Severe Liver and Renal Injury From Tribulus Terrestris.

Tribulus terrestris is a shrub that is found worldwide. Although it has been linked to severe jaundice and death in grazing animals, there are only a few case reports of hepatotoxicity in humans. We describe a case of a 46-year-old man who took tribulus supplements daily for 2 months. He developed severe jaundice prompting hospital admission. His total bilirubin peaked at 48 mg/dL, with concomitant renal dysfunction (creatinine of 7.1). His liver biopsy showed features consistent with drug-induced liver injury. He was initiated on a trial of plasmapheresis and underwent 3 sessions with a subsequent decrease in bilirubin with each session. He had appropriate renal recovery and was discharged home and on follow-up, continues to do well with most recent bilirubin of 1.1 mg/dL.

Iliac Artery-Inferior Vena Cava-Duodenal Fistula: An Unusual Cause of Massive Gastrointestinal Bleeding.

An arteriovenous-enteric fistula is a 3-way connection between the vascular and enteric system and associated with high mortality. We describe a case of iliac artery-inferior vena cava-duodenal fistula in a young female with a retroperitoneal mass presenting with sepsis and hemorrhagic shock with a catastrophic clinical course. These fistulas can be missed on endoscopy/colonoscopy and are usually diagnosed on computed tomography angiogram of the abdomen. Complex vasculoenteric fistula should be among differentials in patients presenting with gastrointestinal bleeding, especially with a history of malignancy, radiation, foreign bodies, and trauma. The management is complex and should involve a multidisciplinary approach involving vascular surgery, intervention radiology, and gastroenterologist.

Predictors and Outcomes of Palliative Care Consultations for Patients With Liver Disease: Results of a Cohort Study of 75 Million Medical Records.

Background: Liver transplant is the only cure for cirrhosis. We studied the impact of palliative care on patient care by conducting a population-based cohort study. Methods: We queried the Explorys database (IBM, New York) database for a diagnosis of 'cirrhosis' followed by 'palliative care consultation' and collected demographic and clinical data. Results: We identified 316,970 patients with cirrhosis. Palliative care was consulted for 10.9% (n = 34,600) of patients. Patients aged >65 [OR 1.33 (1.30-1.36), P < .0001], men [OR 1.13 (1.11-1.16), P < .0001], a diagnosis of hepatocellular carcinoma (HCC) [OR 2.53 (2.45-2.60), P < .0001] were more likely to receive a palliative care consultation. Patients for whom palliative care were consulted were less likely to undergo surgical procedures [OR .49 (.47-.50)]. Conclusion: Only about 1 in 10 cirrhotics received a palliative care consultation. Older patients, males, and patients with a diagnosis of HCC are more likely to receive palliative care.

Acute hypotensive hematochezia due to jejunal diverticular bleed.

Small bowel diverticulum, though rare, can result in complications including diverticulitis, hemorrhage, intussusception, fistula, perforation, or bacterial overgrowth. Here, we present a case of gastrointestinal bleeding as a complication of jejunal diverticulum, resulting in hemorrhagic shock. The patient had a negative endoscopy and colonoscopy, prompting computed tomography angiogram, which identified one jejunal diverticulum with active contrast extravasation into the lumen of the small bowel. She underwent successful coil embolization, resulting in cessation of bleeding. This case demonstrates the difficult but successful identification of nonsteroidal antiinflammatory drug-induced jejunal diverticular bleeding in the acute emergent setting.

Incidence, outcomes, and impact of COVID-19 on inflammatory bowel disease: propensity matched research network analysis.

BACKGROUND: Accurate estimates for the risk of COVID-19 in IBD, and an understanding of the impact of COVID-19 on IBD course and the risk of incident post-infectious IBD are needed. AIMS: To estimate the risk of COVID-19 in IBD and study its impact on IBD course and the risk of incident post-infectious IBD. METHODS: A retrospective propensity score matched cohort study utilising multi-institutional research network TriNetX. COVID-19 patients with and without IBD were identified to quantify the risk of COVID-19 in patients with IBD, COVID-19 outcomes in patients with IBD and the impact of COVID-19 on IBD disease course. The risk of incident post-infectious IBD in COVID-19 patients was compared to the population not infected with COVID-19 during a similar time period. RESULTS: Incidence rate ratio for COVID-19 was lower in IBD patients compared to the non-IBD population (0.79, 95% CI: 0.72-0.86). COVID-19-infected patients with IBD were at increased risk for requiring hospitalisation compared to non-IBD population (RR: 1.17, 95% CI: 1.02-1.34) with no differences in need for mechanical ventilation or mortality. Patients with IBD on steroids were at an increased risk for critical care need (RR: 2.22, 95% CI: 1.29-3.82). Up to 7% of patients with IBD infected with COVID-19 suffered an IBD flare 3-months post-infection. Risk for incident IBD post-COVID was lower than that seen in the non-COVID population (RR: 0.64, 95% CI: 0.54-0.65). CONCLUSION: We observed no increase in risk for COVID-19 amongst patients with IBD or risk for de novo IBD after COVID-19 infection. We confirmed prior observations regarding the impact of steroid use on COVID-19 severity in patients with IBD.

