A Rare Case of Sigmoid Colon Perforation in a Patient With Severe Acute Pancreatitis.

Severe acute pancreatitis can cause systemic inflammation and multiorgan failure. We present the case of a 60-year-old woman who presented with necrotizing pancreatitis and subsequently developed a sigmoid colon perforation. The perforation presumably occurred because of extravasation of pancreatic enzymes into the abdominal cavity, resulting in colonic wall injury. Our case highlights the rare colonic complications of severe acute pancreatitis.

Validation of GPT-4 for clinical event classification: A comparative analysis with ICD codes and human reviewers.

BACKGROUND AND AIM: Effective clinical event classification is essential for clinical research and quality improvement. The validation of artificial intelligence (AI) models like Generative Pre-trained Transformer 4 (GPT-4) for this task and comparison with conventional methods remains unexplored. METHODS: We evaluated the performance of the GPT-4 model for classifying gastrointestinal (GI) bleeding episodes from 200 medical discharge summaries and compared the results with human review and an International Classification of Diseases (ICD) code-based system. The analysis included accuracy, sensitivity, and specificity evaluation, using ground truth determined by physician reviewers. RESULTS: GPT-4 exhibited an accuracy of 94.4% in identifying GI bleeding occurrences, outperforming ICD codes (accuracy 63.5%, P < 0.001). GPT-4's accuracy was either slightly lower or statistically similar to individual human reviewers (Reviewer 1: 98.5%, P < 0.001; Reviewer 2: 90.8%, P = 0.170). For location classification, GPT-4 achieved accuracies of 81.7% and 83.5% for confirmed and probable GI bleeding locations, respectively, with figures that were either slightly lower or comparable with those of human reviewers. GPT-4 was highly efficient, analyzing the dataset in 12.7 min at a cost of 21.2 USD, whereas human reviewers required 8-9 h each. CONCLUSION: Our study indicates GPT-4 offers a reliable, cost-efficient, and faster alternative to current clinical event classification methods, outperforming the conventional ICD coding system and performing comparably to individual expert human reviewers. Its implementation could facilitate more accurate and granular clinical research and quality audits. Future research should explore scalability, prompt and model tuning, and ethical implications of high-performance AI models in clinical data processing.

Development of a Risk Stratification Model for Pre-liver-Transplant Screening Colonoscopy.

BACKGROUND AND AIMS: Colonoscopies are routinely obtained before liver transplantation, although their utility is a highly debated topic in the literature. We aimed to determine the risk factors in patients with decompensated cirrhosis (DC) for post-colonoscopy complications (PCC). MATERIALS AND METHODS: We performed a single-center retrospective study of patients with DC undergoing colonoscopy as part of their pre-liver-transplant evaluation. The primary composite outcome was defined as a complication occurring within 30 days of the colonoscopy. Complications included acute renal failure, new or worsening ascites or hepatic encephalopathy, gastrointestinal bleeding, or any cardiopulmonary or infectious complication. Logistic regression analysis was utilized to derive a risk score in predicting the primary composite outcome. RESULTS: The strongest predictors of post-colonoscopy complication were MELD-Na ≥21 [aOR 4.0026 ( P =0.0050)] and history of any infection in the 30 days before colonoscopy [aOR 8.4345 ( P =0.0093)]. The area under the receiver operating characteristic curve of the final model was 0.78. The predicted risk of any complication at the lowest quartile was 16.2% to 39.4%, and the observed risk was 30.6% (95% CI: 15.5-45.6%), while the predicted risk at the highest quartile was 71.9% to 97.1%, and the observed risk was 81.3% (95% CI: 67.7-95%). CONCLUSION: In this cohort of patients with DC undergoing colonoscopy for pre-liver-transplant evaluation, a history of ascites, spontaneous bacterial peritonitis, and MELD-Na were found to be predictive of PCC. This risk score may help to predict PCC in patients with DC undergoing a pre-transplant colonoscopy. External validation is recommended.

