The Unmasking of Cytomegalovirus as an Accomplice to Helicobacter pylori-Induced Severe Acute Gastroenteritis in a Healthy Host.

Cytomegalovirus (CMV) belongs to the Herpesviridae family, and it is considered the largest virus to infect humans. Primary CMV infection frequently targets immunodeficient patients and is often symptomatic. However, it may remain latent or clinically unapparent for years in immunocompetent individuals. CMV infection rarely presents as an invasive disease in the latter group of individuals, in which case, the most common site of involvement in the gastrointestinal tract. When CMV affects the gastrointestinal tract, the colon and stomach are the 2 frequently involved sites. This case report describes a unique case of an immunocompetent patient who presented with acute excruciating periumbilical pain and was diagnosed with acute gastritis secondary to CMV infection and possible Helicobacter pylori-associated chronic active gastritis. Symptoms resolved entirely soon after treatment with antimicrobials that cover for both infections. The diagnosis was based on histopathologic findings from biopsies taken from the stomach during the endoscopic evaluation combined with positive CMV serology and positive CMV-deoxyribonucleic acid.

Rates, Reasons, and Independent Predictors of Readmissions in Portal Venous Thrombosis Hospitalizations in the USA.

Background: Portal vein thrombosis (PVT), generally considered rare, is becoming increasingly recognized with advanced imaging. Limited data exist regarding readmissions in PVT and its burden on the overall healthcare cost. This study aimed to outline the burden of PVT readmissions and identify the modifiable predictors of readmissions. Methods: The National Readmission Database (NRD) was used to identify PVT admissions from 2016 to 2019. Using the patient demographic and hospital-specific variables within the NRD, we grouped patient encounters into two cohorts, 30- and 90-day readmission cohorts. We assessed comorbidities using the validated Elixhauser comorbidity index. We obtained inpatient mortality rates, mean length of hospital stay (LOS), total hospital cost (THC), and causes of readmissions in both 30- and 90-day readmission cohorts. Using a multivariate Cox regression analysis, we identified the independent predictors of 30-day readmissions. Results: We identified 17,971 unique index hospitalizations, of which 2,971 (16.5%) were readmitted within 30 days. The top five causes of readmissions in both 30-day and 90-day readmission cohorts were PVT, sepsis, hepatocellular cancer, liver failure, and alcoholic liver cirrhosis. The following independent predictors of 30-day readmission were identified: discharge against medical advice (AMA) (adjusted hazard ratio (aHR) 1.86; P = 0.002); renal failure (aHR 1.44, P = 0.014), metastatic cancer (aHR 1.31, P = 0.016), fluid and electrolyte disorders (aHR 1.20, P = 0.004), diabetes mellitus (aHR 1.31, P = 0.001) and alcohol abuse (aHR 1.31, P ≤ 0.001). Conclusion: The readmission rate identified in this study was higher than the national average and targeted interventions addressing these factors may help reduce the overall health care costs.

A Case of Acute Liver Failure in a Patient on Isoniazid Prophylaxis for Latent Tuberculosis.

Isoniazid (INH) is widely used for latent Mycobacterium tuberculosis despite the known risk of liver injury, with severe hepatitis occurring in up to 1% of patients. We report a patient who presented with two weeks of anorexia, nausea, and jaundice following six months of INH monotherapy for latent tuberculosis (TB). After other causes of liver injury were ruled out, she underwent a liver biopsy showing submassive necrosis, hepatocellular dropout, and lobular inflammation with no evidence of fibrosis. She was also found to have acute portal hypertension. She was diagnosed with drug-induced liver injury (DILI) and was treated with n-acetyl cysteine (NAC), ursodiol, and vitamin K. She recovered without the need for a liver transplant. This case supports the need for monitoring of liver tests in high-risk individuals on INH therapy to reduce the risk of hepatotoxicity.

Esophageal Food Impaction: A Retrospective Chart Review.

