Introduction: Patient education is a crucial part of delivering optimal medical care. Printed educational material (PEM) with visual aids is commonly used for patient education in Gastroenterology. The aim of this quality improvement project is to assess the accuracy of the information provided to patients, and to establish a process of periodic revision and update of disease-related PEM. Methods: All PEM related to Gastrointestinal (GI) diseases and procedures was collected. This PEM is usually provided to patients in the endoscopy unit and in the GI clinic. PEM is also available to primary care providers to share with patients. A rigorous review of literature and the most recent clinical practice guidelines by major GI societies was performed. All outdated and inaccurate data in the PEM was identified. A process to update outdated data and to ensure periodic review of PEM was established. Results: A total of 48 GI-related PEM was reviewed. Procedure-related PEM, such as procedure description, pre-procedure and post-procedure instructions represented 62.5% (N=30) of all PEM. About 37.5% (N=18) of the PEM were related to diagnosis and management of common GI diseases. 19% of all PEM and 50% of disease-related PEM contained either outdated or inaccurate information (N=9). A two-phase process to update the PEM was established. Phase I aimed to correct and update all outdated data in accordance with the most recent clinical practice guidelines and in collaboration with the medical media division. Phase II was to establish a process to ensure periodic review of all PEM. Phase II included adding a footnote in each PEM indicating when it was last reviewed by a medical provider. A reminder will be sent every 3 years to the GI division and to the medical media division to ensure a periodic review of all PEM by a medical provider. Conclusion: PEM plays an important role in patient education in the field of Gastroenterology. However, they may contain outdated information that may have a negative impact on patient care. A process to ensure periodic revision and update of all PEM by a medical provider should be established in each institution.

A 65-year-old male patient with chronic dysphagia was found to have a 2cm mass at gastro-oesophageal junction on endoscopy. Biopsy showed squamous hyperplasia without malignancy. Controlled radial expansion balloon dilatation and partial resection were performed but the symptoms recurred. He finally underwent endoscopic mucosa resection and histology showed well-differentiated verruciform squamous proliferation limited to the mucosa. Small amounts of tumour remnants were treated during subsequent follow-up endoscopies and the patient has been tumour free since then. Diagnosis of oesophageal verrucous carcinoma can be challenging and could be managed with endoscopic resection. In this report, we review the literature and present our experience with a patient with oesophageal verrucous carcinoma.

Prominent colonic mucosal folds are referred as myochosis. Myochosis results from shortening of taeniae from elastosis, squishing together of the sigmoid like an accordion, creating deep recesses between prominent folds.(1) These changes are often under-reported in endoscopy notes. Here, we report development of an endoscopic classification system for diagnosis, grading and reporting of myochosis. We also evaluated the obstructive nature of myochosis. This article is protected by copyright. All rights reserved.

ECGI is effective in achieving hemostasis of bleeding GV and their eradication. Recurrent bleeding and recurrence of varices after complete obliteration however are not infrequent and continued surveillance is advisable.

Background: predicting the development of severe disease has remained a major challenge in management of acute pancreatitis. The Bedside Index for Severity in Acute Pancreatitis (BISAP) is easy to calculate from the data available in the first 24 hours. Here, we performed a systematic review to determine the prognostic accuracy of the BISAP for severe acute pancreatitis (SAP). Methods: major databases of biomedical publications were searched during the first week of October 2015. Two independent reviewers searched records in two phases. Studies that reported prognostic accuracy of the BISAP for SAP from prospective cohorts were included. The pooled area under the receiver operating curve (AUC) was calculated. Results: Twelve studies were included for data-synthesis and methodology quality assessment was performed for 10. All the studies had enrolled consecutive patients, had a broad spectrum of the disease severity, reported explicit interpretation of the predictor, outcome of interest was well defined and had adequate follow-up. Blinded outcome assessment was reported in only one study. The pooled AUC was 0.85 (95% CI 0.80-0.90). There was significant heterogeneity, I-2 86.6%. Studies using revised Atlanta classification in defining SAP had a pooled AUC of 0.92 (95% CI, 0.90-0.95), but heterogeneity persisted, I-2 67%. Subgroup analysis based on rate of SAP (>20% vs <20%) did not eliminate the heterogeneity. Conclusion: the BISAP has very good predictive performance for SAP across different patient population and etiologies. Studies to evaluate the impact of incorporating the BISAP into clinical practice to improve outcome in acute pancreatitis are needed before adoption could be advocated with confidence.

