Alpha heavy chain disease (alpha HCD) is a rare variant of the mucosa-associated lymphoid tissue lymphoma characterized by expression of a monotypic truncated immunoglobulin alpha heavy chain. alpha HCD frequently involves the gastrointestinal (GI) tract, and its pathogenesis has been linked to clonal B-cell expansion from chronic immune stimulation by infectious agents. We report a rare case of GI alpha HCD with 5 concomitant pathogens identified on a GI multiplex real-time polymerase chain reaction panel, featured by persistent Campylobacter jejuni colonization and refractory giardiasis.

Cyclic vomiting syndrome (CVS) is a functional gastrointestinal disorder which leads to multiple hospitalizations and causes significant impairment of quality of life. Cannabis use is common in patients with CVS, and there are limited data on the national trends in the prevalence of its use in the United States.

BACKGROUND:Ineffective esophageal motility (IEM) is defined as a distal contractile integral < 450 mmHg/s/cm in at least 50% of ten liquid swallows on high-resolution esophageal manometry (HREM). Whether this latest definition correlates with degree of symptoms has not been studied. METHODS:Patients presenting for HREM prospectively rated their symptoms using the Eckardt score. Topography plots were retrospectively reviewed and classified according to the latest Chicago Classification. Patients with non-obstructive dysphagia and an Eckardt score of at least 1 were included. Patients with major motility disorders were excluded. Scores between patients with IEM (group A) and patients with normal classification (group B) were compared using two-tailed t-tests. Spearman's correlation coefficient was calculated to determine correlation between symptoms and percent bolus clearance. RESULTS:A total of 241 patients were screened; 33 patients met criteria for group A and 44 patients for group B. There was no difference between the two groups in mean symptom severity for dysphagia (1.63 vs. 1.61, P = 0.89), chest pain (0.67 vs. 0.75, P = 0.64), regurgitation (1.06 vs. 0.85, P = 0.32), or weight loss (0.85 vs. 0.49, P = 0.11). The percent bolus clearance was significantly lower in group A (46.5% vs. 76.7%, P > 0.01). There was a moderate inverse correlation between dysphagia and percent bolus clearance (R = - 0.37) in group A, but none in group B (R = 0.09). CONCLUSION:The classification of IEM did not discriminate from normal studies for symptom severity in our cohort. However, patients with IEM did have an inverse correlation between dysphagia score and bolus clearance, but those without IEM did not. Adding impedance information to the motor pattern classification should be considered in the symptom assessment in minor motility disorders.

Background and aims Cannabinoids are increasingly used for medicinal purposes, including neuropathy. Gastroparesis is a neuromuscular disorder and neuropathy plays a large role in its pathogenesis. It is thus reasonable that cannabinoids can serve a beneficial role in the management of gastroparesis. Our study evaluates the effect of cannabinoids on gastroparesis symptoms. Methods Twenty-four (n=24) patients with gastroparesis and refractory symptoms were selected from a single gastroenterology practice associated with a tertiary care medical center. The 'Gastroparesis Cardinal Symptom Index' (GCSI) and an analog scale rating abdominal pain were applied to prospectively assess the effect of cannabinoids, in the form of dronabinol and medical cannabis, on refractory gastroparesis symptoms. Patients completed a GCSI form and rated their abdominal pain, before and after treatment. There was a minimum of 60 days of cannabinoid use between reporting intervals. Total composite GCSI symptom scores, GCSI symptom subset scores, and abdominal pain scores were calculated before and after treatment. Results A significant improvement in the GCSI total symptom composite score was seen with either cannabinoid treatment (mean score difference of 12.8, 95% confidence interval 10.4-15.2; p-value < 0. 001). Patients prescribed marijuana experienced a statistically significant improvement in every GCSI symptom subgroup. Significant improvement in abdominal pain score was also seen with either cannabinoid treatment (mean score difference of 1.6; p-value < 0.001). Conclusions Cannabinoids dramatically improve the symptoms of gastroparesis. Furthermore, an improvement in abdominal pain with cannabinoids represents a breakthrough for gastroparesis-associated abdominal pain treatment, for which there are currently no validated therapies.