BACKGROUND: Esophageal food impaction (EFI) is the third most common non-biliary emergency in gastroenterology, with an annual incidence rate of 13 episodes per 100,000 person-years and 1,500 deaths per year. Patients presenting with food impaction often have underlying esophageal pathology. We evaluated the possible risk factors for EFI in our study. METHODS: We performed a retrospective chart review of 455 patients at Staten Island University Hospital (SIUH) that presented with symptoms of food impaction from 1999 to 2017. We analyzed relevant clinical data such as age, risk factors, type of food bolus, location, administration of glucagon, endoscopic technique and complications. RESULTS: Overall, 174 patients had endoscopically confirmed EFI. The majority were males 102/174 (58.6%). Esophageal pathological findings included esophagitis in 58/174 (33.3%), strictures in 43/174 (24.7%), hiatal hernias in 29/174 (16.6%) and Schatzki's rings in 15/174 (8.6%). Thirty-two out of 174 (18.3%) had normal endoscopic findings. Diabetes mellitus (DM) was reported in 20/174 (11.4%) patients. The type of food impacted was mostly meat in 73/174 (41.9%) cases. The location of EFI was mainly in the lower one-third of the esophagus in 94/174 (54%). The endoscopic push technique was used in 95/174 (54.5%) patients and the pull technique in 83/174 (47.7%) cases. The endoscopic therapeutic intervention was successful as a first attempt in 165/175 (94.8%) patients. Complications were reported in only 5/174 (2.8%), and these mostly comprised of perforations and tears. Glucagon was given to 74/174 (42.5%) patients. The median door-to-scope time (time of presentation at the emergency department to endoscopic intervention) was 7 h (range 1.5 - 24 h) in patients who had received glucagon as opposed to 7 h (range 1 - 24 h) in patients who did not receive it. CONCLUSION: EFI is more common in males. Esophageal strictures and hiatal hernias were the most common pathologies found in endoscopy. Esophagitis was evident in 33.3% of patients, but if it was the cause or consequence of EFI is not clearly understood. DM was associated with food impaction in only 11.4% of patients, but more studies are needed to determine if DM has a stronger association with EFI. The door-to-scope time was shorter in patients who had received glucagon. Endoscopy is a safe and effective therapeutic intervention for EFI, and complications reported were minimal.

Gastropancreatic Fistula: A Rare Complication of Peptic Ulcer Disease.

Peptic ulcer disease (PUD) has a significant health burden. Penetration is a rare complication of PUD, where an ulcer erodes into another organ. To the best of our knowledge, we present the fourth case in the literature where a gastric ulcer has penetrated the pancreas. A 67-year-old man with a history of PUD presented to the emergency department for epigastric pain. Endoscopy revealed a large gastric ulcer at the incisura with magnetic resonance imaging demonstrating gastropancreatic fistula. Our case emphasizes on the importance of timely identification and treatment strategies for gastropancreatic fistula, the rarest complications of PUD.

A Comprehensive Review of Infectious Granulomatous Diseases of the Gastrointestinal Tract.

A granuloma is defined as a localized inflammatory reaction or a hypersensitive response to a nondegradable product leading to an organized collection of epithelioid histiocytes. Etiologies of granulomatous disorders can be divided into two broad categories: infectious and noninfectious (autoimmune conditions, toxins, etc.) causes. The endless list of causalities may prove challenging for gastroenterologists and pathologists to formulate a list of clearly defined differentials. This is true when distinguishing these etiologies based on various clinical presentations and endoscopic and histological findings. We aim to provide a comprehensive review of some of the frequent and rare infectious granulomatous diseases of the gastrointestinal tract documented in the literature to date. We provide an overview of each infectious pathology with an emphasis on epidemiology, clinical presentation, and endoscopic and histologic findings, in addition to treatment.

A Novel Approach to Percutaneous Endoscopic Gastrostomy Tube Replacement: Can You Save the Site?

