Background and Aims: Current guidelines recommend multiple biopsies from the first (D1) and second (D2) part of duodenum to establish a diagnosis of celiac disease. In this meta-analysis we aimed to find whether D1 biopsy can increase the diagnostic yield of adult celiac disease. Methods: Literature databases were searched until January 2023 for studies reporting diagnosis of celiac disease in the adult population using D1 biopsy. Meta-analysis was done using a random-effects model. Heterogeneity was assessed by I 2 % and 95% prediction interval statistics. Measured outcomes were diagnostic yield with D1 and D2 biopsies and from 4 versus 2 biopsy samples. Results: A total of 16 studies were included in the final analysis. The pooled diagnostic rate of celiac disease from D1 biopsy was 77.4% [95% CI (64.7-86.5, I 2 94%)] and from D2 biopsy was 75.3% [60.8-85.7, I 2 96%]. The pooled rate of increase in diagnostic yield with D1 biopsy was 6.9% I [4.6-10.2, I 2 66%]. The pooled diagnosis rate with 2 biopsy samples were 77.3% [50-92, I 2 93%] and 86.4% I [58.4-96.7, I 2 87%] from D1 and D2 respectively, whereas that with 4 biopsy samples were 83.3% [49.8-96.2, I 2 76%] and 70.5% I [51-84.6, I 2 96%] from D1 and D2, respectively, the difference being non-significant. Conclusion: Our study demonstrates that taking 4 biopsy samples does not incur any additional diagnostic value over taking 2 biopsy samples from each duodenum segment. Although biopsy from the D1 and D2 has similar diagnostic yield in the adult population, there was an overall increase in diagnostic yield with D1 biopsy, especially in those with a patchy disease distribution.

Thyrotoxicosis can exhibit overlapping symptoms of psychosis in the general population. Each of these pathologies has well -established workups and management. Rare presentations of thyroiditis and psychosis in the postpartum state have been seen in case studies mostly, but data on the prevalence of postpartum psychosis in association with postpartum thyroiditis are not available. Here, we present a unique case of a patient with a history of bipolar disorder who originally presented with postpartum thyroiditis that was worked up and managed appropriately. However, on follow-up, the patient was found to have progressed into prominent psychosis. Both thyroiditis and psychosis were managed individually with full remission upon discharge and is doing well today. The co -occurrence of postpartum psychosis and thyroiditis presents a unique challenge for timely diagnosis and management. We present a case of a young woman initially diagnosed with postpartum thyroiditis needing further management of postpartum psychosis due to persistent symptoms. Clinical presentation supported with a prior history of mood disorder increases the likelihood of these diagnoses together.

Chronic sequelae of COVID-19 remain undetermined. We report a case of postinfection sequelae in a patient presenting with subacute obstruction 2 months after COVID-19 infection. A 34-year-old man with a prior prolonged hospital stay due to COVID-19 complicated by upper gastrointestinal (GI) bleed presented with subacute obstruction and failure to thrive. Upper GI push enteroscopy revealed residual ulcers and multiple proximal jejuno-jejunal fistulae. Midline laparotomy revealed strictures with dense intra-abdominal adhesions, a large jejuno-jejunal fistula, and evidence of prior jejunal perforation following severe COVID-19 infection. The patient recovered after small bowel resection with anastomoses and was discharged home. Histopathological examination of resected specimen confirmed transmural infarction with evidence of prior hemorrhage, diffuse ulcers, and multifocal inflammation. This is the first report of a chronic GI sequelae resulting from COVID-19. As the pandemic evolves, medical professionals must be vigilant to consider alternative GI diagnoses in the COVID-19 survivors.