A Curious Case of a Posterior Mediastinal Mass.

Gastrointestinal stromal cell tumors (GISTs) are mesenchymal stromal tumors that are characteristically CD117 positive. Distinction from other spindle cell tumors such as leiomyomas and leiomyosarcomas is based on clinical, histological, and molecular features. Endoscopic ultrasonography-guided fine-needle aspiration has become a highly used means of preoperative identification of GIST, especially if immunohistochemical staining for CD117 can be performed. We present a case of a posterior mediastinal mass diagnosed as GIST after being found to be CD117 positive, later found to be a metastatic leiomyosarcoma.

Quality Gaps in Management of Acute Pancreatitis: A Tertiary Care Center Experience.

OBJECTIVES: Acute pancreatitis (AP) is a leading cause of inpatient care among gastrointestinal conditions. Our study compares the management of AP and adherence to guidelines among teaching medicine, nonteaching medicine, and surgical services within the same center. METHODS: We performed a retrospective chart review of AP patients admitted to our center between January 2016 and January 2017 and analyzed the clinical and epidemiological data. RESULTS: Of 115 patients, 65% were admitted to medicine (IM), and 35% were admitted to surgery. Mean age was 53.9 (standard deviation [SD], 15) years, and 52% were males; 38.6% (n = 29) of IM patients were prescribed lactated Ringer's solution for fluid resuscitation (mean rate of 153 [SD, 44.98] mL/h on teaching and 113 [SD, 43.56] mL/h on the nonteaching service). Antibiotics were prescribed to 22.6% (n = 17) of IM patients. On the surgical service, 77.5% of patients were prescribed lactated Ringer's solution for fluid resuscitation (mean rate of 108.25 [SD, 1.19] mL/h); 52.5% of patients received antibiotics. CONCLUSIONS: Adherence to guidelines for management of AP is inadequate, and nonuniformity exists across different services within the same institution. There is a need for quality improvement initiatives.

Convolutional neural networks in the computer-aided diagnosis of Helicobacter pylori infection and non-causal comparison to physician endoscopists: a systematic review with meta-analysis.

BACKGROUND: Helicobacter pylori (H. pylori) infection, if left untreated, can cause gastric cancer, among other serious morbidities. In recent times, a growing body of evidence has evaluated the use of a type of artificial intelligence (AI) known as "deep learning" in the computer-aided diagnosis of H. pylori using convolutional neural networks (CNN). We conducted this meta-analysis to evaluate the pooled rates of performance of CNN-based AI in the diagnosis of H. pylori infection. METHODS: Multiple databases were searched (from inception to June 2020) and studies that reported on the performance of CNN in the diagnosis of H. pylori infection were selected. A random-effects model was used to calculate the pooled rates. In cases where multiple 2×2 contingency tables were provided for different thresholds, we assumed the data tables were independent from each other. RESULTS: Five studies were included in our final analysis. Images used were from a combination of white-light, blue laser imaging, and linked color imaging. The pooled accuracy for detecting H. pylori infection with AI was 87.1% (95% confidence interval [CI] 81.8-91.1), sensitivity was 86.3% (95%CI 80.4-90.6), and specificity was 87.1% (95%CI 80.5-91.7). The corresponding performance metrics for physician endoscopists were 82.9% (95%CI 76.7-87.7), 79.6% (95%CI 68.1-87.7), and 83.8% (95%CI 72-91.3), respectively. Based on non-causal subgroup comparison methods, CNN seemed to perform equivalently to physicians. CONCLUSION: Based on our meta-analysis, CNN-based computer-aided diagnosis of H. pylori infection demonstrated an accuracy, sensitivity, and specificity of 87%.

EUS-directed transgastric endoscopic retrograde cholangiopancreatography versus laparoscopic-assisted ERCP versus deep enteroscopy-assisted ERCP for patients with RYGB.