Inadvertent removal or dislodgement is the most commonly encountered complication in patients with percutaneous endoscopic gastrostomy (PEG) tube. Once the gastrocutaneous fistula is formed, bedside tube replacement can be performed at the same site, within 24 hours of dislodgement. Usually, after this timeframe, the tract closes; hence, it is recommended to perform a replacement at a different site. We report a case of a 52-year-old female who presented after 24 hours of inadvertent PEG tube removal. A replacement was performed successfully via endoscopy at the same site of the erstwhile PEG tube, although it appeared to be closed.

Roth Net-Assisted Endoscopic-Guided Manometry Catheter Placement.

High-resolution esophageal manometry (HRM) has become the gold standard to diagnose esophageal motility disorders. Usually, this procedure is performed by introducing the catheter, which has pressure sensors, into the esophagus and proximal stomach via the nares. Repeated coiling of the catheter and inability to pass through the gastroesophageal junction (GEJ) are common challenges encountered. Endoscopy-guided placement of the catheter can overcome these difficulties. However, sometimes even with the use of endoscopy, it is difficult to advance catheter due to anatomical variants. The extreme fragility of the catheter and sensors and the high cost of this reusable device precludes the use of biopsy forceps or snare to advance the catheter. There is no literature on using accessories during endoscopy in case of difficult placement under direct visualization. We report a unique case of using Roth Net via the suction channel to advance esophageal manometry catheter into the stomach by using endoscopy.

A Case of Wernicke's Encephalopathy in a Pregnant Woman With a History of Sleeve Gastrectomy.

Wernicke's encephalopathy (WE) is a neurological complication of thiamine deficiency characterized by a triad of acute confusion, ataxia, and ophthalmoplegia. Even though it is most common in chronic alcoholism, an increase in prevalence has been reported recently due to the increased popularity of bariatric surgeries. WE is a known neurological complication after gastric bypass surgery but rarely reported after sleeve gastrectomy. We present a unique case of WE in pregnant women four months after sleeve gastrectomy.

Acute Liver Failure in a COVID-19 Patient Without any Preexisting Liver Disease.

In December 2019, an outbreak of novel coronavirus started in Wuhan, China, which gradually spread to the entire world. The World Health Organization (WHO) on February 11, 2020, officially announced the name for the disease as coronavirus disease 2019, abbreviated as COVID-19. It is caused by severe respiratory distress syndrome coronavirus 2 (SARS-CoV-2). The WHO declared SARS-CoV-2 as a pandemic on March 11, 2020. SARS-CoV-2 mainly causes fever as well as respiratory symptoms such as cough and shortness of breath. Gastrointestinal/hepatic sequelae such as diarrhea, nausea, vomiting, and elevated liver enzymes have been reported as well. Studies and data so far on coronavirus infections from China, Singapore, and other countries showed that liver enzymes elevation could be seen in 20-50% of cases. More severe disease can correlate with the worsening of liver enzymes. However, acute liver failure in patients with COVID-19 has not been described. Herein we report a case of acute liver failure in an elderly patient with COVID-19 infection who did not have a history of preexisting liver disease.

Cerebral Cavernous Malformations, Developmental Venous Anomaly, and Its Coexistence: A Review.