Mediastinal pancreatic pseudocysts are a rare complication of acute and chronic pancreatitis. They occur as a result of posterior rupture of the pancreatic duct into the retroperitoneal space and subsequent drainage of pancreatic fluids though the diaphragmatic orifices into the mediastinum. No uniform diagnostic or treatment standards exist in the management of these cysts. Here we report the case of a 50-year-old male with history of alcohol abuse and recurrent pancreatitis, last episode ten months prior, who presented with rapidly progressive dysphagia and odynophagia. He was previously evaluated at another institution where a cardiac workup was noted to be negative and he was discharged home with a diagnosis of esophageal spasm. On presentation to our facility, patient was afebrile, hemodynamically stable, with a normal physical exam and normal labs. Chest radiography on admission showed small pleural effusions bilaterally and bibasilar opacities attributed to atelectasis or pneumonia. CT chest was notable for multiple cystic lesions in the gastroesophageal (GE) junction and gastrosplenic regions with associated stenosis of the esophagus at GE junction (Figures 1 and 2). A subsequent CT abdomen and pelvis with contrast revealed a large 5 x 4 cm pseudocyst anterior to the distal GE junction with mass effect and compression. Endoscopic ultrasound (EUS) was performed revealing a heterogenous periesophageal cyst, measuring 4 cm x 6.7 cm with mixed liquid and solid components (Figure 3). The cyst fluid was successfully aspirated with a transesophageal FNA. The remaining cyst with solid debris measured 2.5 x 5 cm after drainage. Analysis of the aspirate was notable for an amylase level of 4136 (U/L) and CEA of 4.8 (mg/dL) thus confirming diagnosis of pseudocyst. The patient was subsequently discharged and has been symptom free since. There are fewer than 100 reported cases of mediastinal pancreatic cyst expansion. This case highlights a rare presentation of a common complication of recurrent pancreatitis and illustrates the importance of considering pancreatic pseudocyst expansion into the mediastinum as a cause of dysphagia and odynophagia in these patients.Figure: CT Chest demonstrating cyst compressing esophagus at GE junction in sagittal view.Figure: CT Chest demonstrating cyst compressing esophagus at GE junction in coronal view.Figure: EUS image of FNA needle in mediastinal pancreatic pseudocyst.

BACKGROUND AND OBJECTIVES:Mesenchymal (spindle cell) neoplasms (SCN) of the gastrointestinal (GI) tract are an important subtype of subepithelial lesions that need subclassification to assess their malignant potential. Reported success rates of accurate subclassification with endoscopic ultrasound (EUS)-guided biopsies are variable. Our goal was to analyze our experience using EUS-guided TruCut biopsy (EUS-TCB) in the majority of patients. METHODS:Retrospective analysis in patients who underwent EUS with biopsies for suspected SCN at our tertiary referral center between 2004 and 2013. RESULTS:A total of 146 patients with suspected SCN underwent EUS with tissue acquisition. Thirteen patients were excluded from analysis because tissue acquisition established a definite diagnosis other than SCN. In the remaining 133 patients, tissue acquisition was diagnostic of SCN in 118 (88.7%) and nondiagnostic in 15 (11.3%). Subclassification based on immunohistochemistry (IHC) was possible in 109 of the 133 cases (81.9%). The final diagnosis was GI stromal tumor in 64, leiomyoma in 39, and schwannoma in 6 cases. The percentage of patients who were subclassified by the various EUS-guided techniques together was 72.18%, and the percentage of patients who were subclassified specifically with EUS-TCB was 61.65%. Tissue specimens that enabled a specific diagnosis based on histological or cytological characteristics in conjunctions with IHC were obtained with EUS core biopsy in 83 (TCB in 82 and ProCore needle biopsy in 1), fine-needle aspiration in 13, mucosal resection in 10, and forceps biopsies (bite-on-bite) in 3 cases. CONCLUSION:EUS with endoscopic tissue acquisition is accurate in the diagnosis and subclassification of SCN. In experienced hands, the EUS-TruCut needle is a valuable tool with a high success rate for this indication.

