Kaolin Clay Anemia.

Iron deficiency anemia is a common diagnosis encountered in the nutrition, primary care, and gastroenterology fields. Iron deficiency anemia most often leads to evaluation for various malabsorption disorders and colonoscopy to exclude colon cancer as an etiology. We present a case of iron deficiency anemia that was caused by geophagia. After the culprit dietary habit was stopped, the patient's iron deficiency anemia subsequently resolved.

Initial Evaluation and Care of the Patient with New-Onset Intestinal Failure.

A total parenteral nutrition (TPN) formula needs to be correctly compounded with the help of a pharmacist and patients cycled to ensure they are tolerating the TPN volume. Selection of and close working relationship with a home infusion company needs to be arranged prior to hospital discharge and can be coordinated with the help of a hospital case manager. For Medicare patients, a certificate of medical necessity must be completed and signed prior to hospital discharge. Patients should undergo education regarding catheter care, infusion pump programming, and preparation of the TPN solution with additives, such as multivitamins and trace elements.

Barriers to treatment of chronic hepatitis C with direct acting antivirals in an urban clinic.

INTRODUCTION AND AIM: Direct-acting antiviral (DAA) agents are highly effective for treatment of chronic hepatitis C virus (HCV) yet access to treatment remains a serious challenge. The aim of this study was to identify barriers to treatment initiation with DAA-containing regimens in an urban clinic setting. MATERIALS AND METHODS: A retrospective cohort of all chronic HCV patients seen in an urban academic practice in Jacksonville, FL, USA from 1/2014 to 1/2017 was analyzed. Baseline characteristics were recorded and a review of medical records was performed to identify barriers to treatment initiation and overall success rates. RESULTS: Two-hundred and forty patients with chronic HCV were analyzed. Fifty-six percent of patients were African-American and 63% were insured through Medicaid/county programs or uninsured. Sixty-nine percent had barriers to initiating antiviral therapy categorized as psychosocial (n=112), provider (n=26), medical (n=20), and insurance-related factors (n=7). The most commonly encountered psychosocial barriers included failure to keep appointments (79/240, 33%), active substance abuse (18/240, 8%), and failure to obtain laboratory testing (11/240, 5%). Overall, only 27% of patients evaluated were initiated on DAA-containing regimens with 18% reaching SVR12 within the 36-month study period. CONCLUSION: In conclusion, only 27% of patients who presented to an urban academic practice with chronic HCV received DAA-containing regimens over a 36-month period. Psychosocial issues were the major barriers to antiviral therapy. These findings illustrate the need for an integrated approach that addresses psychosocial factors as well as comorbidities and adherence to care in order to increase rates of HCV treatment in at risk patients.

Comparison of EUS-guided versus percutaneous and transjugular approaches for the performance of liver biopsies.

BACKGROUND: Liver biopsy through endoscopic ultrasound (EUS) has become a novel approach for tissue acquisition. We aim to evaluate the adequacy of EUS-guided liver biopsies in comparison to those obtained through interventional radiology (IR) techniques. METHODS: A retrospective single-center analysis was performed of all IR (transjugular or image-guided percutaneous) and EUS-guided liver biopsies performed at an academic medical center from January 2016 to January 2018. Patient demographics, histologic characteristics, and clinical outcomes were collected. RESULTS: 152 procedures were included for analysis. 45% of liver biopsies were performed through EUS-guidance. The most common indication for liver biopsy was NASH fibrosis staging (n = 64). IR-guided biopsies contained a higher number of complete portal triads (13.6 vs. 10.8 p ≤ 0.01) while EUS-guided biopsies produced an increased total specimen length (4.6 cm vs. 3.6 cm p ≤ 0.01).47% of biopsy samples were fragmented with the majority of these (72%) occurring with EUS-guided procedures (p ≤ 0.01). IR-guided biopsies led to more complications in comparison to EUS-guided procedures (p = 0.03) CONCLUSION: Liver biopsies performed through EUS-guidance are comparable to IR-guided liver biopsies and may have an enhanced safety profile with acceptable tissue acquisition characteristics. Standardization of techniques and needles is needed for optimization of tissue sampling.

Predictors of No-show Rate in the GI Endoscopy Suite at a Safety Net Academic Medical Center.