BACKGROUND: Cerebral cavernous malformations (CCMs) are intracranial vascular malformations that can exist as a single lesion or mixed vascular lesions. The most common mixed form is the coexistence of CCM with an associated developmental venous anomaly (DVA). In this paper, we aim to give a comprehensive review of CCM, DVA, and their coexistence as mixed lesions. A PubMed search using the keywords "Cerebral cavernous malformations, Developmental venous anomaly, Mixed Cerebral cavernous malformations with Developmental venous anomaly" was done. All studies in the English language in the past 10 years were analyzed descriptively for this review. SUMMARY: The search yielded 1,249 results for "Cerebral cavernous malformations," 271 results for "Developmental venous anomaly," and 5 results for "Mixed Cerebral cavernous malformations with Developmental venous anomaly." DVA is the most common intracranial vascular malformation, followed by CCM. CCM can have a wide array of clinical presentations like hemorrhage, seizures, or focal neurological deficits or can also be an incidental finding on brain imaging. DVAs are benign lesions by nature; however, venous infarction can occur in a few patients due to acute thrombosis. Mixed CCM with DVA has a higher risk of hemorrhage. CCMs are angiographically occult lesion, and cerebral digital subtraction angiography is the gold standard for the diagnosis of DVA. Mixed lesions, on the other hand, are best diagnosed with magnetic resonance imaging, which has also been effective in detecting specific abnormalities. Asymptomatic lesions are treated through a conservative approach, while clinically symptomatic lesions need surgical management. CONCLUSION: Individual CCM or DVA lesions have a benign course; however, when they coexist in the same individual, the hemorrhagic risk is increased, which prompts for rapid diagnosis and treatment.

A Case of Acute Esophageal Necrosis from Unruptured Thoracic Aortic Aneurysm.

Acute esophageal necrosis (AEN), also known as black esophagus due to its appearance on endoscopy, classically involves the distal esophagus (97% of cases). AEN affecting the midesophagus with sparing of the distal esophagus is rare and usually occurs in patients with thoracic aortic aneurysmal (TAA) rupture or aortic dissection. Herein, we report a unique case of AEN in the midesophagus in a patient with an unruptured and undissected TAA.

Over-the-Scope Clip to the Rescue! A Novel Tool for Refractory Acute Nonvariceal Upper Gastrointestinal Hemorrhage.

Nonvariceal upper gastrointestinal hemorrhage (NVUGIH) is more prevalent than lower gastrointestinal hemorrhage and carries a high risk of mortality in the elderly, especially those with significant cardiovascular comorbidities. Traditional endoscopic methods, such as through-the-scope clips, electrocautery, and epinephrine injection, are frequently used to control these bleeds; however, they carry a 10% risk of rebleeding, and this itself carries a mortality risk of 36%. The larger over-the-scope clips (OTSC) that were initially used for the closure of fistulas and perforations are now gradually being implemented to manage NVUGIH. To our knowledge, we present the first cases to be reported in the literature where OTSC was successfully used as salvage therapy for refractory acute upper gastrointestinal bleeders who failed traditional endoscopic management and interventional radiology-guided embolization of the bleeding artery. We also provide an up-to-date literature review on the use of OTSC and its superiority to traditional endoscopic interventions in the management of complicated NVUGIH.

Endoscopic Papillectomy for Major and Minor Papillary Adenoma in Familial Adenomatous Polyposis.

Ampullary adenomas can occur sporadically or in the patients with adenomatous polyposis syndrome, including familial adenomatous polyposis (FAP) and MUTYH-associated polyposis. The potential for malignant transformation is high in the setting of FAP. Although endoscopic resection of major papillary adenoma has been well described, minor papilla adenomas are exceptionally rare. This is the second documented case of an endoscopic papillectomy in a patient with FAP with simultaneous ampullary adenoma of the major and minor papilla.

Bouveret's Syndrome.

Bouveret syndrome is a very rare form of gastric outlet obstruction following the passage of a gallstone from the gallbladder to the duodenum or pylorus through a bilioenteric fistula. We present a unique case of a 78-year-old male complaining of right upper quadrant abdominal pain and who was found to have a gallstone in the proximal duodenum along with pneumobilia and cholecysto-duodenal fistula suggestive of Bouveret's syndrome.

Acute Esophageal Necrosis: A View in the Dark.