Introduction: Acute Kidney Injury (AKI) is common in patients with cirrhosis.We performed this meta-analysis to determine the prevalence of AKI and its impact on mortality and hospital resource utilization.Methods: We searched PUBMED and EMBASE through August 2015 to select prospective and retrospective studies describing prevalence of AKI defined based on acute kidney injury network criteria.MeSH words "acute kidney injury" and "cirrhosis" were used for search.Pooled data were reported as odds ratios (OR) with 95% confidence intervals (95% CI), using the random effects model of the comprehensive metaanalysis software.I 2 index and Eger's regression tests were used to determine heterogeneity and publication bias respectively.P value <0.05 was considered significant.Results: A total of 19 studies were selected for analysis.Among 17 studies on 12,177 patients, AKI was present in 2,287 patients with pooled prevalence of 27.8% (95% CI: 19.5-37.9%).Prevalence was higher in ICU patients (2 studies) compared to patients on the floor (15 studies): 54.3% (45.2-63.1%) vs. 24.8%(17.6-33.7%).In hospital mortality was higher in the presence of AKI: 62% (447/726) vs. 26% (324/1256), with over 6 fold higher risk of dying in the presence of AKI (Figure ), P<0.0001.Data were heterogeneous (I 2 =75, P<0.0001) without any publication bias (Egger's P=0.31).Variations in sample size, study design, and inclusion / exclusion criteria probably explain the heterogeneity.Need for intensive care and cardiovascular support was also higher in the presence of AKI: 217 out of 350 (62%) vs. 110 out of 299 (37%); with about 4 fold higher need in AKI patients, 3.9 (2.4-6.2,P<0.0001).These data were homogeneous and publication bias could not be assessed with only 2 studies in this analysis.Conclusion: AKI occurs in about 28% of patients with cirrhosis and twice more common in ICU patients as compared to patients on the floor.AKI is associated with higher in-hospital mortality and need for hospital resources.Prospective studies are needed as basis for developing strategies to reduce the incidence of AKI among patients with cirrhosis and improve their outcomes.Forrest plot on the impact of AKI on in-hospital mortality in patients with cirrhosis.

Introduction: Lubiprostone activates the type 2 chloride channels and increases the chloride concentration in intestinal fluid, thereby, increasing the intestinal fluid secretion. Thus, it increases the passage of stools and alleviates symptoms associated with chronic constipation. Hence, we performed systematic review and meta-analysis of the randomized controlled trials to evaluate the efficacy and safety of 24mcg lubiprostone in patients with chronic idiopathic constipation. Methods: All randomized controlled trials enrolling adult patients that reported clinical safety and efficacy of Lubiprosone were identified from PubMed, MEDLINE, Embase, and Cochrane Central Register of Controlled Trials through May 30, 2016. Three randomized controlled trials were identified. Primary outcome of our study was failure to respond to therapy. Response was defined as spontaneous bowel movement after 24 hours of treatment. Secondary outcomes were adverse effects of nausea and diarrhea. Random effects model was used to estimate the odds ratios (OR) and 95% confidence intervals (CI) using Cochrane Collaborative software, RevMan 5.3. Measure of heterogeneity between the studies was assessed using the chi square test and was considered significant if I2> 50%. Results:Failure to respond to therapy We included 3 RCTs with a total of 546 participants in our analysis, of which 271 received 24 mcg Lubiprostone twice daily and 275 were on placebo. Of the 271 patients who received lubiprostone, 111 (40.9%) of 271 patients failed to respond to therapy, compared with 183 (66.6%) of 275 placebo patients (OR=0.35; 95% CI 0.25 to 0.50), with no significant heterogeneity between studies (I2=0%, p=0.41) (figure 1). The NNT was 3 (95% CI 2 to 5). All 3 RCTs used a dose of 24 mcg twice daily. Adverse events with lubiprostone Of the 333 patients in the lubriprostone group, 94 (28%) had nausea, compared with 9 (3%) of 273 placebo patients (OR=9.66, 95% CI 4.62 to 20.21; NNH=4, 95% CI 3 to 5) (figure 2). Of the 333 patients in the lubriprostone group, 73 (21.9%) had diarrhea, compared with 4 (1.5%) of 273 placebo patients (RR=10.47, 95% CI 4.28 to 25.61, NNH=4, 95% CI 3 to 6) (figure 3).Figure 1Figure 2Figure 3Conclusion: Lubiprostone is effective in relieving symptoms of chronic idiopathic constipation. Adverse events including diarrhea and nausea are significantly higher with lubiprostone.

