Advanced endoscopy meets molecular diagnosis of cholangiocarcinoma.

Cholangiocarcinoma remains an aggressive and deadly malignancy that is often diagnosed late. Intrinsic tumour characteristics and the growth pattern of cancer cells contribute to the challenges of diagnosis and chemoresistance. However, establishing an early and accurate diagnosis, and in some instances identifying targetable changes, has the potential to impact survival. Primary sclerosing cholangitis, a chronic cholangiopathy prodromal to the development of a minority of cholangiocarcinomas, poses a particular diagnostic challenge. We present our diagnostic and theranostic approach to the initial evaluation of cholangiocarcinomas, focusing on extrahepatic cholangiocarcinoma. This involves a multipronged strategy incorporating advanced imaging, endoscopic methods, multiple approaches to tissue sampling, and molecular markers. We also provide an algorithm for the sequential use of these tools.

Novel through-the-scope suture closure of colonic EMR defects (with video).

BACKGROUND AND AIMS: Large colon polyps removed by EMR can be complicated by delayed bleeding. Prophylactic defect clip closure can reduce post-EMR bleeding. Larger defects can be challenging to close using through-the-scope clips (TTSCs), and proximal defects are difficult to reach using over-the-scope techniques. A novel, through-the-scope suturing (TTSS) device allows direct closure of mucosal defects without scope withdrawal. The goal of this study was to evaluate the rate of delayed bleeding after the closure of large colon polyp EMR sites with TTSS. METHODS: A multicenter retrospective cohort study was performed involving 13 centers. All defect closure by TTSS after EMR of colon polyps ≥2 cm from January 2021 to February 2022 were included. The primary outcome was rate of delayed bleeding. RESULTS: A total of 94 patients (52% female; mean age, 65 years) underwent EMR of predominantly right-sided (n = 62 [66%]) colon polyps (median size, 35 mm; interquartile range, 30-40 mm) followed by defect closure with TTSS during the study period. All defects were successfully closed with TTSS alone (n = 62 [66%]) or with TTSS and TTSCs (n = 32 [34%]), using a median of 1 (interquartile range, 1-1) TTSS system. Delayed bleeding occurred in 3 patients (3.2%), with 2 requiring repeated endoscopic evaluation/treatment (moderate). CONCLUSION: TTSS alone or with TTSCs was effective in achieving complete closure of all post-EMR defects, despite a large lesion size. After TTSS closure with or without adjunctive devices, delayed bleeding was seen in 3.2% of cases. Further prospective studies are needed to validate these findings before wider adoption of TTSS for large polypectomy closure.

Underutilization of Peptic Ulcer Disease Prophylaxis Among Elderly Users of Antiplatelets and Anticoagulants.

INTRODUCTION: Peptic ulcer disease (PUD) develops in approximately 25% of chronic users of non-steroidal anti-inflammatory drugs (NSAIDs). The incidence of uncomplicated PUD has been declining over the past 3 decades unlike that of complicated PUD in the elderly. An expert consensus document published jointly in 2008 by the American College of Gastroenterology (ACG), the American College of Cardiology Foundation (ACCF), and the American Heart Association (AHA) provided recommendations on prevention of PUD among users of antiplatelets and anticoagulants. This work aimed to evaluate physicians' compliance with these guidelines in a tertiary academic setting. METHODS: We examined our medical record database for the 9 month period extending from April 2018 until December 2018. Using this database, we identified elderly patients (> 64 years old) who were chronic (> 3 months) users of low dose aspirin (81 mg once daily) and had an indication for PUD prophylaxis as per the ACG-ACCF-AHA guideline document. We performed a retrospective chart review of patients included in this study. Descriptive statistics were compared using χ2 and independent sample t tests. RESULTS: A total of 852 patients were included in this study. The mean age was 75 years old, and 43% of patients were females. In addition to aspirin, patients were prescribed P2Y12 inhibitors (45.5%), direct oral anticoagulants (DOACs) (23%), warfarin (12%), steroids (9%) or enoxaparin (1%). Users of DOACs were most commonly prescribed apixaban (16%), followed by rivaroxaban (6%) and dabigatran (1%). Overall, only 40% of patients with an indication for PUD prophylaxis received a proton pump inhibitor. CONCLUSION: PUD prophylaxis may be underutilized in elderly patients. This finding, along with increasing rates of NSAID use and an aging population, may help explain the increased incidence of complicated PUD in the elderly. Efforts are needed to raise physician awareness of PUD prophylaxis guidelines.