Acute esophageal necrosis (AEN), also known as Gurvits syndrome, black esophagus, or acute necrotizing esophagitis, is a rare clinical entity and an unusual reason for upper gastrointestinal bleeding. It is typically described in critically ill patients with multiple medical conditions, arising from a combination of ischemic insult to the esophageal mucosa due to low-flow vascular states, corrosive injury caused by reflux of acid and pepsin, and decreased function of the mucosal barrier systems and reparative mechanisms as occurs in malnourished and debilitated physical states. Patients with AEN tend to be older men, as medical comorbidities including vascular disease, diabetes, hypertension, renal insufficiency, cardiac disease, pulmonary disease, stroke, and cirrhosis may be more common. Typically, patients present with upper gastrointestinal bleeding, and hematemesis or melena is seen in up to 90% of cases. Herein we present 3 cases of AEN in critically ill patients. We also provide a review of the literature to highlight what is currently known about this relatively uncommon esophageal disease.

A Bleeding Dieulafoy's Lesion in the Anal Canal.

Dieulafoy's lesion (DL) is a dilated aberrant submucosal vessel that erodes through the overlying epithelium in the absence of a primary ulcer. It is a known cause of gastrointestinal (GI) bleeding and commonly located in the lesser curvature of the stomach, but it is rare in the anal canal. We report a unique case of a middle-aged man presenting with lower GI bleeding secondary to an anal DL diagnosed by colonoscopy, managed successfully with endoscopic hemoclips.

Gastrointestinal Bleeding in Patients With Acute Respiratory Distress Syndrome: A National Database Analysis.

BACKGROUND: The goal of our study was to determine the impact of gastrointestinal bleeding (GIB) on in-hospital outcomes among acute respiratory distress syndrome (ARDS) patients, and subsequently determine the potential risk factors for the development of GIB. METHODS: ARDS patients with and without GIB were identified using the National Inpatient Sample (2002 - 2012). Linear regression analysis was used to assess impact of GIB on in-hospital mortality, length of stay and total charges. Univariate logistic regression was used to determine associated odds ratios (OR) for causes of ARDS and common comorbid conditions. RESULTS: We identified 149,190 ARDS patients. The incidence of GIB was the highest among patients > 60 years (P < 0.001). GIB was associated with longer hospitalization days (7.3 days versus 11.9 days, P < 0.001), higher mortality (11% versus 27%, P < 0.001) and greater economic burden ($82,812 versus $45,951, P < 0.001). GIB was common in cirrhosis (OR: 8.3), peptic ulcer disease (OR: 3.7), coagulopathy disorders (OR: 3.003), thrombocytopenia (OR: 2.6), anemia (OR: 2.5) and atrial fibrillation (OR: 1.5). ARDS secondary to aspiration pneumonia (OR: 2.0), pancreatitis (OR: 2.0), sepsis (OR: 1.6) and community acquired pneumonia (OR: 0.8) was more likely to have GIB. CONCLUSION: Our study demonstrates that GIB in ARDS patients is associated with significant increased mortality, hospitalization and health care cost.

Perforated Jejunal Diverticulitis.

Small intestinal diverticula are very rare; their incidence ranges from 0.06 to 1.3%, with a higher prevalence after the 6th decade of life. Among these small intestinal diverticula, duodenal diverticula are more frequent, followed by diverticula of the jejunum and ileum. A jejunal diverticulum is usually asymptomatic; sometimes patients complain of vague chronic symptoms like malabsorption, pain, or nausea that easily lead to misdiagnosis. Complications are rarely reported, only in 10% of patients. We report a unique case of a 70-year-old female who presented with confusion due to sepsis from perforated jejunal diverticulitis, which was successfully managed with initial resuscitation and definitive surgery.

Severe de novo Ulcerative Colitis following Ixekizumab Therapy.

Ixekizumab is a selective monoclonal antibody targeting interleukin-17A, approved for the treatment of chronic plaque psoriasis. It has rarely been associated with inflammatory bowel disease (IBD) in randomized trials only. We report a unique case of severe new-onset ulcerative colitis in a young male complicated by cytomegalovirus infection who was on ixekizumab therapy for plaque psoriasis. We recommend that clinicians should exercise caution before prescribing ixekizumab as it seems to induce and exacerbate IBD.