Introduction: Osseous metaplasia is very rare to find in the gastrointestinal tract. Only 2 cases of metaplastic bone formation in a non-malignant gastric polyp have been described in the literature. We present a case of osseous metaplasia in a hyperplastic gastric polyp in a cirrhotic patient. Case Description: 48-year-old male with history of cirrhosis secondary to NASH was referred to our GI clinic for evaluation of iron deficiency anemia. He had already undergone a colonoscopy at an outside hospital showing diverticulosis. Medications included daily aspirin 81 mg and sulindac 200 mg twice a day. EGD was performed which showed multiple antral polyps, largest being 1.5 cm in size with surface erosion suggestive of recent bleeding but without any active bleeding (pic 1). The polyp was removed completely using hot snare polypectomy and pathology showed a hyperplastic polyp with focal osseous metaplasia (pics 2 and 3).Figure 1Discussion: Hyperplastic polyps are inflammatory proliferations of foveolar gastric epithelium in response to tissue injury. They are the second most common type of gastric polyps after fundic gland polyps. They are usually benign lesions and the rate of malignant transformation ranges from 1.5% to 2.1% with one study reporting dysplasia in 20% of all hyperplastic gastric polyps. It is recommended to resect gastric polyps > 1 cm in size as they are associated with a higher rate of dysplasia, or if they have surface erosions that may lead to iron deficiency anemia. Since forceps biopsies do not detect dysplasia in a reliable manner, complete polypectomy is recommended for such large polyps. Annual surveillance is then suggested in such cases. Our patient had a large polyp and pathology showed osseous metaplasia. The exact etiology of the osseous metaplasia is not known, however, it is not believed to have any clinical significance. Previously osseous metaplasia has been described in only 2 patients with hyperplastic gastric polyps, and 1 patient with adenomatous polyps. Elsewhere in the GI tract, cases of osseous metaplasia have also been described in inflammatory rectal polyps. Conclusion: This is the 3rd reported case of osseous metaplasia in a hyperplastic gastric polyp. Although the etiology is not well described, it does not have any clearly defined clinical significance, and surveillance solely for osseous metaplasia is not required.Figure 2Figure 3