Immunomodulatory Therapy and an Insidious Presentation of a Large Intra-Abdominal Abscess.

Crohn's disease is a disorder characterized by transmural inflammation which can potentially affect any part of the gastrointestinal tract from the mouth to the perianal area. Cohn's disease is a systemic disease characterized by a relapsing remitting course, with variable intestinal and extra-intestinal complications. Abdominal and pelvic abscesses are not an uncommon complication of Crohn's disease occurring in 10-30 percent of all patients. We present the case of a 21-year-old male with Crohn's disease presenting with a massive abdominal abscess, whose diagnosis was delayed given lack of typical symptoms. Shortly after initiating therapy with Prednisone and Adalimumab he presented with worsening abdominal distention. Cross sectional imaging of the abdomen with IV contrast (Figure 1) demonstrated a 34cm x 23 cm x 11 cm rim-enhancing fluid collections in the abdomen and pelvis consistent with a large intra-abdominal abscess. He underwent an exploratory laparotomy, abdominal washout, and wound vacuum placement. Five liters of purulent fluid were aspirated and cultures grew citrobacter, veillonella and candida glabrata. A bowel perforation was suspected as the etiology for abscess formation; however magnetic resonance heterography (Figure2) was unremarkable. He was treated with appropriate antibiotics, antifungal agents, and was started on Aprisa. His course was complicated with recurrence of intra-abdominal abscesses and a colocutaneous fistula for which he underwent an open sigmoidectomy with a diverting loop colostomy. After condirmation of healing with repeat imaging, he was an uneventful postoperative course. He followed as an outpatient and continues to do well on Infliximab. Most abscesses are picked up in their early stages given characteristic symptoms; however in presence of immunosuppressive therapy the host immune system can be suppressed leading to delayed diagnosis. The presence of a massive intra-abdominal purulent fluid collection of this size has not been described on our review of the literature. Furthermore, despite the abscess taking up most of the abdominal cavity, the fairly limited symptom burden highlights the importance of having high degree of clinical suspicion for infectious compications in Crohn's disease patients even when classical symptoms are not present.

Impact of COVID-19 infection on patients admitted with nonvariceal upper gastrointestinal bleeding: an analysis from the National Inpatient Sample.

Background: Nonvariceal upper gastrointestinal bleeding (NVUGIB) is a medical emergency that has significant morbidity and mortality. The available data about the impact of COVID-19 infection on mortality in patients with NVUGIB is limited. Methods: We identified all hospitalizations with a principal diagnosis of NVUGIB in 2020. The baseline characteristics and clinical outcomes of patients with COVID-19 infection were compared to those without COVID-19 infection. Results: NVUGIB patients with COVID-19 infection had higher mortality (5% vs 2%, P < 0.0001), a longer mean length of stay (6.85 vs 4.48 days, P < 0.0001), and a lower rate of esophagogastroduodenoscopy utilization (40% vs 51%, P < 0.0001) than those without COVID-19 infection. Multivariate logistic regression analysis showed that COVID-19 infection was associated with a higher mortality rate (odds ratio 2.2, 95% confidence interval, 1.4-3.4). Conclusions: COVID-19 infection is an independent predictor of mortality in adults hospitalized with NVUGIB.

Endoscopic Imaging of Pancreatic Cysts.

Pancreatic cystic lesions (PCLs) have been diagnosed with increasing frequency likely due to the widespread use of cross-sectional imaging. A precise diagnosis of the PCL is important because it helps identify patients in need of surgical resection and those who can undergo surveillance imaging. A combination of clinical and imaging findings as well as cyst fluid markers can help classify PCLs and guide management. This review focuses on endoscopic imaging of PCLs including endoscopic and endosonographic features and fine needle aspiration. We then review the role of adjunct techniques, such as microforceps, contrast-enhanced endoscopic ultrasound, pancreatoscopy, and confocal laser endomicroscopy.

Primary sclerosing cholangitis hospitalizations in the United States: characteristics and predictors of clinical outcomes.

