Need for a More Objective, Inclusive, and Equitable Selection Process for Gastroenterology Fellowships.

Diseases related to the digestive system account for a significant proportion of the diseases burden in the United States and result in 36.8 million ambulatory visits, 3.8 million hospital admissions, and 22.2 million gastrointestinal endoscopies. To meet the challenge that this quantum of gastroenterological disorders poses, we are obligated to select and train competent gastroenterologists. Admission into a Gastroenterology (GI) fellowship program is highly selective. In 2023, only 62.7% of candidates who applied were successful in matching into a fellowship program, making it even more competitive than a cardiology fellowship (match rate of 68.4%). Therefore, it is imperative that we ensure that the selection process is fair and transparent. Additionally, we need to be socially more responsible by emphasizing diversity and inclusivity to produce gastroenterologists who reflect the changing society we live in. An analysis of current practices indicates that the process of selection is not standardized and is more subjective than objective. This review is an attempt to identify deficiencies that can be rectified by the introduction of a standardized system that includes structured interviews, Standard Letters of Recommendation (SLOR), and objective scoring protocols-all of which would make the process of selection more equitable, diverse, and inclusive. Newer methods like Casper exam, Psychometric testing, and Preference Signaling can also be explored to this end.

Severe de novo Ulcerative Colitis following Ixekizumab Therapy.

Ixekizumab is a selective monoclonal antibody targeting interleukin-17A, approved for the treatment of chronic plaque psoriasis. It has rarely been associated with inflammatory bowel disease (IBD) in randomized trials only. We report a unique case of severe new-onset ulcerative colitis in a young male complicated by cytomegalovirus infection who was on ixekizumab therapy for plaque psoriasis. We recommend that clinicians should exercise caution before prescribing ixekizumab as it seems to induce and exacerbate IBD.

Systematic Review and Meta-analysis: Adalimumab Monotherapy Versus Combination Therapy with Immunomodulators for Induction and Maintenance of Remission and Response in Patients with Crohn's Disease.

BACKGROUND: It is unclear whether the combination of adalimumab (ADA) and immunomodulators is superior to ADA monotherapy in patients with Crohn's disease. METHODS: PubMed, Medline, Embase, Web of Science, and other databases were searched. Randomized controlled trials, open-label, prospective cohort, and retrospective studies, and pooled analyses were included. Primary outcomes were induction (≤12 wk) and maintenance (up to 56 wk) of remission and response. Secondary outcomes were severe adverse events, opportunistic infections, and development of antibodies to adalimumab. RESULTS: Twenty-four of 1194 articles were eligible for inclusion. No significant difference was noted between regimens for induction of remission (odds ratio [OR] 0.86; 95% confidence interval [CI]: 0.70-1.06; P = 0.19) and response (OR 1.01; 95% CI: 0.62-1.65; P = 0.96). Similarly, no difference was noted for maintenance of remission (OR 0.97; 95% CI: 0.79-1.14; P = 0.75) or response (OR 0.91; 95% CI: 0.54-1.54; P = 0.74). Severe adverse events and opportunistic infections were not different between arms. Patients on combination therapy had lower odds of developing antibodies to adalimumab (OR 0.24; 95% CI: 0.07-0.82; P = 0.02). Subgroup and sensitivity analyses showed significantly higher odds of successful induction (OR 1.26; 95% CI: 1.06-1.49, P = 0.008) and opportunistic infections (OR 2.44; 95% CI: 1.07-5.54, P = 0.03) in anti-TNF-experienced patients. CONCLUSIONS: The combination of ADA and immunomodulators does not seem superior to ADA monotherapy for induction and maintenance of remission and response in Crohn's disease. Combination therapy is associated with lower immunogenicity. Analyses associating combination therapy with better induction of remission in anti-TNF-experienced patients and a higher rate of opportunistic infections deserve further evaluation.

Solitary Polypoid Angiodysplastic Lesion Mimicking a Tumor in the Jejunum.

Small bowel bleeding should be considered in patients with overt or occult gastrointestinal hemorrhage after normal upper and lower endoscopic examination. Angiodysplasia appearing as multiple flat vascular tufts is the most common cause of small bowel bleeding in patients over 40 years old. Polypoid angiodysplasia, however, is extremely rare. This report illustrates a unique case of solitary polypoid angiodysplasia in the jejunum of an adult with chronic kidney disease, who presented with an occult gastrointestinal bleed. The angiodysplasia mimicked tumorous growth, potentially indicative of malignant neoplasm. The patient underwent surgical resection and was histologically diagnosed as having angiodysplasia.

Factors predicting early discharge and mortality in post-percutaneous endoscopic gastrostomy patients.

BACKGROUND: The aim of our study was to ascertain factors that favor early discharge and predict mortality in post-percutaneous endoscopic gastrostomy (PEG) patients. METHODS: Successive patients who underwent successful PEG placement during a 10-year period in a single New York City hospital were included in the study. Data was retrospectively extracted from hospital electronic medical records. RESULTS: Two hundred and eighty-four patients underwent successful PEG placement. Forty-six patients (16%) were discharged within 3 days of PEG placement (early discharge). Two hundred and thirty six patients (84%) remained in hospital from 4 to 244 days (median 13.5) after PEG insertion (late discharge). Twenty-six (9%) patients died in-house after PEG placement. A serum albumin level <2.2 g/dL (P=0.007) and presence of 2 or more co-morbidities (P=0.019) were predictors of late discharge. A dementia indication was twice as likely to result in an early discharge compared to a stroke indication (OR 2.39; 95% CI 1.07-5.36; P=0.033). Female sex, positive urine cultures and low serum albumin levels were independent predictors of in-house mortality. CONCLUSION: Clinical and laboratory markers may predict post-PEG mortality as well as early patient discharge.

