A Rare Etiology of Esophageal Obstruction: Esophageal Clot Formation After Teeth Extraction.

Esophageal obstruction represents an endoscopic emergency owing to the high mortality rate associated with complications, including perforation and airway compromise. While typically caused by food or foreign body ingestion, esophageal clot represents a rare etiology of obstruction. We present a case of esophageal obstruction in the context of an anastomotic stricture and chronic anticoagulation for atrial fibrillation caused by clot formation due to oral hemorrhage after dental extractions. Clot retrieval was accomplished via endoscopic suction, and balloon dilation of the anastomotic stricture was performed to prevent recurrence. Our case illustrates the importance of considering oral hemorrhage, therapeutic anticoagulation, and esophageal strictures as risk factors for esophageal obstruction due to clot formation in order to make a timely diagnosis and treatment of this potential endoscopic emergency.

White Esophagus: The Result of Polypharmacy.

Candida esophagitis can occur in immunocompetent patients through impairment of host defense mechanisms including salivation, esophageal motility, acidic pH, and innate immunity. Commonly prescribed medications inhibit these mechanisms, and polypharmacy has been shown to have an additive effect on promoting Candida infection. We present the case of an immunocompetent patient who was chronically prescribed multiple medications associated with Candida esophagitis but experienced infection only after the addition of oral delayed-release budesonide, which has not previously been associated with Candida esophagitis.

Pembrolizumab-Induced Immune-Mediated Hepatitis and Concurrent Hepatitis B Reactivation in a Patient With Non-Small Cell Lung Cancer.

New immuno-therapeutic agents like pembrolizumab used in cancer treatment are known to cause immune-mediated hepatitis. Most of these cases are straightforward when the onset of transaminitis correlates with the introduction of the medication. This agent causing hepatitis B reactivation has been reported only once. To have both these adverse effects occurring at the same time in a patient is uncommon and presents a clinical challenge. Our patient was a 49-year-old gentleman diagnosed with metastatic adenocarcinoma of the lung seven months ago. He was started on pembrolizumab, as the malignant tissue obtained during biopsy had high program death-ligand 1 (PDL1) expression. On reviewing the labs ordered during the time of cancer diagnosis, this man has evidence of chronic hepatitis B with positive hepatitis B surface antigen and positive hepatitis B core immunoglobulin G (IgG) antibody. He presented with acute hepatitis, and workup showed features of hepatitis B reactivation, but the extent of reactivation was not adequate to explain the presentation, hence investigations were pursued. This led the way to the diagnosis of a combined hepatitis B reactivation and drug-induced immune hepatitis in this case. He responded promptly to the withdrawal of the agent and steroids. On follow-up, his liver function panel had significantly improved.  This case is very unique in two aspects. First, to our knowledge, there is only one case reported of pembrolizumab-induced hepatitis B reactivation. In addition, our patient also had immune-mediated hepatitis induced by pembrolizumab. It is very rare to have a combination of these two presentations to be seen in a patient at the same time. Pembrolizumab-induced immune hepatitis can coexist with hepatitis B reactivation following therapy with this agent.

Ibuprofen Overuse Leading to Life-threatening Hypokalemia Associated with Renal Tubular Acidosis in Two Patients.

Ibuprofen is a commonly used medication in the United States and is used both by prescription and over the counter, while hypokalemia is a life-threatening condition caused by various etiologies, one of which is the side effect of medications. Ibuprofen is well-known for its various nephrotoxic side effects, including hyperkalemia as a common electrolyte abnormality, however, renal tubular acidosis leading to hypokalemia with the use of ibuprofen has been reported rarely. We present here two cases of life-threatening hypokalemia due to over-the-counter use of large doses of ibuprofen and describe its management.

Variations in Screening Adenoma Detection Rate by Specialty of Physicians in a Predominately African American Population.

BACKGROUND: Screening colonoscopy aims to interrupt the adenoma-carcinoma sequence by removing all precancerous adenomatous polyps. Adenomatous polyp detection rate (ADR) can vary between endoscopists as well as between race, age, and risk of colorectal cancer (CRC). The purpose of this study was to compare ADR among academic gastroenterologists (A-GI), non-A-GI, and surgeons for endoscopies performed in the same endoscopic suite of a large medical center with a predominately African American (AA) population. METHODS: All screening colonoscopies performed in 2014 for patients aged 62-76 years were identified using the electronic medical records data. Patients with average risk and high risk of CRC defined as having a 'personal history of polyps' or 'family history of CRC', and history of ulcerative colitis and Fecal Occult Blood Test/Fecal Immunochemical Test (FOBT/FIT) positivity were included. Patients with incomplete colonoscopy (defined as failing to achieve cecal intubation or poor preparation) and unrecovered tissue biopsy were excluded. ADR was calculated for three groups of endoscopists: A-GIs, non-A-GIs, and surgeons. RESULTS: A total of 573 screening colonoscopies was analyzed. The endoscopists comprised five A-GIs, eight non-A-GIs, and six surgeons. The majority of patients were of AA decent (71%), female (54%) with an average age of 66 years. Patients classified as average risk comprised 79% of the population. Most of the colonoscopies were performed by A-GI (n=339), followed by non-A-GI (n=144), and surgeons (n=90). The ADR for A-GI was 50% as compared to 32% for non-A-GI (p<0.001) and 25% for surgeons (p<0.001). Also, A-GI were more likely to identify ≥3 adenomas during screening colonoscopies. Significant differences were observed (p<0.001) in the mean time of colonoscopy for A-GI (30 mins) non-A-G (14 mins), and surgeons (18 mins). CONCLUSION: Significant variation in the ADR between endoscopists belonging to different specialties were observed. Although all appear to achieve acceptable ADR (ie at least 25 for men and 15 for women), academic gastroenterologists had better performance than non-academic GI and surgeons. This may be explained by a significantly longer average duration of procedures for the highest ADR group.