Despite the growing disease burden of non-alcoholic fatty liver disease (NAFLD), approved medical treatments to improve or prevent liver fibrosis are effective only in a small number of patients. Recent studies have found the new use of antiplatelet agents for antifibrotic benefits in NAFLD, but human studies are still limited. The goal of this meta-analysis was to combine the findings of existing relevant studies to investigate the effects of antiplatelet therapy in reducing or preventing advanced liver fibrosis in patients with NAFLD. We conducted a systematic literature search in PubMed, EMBASE, and Web of Science databases from inception to January 2021 to identify all original studies that investigated the use of antiplatelet agents in patients with NAFLD. We used the National Institutes of Health’s quality assessment tool for observational cohort and cross-sectional studies to assess study quality and risk of bias. The primary outcome was the prevalence of advanced liver fibrosis stage 3–4. Data from each study was combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate pooled odds ratio (OR) and 95% confidence intervals (CIs). Of the 2,498 studies identified, 4 studies involving 2,593 patients with NAFLD were included in this study (949 antiplatelet agent users and 1,644 non-antiplatelet agent users). The use of aspirin and/or P2Y12 receptor inhibitors was associated with a lower pooled OR of advanced liver fibrosis in patients with NAFLD (pooled OR = 0.66; 95% CI: 0.53–0.81, I2 = 0.0%; p < 0.001). This study focuses on the outcome of advanced liver fibrosis in patients with NAFLD. Our study is limited by the small number of studies that were included. Preliminary evidence from this meta-analysis suggests a protective association between antiplatelet therapy and the prevalence of advanced liver fibrosis in patients with NAFLD. Our findings support future research into repositioning an antiplatelet agent as a novel NAFLD treatment.

Since the era of antibiotics, the frequency of secondary syphilis manifestations has declined. During the last decade, there has been a resurgence of syphilis cases. We describe a case of a 28-year-old man with various secondary syphilis symptoms including alopecia with the well-described characteristic "crown of Venus" pattern not commonly seen during this decade, as well as mucosal plaques, pustules, and palmoplantar macular rash. This case suggests that syphilis should be included in the differential diagnosis of hair loss for a correct screening, diagnosis, and early treatment.

Abstract Cutaneous manifestations of COVID-19 infections include “COVID toes.” These are pernio-like, pale purple, painful, ill-defined cyanotic lesions that have inflammatory infiltrates on histologic studies. COVID toes can also develop following COVID vaccination. COVID toes was reported by 29 individuals to the Vaccine Adverse Event Reporting System maintained by the Centers for Disease Control and Prevention through May 25, 2021. The mean age of these individuals was 52 ± 18 years; 23 (79%) were women. They had received both mRNA vaccines and the adenovirus vector-based vaccine. This discoloration developed 4.5 ± 9.8 days following vaccination, usually after the first dose. Four individuals required hospitalization for systemic symptoms, and one died. This information indicates that some individuals develop important clinical syndromes following vaccination and suggests that some of the manifestations of COVID-19 infection represent immune responses and not necessarily active tissue infection.

Introduction: Laparoscopic sleeve gastrectomy (LSG) is a popular weight loss surgery. LSG staple line leak occurs in 0.1% of patients. We present a case of LSG leak successfully managed with OverstitchTM endoscopic suturing system (OESS) and esophageal stent (ES) placement. Case Description/Methods: A 54-year-old man with HTN, DM and morbid obesity with one week status post LSG performed in a neighboring country presented to emergency room with diffuse abdominal pain, nausea, vomiting, and constipation since surgery. His BP was 106/72mmHg, HR was 125bpm, T was 97.8 F, WBC was 19.04 k/ul, and Hb was13.6 g/dL. CT abdomen showed large intraabdominal fluid collections. An LSG staple line leak was suspected. An NG tube was placed for decompression, antibiotics were begun, and he was taken for urgent diagnostic laparoscopy revealing large amount of intraperitoneal serosanguinous fluid. Gastric leak was confirmed, and multiple abdominal and pelvic drains were placed. Significant friable tissues prevented surgical repair of the leak. Total parenteral nutrition (TPN) was started. A week later GI service was consulted. EGD showed a 20 mm perforation along LSG staple line located 3cm below gastroesophageal junction (GEJ). Using OESS the defect was successfully closed followed by placement of a 23mmx155mm fully covered ES. Upper GI series (UGI) along with per oral methylene blue administration excluded leak. Naso-jejunal (NJ) feeding was then started and TPN was weaned off. Patient did well and discharged home. ES was removed at a follow up EGD in five weeks, and 2-3mm residual LSG staple line defect without contrast extravasation was identified and endoscopic suturing was repeated. NJ feeding was continued. UGI in 1 week showed no leak. NJ feeding was discontinued, and oral feeding was begun. Patient has been doing well since on subsequent follow up in the clinic. (Figure) Discussion: LSG is a popular bariatric procedure due to its simplicity and efficacy. But LSG leak can be fatal if not managed appropriately. Prompt surgical measures are the key steps. In unusually complicated cases as ours, multidisciplinary management brings a favorable outcome. Endoscopic closure of the LSG defect can be vital in source control when surgical measures fail. The success of endoscopic therapy depends on leak onset, with healing achieved in about 48.5% at one month to 73.6% at 6 months. In our case, OESS coupled with covered esophageal stent placement completely healed a large LSG defect.Figure 1.: (A) Endoscopic view of large LSG staple line defect that is in open communication with peritoneal cavity with pus, a drainage tube was seen in situ. Note healthy gastric mucosa (B) Total closure of the LSG staple line defect with OverstitchTM endoscopic suturing system (C) Stent fixation with OverstitchTM Endoscopic Suturing System (D) UGI shows no contrast extravasation, and black arrow points at the location of the endoscopic suture placement.

