Ischemic colitis (IC) should be considered as a cause for gastrointestinal symptoms in patients with recent vigorous physical activity. Vasoconstriction driven by increased sympathetic tone during exercise is believed to mediate exercise-induced IC. In this report, a 21-year-old man with no medical history developed self-resolving, sudden-onset hematochezia and abdominal pain after playing in a collegiate soccer match for 90 minutes. Colonoscopy with biopsy showed changes consistent with IC. He improved without further treatment. In most cases, exercise-induced IC resolves completely with supportive care and correction of hypovolemia. Careful monitoring is appropriate before pursuing further evaluation.

Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) poses the risk of radiation exposure (RE) to patients and staff and increases the risk of adverse biological effects such as cataracts, sterility, and cancer. Newer fluoroscopy equipment (C-Arm) provides options to limit radiation in the form of lower radiation dose and frame rate or time-limited "pulsed" settings. However, the impact of lower settings on image quality has not been assessed, and no standard protocol exists for fluoroscopy settings used during ERCP. Patients and methods This was a single-center, double-blind, prospective randomized study of consecutive adult patients undergoing standard-of-care ERCP at a tertiary academic medical center. Patients were randomized into two groups: 1) standard-dose pulsed and 2) low-dose pulsed. Pulsed mode (8 fps) was defined as x-ray exposure either in the manufacturer standard-dose or low-dose settings limited to 3 seconds each time the foot-operated switch was depressed. Results Seventy-eight patients undergoing ERCP were enrolled and randomized. No difference in age, gender, or body mass index was found between the two groups. No significant difference in image quality was found between standard-dose and low-dose fluoroscopy P = 0.925). The low-dose group was exposed to significantly less radiation when compared with standard-dose P < 0.05). Fluoroscopy time (minutes) was similar in both groups (2.0 vs 1.9), further suggesting that group assignment had no impact on image quality or procedure time. Conclusions Low-dose pulsed fluoroscopy is a reliable method that substantially reduces radiation without compromising image quality or affecting procedure or fluoroscopy times. This underscores the need for standardization in ERCP fluoroscopy settings to limit radiation exposure.

Introduction: Ischemic colitis in young adults is rare. The incidence in adults less than 40 years is 1.1 per 100,000. It can present with abdominal pain and rectal bleeding after vigorous exercise. In one study, 2% of marathon runners reported blood in stool following races, and 20% of runners had positive fecal occult blood test (FOBT) after marathons.1 The aim of this case report is to heighten awareness of ischemic colitis as possible cause for gastrointestinal bleed in those with recent sports activity. Case Description/Methods: The patient is a 21-year-old man college student with no past medical history who presented with abdominal pain, hematochezia and coffee ground emesis after playing nearly the entire 90 minutes of a NCAA Division 1 soccer match. No prior episodes of hematochezia reported, and he denied use of NSAIDs, performance enhancing medications, or illicit substances. On admission, bradycardia and abdominal discomfort were noted. Labs revealed elevated serum creatinine 2.1 mg/dL consistent with acute kidney injury, elevated creatinine kinase (504 U/L) and lactic acidosis (3.1 mmol/L). Abdominal/pelvic CT angiography and upper GI endoscopy were normal. Colonoscopy revealed ischemic colopathy in the splenic flexure, transverse colon, hepatic flexure and ascending colon (Figure 1A and B). Biopsies from ascending and transverse colon were consistent with ischemic colitis (Figure 1C). He was managed with intravenous fluids, and all symptoms resolved within 24 hours. Discussion: Ischemic colitis in young adults is often associated with hypovolemia and decreased colonic perfusion. Increased sympathetic tone during exercise in hot environment can cause decreased blood flow to colon by 50-80%, thus precipitating ischemic colitis. Areas most affected are the “watershed areas,” areas of colon with the least amount of blood supply, typically at the junction of vascular territories. Management depends on the degree of injury. Non-gangrenous colitis typically resolves spontaneously, whereas antibiotics and surgery should be considered in cases of ischemic colitis with hemodynamic instability with associated full thickness necrosis. This case is an example of exercise induced hypovolemia leading to colonic ischemia. Our patient was managed conservatively with intravenous fluids and recommended for two weeks of cessation from athletics. Reference 1Eichner ER. Gastrointestinal Bleeding in Athletes. Phys Sportsmed. 1989;17(5):128-140.Figure 1.: A and B: Scattered and patchy granular areas in ascending and transverse colon consistent with ischemic colopathy; C: Colonic mucosa with focal ischemic changes.