Acute esophageal stricture after bone marrow transplant.

Esophageal stricture after bone marrow transplantation (BMT) is exceptionally rare, with only a few cases reported in the literature. We present an interesting case of a 58-year-old male with refractory multiple myeloma who developed dysphagia five days following his second bone marrow transplantation. He was found to have a severe esophageal stricture. The patient was treated with multiple esophageal dilations and triamcinolone injections in the following weeks to months, resulting in an improvement in symptoms. Although the exact underlying mechanism remains unknown, high-dose chemotherapy conditioning with melphalan prior to BMT likely contributed to the stricture. Our case highlights the importance of heightened post-bone marrow transplantation management for rare complications, such as an esophageal stricture.

Validation of prediction tools for GI bleeding in patients on dual anti-platelet therapy after percutaneous coronary intervention.

BACKGROUND AND AIMS: The management of dual anti-platelet therapy after percutaneous coronary intervention (PCI) and GI bleeding (GIB) remains a clinical dilemma. We sought to identify predictors of GIB and recurrent bleeding and to determine whether recurrent bleeding increases the risk of major adverse cardiovascular events (MACEs). METHODS: In this single-center retrospective study, patients undergoing PCI were identified. The primary and secondary endpoints were GIB at 180 days and recurrent bleeding or MACE at 365 days. Logistic regression was used to identify predictors of GIB and recurrent bleeding. Cox proportional hazards modeling was used to determine whether recurrent bleeding can predict a MACE. RESULTS: Five hundred thirty-six patients were included. On multivariable analysis, PCI for acute coronary syndrome was associated with a 95% increased odds of GIB (P < .001). The P2Y12 inhibitor was continued in >90% of patients, which trended toward significance for recurrent bleeding (P < .10). The HAS-BLED score (Hypertension, Abnormal renal and liver function, Stroke, Bleeding tendency or predisposition, Labile INRs, Elderly, Drugs), including a labile international normalized ratio and prior major bleeding, was strongly associated with recurrent bleeding (P ≤ .009). Recurrent bleeding was associated with a 115% increased risk of MACEs (P = .02). We derived a novel risk score, named the SIGE score ([S]TEMI at PCI, having a labile [I]NR at PCI, index [G]IB within 180 days of PCI, and previous precatheterization [E]ndoscopy within 6 months), to predict recurrent bleeding at 365 days with a high predictive accuracy (area under the curve, .773; 95% confidence interval, .702-.845). CONCLUSIONS: The SIGE score may help to predict recurrent bleeding, which was shown to be associated with an increased risk of MACEs. Further external validation is needed.

Effect of an artificial intelligence-assisted system on endoscopic diagnosis of superficial oesophageal squamous cell carcinoma and precancerous lesions: a multicentre, tandem, double-blind, randomised controlled trial.