Background and study aims Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP) (EDGE) is a novel technique for managing pancreaticobiliary diseases in patients with a history of Roux-en-Y Gastric Bypass (RYGB). It has shown to have high technical success rates and fewer adverse events as compared to laparoscopic-assisted ERCP (LA-ERCP). We compared the technical success and clinical outcomes of EDGE vs. LA-ERCP vs. E-ERCP. Patients and methods A retrospective chart review was performed for 56 patients, of whom 18 underwent LA-ERCP, 12 underwent E-ERCP, and 26 had EDGE, and a comparison of technical success and complication rates was done. Results Baseline demographic characteristics of patients undergoing these procedures, including age and gender, were comparable. The technical success rate for patients in the EDGE group were 100 % (n = 26), compared with 94 % (n = 17) and 75 % (n = 9) in the LA-ERCP and E-ERCP groups ( P  = 0.02). In the EDGE group, 8 % of patients (n = 2) had bleeding, and 4 % of patients (n = 1) had lumen-apposing metal stent migration occur during the procedure. In the LA-ERCP group 6 % (n = 1) of patient had bleeding, 6 % (n = 1) post-ERCP pancreatitis and 6 % (n = 1) were diagnosed with an intra-abdominal infection post-procedure. Time to complete the EDGE procedure was significantly shorter at 79 ±â€Š31 mins, compared with 158 ±â€Š50 mins for LA-ERCP and 102 ±â€Š43 mins for E-ERCP ( P  < 0.001). Conclusion EDGE is a novel procedure with short procedure times and an effective alternative to LA-ERCP and E-ERCP in management of pancreaticobiliary diseases in patients with a history of RYGB.

Endoscopic Ultrasound Guided Drainage of a Post-Surgical Fluid Collection Using a Lumen-Apposing Metal Stent in a Patient With Crohn's Disease.

Patients with Crohn's disease (CD) are susceptible to postsurgical fluid collections and abscesses. Traditionally, these have been drained either percutaneously or surgically. Endoscopic ultrasound-guided drainage using a lumen apposing metal stent has not been used commonly for drainage of abdominal abscesses in patients with CD, given the concern of fistula formation because of transmural inflammation in patients with CD. We report a case of a large perigastric abscess that was drained through the stomach, using a lumen apposing metal stent with complete resolution of the abscess.

Endoscopic Stricturotomy Is an Efficacious Option for Management of Strictures in Patients With Inflammatory Bowel Disease.

Background: Strictures are a common complication for patients with inflammatory bowel disease. Endoscopic stricturotomy (ESt) is a novel procedure for treatment of these strictures. Methods: A chart review was performed for patients with strictures who underwent ESt. Results: Eleven patients were included in the study and the total number of strictures treated was 12. The mean length of the strictures was 10.25 ± 4.36 mm. Technical success was achieved in 92% (n = 11) of the procedures. Postprocedural bleeding occurred in 9% (n = 1) of patients, and none of the patients had complications of infection or perforation. Conclusions: ESt is a safe technique with high technical success rate.

Barrett's esophagus: What do we need to know?

Barrett's esophagus (BE) is characterized by a change in the mucosal lining of the distal esophagus whereby the squamous epithelium of the esophagus is replaced by the metaplastic columnar epithelium. It is a pre-malignant lesion associated with esophageal adenocarcinoma. Patients with gastroesophageal reflux disease who have additional risk factors (Caucasian race, male gender, age > 50 years, tobacco use, and central obesity) should undergo an esophagogastroduodenoscopy to screen for Barrett's esophagus. Patients with Barrett's esophagus should undergo endoscopic surveillance every 3-5 years if no dysplasia is found. Patients with Barrett's esophagus who are found to have dysplasia should be treated endoscopically. We present a comprehensive review of the pathophysiology, diagnosis, surveillance and management of Barrett's esophagus.

Adherence to post colorectal cancer surveillance colonoscopy guidelines at a tertiary care center / Adesão às diretrizes de colonoscopia para rastreamento após câncer colorretal em um centro de atendimento terciário

Abstract Background: Surveillance colonoscopy 1 year after resection of colorectal cancer is recommended by all major societies, including National Comprehensive Cancer Network and United States Multi Society Task Force. Study objectives: Our study assesses adherence to post colorectal cancer resection surveillance colonoscopy guidelines at a large tertiary care center and aims to identify reasons for non-adherence. Methods: A retrospective study was conducted for patients who underwent curative resection for colorectal cancer between January 2016 and June 2017. Adherence to surveillance colonoscopy for non-obstructed or partially obstructed colon and rectal cancers was defined as performance of colonoscopy 11-14 months and 11-15 months after surgery, respectively. Results: A total of 80 patients were identified. Mean age was 66 ± 13 years and 58% (n = 46) were males. 60% (n = 48) had colon cancer and 40% (n = 32) had rectal cancer. 69% (n = 24) of patients with colon cancer and 42% (n = 8) of patients with rectal cancer adhered to surveillance colonoscopy guidelines and the mean time to colonoscopy was 315 ± 44 days and 369 ± 103 days, respectively. The most commonly identified reasons for non-adherence to surveillance colonoscopy included metastases (10.9%) and patients' refusal to undergo surveillance (6.5%). Conclusion: Overall, post colorectal cancer resection to follow up surveillance is inadequate. There is a need to identify barriers to surveillance post colorectal cancer resection and address them.