Introduction: Higher volume of endoscopic procedures by a provider may impact quality of colonoscopy. Adenoma detection rate (ADR) among primarily endoscopists has been reportedly 10% higher than of non-endoscopists. We performed a retrospective, single institution study to assess differences in colonoscopy quality indicators between gastroenterologists and transplant hepatologists. Methods: Data was collected from colonoscopies performed at Westchester Medical Center between Jan 1, 2017 and Dec 31, 2017. Patients with documented familial adenomatous polyposis, Lynch syndrome, BRCA1 gene mutation, inflammatory bowel disease or gastrointestinal bleeding were excluded. We studied patient demographics age, gender and race, indication for colonoscopy, particulars of the performing physician and adequacy of bowel preparation were also documented. Results: We collected data from 623 colonoscopies performed by 6 gastroenterologists (N=559) and 2 transplant hepatologists (N=64). 48.6% (N= 303) were performed for average risk screening and 31.9% (N=199) were performed due to prior history of colon polyps<./p>Mean number of years since graduation from GI fellowship was 17.5 years for hepatologists and 21.5 years for primary gastroenterologists. Likelihood of adenoma removal was higher for gastroenterologists (35.2%) than hepatologists (31.3%, Table 1). For screening colonoscopies, the difference in ADR between gastroenterologists (33.6%) and hepatologists (18.8%) was more pronounced but not statistically significant. Unadjusted odds ratio for adenoma removal among gastroenterologists was 2.192 for screening colonoscopies and 1.197 for all colonoscopies. Gastroenterologists (all colonoscopies: 89.8%, screening colonoscopies: 88.2%) were significantly more likely to have adequate bowel preparation than hepatologists (all colonoscopies: 73.4%, screening colonoscopies: 71.9%). Conclusion: Gastroenterologists had a trend toward higher ADR and significantly higher likelihood of adequate bowel preparation compared to transplant hepatologists. It is possible that hepatologists' patients were sicker, leading to a desire to minimize sedation time and defer removal of small adenomas due to underlying bleeding risk. Furthermore, there is data to suggest that patients with advanced liver disease are more likely to have inadequate bowel preparation. Hepatologists may wish to prescribe additional medication for bowel preparation and support staff can improve the quality of bowel prep by optimizing patient education.1120_A Figure 1. Comparing proportions of adenoma detection among attendings1120_B Figure 2. Comparison of proportions of adequate bowel prep among attendings1120_C Figure 3. Unadjusted odds ratio associated with adenoma detection for physician characteristic

Introduction: Neuropathy plays a large role in the pathogenesis of gastroparesis. Neuropathic pain in gastroparesis is an often difficult—to—treat symptom of the disease, despite 80—90% of patients with gastroparesis reporting abdominal pain as a symptom. Treatment for gastroparesis—related pain is especially limited. Neuromodulators are used for this purpose despite a lack of evidence supporting their effectiveness. Cannabinoids, primarily delta—9—tetrahydrocannabinol (THC) and cannabidiol (CBD), are increasingly utilized for medicinal purposes. In New York medical marijuana is approved for the treatment of neuropathy with severe pain. Similarly, Dronabinol (a synthetic THC analogue) has been used for nausea vomiting and anorexia for years. We showed that cannabinoids are effective in the treatment of gastroparesis—related abdominal pain. Methods: The effects of prescribed cannabinoids on gastroparesis symptoms were assessed in 24 patients (Table 1, baseline characteristics). All patients' symptoms were refractory to standard therapies for gastroparesis. Patients were prescribed either Dronabinol, medical cannabis, or both for symptom management. Patients who received both treatments were prescribed them sequentially (Dronabinol then marijuana) if Dronabinol did not adequately relieve symptoms. Medical marijuana was prescribed as needed at varying THC: CBD ratios and was taken via vaporized inhalation or sublingual drops. Dosage of Dronabinol ranged from 2—10mg twice daily to four times daily. Patients filled out a ‘Gastroparesis Cardinal Symptom Index’ (GCSI) questionnaire before and after treatment. Additionally, patients rated their abdominal pain before and after cannabinoid use, using a 1—5 analog scale. Results: Six patients were prescribed Dronabinol, ten were prescribed marijuana and eight were prescribed Dronabinol followed by marijuana. Paired sample T—tests were performed and statistically significant improvement in abdominal pain score was seen in patients who received either cannabinoid treatment. When analyzed individually, both marijuana and Dronabinol showed statistically significant improvement in abdominal pain scores as well (Table 2, Figure 1).1204_A Figure 1. Baseline patient characteristics.Conclusion: Our study shows that cannabinoids may play an important role in the management of gastroparesis—related abdominal pain. There are currently no treatments shown to be effective for gastroparetic pain in clinical trials, and cannabinoids may serve a niche for this under—treated symptom.1204_B Figure 2. Paired sample t—tests and differences of the mean for abdominal pain analog score before and after cannabinoid treatment.1204_C Figure 3. Comparison of abdominal pain scores pre— and post— cannabinoid treatment. Results are shown for marijuana alone, Dronabinol alone and for any cannabinoid (either marijuana or Dronabinol).

