NHWs. Additionally, Hispanic IBD patients had lower rates of smoking compared to NHWs.

PowerPoint to the People: The Four Secrets to Delivering a Great Medical Talk.

Medical talks are a staple of post-medical school education, but the effectiveness of these lectures can be quite variable. One significant reason for this is that while physicians and trainees are well trained at presenting information to one another, they have little to no formal training on giving hour-long medical didactics. Focusing on four specific categories including creating a strong first impression, effective use of PowerPoint, impactful delivery of information, and thorough preparation a physician at any stage in training can become a strong presenter.

Impacting Underserved Communities as a GI Trainee.

Gastroenterology fellowship programs commonly include VA and county hospitals whose patient populations consist of some of the most vulnerable and underserved populations in the country who have a multitude of socioeconomic hurdles that limit their ability to address ongoing medical issues, all while having a restricted political voice and receiving care in under-resourced clinical settings. Since trainees are integral to the care of these patients, they have available two approaches that can affect community and hospital-based change, namely quality improvement (QI) and healthcare advocacy. QI projects focused on optimizing colorectal cancer screening, and Helicobacter pylori testing/eradication can provide value at an institutional level. Healthcare advocacy can be approached through involvement in national gastroenterological associations or locally through means such as establishing a fellowship-based advocacy group similar to a journal club. Both routes enable trainees to positively impact underserved communities.

Hemobilia: Historical overview, clinical update, and current practices.

Hemobilia refers to macroscopic blood in the lumen of the biliary tree. It represents an uncommon, but important, cause of gastrointestinal bleeding and can have potentially lethal sequelae if not promptly recognized and treated. The earliest known reports of hemobilia date to the 17th century, but due to the relative rarity and challenges in diagnosis of hemobilia, it has historically not been well-studied. Until recently, most cases of hemobilia were due to trauma, but the majority now occur as a sequela of invasive procedures involving the hepatopancreatobiliary system. A triad (Quincke's) of right upper quadrant pain, jaundice and overt gastrointestinal bleeding has been classically described in hemobilia, but it is present in only a minority of patients. Therefore, prompt diagnosis depends critically on a high index of suspicion based on a patient's clinical presentation and a history of recently undergoing hepatopancreatobiliary intervention or having other predisposing factors. Treatment of hemobilia depends on the suspected source and clinical severity and thus ranges from supportive medical care to urgent advanced endoscopic, interventional radiologic, or surgical intervention. In the present review, we provide a historical perspective, clinical update and overview of current trends and practices pertaining to hemobilia.

Colonic Stenting for Nonmalignant Large Bowel Obstruction to Avoid Emergency Decompressive Surgery.

Self-expanding metallic stents (SEMSs) are frequently used to decompress malignant large bowel obstruction (LBO) and avoid emergent surgery with often permanent colostomy creation. However, limited data are available on the use and outcomes of SEMS in patients with nonmalignant LBO. We present a case series of 4 patients who were found to have nonmalignant LBO for which they underwent emergent colonic stenting as a bridge to elective surgery following interdisciplinary discussion between gastroenterology, colorectal surgery, and radiology. Through each patient vignette, we illustrate the use of SEMSs as a potential alternative to emergent surgery. 2 of 4 patients avoided stoma creation at the time of surgery, and 1 patient avoided surgery altogether; overall, however, the outcomes of this approach were mixed in this series, indicating a need for further investigation to better identify the patient population that would benefit most from initial SEMS placement for decompression of nonmalignant LBO.

Homomorphic Adenocarcinoma Metastases to the Liver: A Report of 2 Cases.

BACKGROUND Distinguishing between primary and metastatic malignancy can be challenging despite advances in diagnostic imaging, tissue sampling techniques, and immunohistochemistry. CASE REPORT Herein, we describe 2 cases of obscure liver lesions which were ultimately determined to be malignant and from metastatic disease. In both cases, the liver metastases were uniquely "homomorphic," i.e., radiographically resembling the primary tumor source (in the first case a dilated tubular appearance akin to the hepatopancreatic ampulla and in the second case a haustrated bowel appearance akin to the colon). CONCLUSIONS These cases illustrate the recently reported concept of tumor homomorphism as a potential diagnostic pearl to facilitate timely diagnosis of malignant-appearing liver lesions of obscure etiology and source and thereby guide management accordingly.