Background: Primary sclerosing cholangitis (PSC) is a chronic progressive disease that primarily affects the medium and large biliary ducts. Methods: This study investigated the baseline characteristics and predictors of clinical outcomes among hospitalized patients with PSC in the US. Using the National Inpatient Sample database from 2018 to 2020, we included adults with a principal diagnosis of PSC. Results: Our study included 2585 adult hospitalizations. The prevalence of cirrhosis, ulcerative colitis (UC), Crohn's disease (CD), and cholangiocarcinoma among hospitalized PSC patients was 44.5%, 32.3%, 13.15%, and 5.2%, respectively. Over a third of patients (38.1%) underwent endoscopic retrograde cholangiopancreatography (ERCP). UC, CD, cholangiocarcinoma, and autoimmune hepatitis had no impact on mortality, length of stay, or ERCP utilization. Interestingly, individuals of Asian/Pacific Islander ethnicity had higher odds of undergoing ERCP compared to White ethnicity (odds ratio 4.67, 95% confidence interval 1.25-17.4). Conversely, patients with cirrhosis and liver transplant recipients were less likely to undergo ERCP. Conclusion: This is the first nationwide study to assess the clinical characteristics and outcomes of hospitalized patients with PSC. It highlights various factors associated with increased utilization of ERCP, longer length of stay, and increased inpatient mortality. Further research is warranted to explore these associations.

Metastatic Hepatocellular Carcinoma Masquerading as Acute Diverticulitis.

Colorectal cancer may masquerade as acute diverticulitis. Our case is a 71-year-old man who presented to the emergency department with abdominal pain and was diagnosed with acute diverticulitis. He was ultimately found to have metastatic hepatocellular carcinoma to the colon without any evidence of diverticular disease on colonoscopy. Although the most common malignancy to masquerade as diverticulitis is colorectal cancer, metastatic deposits should also be considered, especially in patients with a history of extracolonic malignancy.

Hepatic Adrenal Rest Tumors Mimicking Hepatocellular Carcinoma: A Case Report and Review of the Literature.

Adrenal rest tumors are rare collections of aberrantly located adrenocortical tissue. They are most commonly found in the kidneys, and hepatic involvement is rare with few published case reports. When located in the liver, imaging findings are frequently indistinguishable from hepatocellular carcinoma (HCC), but when resected, histologic examination shows adrenocortical tissue. Here, we present a patient with a history of nonalcoholic steatohepatitis with advanced fibrosis who was identified as having HCC by cross-sectional imaging but was found to have a hepatic adrenal rest tumor (HART) after resection. HARTs can share imaging characteristics with HCC, and this alternative diagnosis should be considered, especially for hepatic segment VII lesions.

Accuracy of virtual chromoendoscopy in differentiating gastric antral vascular ectasia from portal hypertensive gastropathy: A proof of concept study.

BACKGROUND: Accurate detection of gastric antral vascular ectasia (GAVE) is critical for proper management of cirrhosis-related gastrointestinal bleeding. However, endoscopic diagnosis of GAVE can be challenging when GAVE overlaps with severe portal hypertensive gastropathy (PHG). AIM: To determine the added diagnostic value of virtual chromoendoscopy to high definition white light for real-time endoscopic diagnosis of GAVE and PHG. METHODS: We developed an I-scan virtual chromoendoscopy criteria for diagnosis of GAVE and PHG. We tested our criteria in a cross-sectional cohort of cirrhotic adults with GAVE and PHG when high-definition white light endoscopy (HDWLE) diagnosis was in doubt. We then compared the accuracy of I-scan vs HDWLE alone to histology. RESULTS: Twenty-three patients were included in this study (65.2% Caucasians and 60.9% males). Chronic hepatitis C was the predominant cause of cirrhosis (43.5%) and seven adults (30.4%) had confirmed GAVE on histology. I-scan had higher sensitivity (100% vs 85.7%) and specificity (75% vs 62.5%) in diagnosing GAVE compared to HDWLE. This translates into a higher, albeit not statistically significant, accuracy of I-scan in detecting GAVE compared to HDWLE alone (82% vs 70%). I-scan was less likely to lead to an accurate diagnosis of GAVE in patients on dialysis (P < 0.05) and in patients with elevated creatinine (P < 0.05). I-scan had similar accuracy to HDWLE in detecting PHG. CONCLUSION: This pilot work supports that virtual chromoendoscopy may obviate the need for biopsies when the presence of GAVE is in doubt. Larger studies are needed to assess the impact of virtual chromoendoscopy on success of endoscopic therapy for GAVE.