Introduction: Cannabinoids, primarily delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD), are increasingly used for medical purposes. Medical marijuana is approved in New York for the treatment of neuropathy with severe nausea or pain. Neuropathy plays a large role in the pathogenesis of gastroparesis, a neuromuscular disorder of delayed gastric emptying. Dronabinol, a THC analogue, is used for nausea, vomiting and anorexia in HIV and cancer, and has been used for symptom management in gastroparesis. We previously demonstrated that both Dronabinol and medical marijuana dramatically improve symptoms of gastroparesis. We compared the difference in symptom improvement between medical marijuana and Dronabinol. Methods: The effects of cannabinoids on gastroparesis symptoms were assessed in 24 patients. All patients' symptoms were refractory to standard therapies. Patients were prescribed either Dronabinol, medical cannabis, or both for symptom management. Those who received both treatments were prescribed them sequentially (Dronabinol then marijuana) if Dronabinol did not adequately relieve symptoms. Marijuana was prescribed as needed at varying THC: CBD ratios and taken via vaporized inhalation or sublingual drops. Dosage of Dronabinol ranged from 2-10mg twice daily to four times daily. Patients filled out a ‘Gastroparesis Cardinal Symptom Index’ (GCSI) form before and after treatment, and rated their abdominal pain before and after treatment using a 1-5 analog scale. Results: Six patients were prescribed Dronabinol, ten were prescribed marijuana and eight were prescribed Dronabinol then marijuana (baseline characteristics, Table 1). Pre- and post-treatment GCSI and abdominal pain scores were compared and unpaired sample t-tests were performed. Marijuana was superior to Dronabinol in improving all symptoms, with statistical significance seen in abdominal pain score (mean difference from baseline score in marijuana group 2.167 and mean difference from baseline score in Dronabinol group 0.929; p-value 0.007) and total symptom composite score (includes GCSI composite score and abdominal pain score; mean difference from baseline score in marijuana group 16.778 and mean difference from baseline score in Dronabinol group 11.429; p-value 0.036) [Table 2, Figure 1].2894_A Figure 1. Baseline patient characteristics.Conclusion: While both cannabinoid therapies dramatically improve gastroparesis symptoms, our analysis shows that marijuana is superior to Dronabinol, especially for improvement of abdominal pain and overall symptoms.2894_B Figure 2. Differences in composite symptom score and symptom subset scores before and after treatment with marijuana and Dronabinol. Unpaired sample t-tests were performed to assess differences in symptom improvement between the two groups. Statistical significance considered if p-value < 0.05.2894_C Figure 3. Comparing mean differences for each symptom category and total symptom composite score between marijuana and Dronabinol groups.