Resumo Introdução: A colonoscopia de rastreamento um ano após a ressecção do câncer colorretal é recomendada por todas as principais sociedades, incluindo a National Comprehensive Cancer Network e a Multi Society Task Force dos Estados Unidos. Objetivos do estudo: Avaliar a adesão às diretrizes de colonoscopia de rastreamento após ressecção de câncer colorretal em um grande centro de atendimento terciário e identificar razões para a não adesão. Métodos: Um estudo retrospectivo foi realizado em pacientes submetidos a ressecção curativa de câncer colorretal entre janeiro de 2016 a junho de 2017. Adesão à colonoscopia de rastreamento em cânceres de cólon e reto não obstruídos ou parcialmente obstruídos foi definida como a realização do procedimento entre 11 a 14 meses e 11 a 15 meses após a cirurgia, respectivamente. Resultados: Um total de 80 pacientes foram identificados. A média de idade foi de 66 ± 13 anos; 58% (n = 46) eram do sexo masculino, 60% (n = 48) tinham câncer de cólon e 40% (n = 32) tinham câncer de reto. Aderência às diretrizes de colonoscopia de rastreamento foi observada em 69% (n = 24) dos pacientes com câncer de cólon e 42% (n = 8) dos pacientes com câncer retal; o tempo médio até a realização da colonoscopia foi de 315 ± 44 dias e 369 ± 103 dias, respectivamente. Os motivos mais frequentemente identificados para a não adesão à colonoscopia de rastreamento incluíram metástases (10,9%) e recusa dos pacientes (6,5%). Conclusão: De forma geral, o rastreamento após a resecção de câncer colorretal é inadequado. É necessário identificar barreiras ao rastreamento após a ressecção do câncer colorretal e abordá-las.

Endoscopic Cyst Esophagostomy Using a Lumen-Apposing Stent for a Large Mediastinal Pancreatic Pseudocyst Compressing the Left Atrium.

Pancreatic pseudocysts and peripancreatic fluid collections extending into the mediastinum are unusual. Endoscopically, intra-abdominal pseudocysts can be drained transmurally through the stomach or duodenum depending on the location. An endoscopic ultrasound-guided esophageal approach for mediastinal pseudocysts has not been reported commonly in the literature. We report a rare case of a large mediastinal pseudocyst that was drained through the distal esophagus with eventual complete resolution of symptoms and pseudocyst.

Unusual Presentation of Gastric Outlet Obstruction Due to Breast Cancer Metastasis: A Case Report.

Gastric outlet obstruction can be caused by various pathologies, including peptic ulcer disease, gastric polyps, and malignancies. The incidence rate of breast cancer metastasis to the stomach is only 0.3%. We describe a rare case of an 83-year-old female with a remote history of breast cancer who presented with symptoms of nausea and vomiting. She underwent an upper endoscopy, and biopsies revealed chronic gastritis. However, when she presented for the second time with similar symptoms, she underwent endoscopic ultrasound (EUS)-guided biopsies, which clinched the diagnosis of breast cancer metastasis causing gastric outlet obstruction. This case describes the importance of keeping a wide differential diagnosis for the causes of gastric outlet obstruction and the significance of deeper EUS-guided biopsies if initial endoscopic biopsies are inconclusive.

Complete Endoscopic and Histopathological Remission of Mantle Cell Lymphoma of the Gastrointestinal Tract.

Mantle cell lymphoma (MCL) is a rare and incurable subtype of non-Hodgkin's lymphoma (NHL). Primary gastrointestinal (GI) MCLs are even rarer, accounting for only 1%-4% of GI lymphomas. We describe a case of a 77-year-old female who presented with complaints of indigestion and abdominal bloating. An upper endoscopy was performed which revealed a duodenal bulb polyp, biopsies of which were consistent with MCL. She was initially observed without any chemotherapy; however, a repeat endoscopy two years later revealed that she now also had MCL of the ileocecal valve. The patient was initiated on treatment with rituximab, cyclophosphamide, vincristine, and prednisone (R-CVP). She underwent regular surveillance with her oncologist after completion of her chemotherapy and repeat surveillance scans remained negative for any recurrence. A repeat upper endoscopy with endoscopic ultrasound and colonoscopy were performed which showed complete endoscopic and histopathological remission of her lymphoma. Patients with MCL typically have a poor prognosis; however, our patient remains symptom free and in complete remission six years from her initial diagnosis.