Background: Quality and safety are recognized as essential components of providing excellent care to patients.Not surprisingly these concepts have extended to endoscopy units.Much of the work to date has focused on procedural aspects of endoscopy.As a result, a robust framework for creating a safety-oriented culture as well as a scalable approach to identifying and solving quality and safety issues has not been well described.Methods:The Endoscopy CUSP team consists of a multi-disciplinary group that represents all the aspects of the endoscopy unit.At our institution this includes: all frontline staff including fellows, gastroenterologists, anesthesiologists, nurses, CRNAs, endoscopy technicians and customer service representatives as well as a physician champion, nursing administrator, and hospital executive.This group meets monthly to promote the CUSP framework by: 1) Training staff in the science of safety -formal education on safe design principles and teamwork, 2) Engaging staff in identifying defects -anonymously and formally survey staff for harms, 3) Partnering with a hospital executive in reviewing defects -provides mechanism for accountability and support, 4) Learning from defects -achieved through discussion and analysis using designated tools, and 5) Implementing improvement -represents action item to prevent future harm from occurring.This framework is iterative and is used for technical and non-technical issues.Results: Technical example: Preventing injury when changing an inverted CO2 tank used in cryotherapy.Defect was identified from event reporting system and discussed at CUSP meeting.Subgroup was formed to identify root causes including: poor strap design; insufficient warning label; manual unavailability; insufficient training from vendor.Solutions to these issues included: discussion with vendor to provide nurse training and suggestions on tank reconfiguration; clear warning labels; attached instruction manual; requirement for annual nursing skills competency assessment.Non-technical example: Establishing a clear and concise observer policy after recognizing an increase in the number of visitors to endoscopy, including vendors, research staff, visiting physicians, trainees, and students.Improving how patient privacy might be improved was discussed at the CUSP meeting.Subsequently, a formal visitor workflow was created including construction of visitor guidebook describing basic rules, visitor identification badge, and visitor confidentiality form attesting to privacy.Conclusion: An endoscopy CUSP team provides a model for creating a safety-oriented culture with a concrete framework for identifying and solving both technical and non-technical quality and safety issues.

Introduction: Naloxegol is the first oral peripheral mu opioid receptor antagonist approved for opioid induced constipation. In clinical trials, patients reported shorter times to first spontaneous bowel movement. However, studies have also reported numerous gastrointestinal and non-gastrointestinal side effects. Hence, we performed a systematic review and meta-analysis to assess the safety and tolerability of 25 mg Naloxegol compared to placebo. Methods: All randomized controlled trials enrolling adult patients that reported clinical safety and tolerability of Naloxegol were identified from PubMed, MEDLINE, Embase & Cochrane Central Register of Controlled Trials through May 30, 2016. Four randomized controlled trials were identified. Primary outcome of our study was mortality. Secondary outcomes studied were nausea, vomiting, upper abdominal pain, abdominal pain, flatulence, diarrhea, headache, and back pain. Random effects model was used to estimate the odds ratios (OR) and 95% confidence intervals (CI) using Cochrane Collaborative software, RevMan 5.3. Measure of heterogeneity between the studies was assessed using the chi square test and was considered significant if I2 > 50%. Results: We included 4 RCTs with a total of 1,750 participants in our analysis, of which 1,009 received 25 mg Naloxegol and 741 received a placebo. No statistical significant difference in the primary outcome of mortality (OR=0.50, 95% CI 0.03 - 8.10) was observed in our study. There was an increased risk of adverse effects in Naloxegol group as compared to placebo: nausea (8.9% versus 4.8%, OR 1.90, 95% CI 1.26-2.87; Number Needed to Harm 24.6), upper abdominal pain (4.6% versus 1.5%, OR - 3.10, 95% CI 1.56 - 6.15; NNH 31.9), abdominal pain (17.3% versus 4.8%, OR 4.08, 95% CI 2.68- 6.21; NNH 7.9), flatulence (6.4% versus 2.1%, OR - 2.86, 95% CI 1.45 - 5.64; NNH 23.35), diarrhea (11.3% versus 4.8%, OR - 2.35, 95% CI 1.59 - 3.48; NNH=15.53), headache (6.9% versus 3.5%, OR - 1.83, 95% CI 1.14 - 2.96; NNH=29.09) and back pain (6.8% versus 3%, OR - 2.01, 95% CI 1.22 - 3.31; NNH=26.6). No statistical significant difference in vomiting was observed between the two groups (OR - 1.29, 95% CI 0.70 - 2.39). Conclusion: Use of Naloxegol was associated with an increased risk of gastrointestinal side effects, headache, and back pain without increased risk of mortality as compared to placebo. As with all medications, a discussion with patients regarding the risks and benefits of this treatment is advised.Figure 1