Introduction: We investigated incidence of gastric cancer after H.pylori eradication in patients with long-term administration of low-dose aspirin (LDA). Methods: The subjects were 101 consecutive outpatients attending the Cardiovascular Department and who had been on LDA therapy for at least 3 months from February 2007 to December 2008. Average age was 67.2 ± 8.3, male/ female ratio was 3.8:1. Firstly all patients were conducted esophagogastroduodenoscopy (EGD) and 13CUrea breath test. H.pyloripositive patients were received eradication treatment. After eradication all patients were received periodic EGD. Results: H.pylori positive was 55cases and negative 46 cases. We detected 4 cases early gastric cancer, detection rate was very high (3.96%). All gastric cancer patients were H.pyloripositive and advanced endoscopic atrophy. We performed H.pylori eradication 41 cases. Afterword we detected 3 cases early gastric cancer, detection rate was also high (6.52%). Interestingly the periods from eradication of H.pylori to detection of gastric cancer was longer (average: 80 month) than that of previous reports in non-LDA users (within 60 month). Total taking LDA period was also very long (average: 184 month). Conclusion: LDA does not prevent from incidence of gastric cancer after H.pylorieradication. But it is possible that taking LDA delay the growth of gastric cancer after H.pylori eradication.

Introduction: Cannabinoids, primarily delta—9—tetrahydrocannabinol (THC) and cannabidiol (CBD), are increasingly used for medicinal purposes. Dronabinol, a THC analogue, is used for nausea, vomiting and anorexia in HIV and cancer. Medical marijuana in New York is permitted to treat neuropathy with severe nausea. Gastroparesis is a neuromuscular disorder that causes many difficult—to—treat symptoms. Neuropathy plays a large role in its pathogenesis. We showed that cannabinoids significantly improve symptoms in patients with refractory gastroparesis. Methods: The effects of cannabinoids on gastroparesis symptoms were assessed in 24 patients. All patients' symptoms were refractory to standard therapies for gastroparesis including dietary modification, medications (prokinetics, antiemetics, neuromodulators), endoscopic therapy, and some patients had gastric stimulators. Patients were prescribed either Dronabinol, medical cannabis, or both for symptom management. Patients who received both treatments were prescribed them sequentially (Dronabinol then marijuana) if Dronabinol did not adequately relieve symptoms. Medical marijuana was taken via vaporized inhalation or sublingual drops and prescribed as needed at varying THC: CBD ratios. Dosage of Dronabinol ranged from 2—10mg twice daily to four times daily. All patients completed a ‘Gastroparesis Cardinal Symptom Index’ (GCSI), a validated symptom index for gastroparesis, before and after treatment. Results: Six patients were prescribed Dronabinol, ten were prescribed marijuana and eight were prescribed Dronabinol then marijuana. Baseline patient characteristics were collected (Table 1). Paired sample T—tests were performed and statistically significant improvement in GCSI total symptom composite score was seen in patients who received either cannabinoid treatment (mean score difference of 14.097, CI 11.487—16.707; p—value < 0.001). Patients prescribed marijuana experienced statistically significant improvement in every symptom subgroup, while the Dronabinol group experienced statistically significant improvement in all symptom subgroups except ‘bloating/distention’ (Table 2, Figure 1).1203_A Figure 1. Patient baseline characteristicsConclusion: Our study shows that cannabinoids significantly improve symptoms of gastroparesis, which is a notoriously difficult condition to manage. Therapeutic options for gastroparesis are limited, so cannabinoids can play an important role in the treatment of the condition, especially in patients with refractory symptoms.1203_B Figure 2. Paired sample T—tests and differences of the mean for composite symptom score and symptom subgroup scores before and after cannabinoid treatment [abbreviations: SD = Standard Deviation; SER = Standard Error of Mean]1203_C Figure 3. Comparison of composite symptom score and symptom subgroup scores before and after cannabinoid treatment (either marijuana or Dronabinol), marijuana treatment alone, and Dronabinol treatment alone