University of Maryland School of Medicine, USA.

Background Extraintestinal manifestations (EIMs) of inflammatory bowel disease (IBD) are a common, frequently debilitating complication of the disease. Biologics are indicated and often required in patients with EIMs to control disease; however, little is known about whether patients with EIMs cycle through more therapies than their counterparts without EIMs.Methods To address this question, we performed a retrospective analysis of patients enrolled in the Study of Prospective Adult Research Cohort with IBD registry seen at our University Medical Center, on data from December 2016 to January 2021. Four hundred fifty-six participants with information on EIMs and biologic use available were included, and demographic and clinical characteristics were analyzed.Results Three hundred thirty-eight and 118 participants without and with EIMs were identified, respectively. Those with EIMs were likelier to have biologic exposure, and cycle through more biologics, both in univariate and multivariate analyses controlling for age, disease duration, sex, corticosteroid use, and IBD type (P-value = .006). In a subanalysis of patients with Crohn's disease (CD), EIMs were associated with increased biologic cycling in ileocolonic disease (P-value = .050).Conclusions To our knowledge, this is the first study assessing biologic cycling in patients with EIMs. Our findings that patients with EIMs are likelier to cycle through biologics, particularly CD patients with ileocolonic disease, highlights the need for more research on which biologics may be most effective for specific subsets of IBD patients, including those with concurrent EIMs. The presence of EIMs is a marker of harder-to-treat IBD and may indicate earlier initiation of advanced therapies. Though extraintestinal manifestations (EIMs) frequently occur in inflammatory bowel disease, data regarding their association with biologic therapy cycling are sparse. We found patients with EIMs cycle through more therapies, and in Crohn's disease, this is associated with ileocolonic involvement. Graphical Abstract

BACKGROUND AND AIMS:Endoscopic submucosal dissection (ESD) is a therapeutic technique for enbloc resection of both large (>20 mm) and smaller, complex gastrointestinal neoplasms. ESD has a higher success rate of en-bloc resection and a lower rate of local recurrence compared with endoscopic mucosal resection. Removal of lesions via ESD can leave large mucosal defects, raising unique challenges leading to adverse events. We aimed to determine clinical outcomes, including delayed bleeding, perforation, and hospitalization, in patients undergoing endoscopic suturing after ESD. METHODS:This was a single-center retrospective study of a prospectively collected database of consecutive adult patients who underwent ESD with mucosal defect closure using endoscopic suturing. Primary outcomes were adverse events, specifically delayed bleeding or perforation. Secondary outcomes included need for hospitalization and suturing complications. RESULTS:Fifty-five patients (mean age: 67 years) were included, with a mean lesion size of 27.4 & PLUSMN; 15 mm. Defect closure occurred in the esophagus (6), gastroesophageal junction (2), stomach (30), cecum (2), sigmoid colon (2), and rectum (13). A mean of 1.8 & PLUSMN; 1.0 sutures were required for defect closure. The hospital admission rates was 14% (8/55), with an average length of stay 2 days (range 1-3 days). Intraprocedural perforation occurred in 2 patients, and both were successfully treated with endoscopic suturing. There was one case of delayed bleeding and no cases of delayed perforation or suturing complications. CONCLUSION:The use of endoscopic suturing following ESD is a safe and clinically reliable method to close mucosal defects. This approach is associated with minimal adverse events and need for hospitalization. Larger studies are needed to further validate these findings.