Anasua Deb: NO financial relationship with a commercial interest | Malak Faragallah: NO financial relationship with a commercial interest | Sebastian Sanchez: NO financial relationship with a commercial interest | Thanita Thongtan: NO financial relationship with a commercial interest | Marawan Elmassry: NO financial relationship with a commercial interest | Busara Songtanin: NO financial relationship with a commercial interest | Sameer Islam: NO financial relationship with a commercial interest

Over 17.7 million gastrointestinal (GI) endoscopic procedures are performed annually, contributing to 68% of all endoscopic procedures in the United States. Usually, endoscopic procedures are low risk, but adverse events may occur, including cardiopulmonary complications, bleeding, perforation, pancreatitis, cholangitis, and infection. Infections after the GI endoscopies most commonly result from the patient’s endogenous gut flora. Although many studies have reported infection after GI endoscopic procedures, a true estimate of the incidence rate of post-endoscopy infection is lacking. In addition, the infection profile and causative organisms have evolved over time. In recent times, multi-drug-resistant microorganisms have emerged as a cause of outbreaks of endoscope-associated infections (EAI). In addition, lapses in endoscope reprocessing have been reported, with some but not all outbreaks in recent times. This systematic review summarizes the demographical, clinical, and management data of EAI events reported in the literature. A total of 117 articles were included in the systematic review, with the majority reported from North America and Western Europe. The composite infection rate was calculated to be 0.2% following GI endoscopic procedures, 0.8% following ERCP, 0.123% following non-ERCP upper GI endoscopic procedures, and 0.073% following lower GI endoscopic procedures. Pseudomonas aeruginosa was the most common culprit organism, followed by other Enterobacteriaceae groups of organisms and Gram-positive cocci. We have also elaborated different prevention methods such as antimicrobial prophylaxis, adequate sterilization methods for reprocessing endoscopes, periodic surveillance, and current evidence supporting their utilization. Finally, we discuss disposable endoscopes, which could be an alternative to reprocessing to minimize the chances of EAIs with their effects on the environmental and financial situation.

The second most common human cancer in the United States is cutaneous squamous cell carcinoma (cSCC), 1 Rogers HW Weinstock MA Feldman SR Coldiron BM. Incidence estimate of nonmelanoma skin cancer (keratinocyte carcinomas) in the US Population, 2012. JAMA Dermatol. 2015; 151: 1081-1086 Crossref PubMed Scopus (1012) Google Scholar which can metastasize but is curable in most patients. Distant metastasis is observed in only 0.4% of cases 2 Schmults CD Karia PS Carter JB Han J Qureshi AA. Factors predictive of recurrence and death from cutaneous squamous cell carcinoma: a 10-year, single-institution cohort study. JAMA Dermatol. 2013; 149: 541-547 Crossref PubMed Scopus (341) Google Scholar involving the lungs, liver, brain, or bone. 3 Alam M Ratner D. Cutaneous squamous-cell carcinoma. N Engl J Med. 2001; 344: 975-983 Crossref PubMed Scopus (973) Google Scholar We report a rare case of cSCC that metastasized to the bilateral adrenal glands and the stomach causing adrenal insufficiency and occult gastrointestinal (GI) bleeding.