Introduction: Neutropenic enterocolitis is a life threatening condition, primarily seen in patients with hematologic malignancies undergoing chemotherapeutic regimen. The true incidence and frequency for neutropenic enterocolitis is thought to be underestimated. In addition, there is a paucity of data on the demographics and prevalence of complications in patients with neutropenic enterocolitis. In this study we aimed to determine the prevalence of neutropenic enterocolitis in patients with leukemia admitted nationwide to US hospitals between 2006-2010. We also aimed to assess the mortality rates and prevalence of associated complications such as perforation, peritonitis, disseminated intravascular coagulation (DIC) and sepsis. Methods: We queried a United States national in-patient database for the years 2006-2010. All patients with diagnosis of leukemia were identified from the National Inpatient sample (NIS) database from 2006-2010 using the 9th revision of the International Classification of Disease (ICD) codes 205.0x for acute myeloid leukemia, 205.1x for chronic myeloid leukemia, 204.0x for acute lymphoid leukemia and 204.1x for chronic lymphoid leukemia. Subsequently all neutropenic patients with enterocolitis were extracted from them. Results: Of 853,080 patients with leukemia, the prevalence of neutropenic enterocolitis was 0.35% (n=3,019), the mean age was 41.4±0.9 years, of which 48% were females. Mean length of hospital stay was 23.9±0.9 days and in-hospital mortality rate was 5.7%. No statistically significant difference in mortality rate was observed in males and females (6.4 versus 4.8%; p=0.46). Complications prevalent in our study were - sepsis 9.4%, gastrointestinal bleeding 6.1%, DIC 3.5%, acute peritonitis 0.3% and intestinal perforation 0.2%. Conclusion: Neutropenic enterocolitis is a growing concern in leukemic patients with substantial morbidity and mortality.

Cannabinoid Hyperemesis Syndrome (CHS) is characterized by cyclic episodes of vomiting and abdominal pain secondary to cannabis use. We present the first reported cases of death due to Cannabinoid Hyperemesis Syndrome. First case: A 41 yo male with a 20-yr history of frequent marijuana use was found dead in his home. For 10 years, he had recurrent, prolonged episodes of nausea, vomiting and abdominal pain. He underwent an extensive GI evaluation including colonoscopy, upper endoscopy, abdominal CT, celiac serology, 24 hr urine porphyrins, and stool ovum/parasites; all testing was unremarkable. 8 months prior to death, he was hospitalized for severe hyponatremic dehydration. 5 days prior to death, he developed intractable nausea, vomiting and weakness; he did not seek medical care. Autopsy showed evidence of dehydration, acute esophageal necrosis with black discoloration of the distal esophagus, focal right lower lobe pneumonia. Vitreous chemistry showed a pattern of hyponatremic dehydration (Na 134 mmol/L, Cl 78 mmol/L, BUN 88 mg/dL and Cr 2.8 mg/dL). Toxicology showed only marijuana (THC) and marijuana metabolite (THC-COOH) in blood and THC-COOH in urine. The cause of death was hyponatremic dehydration due to exacerbation of CHS. Second case: A 48 yo male with a history of fibromyalgia, anxiety, depression, prior diagnosis of somatization disorder and episodes of intractable nausea and vomiting was found in his bathtub after a neighbor reported continuous running water for 2 days. Autopsy revealed evidence of dehydration, acute esophageal necrosis and focal early pneumonia in the right lung likely from aspiration. Vitreous chemistry showed severe hyponatremic dehydration. Toxicology revealed THC, THC-COOH, 7-aminoclonazepam (clonazepam metabolite) and pregabalin. The cause of death was hyponatremic dehydration in the setting of probable CHS. Discussion: CHS is one of the known adverse effects of cannabinoid use, which patients frequently report is relieved by hot bathing. Cessation of the substance is the only treatment, although time to improvement is variable. The use of recreational and medical marijuana has become more widely accepted, and the predominant public sentiment is that marijuana is relatively harmless. These are the first reports of death directly attributable to marijuana use. These two cases of death should increase awareness of severity and potentially fatal effects of CHS.

