Obesity reduces the requirement for subsequent esophageal stricture dilation in adults with eosinophilic esophagitis.

BACKGROUND: Eosinophilic esophagitis (EoE) causes esophageal narrowing and strictures, but factors that modify the severity of strictures and requirement for subsequent dilation are not well described. The aim of this study was to identify characteristics that impact the need for repeat (> 1) esophageal dilations in EoE patients. METHODS: This was a single center retrospective cohort study over a 12-year period (September 2005-October 2017). Patients were identified using ICD9, ICD10, and CPT codes for esophageal dilation, eosinophilic esophagitis, and esophageal obstruction. Data for EoE clinical characteristics, treatments, and BMI were extracted and correlated to the number of esophageal dilations and time elapsed between dilations. RESULTS: Of the 21 patients who met inclusion criteria, 11 (52%) had at least two dilations and 9 (43%) had three dilations. There was no differences baseline demographics between patients who needed ≥ 2 vs. those who needed one dilation. However, patients with a BMI > 30 had a significantly longer median time to second dilation compared to non-obese patients (4.9 years vs. 1.8 years; p = 0.027). Stratification by either high dose PPI or inhaled steroid use did not change this result. CONCLUSIONS: EoE patients with strictures who are obese have a reduced requirement for subsequent esophageal dilation. While the mechanism for this is not clear, increased attention of non-obese patients with fibrostenotic EoE is indicated as they are at higher risk for recurrent strictures.

Esophageal Button Battery Retrieval: Time-In May Not Be Everything.

The management of ingested foreign bodies is a challenging task because each case is unique with multiple varying factors including a patient's age, anatomical considerations, clinical presentation, and the type and location of the foreign body ingested. Additionally, concern over complications associated with button battery ingestion typically drives management decisions. The common practice is the urgent retrieval of the foreign body within two to six hours of presentation. An unusual case is presented here that demonstrated significantly delayed endoscopic removal of an ingested button battery without complication, avoiding the many risks associated with any emergent endoscopic procedure. However, this practice is a case-by-case decision because there is a lack of literature to guide the current management.

Epstein-Barr Virus Reactivation Causing Cholestatic Hepatitis.

Infection with Epstein-Barr virus (EBV) is common and associated with a high seroprevalence. It is often asymptomatic, but infectious mononucleosis (IM) is the clinical hallmark of this disease especially among teens. Hepatic involvement during primary EBV infection often results in mild self-resolving elevation of liver enzymes, typically in association with IM. However, cholestatic hepatitis might sporadically occur. EBV reactivation is rare, especially among immunocompetent patients. Moreover, reactivation of EBV causing isolated cholestatic hepatitis is extremely rare and only reported in patients who are immunocompromised. Here we present a unique case of EBV reactivation causing cholestatic hepatitis in an otherwise healthy and immunocompetent female and we review the epidemiology, clinical presentation, diagnosis, and treatment of EBV induced cholestatic hepatitis.

An Uncommon Cause of Biliary Obstruction in a Patient With Budd-Chiari Syndrome.

Biliary varices (BVs) are an infrequent complication of chronic portal hypertension. Most cases of BVs are asymptomatic and are likely underdiagnosed. We present a case of a 34-year-old woman with Budd-Chiari syndrome who was found to have BVs caused by a significant inferior vena cava (IVC) stenosis. This case demonstrates that preprocedure imaging for variceal screening should be considered before biliary tract procedures to prevent complications.

Small bowel T-cell lymphoma: a MEITL-ing diagnosis.

Monomorphic epitheliotropic intestinal T-cell lymphoma (MEITL), previously known as Type-II enteropathy-associated T-cell lymphoma (EATL), is a rare subset of relatively aggressive lymphoma with a poor prognosis. We present a case of a previously healthy 59-year-old male with a 2-week history of abdominal distention who was found to have a non-bleeding ulcerated segment in the proximal jejunum secondary to MEITL. This exceedingly rare type of lymphoma usually presents with non-specific symptoms and can be challenging to diagnose. Our case demonstrates the importance of understanding the endoscopic and histological findings to allow the prompt diagnosis and treatment of this aggressive disease.

The rise of proximal colorectal cancer: a trend analysis of subsite specific primary colorectal cancer in the SEER database.

BACKGROUND: Colorectal cancer (CRC) is the third most common cancer worldwide and the second leading cause of cancer-related deaths. Given the significant prevalence of CRC, regular preventative screening is required. CRCs in different locations of the colon have variable molecular pathogenesis, gross appearance, and general disease outcomes. While the overall incidence of CRC has been decreasing, the decrease in proximally located CRC significantly lags behind the other forms of CRC. The objective of this study was to establish independent risk factors for proximal CRC for better identification of populations at risk for closer CRC monitoring and observation. METHODS: A time-trend analysis was conducted using data from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database from 1973-2007, comparing patient characteristics (age, sex, race/ethnicity, year of diagnosis, age of diagnosis, tumor grade, tumor stage, and urban-rural setting) between CRCs originating in different locations. RESULTS: Analysis demonstrated that black race, female sex, age over 60, and being diagnosed in the 21st century (rather than 20th) were associated with an increased risk of proximal CRC compared to CRCs originating in other locations. CONCLUSIONS: Our study showed that black race, female sex, and age over 60 independently increased the likelihood of proximal CRC diagnosis. Furthermore, CRC trends identify an increasing proportion of all CRCs being of proximal origin. It is imperative that patients undergo regularly scheduled complete colonoscopies by trained endoscopists, especially if they belong to the high-risk groups previously identified.

Primary Sclerosing Cholangitis and Primary Biliary Cirrhosis Overlap Syndrome: A Review.

Primary sclerosing cholangitis (PSC) and primary biliary cirrhosis (PBC) are slow progressive diseases which have been increasing in prevalence. The pathogeneses of PBC and PSC are incompletely understood but the underlying mechanisms appear to be fundamentally autoimmune in origin. Although PBC and PSC appear to be separate entities, overlap has been described. Diagnosis depends on a combination of serological markers, imaging, and pathological criteria. The mainstay of treatment has been ursodeoxycholic acid and in some cases of extrahepatic biliary obstruction and overlap disorder, endoscopic retrograde cholangiopancreatography has been useful.

Differentiating Delayed Esophageal Clearance From Reflux in Scleroderma.

Abnormal acid exposure to the esophagus and esophageal dysmotility leading to symptoms of refractory reflux and dysphagia are common findings amongst patients with advanced systemic scleroderma (SSc). Although treatments and diagnostic methods for esophageal disease in the setting of SSc are currently limited to those used for gastroesophageal reflux disease (GERD), certain advancements in diagnostic testing allow potential for improved detection of the exact etiology and clinical management. Through the lens of a case presentation, we found that while GERD is usually diagnosed with high acid exposure from decreased lower esophageal sphincter tone, the high esophageal acidity seen in scleroderma can be attributed to esophageal hypo-motility, leading to fermentation of food residue.

The Two Challenges in Management of Gastric Glomus Tumors.

Gastric glomus tumors (GGTs) are rare gastrointestinal lesions originating from the neuromuscular arterial canal or vascular lumen which share many overlapping features with other stromal lesions. Despite most cases of GGTs being benign, there is a lack of reliable histological features predictive of tumor behavior. We present a case of a 42-year-old male who was determined to have a GGT via histological diagnosis and underwent surgical wedge resection. This case highlights the importance of establishing an accurate diagnosis and the various factors that must be taken into consideration to best determine malignant potential and management options.