Collagenous gastritis is a rare cause of heartburn in adults. Histopathological examination of gastric mucosal biopsy from the stomach shows submucosal collagen deposition. The pathophysiologic mechanism is unknown, and collagenous gastritis cases have been associated with certain drugs, such as olmesartan and non-steroidal anti-inflammatory drugs, and certain medical conditions, such as common variable immunodeficiency, primary IgM deficiency, autoimmune disorders, and psoriatic arthropathy. Here we report a case of collagenous gastritis in a 29-year-old woman with psoriatic arthropathy who presented with persistent heartburn. She was successfully treated with oral pantoprazole. Key words: heartburn, collagenous gastritis,

Introduction: Recent progress in molecular biology and cancer genome research had opened a new venue for clinical research and changed treatment paradigm for metastatic colorectal cancer. Case Description/Methods: Case 1: A 61-year -old Hispanic male underwent colonoscopy which revealed an mass in the proximal ascending colon with biopsy showing moderately differentiated adenocarcinoma. The patient underwent a right hemicolectomy in 2012. He subsequently completed chemotherapy with mFOLFOX-6. Further treatment was declined by patient. Follow up chest CT scan in April 2018, uncovered progression of pulmonary nodules (Figure, Panel 1). Patient was put on FOLFIRI/bevacizumab chemotherapy. NGS study showed following results; MS stable; TMB 4 mutations/Mb (low); APCR1450, BRAF D594N, FAM 123B K761, SOX9 G225fs, and TP53 R175H.The patient has stable disease on follow up. Case 2: A 73-year-old Hispanic male underwent colonoscopy showing a obstructing mass in the sigmoid colon. Biopsy showed moderately differentiated adenocarcinoma in December 2013. Patient underwent sigmoidectomy. Liver masses were found on repeat CT abdomen. The NGS reported as follows; MS-Stable, TMB 1 muts/Mb(low), APC T282fs*12/P1453fs*20, CDK8 amplification, fms like tyrosine kinase 3 (FLT3) amplification, KRAS amplification and TP53 V147D. It also detected wild type KRAS mutations in exons 2, 3 and 4. The patient was started on chemotherapy with mFOLFOX. Follow- up studies show stable disease. Case 3: A 73-year-old Hispanic male underwent colonoscopy showed a completely obstructing mass in the sigmoid colon. Biopsy showed moderately differentiated adenocarcinoma in June 2012. The tumor cells have KRAS G12D mutation in in codon 12 of KRAS. He underwent a left hemicolectomy. He completed mFOLFOX6.PET scan was done and showed a right upper lobe mass consistent with metastatic cancer. He was started on FOLFIRI/ bevacizumab. NGS reported as follows; MS-Stable, TMB 1 muts/Mb(low), APC V1452fs*21, and ATM S47fs*11. Bone Scan intense uptake in the right distal tibia (Figure, Panel 2). MRI of the right lower extremity showed a lesion in the distal tibia. He was then switched to irinotecan and bevacizumab regimen. He has stable disease. Discussion: Identification of genomic signature is key to understanding the molecular mechanism of CRC and the development of novel therapeutics.Figure 1.: Panel 1 (left) shows CT Chest for Case 1 with multiple pulmonary nodules few with cavitation, largest 9mm. Panel 2 (right) shows Bone Scan for Case 3 in February 2021 with intense uptake in the right distal tibia.

