Introduction: Cancers most commonly metastasize to the lymph nodes, liver, and lungs. Metastases to the hollow gastrointestinal tract (HGIM) are rare but can present at the time of primary diagnosis or many years later. HGIM often presents with non-specific symptoms and variable endoscopic manifestations that require tissue biopsy with histologic confirmation, which can potentially delay definite diagnosis and treatment. We report a case series of 5 patients from a single center who were diagnosed with HGIM from different primary tumor locations. Case Description/Methods: We describe 5 patients with HGIM diagnosed by endoscopy at a single tertiary care center. Patient charts were reviewed for age of diagnosis, gender, type of primary tumor, ages at which the primary tumor and metastatic GI sites were found, symptoms of HGIM, and endoscopic findings. Each patient had a different primary tumor site – breast, lung, prostate, bile duct and bladder. At the time of diagnosis of HGIM, 3 patients had abdominal pain, 3 patients had decreased appetite, 1 patient had worsening anemia and 1 patient had intermittent rectal bleeding (Table 1). Three patients had died, succumbing to their metastatic cancers; 60% were women. The mean age at diagnosis of the primary tumor was 56.8 ± 5.0 years, and the mean age at diagnosis of HGIM was 59.0 ± 5.2 years. The duodenum and colon were the most common sites of HGIM (40% each), followed by the stomach (20%) (Figure 1). The average interval between the initial diagnosis of cancer and a diagnosis of HGIM was just over 2 years; all the patients had known cancer prior to endoscopy. Discussion: The most common extra-abdominal tumors reported to metastasize to the GI tract are lung and breast cancers, with 4.7%-14% and 8%-35% of cases respectively. Two point five percent of prostate cancers metastasize to the GI tract. Only 7 cases of colonic metastases from cholangiocarcinoma have been described in the literature. Only about 16 cases of bladder metastasis to the GI tract have been reported. Although rare, GI metastasis should be considered for any patient with an underlying cancer diagnosis who presents with GI symptoms, even if non-specific. Given the increased survival of cancer patients with current therapeutic regimes, it is anticipated that there will be an increased occurrence of unusual presentations of metastatic disease, including involvement of the GI tract. Recognizing the range of possible presentations is important for early diagnosis and treatment.Figure 1.: Endoscopic images of 5 cases of HGIM. A) Case 1; B) Case 2; C) Case 3; D) Case 4; E) Case 5. Table 1. - Patient characteristics of 5 cases of HGIM Case Primary tumor site Gender Age of primary tumor diagnosis GI symptoms Site of gastrointestinal metastasis Age of gastrointestinal metastasis diagnosis #1 Breast Woman 57 Epigastric pain, decreased appetite Body of stomach 59 #2 Prostate Man 57 Worsening anemia Duodenum 62 #3 Bladder Woman 63 Abdominal pain, decreased appetite Duodenum 63 #4 Lung Man 58 Abdominal pain, decreased appetite Proximal transverse colon 61 #5 Bile duct Woman 49 Intermittent rectal bleeding Sigmoid colon 50

Introduction: H. pylori is 1 of the most common chronic bacterial infections worldwide affecting approximately 30-40% of the US population. Left untreated, infection can result in ulcers and malignancy. Data on local antibiotic resistance trends is scarce and the ACG has identified a need to document and survey local antibiotic resistance patterns to better guide treatment. This study seeks to investigate the H. pylori cure rates (CR) of various treatment regimens among our institution’s inner-city patient population in the Bronx, NY, comprised of majority Hispanic and Black patients, and determine if CR is affected by ethnicity, preferred language, and/or zip code to potentially tailor individualized treatment plans. Methods: The study was conducted retrospectively with IRB approval. Inclusion criteria included adults diagnosed with H. pylori via stool antigen testing, treated at our institution, with subsequent follow up testing. Patients without record of treatment, documented non-adherence, or those without follow up testing were excluded. Data from 2016-2023 were reviewed. Results: Of the 3,470 patients included, 52% were Hispanic and 20% were Black. 