Gossypiboma Masquerading as Small Bowel Malignancy.

Gossypiboma refers to inadvertently retained foreign objects after surgical operations. High body mass index and emergency surgery are risk factors of the condition. Presenting symptoms are usually non-specific and it may result in serious complications such as bowel obstruction. Removal can be attempted with endoscopic or surgical approaches depending on the site and presence of complications. This case highlights the need for considering gossypiboma in patients presenting with abdominal symptoms after recent abdominal surgery. Herein we report the case of a 30-year-old woman with abdominal pain two months after mini-gastric bypass surgery. Cross-sectional imaging showed a hyperdense area in the small bowel concerning for malignancy. However, upper endoscopy revealed a 10 × 40 cm retained surgical gauze in the afferent loop that was successfully retrieved. Although rare, retained foreign body should be considered in the differential diagnosis of postoperative abdominal pain.

Epidemiology and Outcomes of Hospitalized Inflammatory Bowel Disease Patients with Asthma in the United States.

Introduction Research on the epidemiology and outcomes of hospitalized inflammatory bowel disease (IBD) patients with a history of asthma in the United States (US) is limited. This study aimed at identifying the sociodemographic and clinical characteristics of hospitalized IBD patients with a diagnosis of asthma. We also examined the association between an asthma diagnosis and the length of stay (LOS) and in-hospital mortality among hospitalized IBD patients. Method Using the National Inpatient Sample (NIS) for the years 2008-2013 and the ninth edition of the International Classification of Diseases codes, we identified adult hospitalized patients with IBD (N = 370,636) and used weighted multilevel hierarchical logistic regression models. Results The overall prevalence of asthma in our cohort of hospitalized IBD patients was 8%. Hospitalized IBD patients with asthma were more likely to be female, <45 years old, have Crohn's disease, and a higher Elixhauser comorbidity index (ECI). IBD patients with ECI of 3 or more had higher odds of having a prior diagnosis of asthma compared to those with no comorbidities (OR 63.33, 95% CI: 54.51-73.58). Having a prior diagnosis of asthma among hospitalized IBD patients was associated with lower odds of prolonged hospital stay and in-hospital mortality (OR 0.72, 95% CI: 0.69-0.74; OR 0.49, 95% CI: 0.43- 0.56, respectively). Patients with both IBD and asthma are more likely to seek medical care with earlier and aggressive treatment modalities, which may explain the lower in-hospital mortality in this group. Conclusion Lower in-hospital mortality and geographic variation are notable in the outcomes of IBD patients with asthma. Future prospective studies are necessary to improve our understanding of the management and interplay of IBD patients with asthma.

Mesenteric Venous Thrombosis Masquerading as Small Bowel Obstruction.

Mesenteric venous thrombosis (MVT) is an uncommon, but increasingly recognized, cause of intestinal ischemia. Presenting signs and symptoms are nonspecific, and diagnosis requires a high index of suspicion. We present the case of a 33-year-old woman who was transferred to our hospital for the management of a jejunal bezoar resulting in small bowel obstruction. She was found to have MVT that was complicated by intestinal infarction and perforation. This case emphasizes the need to consider MVT in the differential diagnosis of small bowel obstruction, as earlier diagnosis and treatment can prevent complications and improve outcomes.

Correlates, Trends, and Short-Term Outcomes of Venous Thromboembolism in Hospitalized Patients with Hepatocellular Carcinoma.