Introduction: Stoma retraction resulting from inadequate mobilization of the colon is seen in 1-6% patients undergoing colostomy. It is usually managed by surgical revision. We discuss successful management of such a case unamenable to surgical revision by an esophageal stent placement. Case Description/Methods: A 36-year-old obese man with paraplegia from gunshot wound, stage 4 sacral decubitus ulcer, and urostomy tube placement presented to ER with fever, vomiting, diarrhea and infection of his sacral wound. He was diagnosed with osteomyelitis of the right ischium and inferior pubic ramus. To avoid fecal contamination of sacral wound, surgery created a diverting sigmoid loop colostomy which 5 days later retracted deep to the level of fascia along with gross fecal leakage through a fistulous track at the laparotomy site. A revision of the retracted colostomy was unsuccessful due to dense intra-abdominal adhesions. (Figure). Gastroenterologic evaluation with a colonoscopy through the stoma showed a moderately stenosed retracted colostomy with gross fecal leakage through mid-line wound. A 23 mm x 155 mm fully covered esophageal stent was then placed within the afferent loop (descending colon) of the colostomy to divert the fecal matter to colostomy bag. ( Figure). The outer end of the stent was sutured to abdominal wall skin. Following this, fecal leakage stopped completely through the mid line wound, and he was discharged home. Over the next 3 weeks, his course was complicated by an episode of external migration of the stent addressed with similar stent replacement followed by fixation of the inner end of stent to the colon wall using lassoes and resolution endo-clips, and the outer end to the abdominal wall skin with surgical sutures. He continues to do well as of today on a regular yet stent favorable diet along with a bowel regimen with Miralax producing a good stool output through colostomy, and to date, there was no fecal leakage through the mid line wound. Discussion: Stoma retraction is a common early post-colostomy complication often requiring months to heal with conservative management with frequent wound care. Surgical revision of retracted stoma or creation of an upstream stoma was not possible in our case due to dense adhesions. A covered esophageal stent was thus placed for the management of the retracted stoma with a favorable outcome thus far. Review of literature showed only one case using esophageal stent in similar clinical scenario with a successful clinical outcome.Figure 1.: A: Fecal contamination of mid-line wound through retracted colostomy, B: Esophageal stent placement in the afferent loop of the colostomy in progress, red rubber catheter at the site of retracted stoma placed by surgery during colostomy revision attempt, C: Stoma site following fully covered esophageal stent placement, D: Fluoroscopy image confirming esophageal stent placement, E: Midline wound free of fecal contamination 5 days after stent placement, F: Midline wound in 3 weeks after the stent placement.

Introduction: Morbidity and mortality rates of esophageal perforation are high. Treatment includes endoscopic, surgical, and conservative approaches. The OverStitchTM Endoscopic Suturing System (OESS) is a novel technique which has proved efficacious in treating an esophageal perforation. Case Description/Methods: A 91-year-old woman with past history of hypertension was transferred to our hospital with a retropharyngeal and mediastinum fluid collection concerning for esophageal perforation. The patient presented with shortness of breath and cough and was found to have right-sided pleural effusion. After chest tube placement, patient complained of dysphagia and reported aspiration. Computed tomography of the chest revealed a retropharyngeal abscess which was suspicious for esophageal perforation. Surgery performed an immediate left neck incision and drainage and placed a gastrostomy tube. A follow-up esophagram showed persistent leakage and gastroenterology was consult. Esophagogastroduodenoscopy revealed a 1cm perforation at the cricopharyngeal plane just above the upper esophageal sphincter. An OESS was performed, and she was kept n.p.o. with gastrostomy tube feeding. At a 17 day follow up, a repeat esophagram showed no evidence of contrast extravasation and the patient was doing well. Discussion: Esophageal perforation is a life-treathening condition and is a surgical emergency. Mortality rate can approach 60% with delays in treatment and can be reduced to 10-25% with immediate treatment. Death is cause by severe mediastinitis, empyema, or sepsis. The standard treatment is still controversial. Surgery remains mainstay of the treatment. In hemodynamically unstable patients, emergency airway should be established followed by primary closure and wide drainage. Non-operative management include volume resuscitation, respiratory supportive, and n.p.o. status. Endoscopic treatment include clips, stent, and suturing. The success of the repair depend on the extent of the nonviable tissue. In our patient, she has persistent leakage after drainage and underwent OverStitch closure. This case demonstrates the utility and efficacy of endoscopic suturing using OverStitch device to treat complicated esophageal perforation.Figure 1.: (A) EGD shows an esophageal perforation at the upper esophageal sphincter (UES) level (B) EGD shows an OverStitch suture in place.