A tracheoesophageal fistula (TEF) is a pathological connection between the trachea and esophagus, which can either occur congenitally or be acquired. An acquired TEF may occur secondary to malignancy, chemoradiotherapy, infection, or trauma. Hallmark symptoms typically associated with TEF include choking with food intake, productive cough, pneumonia, or failure to thrive. The management of TEF has predominantly involved surgical or endoscopic intervention such as esophageal or airway stenting, suturing, or ablation. More recently, the endoscopic over-the-scope clip (OTSC) has emerged as an effective method of TEF management. The OTSC grasps the mucosa overlaying lesion and seals the defect, thus making it an effective treatment option for the endoscopic closure of various GI defects such as fistulas, bleeding ulcers, and perforations. We report a case of a TEF, acquired secondary to underlying malignancy, and its successful treatment with the use of an OTSC placement. A 79-year-old female with a significant history of diffuse large B-cell lymphoma (DLBCL) currently undergoing chemotherapy was admitted to the hospital for aspiration pneumonia. She presented with persistent productive cough and subsequent limited oral intake ability while initially presenting for DLBCL six months prior with an enlarging right-sided neck mass. Her positron emission tomography-computed tomography (PET-CT) imaging showed a cavitary lesion in the superior mediastinum with increased fluorodeoxyglucose (FDG) lymphatic uptake. She had an esophagogram followed by an esophagogastroduodenoscopy (EGD), due to aspiration concerns, which demonstrated a fistula site with tracheal secretions about 20 cm from the incisors. An OTSC was used to close the esophageal opening and successful closure was confirmed using real-time fluoroscopic imaging by the unimpeded passage of contrast in the stomach without leakage. At follow-up, she was able to tolerate an oral diet without any significant difficulty or symptom recurrence. We present a case of successful endoscopic management of TEF with an OTSC that resulted in immediate fistula closure and improvement in the patient’s quality of life. This particular case highlights the ability of OTSC to provide more durable and long-term closure than other management techniques due to its mechanism of grasping more tissue for approximation and its association with less morbidity compared to alternative surgical interventions. Although previous reports describing the technical feasibility and utility of OTSC in TEF repair support its use, there is still a paucity of data exploring the long-term efficacy of OTSC in TEF management; therefore, additional prospective studies are necessary.

Introduction: Ischemic gastritis is rare, given that blood supply of stomach is rich. It is associated with a high mortality; therefore, early recognition is important for choosing appropriate course of management.The aim of this case report is to heighten awareness regarding the possibility of ischemic gastritis in the presence of conditions that can limit blood flow to stomach. We also discuss the role of hemostatic spray in controlling active bleeding in this scenario. Case Description/Methods: A 62-year-old man with history of hypertension and peptic ulcer disease was admitted with extensive type A aortic dissection. During hospital course, he was having bloody nasogastric output. Hemoglobin had acutely dropped from 14.8 g/dL to 8.2 g/dL. INR was normal 1.3. CT scan abdomen/pelvis showed extensive aortic dissection extending into celiac artery and possible superior mesenteric artery (Figure 1A) along with edematous changes in stomach concerning for ischemic insult. Upper endoscopy revealed diffuse severe hemorrhages and ulcerations in the entire stomach along with diffuse ulceration in the bulb and second part of duodenum (Figure 1B). Hemostatic spray was deployed to stop active bleeding (Figure 1C). Patient’s hemoglobin remained stable for 4 days after this intervention and he did not require blood transfusion during this interval. He was started on broad spectrum antibiotics, proton pump inhibitor infusion and total parenteral nutrition for bowel rest. Repeat upper endoscopy after 2 weeks revealed improved ulceration & necrosis of gastric mucosa (Figure 1D). Oral diet was resumed which was tolerated well by the patient. Discussion: Suspicion for ischemic gastritis should be high in the presence of etiologies that can limit blood flow to the stomach such as aortic dissection, systemic hypotension or disseminated thromboembolism. Management is mostly conservative including nasogastric tube placement for intermittent air and fluid aspiration to prevent gastric distention, broad spectrum antibiotics, aggressive acid reduction using proton pump inhibitors, and parenteral nutrition. Surgery is indicated for gastric perforation and gangrenous or necrotizing gastritis that are not responding to supportive care and broad-spectrum antibiotic therapy (1). Reference (1) Tang SJ, Daram SR, Wu R, Bhaijee F. Pathogenesis, diagnosis, and management of gastric ischemia. Clin Gastroenterol Hepatol. Feb 2014;12(2):246-52.e1.Figure 1.: A: Extensive aortic dissection; B: Diffuse severe hemorrhages and ulcerations in pre-pylorus; C: Stomach post Hemostatic spray deployment; D: Improved ulceration & necrosis of gastric mucosa after 2 weeks.