Esophageal verrucous carcinoma is a rare type of squamous cell cancer. The diagnosis can be challenging, and consensus treatment recommendations are lacking. We describe the case of a patient diagnosed with esophageal verrucous carcinoma and treated successfully with endoscopic therapy. Case Presentation A 65 year old male presented with dysphagia. EGD showed a 2-cm frond like exophytic tumor in the distal esophagus and a benign peptic stricture at the GE junction (pic 1). Biopsies showed squamous hyperplasia and ulceration. CT showed no nodal or distant metastases. Upper EUS showed no submucosal invasion. Repeat EGD was performed with additional snare biopsies, and histology was similar. Given the recurrent and extensive nature of proliferation, there was suspicion for verrucous carcinoma. The tumor was removed via endoscopic mucosal resection (EMR). Histology confirmed well-differentiated verruciform squamous proliferation (pic 2). Three repeat EGDs at 3, 6 and 7 months later showed a small amount of tumor, treated with further endoscopic therapies (snare, APC, EMR). The fourth EGD after the initial EMR showed no recurrent/residual tumor (pic 3). Discussion Esophageal verrucous carcinoma was first reported in 1967, and less than 50 cases have been reported. It is more common in males, symptoms may include weight loss or dysphagia, and be associated with GERD. Risk factors include cigarette smoking, alcohol, achalasia and esophageal diverticula. Diagnosis is made with characteristic endoscopic appearance of an exophytic, whitish, frond like mass along with histology. Due to the rarity of this disease, there is limited evidence to guide treatment. Work up should include EUS and CT to evaluate for nodal or distant metastasis, both of which are very rare. Previously surgical resection was recommended, however due to the pattern of local proliferation and limited tendency for invasion and metastases, EMR and endoscopic submucosal dissection (ESD) have been successfully performed. Recently, a study described 9 patients treated with local endoscopic therapy. However, only 4 patients were treated with intent to cure requiring up to 48 sessions in one patient. As endoscopic therapies improve, this is likely to be a viable treatment modality for this disease, as seen in our case. Conclusion Verrucous carcinoma is a rare subtype of esophageal carcinoma with limited tendency for metastases, and can be successfully treated endoscopically in appropriate cases.Figure 1Figure 2Figure 3

Introduction: Bleeding occurs in about 25% of patients with gastric varices and is associated with a high mortality. Data on primary bleeding prophylaxis with endoscopic cyanoacrylate glue injection (ECGI) are limited. We report our experience at a US tertiary referral center. Methods: A retrospective chart review was performed of patients undergoing elective ECGI for gastric varices as primary prophylaxis at a tertiary care center between 2005 to 2015. ECGI was done in combination with EUS-guided coil placement in 1 patient. Complete obliteration of gastric varices, variceal bleeding during follow-up and recurrence of gastric varices were the outcomes assessed.Figure 1Results: Sixteen patients underwent ECGI for large gastric varices. Mean age was 63 years (SD 11 years), 75 % were male. Fourteen patients had cirrhosis (Child class A in 9, B in 4 and C in 1), one of them had splenic vein thrombosis and two had non-cirrhosis portal hypertension. Concomitant esophageal varices were present in 13, and 3 patients has isolated fundic gastric varices. Ten patients (63%) were on non-selective beta-blockers. At least one surveillance endoscopy was done in all patients. Median follow up was 27 months (IQR, 7 - 47 months). Complete obliteration of gastric varices was achieved in 15 patients (94%) This required a single session in 10, two sessions in 3 and three sessions in 2 patients. One patient had splenic artery embolization. One patient underwent liver transplantation, one needed transjugular intrahepatic portosystemic shunt (TIPS) for recurrent bleeding, another patient had TIPS for refractory ascites. Four patients had bleeding during follow-up, two from patent gastric varices (partially treated or additional varices, at 4 months and 6 months, respectively) and two patients had transient bleeding from glue ulcers. One patient was found to have asymptomatic glue emboli to the liver. Mean time to recurrence of gastric varices after complete obliteration was 18 months. Two out of 13 patients (15%) treated solely with ECGI had variceal bleeding during the follow-up. Conclusion: Complete obliteration of gastric varices can be achieved in the majority of patient with endoscopic cyanoacrylate glue injection and 2-year variceal bleeding rate is 15%. Recurrence after complete obliteration however is not infrequent and continued surveillance is advisable.