BACKGROUND: Despite the usefulness of white light endoscopy (WLE) and non-magnified narrow-band imaging (NBI) for screening for superficial oesophageal squamous cell carcinoma and precancerous lesions, these lesions might be missed due to their subtle features and interpretation variations among endoscopists. Our team has developed an artificial intelligence (AI) system to detect superficial oesophageal squamous cell carcinoma and precancerous lesions using WLE and non-magnified NBI. We aimed to evaluate the auxiliary diagnostic performance of the AI system in a real clinical setting. METHODS: We did a multicentre, tandem, double-blind, randomised controlled trial at 12 hospitals in China. Eligible patients were aged 18 years or older and underwent sedated upper gastrointestinal endoscopy for screening, investigation of gastrointestinal symptoms, or surveillance. Patients were randomly assigned (1:1) to either the AI-first group or the routine-first group using a computerised random number generator. Patients, pathologists, and statistical analysts were masked to group assignment, whereas endoscopists and research assistants were not. The same endoscopist at each centre did tandem upper gastrointestinal endoscopy for each eligible patient on the same day. In the AI-first group, the endoscopist did the first examination with the assistance of the AI system and the second examination without it. In the routine-first group, the order of examinations was reversed. The primary outcome was the miss rate of superficial oesophageal squamous cell carcinoma and precancerous lesions, calculated on a per-lesion and per-patient basis. All analyses were done on a per-protocol basis. This trial is registered with the Chinese Clinical Trial Registry (ChiCTR2100052116) and is completed. FINDINGS: Between Oct 19, 2021, and June 8, 2022, 5934 patients were randomly assigned to the AI-first group and 5912 to the routine-first group, of whom 5865 and 5850 were eligible for analysis. Per-lesion miss rates were 1·7% (2/118; 95% CI 0·0-4·0) in the AI-first group versus 6·7% (6/90; 1·5-11·8) in the routine-first group (risk ratio 0·25, 95% CI 0·06-1·08; p=0·079). Per-patient miss rates were 1·9% (2/106; 0·0-4·5) in AI-first group versus 5·1% (4/79; 0·2-9·9) in the routine-first group (0·37, 0·08-1·71; p=0·40). Bleeding after biopsy of oesophageal lesions was observed in 13 (0·2%) patients in the AI-first group and 11 (0·2%) patients in the routine-first group. No serious adverse events were reported by patients in either group. INTERPRETATION: The observed effect of AI-assisted endoscopy on the per-lesion and per-patient miss rates of superficial oesophageal squamous cell carcinoma and precancerous lesions under WLE and non-magnified NBI was consistent with substantial benefit through to a neutral or small negative effect. The effectiveness and cost-benefit of this AI system in real-world clinical settings remain to be further assessed. FUNDING: National Natural Science Foundation of China, 1·3·5 project for disciplines of excellence, West China Hospital, Sichuan University, and Chengdu Science and Technology Project. TRANSLATION: For the Chinese translation of the abstract see Supplementary Materials section.

Gastrointestinal hospitalization during COVID-19 pandemic in the United States: Analysis of a nationwide inpatient sample.

BACKGROUND AND AIM: We aim to systematically investigate gastrointestinal (GI) hospitalizations in the United States during the early phase of the COVID-19 pandemic on a national level and the consequence that may inform practice and policies. METHODS: A retrospective cross-sectional analysis of adult hospitalizations with GI-related diagnoses or procedures in the United States in 2020 was used, with hospitalizations from 2016 to 2019 used for contextual information. RESULTS: Hospitalizations with principal and secondary GI diagnoses decreased by 13.3% and 8.2% from 2019 to 2020, respectively. Most GI diagnoses decreased in 2020, with a few exceptions including alcoholic liver disease (increased by 7.8% as a principal diagnosis) and acute liver failure (increased by 11.6% as a secondary diagnosis). The mortality rate of hospitalizations with GI disease increased in 2020 compared with 2019 (for principal diagnosis: adjusted odds ratio 1.08, 95% confidence interval 1.03-1.13, P = 0.001; for secondary diagnosis: adjusted odds ratio 1.10, 95% confidence interval 1.07-1.13, P < 0.001). Most GI procedures decreased except for a notable 8.3% increase in gastrostomy. The per-GI-hospitalization rate of procedures increased for hospitalizations with a principal GI diagnosis (56.4% vs 55.6%, P = 0.003) or unchanged for hospitalizations with secondary GI diagnoses (18.3% vs 18.2%, P = 0.512). CONCLUSION: The COVID-19 pandemic resulted in a decrease in the volume of GI hospitalizations and procedures in 2020, but there was an increase in the mortality rate and some specific diagnoses including alcoholic liver disease and acute liver failure. These findings will likely enlighten future research and healthcare resource allocation for GI diseases.

Number of bottles of esophageal biopsies in the evaluation of eosinophilic esophagitis and clinical outcomes.