Background and Aims: Benign esophageal strictures often present with dysphagia and can significantly impair a patient’s quality of life, especially when refractory to standard endoscopic techniques. When repeat dilations fail to achieve an adequate luminal diameter or resolve dysphagia, further therapy with needle-knife or steroid injections is needed. However, patients can still clinically fail. To manage such strictures, we employed a novel combination of all three techniques. Methods: Single-center case series of adult patients with benign strictures that were refractory to conventional endoscopic therapy and removable self-expanding metal stenting. Primary clinical success was defined as complete resolution in dysphagia. Secondary outcomes included periodic dilation index (frequency of dilations over the follow-up time), esophageal diameter changes, technical success, and complications. Results: Four patients (median age 49.7 years old, interquartile range [IQR] 30–59) underwent endoscopic therapy for complex, benign strictures using our triple therapy technique. Etiologies of the strictures included peptic strictures (n = 3) and an anastomotic stricture (n = 1). There was 100% technical success rate with no associated adverse events. There was a 50% clinical success rate, with 1 additional patient having partial improvement in dysphagia. The median diameter of the esophagus before and after triple therapy was 3.2 mm (IQR 3.5–5.5) and 12.8 mm (IQR 11.7–14.2), respectively. The periodic dilation index was 6.3 before and 1.5 after triple therapy. The median length of follow-up was 362.5 days. Conclusion: Triple combination therapy may be useful in benign strictures that are refractory to standard techniques. Larger studies are needed to validate these findings.

Background Active smoking is a well-established risk factor for developing Crohn’s disease (CD) and negatively impacts overall disease progression. Patients who start or continue smoking after CD diagnosis are at risk for poor outcomes, higher therapeutic requirements, and have higher rates of relapse. However, it remains unclear if the exposure to smoking leads to increased sequencing through treatment therapies, especially biologics. Methods The Study of Prospective Adult Research Cohort with IBD (SPARC IBD) registry has been collecting patient-reported outcomes data in real-time, as well as laboratory, endoscopic, and pathologic samples from 17 tertiary referral centers since 2016. In this study, we conducted a retrospective review of the SPARC clinical registry collected between December 2016 and January 2021 from 1 participating site, the University of Maryland School of Medicine’s Inflammatory Bowel Disease Program. A total of 619 patients were enrolled in the SPARC IBD database. Four hundred twenty-five patients with CD were included for initial review of completeness of data; of these, 144 patients were excluded due to missing data on smoking status and/or biologic treatment, resulting in a final cohort of 281 patients. We collected and analyzed baseline demographic and clinical characteristics. The final cohort was categorized into 3 exposure groups: current, former, and never smokers. Our outcome of interest was number biologics used, categorized into 3 groups: 0, 1, or ≥2 biologics. Results One hundred seventy-two never smokers, 70 former smokers, and 39 current smokers were identified. Current, former, and never smokers had no statistically significant differences in number of biologics used (ie, biologic sequencing). However, statistically significant independent risk factors for increased sequencing of biologics were identified. These risk factors included female sex, ileocolonic disease location, younger age at diagnosis, and prolonged disease duration; none of these factors remained significant in adjusted analyses. Conclusion To date, this is the first study assessing the association of smoking and sequencing of biologics. Although current or former smokers were not found to sequence through more biologics when compared with never smokers, smoking is a well-established risk factor for poor health outcomes, and efforts should be made to counsel patients to quit. Further, additional research must be done to stratify risk to patients based on amount of tobacco exposure.

