Acquiring the Diagnosis of an Acquired Tracheoesophageal Fistula with EtCO2: A Case Discussion with Review of the Literature.

Acquired tracheoesophageal fistula (TEF) is a rare complication of esophageal or lung cancer. A 57-year-old male presented with complaints of vomiting, cough, 20 lb weight loss, and progressive dysphagia. Early laryngoscopy and CT chest showed a normal pharynx with an irregular thickness of the thoracic esophagus. The upper gastrointestinal endoscopy (UGIE) and upper endoscopic ultrasound (EUS) revealed a hypoechoic mass evolving as complete obstruction. During the procedure, minimal CO2 was used for insufflation; however, when attempts were made to traverse the obstruction, capnography revealed an end-tidal CO2 (EtCO2) estimating 90 mmHg indicating possible TEF. This case depicts the use of capnography during UGIE in diagnosing an acquired TEF.

Gastric and Duodenal Neuroendocrine Tumor Incidentally Found on Endoscopy During the Evaluation of Iron-Deficiency Anemia.

Neuroendocrine tumors (NET) are a small fraction of overall gastrointestinal (GI) malignancies. Recently the incidence of NETs has increased due to advancements in diagnostic modality. While solid tumors are easily visible on routine endoscopy, identifying endocrine tumors can be difficult, and low incidence and non-specific presentation can be easily missed on upper gastrointestinal endoscopy (UGIE). The management differs based on the type of tumor and location, but the overall prognosis is good. We present a 59-year-old male with multiple NETs throughout the GI tract, diagnosed on repeat esophagogastroduodenoscopy (EGD) with endoscopic ultrasound (EUS) showing multiple gastric folds. A biopsy of multiple nodules was taken to diagnose type I NET with grade 2 differentiation finally. The mucosal nodules were resected with a band ligator, and surveillance endoscopy was recommended.

Drugs in Development for Hepatitis B.

With high morbidity and mortality worldwide, there is great interest in effective therapies for chronic hepatitis B (CHB) virus. There are currently several dozen investigational agents being developed for treatment of CHB. They can be broadly divided into two categories: (1) direct-acting antivirals (DAAs) that interfere with a specific step in viral replication; and (2) host-targeting agents that inhibit viral replication by modifying host cell function, with the latter group further divided into the subcategories of immune modulators and agents that target other host functions. Included among the DAAs being developed are RNA interference therapies, covalently closed circular DNA (cccDNA) formation and transcription inhibitors, core/capsid inhibitors, reverse transcriptase inhibitors, hepatitis B surface antigen (HBsAg) release inhibitors, antisense oligonucleotides, and helioxanthin analogues. Included among the host-targeting agents are entry inhibitors, cyclophilin inhibitors, and multiple immunomodulatory agents, including Toll-like receptor agonists, immune checkpoint inhibitors, therapeutic vaccines, engineered T cells, and several cytokine agents, including recombinant human interleukin-7 (CYT107) and SB 9200, a novel therapy that is believed to both have direct antiviral properties and to induce endogenous interferon. In this review we discuss agents that are currently in the clinical stage of development for CHB treatment as well as strategies and agents currently at the evaluation and discovery phase and potential future targets. Effective approaches to CHB may require suppression of viral replication combined with one or more host-targeting agents. Some of the recent research advances have led to the hope that with such a combined approach we may have a functional cure for CHB in the not distant future.

Tenofovir alafenamide for the treatment of chronic hepatitis B virus infection.

INTRODUCTION: In April 2017 tenofovir alafenamide (TAF) was added to the list of first-line therapies recommended for chronic hepatitis B (CHB). TAF has pharmacology similar to tenofovir disoproxil fumarate (TDF) with higher cell delivery to the hepatocytes but less systemic exposure. Areas covered: We review here studies leading to TAF's approval and comparing it to TDF. In two major clinical trials, TAF was non-inferior to TDF in achieving HBV DNA levels below 29 IU/ml. TAF-treated patients had significantly smaller decreases in bone mineral density (BMD) at the hip and spine in both HBeAg-positive and HBeAg-negative patients, and smaller mean increases in serum creatinine, although the difference was only statistically significant in HBeAg-positive patients. Patients treated with TDF for 96 weeks and then switched to TAF had improvements in renal and BMD measures only 24 weeks after switching. Expert commentary: With clear evidence from major studies showing that TAF is safe, tolerable, and non-inferior to TDF, its recommendation as a first-line therapy is appropriate. Longer term follow up will be required to determine if the differences in adverse bone and kidney effects seen with TAF in comparison to TDF will be clinically relevant.

An experience of capsule endoscopy from a tertiary care hospital in Pakistan.

OBJECTIVES: To evaluate the effectiveness of capsule endoscopy in the management of patients with obscure gastrointestinal bleeding. METHODS: A prospective descriptive study was conducted at surgical unit IV, Civil Hospital Karachi over a period of 2 years from December 2007 to November 2009. Twenty eight consecutive patients presenting with obscure gastrointestinal bleeding were included in the study. Patients having history of acute intestinal obstruction were excluded. Study was approved by the hospital ethical committee. Informed and written consent was taken from all the patients included in the study. The procedure was performed as day case. Patients were asked to swallow a capsule with a glass of water after an overnight fast and bowel preparation. Endocapsule (Olympus MAJ-1469) was used in the study. Examination was termed as complete when the capsule reached the caecum or incomplete if capsule failed to enter the caecum or the battery life was exhausted. Computer recordings were read by two examiners and finally results were interpreted. Follow up was done on telephone every 24 hours till the passage of capsule and then monthly for 4 months. In case of failure to pass the capsule after 14 days or adverse effects like vomiting, abdominal pain, an abdominal radiograph was obtained and decision regarding surgical intervention was made. RESULTS: A total of twenty eight patients were included in this study, 15 (53.6%) males and 13 (46.4%) females. Age of the patients ranged from 15-85 years (mean 56.25 +/- 19.6 years). There were 8 (28.6%) diabetics, 8 (28.6%) hypertensives and 5 (17.9%) hepatitis C positive patients. The indication for the capsule endoscopy was malena in 9 (32.1%), occult bleed in 18 (64.3%) and non specific abdominal pain in 1 (3.6%). Examination was completed in 22/28 (78.6%) patients while 6 (21.4%) patients had incomplete examination. In 2/28 (7.1%) patients endoscopic assistance was required to push the capsule through the pylorus. There was history of abdominal surgery in 3/28 (10.7%) patients prior to capsule endoscopy. Capsule entrapment occurred in 2/28 (7.1%) patients who were subjected to surgery. The results of capsule endoscopy showed ulceration and bleeding in distal ileum in 7 patients followed by Arterio Venous Malformation in 6 patients. The management and follow up was done accordingly. CONCLUSION: The diagnostic yield of CE in this study was 64.28% (18/28 patients). In a total of 28 patients referred for capsule endoscopy, bleeding was resolved in 13 patients (46.42%). Capsule endoscopy is a well tolerated and safe examination of the small bowel with a diagnostic yield superior to radiological investigations.