BACKGROUND/OBJECTIVES: Noncompliance with physician and procedure appointments is associated with poor disease control and worse disease outcomes. This also impacts the quality of care, decreases efficiency, and affects revenue. Studies have shown that no-show rates are higher in clinics caring for underserved populations and may contribute to poorer health outcomes in this group. METHODS: We performed a 17-month retrospective observational cohort study of patients scheduled for outpatient procedures in the Gastroenterology endoscopy suite at the University of Florida Health, Jacksonville. Multivariate logistic regression analysis was performed to evaluate associations between attendance and predictors of no-show. RESULTS: In total, 6157 patients were scheduled to undergo different GI procedures during the study period. A total of 4388 (71%) patients completed their procedure, whereas 2349 (29%) failed to attend their appointment and were considered "no-show". There was a significant relationship between the visit attendance and race, insurance, gender, and marital status. Males had a higher no-show rate compared with females (30% vs. 28%; P<0.05). African Americans had the highest no-show rate (32%; P<0.05) amongst different races. Patients scheduled for surveillance colonoscopy (ie, history of polyps, IBD, Colon cancer) were more likely to show (78%) than those obtaining initial colorectal cancer screening (74%) or other indications (71%) (P<0.05).In the logistic regression model, patients with commercial insurance are more likely to show for their appointments than those with noncommercial insurance (eg, Medicare, Medicaid, City contract etc) [odds ratio (OR), 2.6; 95% confidence interval (CI), 2.2-3.0]. The odds of showing up are 1.7 times higher for married men compared with single men (OR, 1.7; 95% CI, 1.3-2.0). Similarly, married females are more likely to show up for appointment than single females (OR, 1.1; 95% CI, 0.9-1.3). We did not find significant association between the type of GI procedure (eg, colonoscopy vs. esophagogastroduodenoscopy vs. advanced endoscopic procedures) (P>0.05). CONCLUSIONS: Predictors of no-shows for endoscopic gastrointestinal procedures included unpartnered or single patients, African American race and noncommercial insurance providers. Patients scheduled for surveillance colonoscopy had better adherence than initial screening. Further studies are required to better characterize these factors and improve adherence to the outpatient appointments based on the identified predictors.

Excessive Tums Intake Can Cause Colonoscope Malfunction.

During a diagnostic esophagogastroduodenoscopy (EGD) and colonoscopy, a foreign material was found coating a patient's stomach and proximal colon. Polypectomy with a hot snare and cold forceps proved unsuccessful, as the endoscope channels clogged. Thereafter, the patient confessed to taking one bottle of Tums (GlaxoSmithKline, St. Louis, Missouri, US) daily for an unknown duration. The medication was discontinued and a repeat colonoscopy showed complete resolution. The costs of repeat procedures, reduced efficacy, as well as equipment damage or refurbishment are substantial, and so providers should note that this may be the result of excessive calcium carbonate (similarly to barium) and instruct the patients to adjust intake accordingly.

Intestinal Spirochetosis: An Obscure Cause of Lower Gastrointestinal Bleeding.

Adherence of spirochetes to the apical membrane of the colonic epithelium has been well-described in the literature, but the exact pathogenesis leading to symptomatic clinical manifestations is poorly understood. Most cases are found incidentally on the pathological evaluation of colonic biopsies taken during diagnostic or therapeutic colonoscopies. However, whether the colonization of the intestinal mucosa can be attributed to clinical symptoms is a matter of debate. Here, we present a case of intermittent hematochezia attributed to the overwhelming invasion of the colonic mucosa by intestinal spirochetes.

Intestinal Schistosomiasis: A Rare Cause of Abdominal Pain and Weight loss.

Abdominal pain is one of the most common reasons for outpatient visits. Although intestinal schistosomiasis is extremely rare in US, it should be considered in the differential diagnosis for those patients with risk factors such as international traveling history. This case report illustrates a unique case of intestinal schistosomiasis, which presented with an eight-week history of nonspecific abdominal pain and weight loss. Her colonoscopy revealed a 10 mm polyp in the colon. Endoscopic mucosal resection confirmed the diagnosis of schistosomiasis. Treatment with Praziquantel resulted in significant improvement of her symptoms.

Poverty, a risk factor overlooked: a cross-sectional cohort study comparing poverty rate and cardiovascular disease outcomes in the state of Florida.

The purpose of this study is to examine the relationship between poverty rate and heart disease in our state. A cross-sectional data analysis was performed using figures provided by the Center for Disease Control's Interactive Atlas of Heart Disease and Stroke Tables. Spearman's correlations and simple regressions were used to determine if there was a relationship between poverty and cardiovascular hospitalization rate and cardiovascular death rate. There was a positive monotonic correlation between poverty rate and cardiovascular hospitalization rate (Rho=0.384, P=0.001). There was a positive monotonic correlation between poverty rate and cardiovascular death rate (Rho=0.646, P<0.0001). County poverty rate had a statistically significant positive relationship with cardiovascular hospitalization and cardiovascular mortality in the state of Florida.