BACKGROUND: The number of bottles of esophageal biopsies needed for the evaluation of eosinophilic esophagitis (EoE) is unclear, despite cost differences. AIMS: Assess the clinical outcomes between patients with one and two bottles of esophageal biopsies for the assessment of EoE. METHODS: Retrospective study of adults who underwent esophagogastroduodenoscopy (EGD) for esophageal symptoms between January 2015 and June 2021 and findings of ≥15 eosinophils per high power field (eos/hpf). Patients with one bottle (1 bottle-EoE) had biopsies from the entire or proximal esophagus. Patients with two bottles had biopsies separated from the distal and proximal esophagus and were separated into those with ≥ 15 eos/hpf in both bottles (2 bottle Dif-EoE), or the distal bottle alone (2 bottle Lim-EoE). The primary outcomes were endoscopic findings at follow-up EGD as assessed by the Eosinophilic Esophagitis Endoscopic Reference Score (EREFS) and the presence of ≥15 eos/hpf. RESULTS: Of 85 patients with esophageal eosinophilia who met inclusion criteria, 49 had 2 bottle Dif-EoE, 18 had 2 bottle Lim-EoE, and 18 had 1 bottle-EoE. At median follow-up of 3.3-5.6 months, more patients with 1 bottle EoE had dysphagia (p = 0.029), however there were no differences in the EREFS (p = 0.14) or presence of ≥15 eos/hpf (p = 0.39). More patients with 2 bottle Dif-EoE were treated with topical steroids (16.3% vs. 0% vs. 0%, p = 0.039) and diet (20.4% vs. 0% vs. 5.6%, p = 0.05). CONCLUSION: Endoscopic and histologic outcomes were similar in patients who had one and two bottles for esophageal biopsies in the evaluation of EoE.

Global Burden of Digestive Diseases: A Systematic Analysis of the Global Burden of Diseases Study, 1990 to 2019.

BACKGROUND & AIMS: This study assessed the worldwide burden of digestive diseases between 1990 and 2019. METHODS: We analyzed data from the Global Burden of Diseases study, covering 18 digestive diseases across 204 countries and territories. Key disease burden indicators, including incidence, prevalence, mortality, and disability-adjusted life years (DALYs), were studied. Linear regression analysis was applied to the natural logarithm of age-standardized outcomes to determine the annual percent change. RESULTS: In 2019, there were 7.32 billion incidents and 2.86 billion prevalent cases of digestive diseases, resulting in 8 million deaths and 277 million DALYs lost. Little to no decrease in global age-standardized incidence and prevalence of digestive diseases was observed between 1990 and 2019, with 95,582 and 35,106 cases per 100,000 individuals in 2019, respectively. The age-standardized death rate was 102 per 100,000 individuals. Digestive diseases accounted for a significant portion of the overall disease burden, with more than one-third of prevalent cases having a digestive etiology. Enteric infections were the primary contributor to incidence, death, and DALYs lost, whereas cirrhosis and other chronic liver diseases had the highest prevalence rate. The burden of digestive diseases was inversely related to the sociodemographic index, with enteric infections being the predominant cause of death in low and low-middle quintiles and colorectal cancer in the high quintile. CONCLUSIONS: Despite significant reductions in deaths and DALYs due to digestive diseases from 1990 to 2019, they remain prevalent. A significant disparity in the burden of digestive diseases exists among countries with different development levels.

An Unusual Cause of GI Blood Loss.

Chronic gastrointestinal bleeding is the leading cause of iron deficiency anemia in developed countries, and most occult bleeds are attributed to upper gastrointestinal tract lesions, which are broadly categorized into mass lesions, vascular, infectious, and inflammatory abnormalities. Gastric polyps account for an exceedingly small portion of these lesions but are of clinical importance because of the risk for progression to malignancy. We describe a patient found to have a gastric foveolar-type adenoma as a rare cause of iron deficiency anemia, with an incidentally found gastric neuroendocrine tumor.