Introduction: It has been reported in the literature that gastroenterology fellow involvement during colonoscopy improves the adenoma detection rate (ADR), thus improving quality of colon cancer screening. [2, 3] We performed a review of colonoscopy procedures at a single teaching hospital to compare fellow adenoma removal percentages with those reported in the literature. [1, 3] Methods: We performed a retrospective chart analysis of the electronic medical record and collected data from colonoscopies performed between January 1, 2017 and December 31, 2017. Patients with documented familial adenomatous polyposis, Lynch syndrome, BRCA1 gene mutation, inflammatory bowel disease or gastrointestinal bleeding were excluded. We studied patient demographics, age, gender, race, indication for colonoscopy, particulars of the performing attending, fellow participation and adequacy of bowel prep were also documented. Results: We collected data from 623 colonoscopies performed at our institution. Out of total 623 colonoscopies, 48.6% (N= 303) were performed for average risk screening and 31.9% (N=199) were performed due to history of colon polyps. The next most common indications were family history of colon cancer (N=55) and personal history of colon cancer (N=21). Mean age of the cohort was 60.6 years. Approximately half (N=313) of the patients were female. The cohort was 60.5% white, 17% black, 15.9% Hispanic and 4% Asian. Fellows were involved in 54.4% (N=176) of colonoscopies included in this study. For screening colonoscopies, ADR for colonoscopies without a fellow was 26%, which improved to 30.8% with first year fellows, 32.7% with second year fellows, 40.0% with third year fellows (Table 1). For 6 out of 8 attendings, ADR improved with involvement of a fellow.Unadjusted odds ratio for adenoma detection during screening colonoscopy was highest when the attending was accompanied by a third year fellow. The odds ratio was lowest when attendings performed colonoscopy without any fellows on the case. Conclusion: Involvement of a gastroenterology fellow in screening colonoscopies significantly increased ADR, hence improving overall quality of colorectal cancer screening. Further studies are needed to assess other outcomes associated with fellow involvement, such as withdrawal time and duration of anesthesia administration.492_A Figure 1. Proportion of adenoma removal by fellow training year.492_B Figure 2. Unadjusted Odds Ratio associated with adenoma detection rate for the fellow involvement.492_C Figure 3. Comparing adenoma detection rate with and without fellow for each attending.

Introduction: Gastroparesis is a debilitating disorder defined as delayed gastric emptying in the absence of a mechanical obstruction. Ehler Danlos syndrome (EDS) as a cause of gastroparesis is not well established in the literature. Prevalence of type III or hypermobility EDS is estimated to be 1 in 5000 people. We report a case of new diagnosis of EDS in a patient with severe gastroparesis. Case presentation: 35 year old woman with past history of obesity status post intentional weight loss presented to our center for evaluation of recurrent nausea, vomiting, diarrhea and abdominal pain. Review of systems was positive for joint hypermobility. Patient had multiple admissions over the past ten years for similar symptoms. Multiple studies including CT scans, MRI and endoscopic procedures were reportedly normal. Normal vital signs. Physical examination revealed a young female in no distress with soft abdomen, non tender and normal bowel sounds. Lab values are within normal parameters. Gastric emptying study showed 44.3% activity in the stomach four hours of procedure. Hospital course complicated by prolonged stay and failure of multiple medications like tricyclic antidepressants, lyrica and Gabapentin. Patient was parenteral nutrition dependent, underwent J tube placement. She tolerated J tube feeds subsequently discharged home. Genetic evaluation revealed EDS type III disorder. Arnold chiari malformation with high intracranial pressure was diagnosed for chronic headaches and underwent neurosurgical intervention. Currently patient is doing well on J tube feedings, symptoms well controlled on erythromycin, medical marijuana, zofran and benadryl. Discussion: EDS can present with both structural problems such as hiatus hernias, visceroptosis, rectoceles, and rectal prolapse as well as functional problems. Grahame et al described that the gastrointestinal symptoms of nausea, abdominal pain, constipation diarrhea is significantly more compared to age and sex matched controls (37% vs. 11%). Our patient was misdiagnosed with Munchausen syndrome and was never enquired of joint hypermobility. The diagnosis of EDS type III in this thirty five year old patient changed the outlook of the physicians from drug seeking behavior or munchausen syndrome to administering appropriate therapy for severe gastroparesis. Hence we propose that genetic testing should be considered in idiopathic gastroparesis with severe debilitating symptoms and joint hypermobility to rule out EDS.