A Rare Report of Infectious Emphysematous Aortitis Secondary to Clostridium septicum without Prior Vascular Intervention.

The term "mycotic aneurysm" was first used by Osler in 1882 to describe a mushroom-shaped aneurysm in subacute bacterial endocarditis. Mycotic aneurysms account for only 2.6% of all aneurysms of the aorta. Rarer still are anaerobic infections secondary to organisms such as Clostridium septicum, which results in emphysematous aortitis. The vast majority of emphysematous aortic infections occur as a result of instrumentation; however, in this case we present an infection de novo. A 75-year-old male presented with a 2-week history of progressive fatigue and chest pain that then developed into constitutional symptoms. Chest radiograph demonstrated an obvious widened mediastinum. CT angiogram of his chest then confirmed this finding as well as significant periaortic gas and focal outpouching. Numerous diverticuli with inflammatory changes consistent with diverticulitis was observed on CT abdomen. Blood cultures returned positive for Clostridium septicum. Definitive treatment was discussed including debridement and graft insertion; however, patient decided on conservative management and was discharged on intravenous antibiotics. Unfortunately, as in most cases of emphysematous aortitis that do not undergo surgical management, the patient succumbed to his illness. The lesson provided will be the epidemiology of emphysematous aortitis, presentation, diagnosis, management, and prognosis through a case report.

Cigarette Lighter Fluid Induced Gastric Ulcer: A Severe Complication of Delayed Foreign Body Removal.

The majority of foreign bodies ingested pass uneventfully through the gastrointestinal tract without endoscopic intervention. Nevertheless, certain ingested objects pose a greater risk for complications and are more challenging to remove than others. This case report describes a 49-year-old male who swallowed a cigarette lighter causing a gastric ulcer. The lighter was successfully removed by flexible endoscopy using a polypectomy snare. Urgent removal is required due to the shape of the object and its hazardous contents. This is the first case report published in the United States describing cigarette lighter ingestion and management.

Melanoma Masquerading as a Zosteriform Rash.

BACKGROUND Primary care physicians and internal medicine specialists frequently encounter a variety of rashes. Many of these cases look and feel typical of common entities, resulting in the potential for misdiagnosis. CASE REPORT This is a case of a zosteriform rash where the surprising true diagnosis of metastatic melanoma was confirmed with bedside skin punch biopsy. Possible mechanisms involve direct cutaneous injury, neuronal, and dorsal root ganglia involvement in metastases. CONCLUSIONS Skin biopsy is indispensable especially when there is a lack of clinical response or deterioration in the clinical condition. The pathophysiology of zosteriform metastasis is unclear.

Anticoagulation for the Pregnant Patient with a Mechanical Heart Valve, No Perfect Therapy: Review of Guidelines for Anticoagulation in the Pregnant Patient.

Heart valve replacement with a mechanical valve requires lifelong anticoagulation. Guidelines currently recommend using a vitamin K antagonist (VKA) such as warfarin. Given the teratogenic effects of VKAs, it is often favorable to switch to heparin-derived therapies in pregnant patients since they do not cross the placenta. However, these therapies are known to be less effective anticoagulants subjecting the pregnant patient to a higher chance of a thrombotic event. Guidelines currently recommend pregnant women requiring more than 5 mg a day of warfarin be switched to alternative therapy during the first trimester. This case report highlights a patient who was switched to alternative therapy during her first pregnancy and suffered a devastating cerebrovascular accident (CVA). Further complicating her situation was during a subsequent pregnancy; this patient continued warfarin use during the first trimester and experienced multiple transient ischemic attacks (TIAs). This case highlights the increased risk of thrombotic events in pregnant patients with mechanical valves. It also highlights the difficulty of providing appropriate anticoagulation for the pregnant patient who has experienced thrombotic events on multiple anticoagulants.

A Curious Case of Proximal Muscle Weakness with Eosinophilic Polymyositis.

Eosinophilic polymyositis (EPM) is part of a rare disorder, eosinophilic myopathies (EM), which is a form of polymyositis characterized by the presence of eosinophils in muscle biopsy sections and occasionally blood eosinophilia. Herein, we are presenting an interesting case of eosinophilic polymyositis presenting with muscle pain with no other organ systems involved.