Colchicine as an Alternative First-Line Treatment of Sclerosing Mesenteritis: A Retrospective Study.

BACKGROUND: Sclerosing mesenteritis is a rare condition characterized by chronic inflammation and fibrotic changes of the mesentery. AIMS: To determine the long-term management and outcomes of patients with sclerosing mesenteritis. METHODS: Patients with biopsy-proven sclerosing mesenteritis at the Mayo Clinic between January 2006 and December 2016 were identified. Clinical data were collected retrospectively. RESULTS: One hundred and three patients were identified, median age 68.0 years (range 35.0-85.3). Most patients were symptomatic (87.4%) at presentation. Patients received no treatment (52.4%), medical therapy (42.7%) or surgery (4.9%) on initial diagnosis. The most common initial regimens were prednisone plus tamoxifen (41.9%), prednisone alone (23.3%), and prednisone plus colchicine (11.6%) with 55.6%, 57.2%, and 60% of patients improving, respectively, p = 0.85 for a difference in response rates. At least half of the patients responded to prednisone plus tamoxifen, prednisone plus colchicine, or prednisone alone at 6.0, 7.2, and 8.4 months, respectively. At a median follow-up of 45.6 months (95% CI 24.1-69.7), 65.4% of patients were receiving medical therapy. Of those receiving tamoxifen-based, steroid-based, or steroid-sparing regimens, 100%, 87.5%, and 77.8% had improved by their last follow-up appointment respectively, p = 0.15. CONCLUSION: Prednisone plus colchicine has a similar efficacy to prednisone plus tamoxifen for the initial and long-term treatment of sclerosing mesenteritis. The majority of patients were initiated on medical therapy over the long term with most reporting symptomatic improvement within a year. Death from SM was rare.

Esophageal Stricture Recalcitrant to Repeated Dilation in Complex Rheumatological Disease.

We report a case of severe refractory esophageal strictures in the setting of rheumatological disease found to be secondary to isolated esophageal autoimmune bullous disease. She had a history of Sjogren syndrome and esophageal strictures with many previous dilations. After rheumatological workup, she was diagnosed with mixed connective tissue disease. Biopsy showed complement and immunoglobulin G deposition in the basement membrane consistent with bullous lupus or bullous pemphigoid. She had no cutaneous bullae and was diagnosed with isolated esophageal bullous disease. She required multiple dilatations over several months of treatment and was started on mycophenolate mofetil with clinical improvement.

Back to Basics: History and Physical Examination Uncover Colonic Metastasis in a Patient With Remote History of Breast Cancer.

We present the cast of a 74-year-old woman with a remote history of recurrent localized breast cancer who presented with nonspecific gastrointestinal symptoms who was subsequently found to have metastatic breast cancer in the transverse colon. Nonspecific gastrointestinal complaints can be the first sign of cancer recurrence in these patients. Providers should maintain a high index of suspicion for disease recurrence when evaluating cancer survivors.

Magnetic bead-assisted endoscopic submucosal dissection: a gravity-based traction method for treating large superficial colorectal tumors.

BACKGROUND: Colorectal endoscopic submucosal dissection (ESD) has always been challenging for endoscopists, but the procedure can be facilitated after adequate exposure of submucosal layer and cutting line. We developed a traction method based on gravity for facilitating colorectal ESD, referred as magnetic bead-assisted ESD (MBA-ESD). This study aimed to compare the safety and effectiveness of MBA-ESD and conventional ESD for treating large superficial colorectal tumors. METHODS: This retrospective study included consecutive patients with large (≥ 20 mm in their maximal diameter) superficial colorectal tumors who underwent MBA-ESD or conventional ESD at our endoscopy center between June 2017 to January 2018. Each patient in the MBA-ESD group was matched to a patient in the conventional ESD group using propensity scores. RESULTS: Thirteen patients in each group were matched for the analyses. The baseline characteristics were balanced after propensity matching. The incidence of overall complications was significantly lower in the matched MBA-ESD group (0% vs. 38.5%, P = 0.039), while similar rates of en bloc resection, R0 resection, curative resection, and tumor recurrence were noted. Although without statistic difference, dissection time and speed were improved when using MBA-ESD (33 min vs. 40 min, P = 0.111; and 21 mm2/min vs. 16 mm2/min, P = 0.143, respectively). CONCLUSIONS: MBA-ESD is a feasible, safe, and effective method for treating large superficial colorectal tumors. Further large, prospective and controlled studies are needed to fully assess this method.