36% of patients listed Spanish as their preferred language, and another 8% listed their preferred language as 1 other than English. Overall, clarithromycin based triple and concomitant therapies had significantly higher CR than other regimens, with 84% and 88% of patients cured respectively (P < 0.01). Bismuth based quadruple therapy had a CR of 75% and other regimens had CRs ranging from 33-73%. There were no statistically significant differences in CR among any ethnicity, preferred language, or zip code. Furthermore, there was no significant change in the CR of any regimen over the period of 2016 to 2023. Conclusion: Among our inner-city population, clarithromycin based regimens were most successful at curing H. pylori. Despite the increasing concerns of clarithromycin resistance in the US, it may still be a preferred treatment option in some populations, possibly due to better insurance coverage, tolerability, or increased adherence. Further research is needed to determine what factors contributed to its higher CR among our patients. CRs in our community have not significantly changed over the last 7 years, indicating that resistance patterns have likely been relatively stable. It is reassuring that CR did not differ by ethnicity, preferred language, or zip code, indicating that our patients are receiving equal care despite potential barriers (Table 1). Table 1. - Cure rates by antibiotic regimen Antibiotic Regimen Cure Rate with 95% CI (P < 0.0001) Clarithromycin based triple therapy 0.84 (0.82, 0.85) Clarithromycin based concomitant therapy 0.88 (0.77, 0.95) Bismuth based quadruple therapy 0.75 (0.71, 0.78) Levofloxacintriple therapy 0.61 (0.54, 0.68) Rifabutin tripletherapy 0.73 (0.39, 0.94) High dose amoxicillin therapy 0.33 (0.04, 0.78)

Introduction: Screening colonoscopy is routinely performed in patients undergoing evaluation for left ventricular assist device (LVAD) implantation. However, current guidelines are inconsistent and there is limited data demonstrating the necessity of pre-LVAD colonoscopy in this comorbid population who carry increased procedural risk. Methods: In this single center retrospective cohort study, we reviewed the charts of all patients who underwent LVAD implantation at Montefiore Medical Center in the Bronx, NY from 1/2019 to 8/2022, comparing the clinical outcomes of those who underwent pre-LVAD colonoscopy vs those who had no form of screening. Inclusion criteria were defined as: adults with end-stage heart failure undergoing evaluation for LVAD. Pediatric patients and those with incomplete electronic medical records were excluded. The primary outcome of our study was the prevalence of malignant and premalignant lesions in patients who underwent screening. The secondary outcomes included post-colonoscopy complications, comparison of post-LVAD GIB rates in both groups, and whether history of pre-LVAD GIB, pre-existing endoscopic findings, or post-LVAD method of anticoagulation had any significant correlation with GI bleeding rates. Results: 96 patient charts were reviewed, of whom 43 were identified to have undergone pre-LVAD colonoscopy, 49 had no screening, and 4 were excluded. Of the patients who underwent pre-LVAD colonoscopy, 20 underwent polypectomy with pathology yielding 0% malignancy, 4% villous or tubulovillous adenoma, 64% tubular adenoma, 4% inflammatory, and 28% hyperplastic. No angioectasias or bleeding lesions were found. Of the 43 who underwent screening, 8 developed an AKI (18%) and 13 suffered from post-LVAD GI bleeding complications (8 Upper GIB, 3 Lower GIB, 2 unclear source), resulting in 1 patient death. Of the 49 who did not undergo screening, 8 had post-LVAD GI bleeding (3 Upper GIB, 2 Lower GIB, 3 unclear source), also resulting in 1 patient death. The difference in bleeding rates was not statistically significant. Conclusion: Our study suggests that screening colonoscopy prior to LVAD may not be necessary as the diagnostic yield (premalignant lesions) was low and it did not significantly reduce rates of GI bleeding post-implant. Further studies comparing colonoscopy to noninvasive screening methods such as FIT testing or CT colonography would be helpful to inform if the latter can be pursued as a safer alternative.