Donor T lymphocyte transfer with hematopoietic stem cells suppresses residual tumor growth (graft-versus-tumor [GVT]) in cancer patients undergoing bone marrow transplantation (BMT). However, donor T cell reactivity to host organs causes severe and potentially lethal inflammation called graft-versus-host disease (GVHD). High-dose steroids or other immunosuppressive drugs are used to treat GVHD that have limited ability to control the inflammation while incurring long-term toxicity. Novel strategies are needed to modulate GVHD, preserve GVT, and improve the outcome of BMT. Regulatory T cells (Tregs) control alloantigen-sensitized inflammation of GVHD, sustain GVT, and prevent mortality in BMT. Helminths colonizing the alimentary tract dramatically increase the Treg activity, thereby modulating intestinal or systemic inflammatory responses. These observations led us to hypothesize that helminths can regulate GVHD and maintain GVT in mice. Acute GVHD was induced in helminth (Heligmosomoides polygyrus)–infected or uninfected BALB/c recipients of C57BL/6 donor grafts. Helminth infection suppressed donor T cell inflammatory cytokine generation and reduced GVHD-related mortality, but maintained GVT. H. polygyrus colonization promoted the survival of TGF-β–generating recipient Tregs after a conditioning regimen with total body irradiation and led to a TGF-β–dependent in vivo expansion/maturation of donor Tregs after BMT. Helminths did not control GVHD when T cells unresponsive to TGF-β–mediated immune regulation were used as donor T lymphocytes. These results suggest that helminths suppress acute GVHD using Tregs and TGF-β–dependent pathways in mice. Helminthic regulation of GVHD and GVT through intestinal immune conditioning may improve the outcome of BMT.

Aim: Investigate the intensity and distribution of IL-33 staining in patients with EoE compared to healthy controls and patients with GERD. Methods: A retrospective study and reviewed pathology specimens from 20 patients with EoE and 20 patients with GERD and 20 healthy subjects. We performed immunohistochemical staining for IL-33 on these samples. The staining distribution was compared with respect to intranuclear or intracytoplasmic IL-33 intensity and the depth of staining intensity in the biopsies. Results: There was increased intensity of nuclear IL-33 staining in biopsies from patients with EoE as compared to healthy subjects patients with GERD (P<0.001), and no difference in cytoplasmic staining, or IL-33 distribution within biopsies thickness among the groups (P=0.42). Conclusion: This study describes enhanced nuclear expression of IL-33 in EoE, a disorder characterized by a predominantly Th2 response and esophageal hypereosinophilia in the absence of GERD. Our observations may have implications for improved understanding of the pathophysiology, diagnosis and treatment of EoE.

BACKGROUND & AIMS: Asymptomatic diverticulosis is commonly attributed to constipation caused by a low-fiber diet, although evidence for this mechanism is limited. We examined the associations between constipation and low dietary fiber intake with risk of asymptomatic diverticulosis.METHODS: We performed a cross-sectional study that analyzed data from 539 individuals with diverticulosis and 1569 without (controls). Participants underwent colonoscopy and assessment of diet, physical activity, and bowel habits. Our analysis was limited to participants with no knowledge of their diverticular disease to reduce the risk of biased responses.RESULTS: Constipation was not associated with an increased risk of diverticulosis. Participants with less frequent bowel movements (<7/wk) had reduced odds of diverticulosis compared with those with regular bowel movements (7/wk) (odds ratio [OR], 0.56; 95% confidence interval [CI], 0.40-0.80). Those reporting hard stools also had reduced odds (OR, 0.75; 95% CI, 0.55-1.02). There was no association between diverticulosis and straining (OR, 0.85; 95% CI, 0.59-1.22) or incomplete bowel movement (OR, 0.85; 95% CI, 0.61-1.20). We found no association between dietary fiber intake and diverticulosis (OR, 0.96; 95% CI, 0.71-1.30) in comparing the highest quartile with the lowest (mean intake, 25 vs 8 g/day).CONCLUSIONS: In our cross-sectional, colonoscopy-based study, neither constipation nor a low-fiber diet was associated with an increased risk of diverticulosis.