Introduction: Adenoma detection rate (ADR) has been widely accepted by gastroenterologists as a surrogate measure of colon cancer screening quality of care. Previous studies have shown a strong inverse correlation between ADR and risk of colorectal cancer. We performed a single teaching institution analysis to assess differences in patient and physician-related factors and their association with ADR. Methods: We performed a retrospective chart analysis, collecting data from colonoscopies performed at Westchester Medical Center between January 1, 2017 and December 31, 2017. Patients with documented familial adenomatous polyposis, Lynch syndrome, BRCA1 gene mutation, inflammatory bowel disease or gastrointestinal bleeding were excluded. We studied patient demographics, age, gender and race, indication for colonoscopy, particulars of the performing attending and adequacy of bowel preparation. Results: We collected data from 623 colonoscopies performed by 6 gastroenterologists (N=559, 89.8%) and 2 transplant hepatologists (N=64, 10.2%). 48.6% (N= 303) were performed for average risk screening and 31.9% (N=199) were performed due to prior history of colon polyps. Mean age of the cohort was 60.6 yrs and half (N=313) of the patients were female. Out of 623 procedures, one or more adenomas were removed in 34.8% (N=217). Among 303 screening colonoscopies the ADR was 32% (N=97). Overall 88.1% of colonoscopies had adequate bowel prep. When comparing different attendings, ADR for the two hepatologists was 21.4% and 16.7%. Men were significantly more likely to have adenomas removed compared with women (40.3% vs 29.4%, p=0.006). There was a strong positive correlation between years of attending experience (calculated number of years since graduation from gastroenterology fellowship) and ADR with Pearson correlation value of 0.849 (p=0.008). Graphical presentation has been shown with a scatterplot Image 1. We performed a multivariable regression analysis and adjusted for age, gender, race, fellow involvement on the case and adequacy of bowel preparation (Table 1). Adequate bowel prep was the strongest factor associated with adenoma detection. Conclusion: ADR has a positive correlation with gastroenterologist years of experience. Gastroenterologists outperformed hepatologists in ADR and adequacy of bowel prep. Improving the quality of bowel prep would most likely increase ADR and boost quality of colon cancer screening249_A Figure 1. Scatter plot presenting relation between years of attending experience and adenoma detection rate249_B Figure 2. Multivariable regression analysis of clinical factors associated adenoma removal.

Cytomegalovirus (CMV)-induced pseudotumors, or mass-like lesions in the colon, are a rare entity. We report a case of CMV-related spindle cell pseudotumor in an immunocompetent patient with a left ventricular assist device. This case highlights the importance of considering CMV-induced inflammatory pseudotumor when evaluating tumorous lesions in the colon, as well as the importance of appropriate diagnostic work-up, including proper biopsy technique and meticulous review of the pathology.

Gastrointestinal (GI) tuberculosis (TB) is rare and can occur in the context of active pulmonary disease or as a primary infection with no pulmonary symptoms. It typically presents with vague abdominal symptoms, making it difficult to discern from alternative disease processes. Although the ileocecal region is the most commonly affected site, tuberculous enteritis can involve any aspect of the GI tract. To demonstrate the importance of maintaining a high clinical suspicion for the disease, we present a case of GI TB presenting as severe malnutrition and segmental colitis of the left colon.