Selective application of fully covered biliary stents and narrow-diameter esophageal stents for proximal esophageal indications.

BACKGROUND: Proximal esophageal stents are poorly tolerated and have a high risk of complications. We report our experience using fully covered, biliary, self-expandable metal stents (B-SEMS) and narrow-diameter, esophageal, self-expandable metal stents (NDE-SEMS) for this group of patients. METHODS: 24 patients underwent placement of B-SEMS or NDE-SEMS for proximal esophageal lesions between 1 January 2011 and 31 July 2016. The outcomes included improvement of dysphagia, healing of fistulas, and adverse events. RESULTS: 10 patients received B-SEMS and 14 had NDE-SEMS. Median follow-up time was 11.5 months (range 0.5 - 62 months). In both cohorts, stents were left in place for a mean of 6 weeks. The dysphagia score decreased in 7 (70 %) and 10 (71.4 %) patients, and fistulas resolved in 3/5 (60.0 %) and 5/8 (62.5 %) patients with B-SEMS and NDE-SEMS, respectively. Stent migration occurred in three patients (30.0 %) with B-SEMS and five patients (35.7 %) with NDE-SEMS. CONCLUSIONS: Both stents were well tolerated and resulted in overall improvement of dysphagia in 70.8 % of patients. B-SEMS appeared to be more favorable for cervical esophageal lesions with narrower diameters, while NDE-SEMS may be better for more distal lesions.

Comparison of flexible endoscopic cricopharyngeal myectomy and myotomy approaches for Zenker diverticulum repair.

BACKGROUND AND AIMS: Incision of the cricopharyngeal (CP) muscle with flexible endoscopy is an important approach for Zenker diverticulum (ZD) repair with symptomatic resolution in approximately 90% of cases, but recurrence has been reported in up to 20%. We report our experience with a new endoscopic myectomy of the CP muscle and compare the outcome with conventional myotomy of ZD. METHODS: Our retrospective study included all patients with ZD who underwent endoscopic repair between August 1, 2014 and July 31, 2017. Conventional CP myotomy was defined as a vertical cut through the CP muscle. CP myectomy was defined as parallel excisions followed by snare resection at the CP resection base. Measurement of ZD size was based on barium esophagram and endoscopic estimation. Outcomes included ZD recurrence, improvement of dysphagia, and procedure adverse events. RESULTS: Sixty-four patients underwent endoscopic repair for ZD, 44 with CP myotomy and 20 with CP myectomy. Mean (standard deviation) size of ZD was 3.3 cm (1.0) and 3.8 cm (1.2) in the myotomy and myectomy cohorts, respectively (P = .11), and median procedure time was 50 and 56 minutes, respectively (P = .73). In the CP myotomy cohort, 10 patients (22.7%) had recurrence of ZD at a median of 19.1 months, whereas no recurrence was documented in the CP myectomy cohort (P = .02). This trend was also shown in multivariate analysis but was not statistically significant (P = .07). There was no statistical difference in improvement of dysphagia and adverse events. CONCLUSIONS: CP myectomy is a new endoscopic technique for ZD repair. In our experience, it was safe and well tolerated, with a high initial success rate and less ZD recurrence when compared with myotomy.