Endoscopic submucosal dissection (ESD) is a feasible, minimally invasive therapeutic technique for en-bloc resection of large (>20 mm) gastrointestinal neoplasms. In addition, ESD has shown a higher success rate of en bloc resection and a lower rate of local recurrence in comparison to endoscopic mucosal resection (EMR). Removal of lesions via ESD can leave large mucosal defects, raising unique closure and procedure-related challenges that may lead to adverse events. However, smaller previous studies utilizing endoscopic suturing of mucosal defects have shown promising results with fewer adverse events and lower hospital costs.

Introduction: Smoking negatively impacts disease progression in Crohn’s disease (CD). Patients who start or continue smoking after CD diagnosis are at risk for poorer outcomes, higher therapeutic requirements, and have higher rates of relapse often requiring surgery. Race, gender, socioeconomic factors, and stressors all affect smoking status in the general population but have not been explored in patients with inflammatory bowel diseases (IBD). Importantly, smokers are at an increased risk of complications from COVID-19 infection. This study aims to determine the risk factors for change in smoking habits in patients with IBD during the COVID-19 pandemic. Methods: Surveys were sent via email to 1589 patients with an electronic medical record coded diagnosis of IBD who were seen at our IBD clinic between January 2017 and September 2020. Those who self-identify as active or former smokers were invited to complete the unpaid, anonymous, online survey regarding demographics, socioeconomic factors, IBD disease phenotype, general anxiety, and smoking habits during the COVID-19 pandemic. Results: One hundred and thirty-nine participants completed the survey. One hundred and three participants either remained non-smokers or did not change the amount they were smoking, 22 started smoking again after previous cessation or increased smoking, and 10 stopped smoking, switched to vaping, or decreased the amount they were smoking. Statistically significant independent risk factors by Fisher’s exact test for change in smoking habits during the COVID-19 pandemic revealed both age 18-34 years (P= 0.011) and never married (p< 0.001) as most likely to change smoking amount. Those with CD (P= 0.041) were least likely to decrease smoking amount. Frequency of anxiety (P= 0.013), preoccupation with anxiety (P= 0.003), nervousness (P= 0.036), uneasiness (P= 0.034) and feeling tense (P= 0.021) were associated with increased smoking during COVID-19 pandemic. Conclusion: Smoking is known to have a negative impact on CD disease progression. In our cohort, participants with CD were least likely to decrease smoking amount during COVID-19 pandemic. Participants with frequent anxiety, preoccupation with anxiety, nervousness, uneasiness, and tension reported increased smoking during the pandemic. Routine screening for anxiety and smoking habits should be performed in all IBD clinical visits.

Esophagopleural fistula (EPF), initially described in 1960, is an abnormal communication between the esophagus and the pleural cavity which can occur due to congenital malformation or acquired due to malignancy or iatrogenic treatment. The most common presenting symptoms are of a respiratory infection, such as fever, chest tenderness, cough and imaging findings consistent with pleural fluid consolidation. In this report, we present a 59-year-old man who exhibited shortness of breath, productive cough, and significant weight loss for 2 weeks. His medical history was significant for smoking-related lung disease and pulmonary squamous cell carcinoma (SCC). His SCC (T4N0) was diagnosed 6 years prior to this presentation and was treated with chemoradiotherapy. The cancer recurred a year ago and he was treated with intensity-modulated proton therapy (IMPT) and consolidation chemotherapy. During admission, he was found to have an EPF by CT scan after initially failing antibiotic treatment for suspected complicated pneumonia and pleural effusion. Multiple attempts of esophagopleural fistula closure were made using endoscopic self-expandable metallic stents and placement of an esophageal vacuum-assisted closure device. However, these measures ultimately failed and, therefore, he required an iliocostalis muscle flap (Clagett window) procedure for closure. Esophageal pulmonary fistulae should be suspected whenever patients have undergone thoracic IMPT and may present with acute pulmonary complications, particularly pneumonia refractory to antibiotic treatment. This case reviews the current literature, potential complications, and treatment options for esophagopleural fistulas.

subjects is much greater than CP patients.PERT use in NPC is often for a short duration with appropriate dosing in a small minority.Education for proper indications and prescribing strategies for PERT to health care professionals is needed. Su2010