Intussusception in the Setting of Tuberous Sclerosis Complex.

A 53-year-old man with tuberous sclerosis complex presented with severe, acute, right lower quadrant pain. The patient was found to have ileocolonic intussusception and a cecal mass on imaging. Diagnostic colonoscopy revealed a 3-cm cecal lesion which was grossly equivocal for hamartoma, adenoma, or other neoplasm, biopsies of which revealed villous adenoma. Given the lesion was believed to represent the trigger point for intussusception, the patient was referred for surgical resection, the histopathology from which the lesion was identified to be invasive adenocarcinoma. The patient underwent hemicolectomy, with plans for routine postoperative colon cancer surveillance. This case is unique because previously published literature has not described adenocarcinoma in an adult with tuberous sclerosis complex and it calls attention to the need to maintain unsuspected cancer high on the differential in adults with intussusception.

Gastro-gastric intussusception in the setting of a neuroendocrine tumor: A case report.

BACKGROUND: While in children intussusception is often idiopathic, in adults it is commonly caused by a pathologic condition functioning as a lead point. It is important to note that a variety of pathologic conditions may trigger intussusception, with malignancy being a relatively frequent culprit in adults; this should be considered high on the differential diagnosis during evaluation. CASE SUMMARY: This is a case of a 40-year-old female presenting to the emergency department (ED) with three days of acute on chronic, peri-umbilical abdominal pain described as waxing and waning, and pressure-like in nature. Initial computed tomography (CT) of the abdomen and pelvis with contrast in the ED (after her pain had resolved) re-demonstrated a previously noted 13 mm lesion in the gastric antrum but no clear cause of the pain. Endoscopic ultrasound was pursued, and the mass lesion was sampled via fine needle biopsy. Post-procedure the patient experienced another episode of severe pain which prompted a repeat stat CT abdomen and pelvis with contrast; this re-demonstrated the 13 mm antral lesion and in addition was remarkable for a gastro-gastric intussusception. An upper gastrointestinal gastrograffin series was ordered (completed only after the pain had subsided) and showed resolution of the intussusception. Histopathology was consistent with a diagnosis of low-grade neuroendocrine tumor (NET). Surgery was initially deferred during the hospitilization given the low grade pathology of the lesion; however further multidisciplinary discussion between Surgery, Oncology, and Gastroenterology recommended resection given the patient's recurrent abdominal pain with the NET functioning as a lead point for further intussusception, and the patient thus underwent robotically-assisted wedge resection. CONCLUSION: We present a unique case of severe, intermittent, peri-umbilical pain related to gastro-gastric intussusception caused by an antral NET lead point. The case highlights the importance of considering neoplasms as the cause of intussusception in adults and the greater diagnostic yield when imaging is obtained while symptoms (in this case severe, episodic abdominal pain) are most apparent.

"Homomorphic" Tumor Metastases as an Endodiagnostic Clue: A Case Series of Renal-Cell Carcinoma Metastatic to the Stomach.

Distinguishing between a primary malignancy and a metastasis can be challenging in some cases. Herein, we describe 2 cases of gastric lesions that were endoscopically sampled and ultimately found to be metastatic from a renal-cell carcinoma. In both cases, the gastric metastases were endoscopically homomorphic to the primary organ (the kidney); i.e., grossly resembling and thus providing an endoscopic clue as to the primary tumor source. We report on the evaluation of obscure metastatic gastric involvement of malignancy and present the concept of homomorphism as a potential diagnostic clue in determining the source of unknown and often unsuspected primary malignancy.

Uncanny Proctopathy: A Case of Lymphogranuloma Venereum.

A 37-year-old man with a history of receptive and penetrating anal sex with men presented with abdominal pain, bright red blood per rectum, and fevers. Recent evaluation by his primary care doctor was notable for negative urine for Neisseria gonorrhea and Chlamydia trachomatis. Rectal swab on admission was positive for C. trachomatis. The patient was ultimately diagnosed with lymphogranuloma venereum, a disease typically seen in tropical climates, although it is more common now in western countries, specifically in men who have sex with men. Treatment consisted of a course of doxycycline for 3 weeks, with resolution of symptoms.