Ulcerative jejunoileitis (UJ) is a rare condition that is difficult to diagnose and treat. We present a case of steroid-responsive UJ. A 62-year-old female presented with 3.5 months of diarrhea, abdominal pain, and pedal edema. Prior workup included an unremarkable EGD and colonoscopy (with unremarkable biopsies), and non-diagnostic MR enterography. Symptoms did not respond to a gluten-free diet. Physical examination revealed bibasilar crackles and anasarca. Laboratory results revealed a serum albumin of 1.4 g/dl and low immunoglobulin levels. Stool studies showed negative bacterial and acid-fast cultures, ova and parasites, helicobacter pylori antigen and C. Difficile toxin. Stool alpha-1-antitrypsin was elevated at 960mg/dl. Serum studies were negative for ESR, CRP, HIV, ANA, ANCA, tTG, CMV, Anti-Saccharomyces Cerevisiae IgA and IgG. Serum and urine protein electrophoresis was normal. Small bowel capsule endoscopy showed small bowel erosions and denuded villi. Push enteroscopy revealed patchy jejunal erythema, erosions and absent or mosaic-appearing villi. Jejunal biopsies showed focal partial villous blunting with loss of brush border without granulomas or dysplasia. T. whipplei PCR was negative. Prednisone 60mg by mouth daily was started, which led to resolution of her symptoms and improvement of her albumin. UJ is likely T-cell mediated and characterized by small bowel ulcerations and villous atrophy. Patients present with non-specific gastrointestinal complaints and signs of malabsorption or protein-losing enteropathy. It is highly associated with Celiac disease. Differential diagnosis includes Celiac and tropical sprue, Crohn's disease, lymphoma, infections, and infiltrative and rheumatologic disorders. Laboratory tests and biopsies ruled out these conditions in our patient. All imaging was negative prior to capsule endoscopy. Literature on UJ is scarce and limited to case series and reports. UJ is typically refractory to treatments including prednisone, azathioprine, cyclosporine, biologic agents and chemotherapy. Even after initial treatment success, the relapse rate is high- 90% in one case series. Prognosis is poor with up to 33% mortality rate within three years. Our patient represents a rare diagnosis of UJ and a rare case of steroid-responsiveness. Further research into the pathophysiology and treatment of this poorly understood and difficult-to-treat condition is warranted.Figure: Image demonstrating normal esophagus, gastroesophageal (GE) junction and stomach on push enteroscopy.Figure: Image demonstrating jejunal mucosa with erythema and erosions, seen on push enteroscopy.Figure: Microscopic examination of the small intestine demonstrating blunting of villi.

Background:The data pertaining to esophageal acid exposure during multichannel intraluminal impedance-pH testing (MII-pH) may be analyzed by using all pH drops (simulating traditional pH-monitoring) or analyzing only pH drops associated with impedance changes.It is unknown whether the acid exposure measurements would differ between these methods in a group of symptomatic patients. Methods:We retrospectively evaluated MII-pH studies of patients from 2008 to 2013.Studies were re-analyzed so that acid measurements were obtained in two methods: 1. Creating nonmealtime pH measurements related to retrograde impedance changes/bolus movements ("pH-MII method") 2. Creating non-mealtime pH measurements anytime the pH fell below 4 regardless of impedance changes ("all-pH method").Statistical analysis was performed using ttest, Fischer's test, and logistic regression.Results: 121 patients were eligible.The mean percent total acid exposure time (4.05) was significantly higher in the all-pH method (vs.1.63, p=0.001).The proportion of patients with abnormal acid exposure time (24.7%) and DeMeester score (24.8%) was higher in the all-pH method (vs.8.3%, p=0.001; vs. 9.1%, p=0.002).Compared to those without a hiatal hernia (HH), more patients with a HH >2cm had significant differences between analysis methods in upright (19.4% vs. 5.56%, p=0.03), recumbent (29% vs. 6.67%;p=0.002), total time (45.2% vs. 6.67%,p=0.001), and DeMeester score (35.5% vs. 8.89%; p=0.001).Adjusting for age, sex, and PPI usage, HH remained a significant predictor of whether results would differ (OR 12; OR 8.75;. Conclusion:Analysis of esophageal acid exposure using all pH data detected more acid reflux than when incorporating impedance measures, particularly in those with a HH.This finding may