Introduction: Mucormycosis is a highly invasive disease caused by fungi in the Mucorales order. Cases of gastrointestinal mucormycosis have been rising over the past few decades. We present a case of gastric mucormycosis found on endoscopic evaluation. Case Description/Methods: We present a 57-year-old man with hypertension and type I diabetes mellitus who had a dual kidney and pancreas transplant one week prior to presentation. After starting immunosuppressive therapy, he was found to have persistent abdominal pain and vomiting in the setting of a new leukocytosis and fever. After undergoing a CT of the abdomen and pelvis, gastric pneumatosis was seen (Figure 1). An esophagogastroduodenoscopy was done, showing necrotic-appearing mucosa of the stomach. Biopsies showed Mucormycosis. Patient’s immunosuppression, except glucocorticoids, were discontinued, and he was immediately started on amphotericin B liposomal. Two weeks later, the patient’s course was complicated by hematemesis. He underwent a laparoscopic total gastrectomy with Roux-en-Y esophagojejunostomy. Intra-operatively, he was noted to have a contained perforation of the stomach fundus. Histologic examination of the resected stomach showed mucormycosis with necrosis. Discussion: Gastrointestinal mucormycosis is rare with the stomach being the most common site of infection, which carries a high mortality rate. In our patient, the most likely cause was his immunosuppressive state after organ transplantation. Mucormycosis’ high mortality rate is attributed to its tendency to invade endothelial cells of the vascular system. Due to non-specific symptoms, diagnosis is often delayed. Amphotericin B is the mainstay of medical therapy for mucormycosis, but it can be inadequate due to poor penetration of antifungal agents at the sites of infection. Surgical intervention with medical therapy increases the survival rate. Although there are no existing studies that correlate timing of surgery and mortality, there are case reports that support early surgical intervention. In conclusion, mucormycosis carries a high morbidity and mortality. Thus, there should be a lower threshold for aggressive diagnostic evaluation, including endoscopy, when appropriate. In addition, treatment of mucormycosis should involve a combination of both antifungal therapy and surgery to improve survival. Further studies are needed to improve management of gastric mucormycosis, including the optimal timing of surgical intervention.Figure 1.: A. Non-contrast CT scan of the abdomen showing gastric emphysema. B. Endoscopic image of the gastric cardia showing necrosis. C. Endoscopic image of the gastric body showing necrosis. D. Endoscopic image of the gastric antrum that shows necrosis in the distal antrum and sparing of the prepyloric region.

A 56-year-old West African man presented with a 50-pound weight loss over three months and three days of right lower quadrant abdominal pain. His physical exam was notable for abdominal distention, mild abdominal tenderness, lungs that were clear to auscultation, and a lack of stigmata of chronic liver disease. Computerized tomography (CT) demonstrated moderate ascites, diffuse peritoneal enhancement and nodularity, and no pulmonary disease. Paracentesis showed exudative fluid with a serum albumin-to-ascites gradient of 0.6 and lymphocyte predominance, prompting concern for tubercular peritonitis. Beyond nationality, no further risk factor for Mycobacterium tuberculosis could be identified. Further questioning revealed that he had consumed unpasteurized goat milk at a farm in Guinea, raising suspicion for Mycobacterium bovis. A laparoscopic peritoneal biopsy showed mesothelial lined fibrous and adipose tissue with focally caseating granulomas. Although culture with Ziehl-Neelsen stain of the ascites fluid was negative, he was treated with two months of rifampin, isoniazid, pyrazinamide, and ethambutol, followed by an empiric isoniazid and rifampin course for M. bovis that was lengthened given presumed pyrazinamide resistance. After four months of therapy, the patient reports significant improvement in his symptoms. Only 2% of extrapulmonary disease affects the peritoneum, and only 3.1% of patients with mycobacterial disease are infected with M. bovis. M. bovis is transmitted to humans mainly through the consumption of unpasteurized milk. In industrialized nations M. bovis is almost nonexistent due to strict regulations. Symptoms are non-specific; vague abdominal pain and distention are common complaints. Peritoneal culture with Ziehl-Neelsen is positive in only 3% of confirmed cases of mycobacterial peritonitis. Therefore, laparoscopy is preferred; histopathology findings of granulomas with caseating necrosis are diagnostic of mycobacterial peritonitis. Routine diagnostic modalities often cannot differentiate between M. bovis and M. tuberculosis when cultures are negative. Despite the many similarities among M. bovis and M. tuberculosis, it is important to note that treatment is longer and prognosis is worse for M. bovis. This case reminds us of the diagnostic challenge of mycobacterial peritonitis and the importance of considering M. bovis, especially in patients presenting from endemic areas.