The Blatchford score is an useful index in the management of Mallory-Weiss tear and gastrointestinal bleeding: experience from an urban community hospital.

OBJECTIVES: The purpose of this study was to determine the utility of individual clinical parameters as well as a composite index like the Blatchford score in predicting the need for endoscopic intervention and prognosticating the out come in patients with Mallory Weiss tear presenting with gastrointestinal bleeding. METHODS: We retrospectively reviewed our endoscopy database and our EMR system to identify patients with Mallory Weiss tear and collect relevant data. RESULTS: A total of 38 cases with Mallory-Weiss tear were identified at our center over a 5 year period. Thirty-two patients presented with gastrointestinal bleeding constituting 3.1% of all cases presenting with upper gastrointestinal bleeding. Nine (28%) of 32 patients were found to have active bleeding or stigmata of recent bleeding at endoscopy and required endoscopic therapy. The Blatchford score ranged from 0 to 11 in the patients with gastrointestinal bleeding. Nine patients had a Blatchford score < 6 (four 0, five 1-4) while 23 patients had a score > 6. None of the patients with a score < 6 required endoscopic intervention or a blood transfusion while 9 (39%) patients with a score > 6 required endoscopic intervention and 17 (74%) required a blood transfusion. Length of stay was significantly longer in patients with a score > 6. CONCLUSIONS: The Blatchford score can be a useful index to risk stratify patients with Mallory Weiss tear who present with gastrointestinal bleeding with regards to hospital admission and identifying patients who warrant urgent endoscopic intervention, require blood transfusion and are likely to have a longer length of stay.

An unusual cause of upper gastrointestinal bleeding: duodenal GIST. A case report and literature review.

A duodenal GIST is an unusual cause of upper gastrointestinal bleeding. Duodenal GISTs are rare and constitute 5% of all GISTs. A significant percentage of duodenal GISTs are located in the third and fourth portion of the duodenum and may not be detected on routine upper endoscopy. Push enteroscopy is necessary to locate these lesions. It is extremely important to differentiate a duodenal GIST from other submucosal tumors like leiomyomas, leiomyosarcomas or leiomyoblastomas which may present in a similar manner, because the treatment and prognosis differ significantly. Appropriate histological and immunohistiochemical staining is required to confirm the diagnosis. Surgical resection is the treatment of choice and may involve limited resection or a pancreaticoduodenectomy. Adjuvant therapy with Imatinib has been shown to prolong survival in patients with GIST in general.

Diabetes is not an independent predictor of gastroparesis in symptomatic patients referred for gastric emptying studies.

BACKGROUND: It is commonly presumed that diabetics are more prone to gastroparesis when compared to non-diabetics. OBJECTIVE: To ascertain whether diabetes is an independent predictor of gastroparesis in symptomatic patients who are referred for gastric emptying studies. METHODS: This was a cross sectional observational study. The study cohort consisted of 172 consecutive patients who had been referred for gastric emptying studies. Seventy-four of the 172 patients had evidence of diabetes. RESULTS: Gastroparesis was diagnosed in 93 of the 172 patients (54%). Multiple logistic regression analysis did not reveal diabetes to be an independent risk factor (OR 0.77, CI 0.37-1.56, p=0.46). But age>50 years was a significant predictor (OR 3.43, CI 1.62-7.23, p=0.001). The sex of the patient was not a contributing variable (OR 1.47, CI 0.72-2.98, p=0.28). CONCLUSION: Diabetes is not an independent predictor of gastroparesis in patients with gastrointestinal symptoms referred for gastric emptying studies. Age over 50 years was a significant predictor.

Pseudocyst management: endoscopic drainage and other emerging techniques.

Pseudocyst formation is a well known complication of pancreatitis. Not all pancreatic pseudocysts require intervention. Selected patients who are asymptomatic can be subject to expectant management. Spontaneous resolution has been shown to occur in 40% to 50% of patients with no serious complications occurring during the observation period. Intervention is warranted if the patient is symptomatic, there is a progressive increase in size or if the pseudocyst is infected. Surgery was the only available treatment for pseudocysts for a long time. Of late other modalities like percutaneous, endoscopic, and laparoscopic drainage have come to be seen as viable alternatives.

CT colonography can be an adjunct to optical colonoscopy in CRC screening.

CT colonography or virtual colonoscopy is a fairly new modality that has the potential to play a significant role in screening for colon cancer. CT colonography is an attractive option for two specific reasons. First, it is non-invasive and, second, it obviates the need for sedation. It thus overcomes the two major drawbacks of optical colonoscopy. CT colonography cannot be a stand-alone technique for colorectal cancer screening because, unlike conventional colonoscopy, it does not possess a therapeutic option or a definite diagnostic capability. However, CT colonography can be a cost-effective complement to traditional colonoscopy if it is reasonably priced and if appropriate cut-off levels (>6 mm polyp) are used to increase its sensitivity.

Corrosive ingestion in adults.

Ingestion of a corrosive substance can produce severe injury to the gastrointestinal tract and can even result in death. The degree and extent of damage depends on several factors like the type of substance, the morphologic form of the agent, the quantity, and the intent. In the acute stage, perforation and necrosis may occur. Long-term complications include stricture formation in the esophagus, antral stenosis and the development of esophageal carcinoma. Endoscopy should be attempted and can be safely performed in most cases to assess the extent of damage. Procedure-related perforation is rare. Stricture formation is more common in patients with second and third degree burns. Corticosteroids may help prevent stricture formation. Esophageal carcinoma may develop beginning 30 to 40 years after the time of injury.