Controlled mechanical ventilation (CMV) plays a key role in triggering the impaired diaphragm muscle function and the concomitant delayed weaning from the respirator in critically ill intensive care unit (ICU) patients. To date, experimental and clinical studies have primarily focused on early effects on the diaphragm by CMV, or at specific time points. To improve our understanding of the mechanisms underlying the impaired diaphragm muscle function in response to mechanical ventilation, we have performed time-resolved analyses between 6h and 14days using an experimental rat ICU model allowing detailed studies of the diaphragm in response to long-term CMV. A rapid and early decline in maximum muscle fibre force and preceding muscle fibre atrophy was observed in the diaphragm in response to CMV, resulting in an 85% reduction in residual diaphragm fibre function after 9-14days of CMV. A modest loss of contractile proteins was observed and linked to an early activation of the ubiquitin proteasome pathway, myosin:actin ratios were not affected and the transcriptional regulation of myosin isoforms did not show any dramatic changes during the observation period. Furthermore, small angle X-ray diffraction analyses demonstrate that myosin can bind to actin in an ATP-dependent manner even after 9-14days of exposure to CMV. Thus, quantitative changes in muscle fibre size and contractile proteins are not the dominating factors underlying the dramatic decline in diaphragm muscle function in response to CMV, in contrast to earlier observations in limb muscles. The observed early loss of subsarcolemmal neuronal nitric oxide synthase activity, onset of oxidative stress, intracellular lipid accumulation and post-translational protein modifications strongly argue for significant qualitative changes in contractile proteins causing the severely impaired residual function in diaphragm fibres after long-term mechanical ventilation. For the first time, the present study demonstrates novel changes in the diaphragm structure/function and underlying mechanisms at the gene, protein and cellular levels in response to CMV at a high temporal resolution ranging from 6h to 14days.

Introduction: Evaluation for gastrointestinal (GI) bleeding occurs on a daily basis. We present a rare case of a life threatening bleed.Figure 1: (A) Bleeding through the papilla of Vater. (B) Pseudoaneurysm in the distal gastroduodenal artery. (C) Embolization of pseudoaneurysm.Case Report: 64-year-old man with history of vascular disease s/p multiple stents, hypertension, and alcoholic pancreatitis presented for catheterization due to vascular complaints. He was found to have a hemoglobin of 6.9 mg/dl. He reported intermittent hematemesis and melena for the last 6 months. On exam, he was in mild distress, heart rate 100 bpm, BP 123/56 mmHg, with epigastric tenderness. Other labs were normal except for a lipase of 675 U/L. EGD was normal except for pooled blood in the second portion of the duodenum. A side viewing endoscope showed blood emerging from the ampulla interspersed with bile. Angiography revealed a pseudoaneurysm of the gastroduodenal artery. The diagnosis was consistent with hemosuccus pancreaticus (HP). He underwent successful embolization. MRI revealed chronic pancreatitis. Discussion: HP is defined as GI bleed via the pancreatic duct. It’s a rare cause of bleeding with ˜100 cases reported. Most common causes are acute and chronic pancreatitis. Tumors, vascular disease, iatrogenic, congenital anomalies, infections, and trauma are rare causes. The pathophysiology is related to pseudoaneurysm formation due to auto-digestion into the peri-pancreatic vessels. The pseudoaneurysm communicates with the pancreatic duct through the pseudocyst or a fistula. Once bleeding occurs, the blood coagulates and obstructs the duct. This leads to increase pressure temporarily tamponading the hemorrhage. As the clot dissolves, hemorrhage recurs, resulting in intermittent bleeding. Patients may present with abdominal pain, GI bleeding and/or hyperamylasemia. Prompt angiography and treatment with angiographic embolization of pseudoaneurysms or surgery is warranted to control bleeding. Failure to recognize and treat HP is associated with mortality up to 90%, declining to 8-37% with treatment. Conclusion: HP should be considered in all patients with a history of pancreatic disease and severe GI bleeding when routine endoscopic findings are non-diagnostic.