Introduction: Ulcerative colitis (UC) is characterized by a bimodal age distribution, with the majority of patients presenting between the 2nd and 4th decade of life and about 10% of patients presenting after the age of 65. While cases presenting in the 8th decade of life are extremely rare, there have been no reported cases for UC initial presentation after the age of 90. Recent literature reported that elderly-onset inflammatory bowel disease (IBD) is relatively mild with considerably little need for biologics. Methods: NA. Results: Case Description: A 92 year-old Caucasian woman was transferred to our tertiary center for severe, unremitting diarrhea of 3 weeks duration. The patient had no history of digestive disorders until 3 months before this admission when she presented to another institution with symptoms of diarrhea and her ileocolonoscopy at that time was consistent with UC. She was treated with mesalamine enemas without a satisfactory clinical response. Consequently, oral corticosteroids were started followed by multiple failed attempts to taper. On transfer to our facility the patient reported bloody diarrhea (6-8 times/day) without abdominal pain or fever. Her medical history was also significant for osteoporosis and deep venous thrombosis. Her vital signs were normal and her physical examination was unremarkable. Her laboratory findings revealed C-reactive protein of 7.3 mg/dl, erythrocyte sedimentation rate of 22 mm/hr and leukocytosis with left shift. Infectious work up was negative. Abdominal CT was consistent with pancolitis. Flexible sigmoidoscopy showed nodular, erythematous, and friable mucosa with microulcerations and spontaneous bleeding, consistent with severe UC. The patient was maintained on intravenous methylprednisone and was started on high-dose oral mesalamine but without significant improvement. Given the patient's persistent symptoms, escalation to Infliximab was pursued. Within a week, the diarrhea resolved but the patient was diagnosed with pulmonary aspergillosis. The patient was subsequently discharged with oral antifungal, prednisone taper, and oral mesalamine. The patient did not follow up after discharge. Conclusion: UC can present as late as the ninth decade of life with our current case being the latest onset of UC reported to date. Elderly-onset IBD can be severe and a special caution with steroids and biologics is warranted given the high risk of severe infections in this age group.Figure 1

Purpose: Dyspepsia is an upper abdominal symptom that includes bloating, early satiety, fullness, nausea and vomiting. Nuclear testing of gastric emptying is often done to evaluate patients with dyspepsia, some of whom are then diagnosed with gastroparesis. However, nuclear results can vary in degree and severity. We studied patients with dyspepsia and attempted to correlate patterns of dynamics of gastric emptying with dyspeptic symptoms. Methods: We evaluated patients with dyspepsia who had an abnormal parameter during the standard gastric emptying study. The T1/2 (the time when half of the meal has exited the stomach) and 4 hour nuclear retention values were recorded. The degrees of abnormalities for each parameter were categorized according to the table below. Nuclear studies were categorized as having early and/or late delay. Symptoms were grouped into predominant complaints of bloating, nausea/vomiting, refractory heartburn and other (i.e., early satiety and discomfort after eating). Concordant results are defined as a similar degree of delay at T1/2 and 4 hours. Discordant results are defined as varying degrees of delay at T1/2 and 4 hours. Results: Seventy patient charts were reviewed (87% female; 13% male). Predominant symptoms were bloating (53%), nausea/vomiting (28%), refractory heartburn (9%) and other (10%). Twenty-nine patients had discordant results with a predominantly abnormal T1/2 and improvement at 4 hours. In these, symptoms were bloating (62%), nausea/vomiting (21%) (p-value 0.01), refractory heartburn (10%) and other (7%). Eight patients had discordant results with a predominantly abnormal 4 hour delay as compared to their T1/2 value. Symptoms were bloating (37%) and nausea/vomiting (63%) (p value 0.5). Thirty-three patients had similar abnormalities at T1/2 and 4 hours. Symptoms were bloating (48%), nausea/vomiting (27%), refractory heartburn (10%) and other (15%). Conclusion: Patients with dyspepsia may have varied abnormal parameters of gastric emptying. Patients with a more predominant initial delay (as measured by T1/2 compared to 4 hour retention) were more likely to complain of bloating, and patients with a predominant late delay were more likely to complain of nausea/vomiting. Correlating dyspeptic symptoms with the dynamic function of gastric emptying may add insight into the physiologic associations with these dyspeptic symptoms. Further studies need to be done to evaluate this discordance.Table: Degrees of abnormality