BACKGROUND AND AIM: The incidence and overall mortality of hepatocellular carcinoma (HCC) in the US have been increasing over the past decade. Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in cancer patients. This study aims at examining the epidemiology, risk factors, and short-term outcomes of VTE in hospitalized patients with HCC. METHODS: We utilized the National Inpatient Sample for the years 2008-2013. Using the International Classification of Diseases codes, ninth edition, we identified hospitalized adult patients with a prior diagnosis of HCC who were diagnosed with VTE. Weighted multivariate logistic regression models were used to examine the effect of patients' sociodemographic and clinical characteristics on the occurrence of VTE, and to evaluate the impact of VTE on in-hospital mortality and length of hospital stay. RESULTS: We identified a total of 54,275 hospitalized patients with a prior diagnosis of HCC. The prevalence of VTE in the study cohort was 2.8% (2.5% in 2008 to 3.0% in 2013, a statistically significant increase). Older age, African American ethnicity, history of metastasis, and higher Elixhauser comorbidity index were associated with higher odds of VTE. However, having a prior diagnosis of cirrhosis, hepatitis C, or diabetes mellitus were associated with lower odds of VTE in HCC patients. Furthermore, development of VTE was associated with longer hospital stay and increased in-hospital mortality. CONCLUSION: Our work highlights significant age, racial, and comorbid factors in the development of VTE in hospitalized patients with HCC in the US. These findings can help in stratification of HCC patients according to their VTE risk. Patients at higher risk of VTE may benefit from more aggressive pharmacologic prophylaxis, an area for future investigation.

Optimal feature set for finger movement classification based on sEMG.

One of the most important electrophysiological signal is the Electromyography (EMG) signal, which is widely used in medical and engineering studies. This signal contains a wealth of information about muscle functions. Therefore, the EMG signal is becoming increasingly important and has started to be used in many applications like finger movement rehabilitation. However, an advanced EMG signal analysis method is required for efficient usage of such applications. This signal analysis can include signal detection, decomposition, processing, and classification. There are many approaches in studying the EMG signals, however, one of the important factor of analyzing is to get the most efficient and effective features that can be extracted from the raw signal. This paper presents the best feature extraction set compared to previous studies. Where eighteen well-known features algorithm has been tested using the sequential forward searching (SFS) method to get excellent classification accuracy in a minimum processing time. Among these novel features only four combinations have been selected with perfect results, which are; Hjorth Time Domain parameters (HTD), Mean Absolute Value (MAV), Root Mean Square (RMS) and Wavelet Packet Transform (WPT). The superiority of this feature set has been proven experimentally, and the results show that the classification accuracy could reach up to 99% to recognize the individual and combined for ten classes of finger movements using only two EMG channels.

Autologous Graft-Versus-Host Disease of the Gastrointestinal Tract in Patients With Multiple Myeloma and Hematopoietic Stem Cell Transplantation.

Multiple myeloma (MM) is the most common indication for autologous hematopoietic stem cell transplantation (HSCT) in North America. Despite occurring in up to 50% of patients undergoing allogeneic HSCT, the incidence of graft-versus-host disease (GVHD) after autologous HSCT is reportedly only 5-20%. Gastrointestinal involvement with graft-versus-host disease (GI GVHD) is a common and serious complication of allogeneic HSCT. GI GVHD after autologous transplant, which is referred to as autologous GVHD (auto-GVHD), has also been described. Auto-GVHD is usually less severe than allogeneic GVHD, and it can be one of the manifestations of engraftment syndrome with release of inflammatory cytokines and infiltration of auto-reactive T cells into affected tissue. Seventy-nine percent of patients respond well to corticosteroids without evidence of recurrence. However, cases of severe auto-GVHD lacking good response to corticosteroids have been reported, most notably in MM patients. Here we present two cases of autologous GI GVHD in recipients of autologous HSCT for treatment of MM. Our cases demonstrate two distinct clinical and endoscopic presentations of this uncommon entity. In the first case, the patient had more severe clinical symptoms accompanied by radiographic, endoscopic, and pathologic findings. The hospital course was complicated by cryptosporidium enteritis and acute cholecystitis in the setting of increased immunosuppression with a corticosteroid for presumed auto-GVHD. In contrast, the second case presented a patient with normal radiologic and endoscopic findings. Pathology revealing frequent apoptotic bodies led to auto-GVHD as a diagnosis. Both our patients received similar courses of chemotherapy prior to autologous HSCT (four cycles of a proteasome inhibitor, lenalidomide, and dexamethasone). Our work highlights the importance of maintaining a high level of clinical suspicion for auto-GVHD in patients presenting with GI symptoms after autologous HSCT, as it is a potentially treatable pathology that may be easily confused with other conditions. Health care providers should be aware of the potential complications of auto-GVHD after autologous HSCT and should be suspicious of auto-GVHD if GI symptoms occur, especially in patients receiving immunomodulatory therapy for MM, even in the absence of gross endoscopic findings.

Self-limited membranous nephropathy after intravitreal bevacizumab therapy for age-related macular degeneration.

BACKGROUND: Monoclonal antibodies targeting vascular endothelial growth factor (VEGF), such as bevacizumab, are administered intravitreally for the treatment of wet or exudative age-related macular degeneration (ARMD). Systemic use of bevacizumab has been linked to a wide range of renal adverse effects including proteinuria and hypertension. CASE PRESENTATION: We present the case of a 77-year-old Caucasian male with a past medical history of hypertension, vitamin D deficiency and paroxysmal atrial fibrillation who presented to primary care clinic with a 2-week history of bilateral lower extremity edema, 2 months after completing four monthly intravitreal injections of bevacizumab for ARMD. Examination was remarkable for blood pressure of 187/91 mm Hg and severe bilateral lower extremity edema. Work up revealed unremarkable complete blood count (CBC), comprehensive metabolic panel (CMP), lipid panel, and echocardiography, except for 491 mg/dL albuminuria. Metoprolol and furosemide were added to hydrochlorothiazide and lisinopril. Work up by nephrology consult team five months later was notable for a urinalysis revealing 3 red blood cells/high power field (RBC/HPF), 24-hour urine protein of 8.6 g, and serum creatinine of 1.2 mg/dL. Viral hepatitis panel, total complement activity (CH50), C3, C4, anti-nuclear antibody (ANA), anti-neutrophil cytoplasmic antibody (ANCA), serum and urine protein electrophoresis were all unremarkable. Renal biopsy was consistent with membranous nephropathy. Age-appropriate cancer screening was negative. Random urine protein-to-creatinine ratio declined to 2 g/g and then to 0.56 g/g at 7 and 10 months follow up, respectively. Serum blood urea nitrogen (BUN) and creatinine remained normal throughout the course of illness and patient did not require any immunosuppressive treatment. CONCLUSIONS: The wide range of nephrotoxicity after systemic bevacizumab has been well documented. Our case describes a self-limited biopsy-proven membranous nephropathy after intravitreal bevacizumab injections.

Chronic dietary oxalate nephropathy after intensive dietary weight loss regimen.

BACKGROUND: Hyperoxaluria has been associated with nephrolithiasis as well as acute and chronic kidney disease. We present a case of end stage renal failure caused by excessive dietary oxalate intake in a dietary weight loss regimen. CASE PRESENTATION: A 51-year-old Caucasian male with the past medical history of type 2 diabetes mellitus, gout, hypertension and morbid obesity was referred to the primary care clinic after being found pale and easily fatigued. The patient had lost 36 kg over a 7-month period by implementing exercise and intense dietary measures that included 6 meals of spinach, kale, berries, and nuts. Physical examination revealed a blood pressure of 188/93 mm Hg with sunken eyes and dry mucus membranes. Laboratory workup was notable for blood urea nitrogen of 122 mg/dL, creatinine of 12 mg/dL, and estimated glomerular filtration rate (eGFR) of 4.4 mL/min/1.73m2. Patient denied any history of renal disease or renal stones, or taking herbal products, non-steroidal anti-inflammatory drugs, antifreeze (ethylene glycol), or any type of "diet pills." Family history was unremarkable for any renal diseases. After failing intravenous fluid resuscitation, patient was started on maintenance hemodialysis. Abdominal imaging was consistent with chronic renal parenchymal disease with no evidence of nephrolithiasis. Renal biopsy revealed numerous polarized oxalate crystal deposition and diabetic nephropathy class IIA. At this point the patient was instructed to adopt a low oxalate diet. A 24-hour urine collection was remarkable for pH 4.7, citrate <50 mg, and oxalate 46 mg. Importantly, serum oxalate level was undetectable. Repeat renal biopsy 5 months later while patient was still on maintenance hemodialysis revealed persistence of extensive oxalate crystal deposition. Patient has been referred for evaluation for renal transplantation. CONCLUSIONS: Clinicians need to maintain a high index of suspicion for dietary hyperoxaluria as a potential etiology for acute or chronic kidney failure, particularly in patients pursuing intensive dietary weight loss intervention.