Introduction: Esophageal lichen planus (ELP) is an under-reported and unusual cause of dysphagia in middle- to older-age women. Lichen planus is a chronic mucocutaneous disease affecting the skin, fingernails, and mucosal surfaces. We present a case of dysphagia and odynophagia due to esophageal stricture and ulceration due to ELP. Case Description/Methods: The patient is an 81-year-old woman who presented to the emergency department with dysphagia and substernal chest pain. She denied unintentional weight loss, regurgitations, nausea, or vomiting. She had a long history of chronic, non-progressive solid food dysphagia and required multiple esophageal dilatations. Upper endoscopy showed ulcerative friable esophageal mucosa with few exudates throughout, which sloughed off easily with insufflation. A stricture was seen at the distal esophagus, for which balloon dilatation was done up to 15 mm in a stepwise fashion. Esophageal biopsy showed active esophagitis with a ringed appearance, ulceration, necrotic debris, occasional dyskeratotic keratinocytes, and reactive squamous mucosa with band-like lymphocytic infiltrates consistent with a diagnosis of lichen planus. She required self-catheterization at home due to chronic retention of urine with chronic vaginal inflammation due to vaginal lichen planus. She also had oral lichen planus lesions. She was treated with budesonide suspension with significant improvement in dysphagia. Discussion: Esophageal lichen planus requires a high index of suspicion by clinicians to make a diagnosis based on patients’ endoscopic and histologic findings, especially in the case of atypical chronic esophagitis with the refractory and recurring stricturing disease in the context of cutaneous and/or oral and anogenital mucocutaneous lesions. Lichen planus often affects the entire esophagus, but the gastroesophageal junction is usually spared, and the proximal and mid-esophagus are involved with the superficial ulceration with exudates and the formation of strictures and rings. There is no established targeted therapy currently. Treatment to improve symptoms and histologic results includes topical steroids as the first-line therapy and immunosuppressant therapy for severe refractory disease. Risk of esophageal cancer is increased with ELP2, and regular endoscopic surveillance is suggested in case of dysplasia. Early diagnosis and treatment with a multidisciplinary approach are critical to this precancerous disease (see Figure 1).Figure 1.: Esophageal lichen planus.

Introduction: Colorectal cancer (CRC) is the second leading cause of cancer-related deaths amongst men and women together in the United States. Screening colonoscopies have been proven to reduce CRC mortality. However, the efficacy of colonoscopies can be hindered by poor bowel preparation due to poor visualization and a higher likelihood of missing polyps and other colonic lesions including CRC. Per ASGE, adenoma detection rate (ADR) for combined male and female population is 25%. This retrospective study aims to identify the ADR for patients with inadequate bowel preparation noted during colonoscopies at our institution to emphasize the importance of quality bowel preparation. Methods: During the years 2018-2020, a total of 250 inadequately prepared colonoscopies were examined at University of Louisville Hospital for our study. 28 colonoscopies were excluded due to being aborted prior to the procedure brown stool being present on exam. 14 colonoscopies did not have pathology reports and were also excluded. The study was a retrospective single-center cohort study reviewing risk factors in patients with inadequate bowel preparation noted during colonoscopy. A Boston Bowel Preparation Scale (BBPS) was used with score of < 6 (inadequate preparation) and ≥6 (adequate preparation). Results: This study specifically examined the adenomatous detection rate for patients with poor colonoscopy preparation. Of these, 27 patients with screening colonoscopy indications had adenomatous or high-risk polyps with an ADR of 10.8%. This was well below the ASGE quality indicator for ADR for screening colonoscopies. 18 non-screening colonoscopies had an ADR of 7.2%. Additionally, there was a total of 91 the patients who came back for repeat colonoscopy within a 3-year time span after having poor bowel preparation or aborted procedure initially. 2 patients were missing pathology reports and excluded. 29 patients were found to have adenomatous or high-risk polyps for a total of 32.5% of patients with repeat colonoscopy who initially had poor bowel preparation or aborted procedure. Conclusion: Having a BBPS score of 5 or less considerably decreased ADR compared to ASGE standards. It is critically important that patients who have poor bowel prep return for repeat colonoscopy due to high risk of missing adenomatous or high-risk polyps as shown by the follow-up data. ADR is far below the endoscopist expectation without adequate bowel preparation in both screening and non-screening colonoscopies.

Introduction: Patients with a history of splenectomy have a higher prevalence of infections with encapsulated organisms due to decreased phagocytic activity and humoral response. One such rare organism is Raoultella ornithinolytica, a Gram-negative bacillus commonly found in the aquatic environment. Here we present a rare case of this bacterium causing liver abscess. Case Description/Methods: A 72-year-old female with a history of hypertension, hyperlipidemia, and splenectomy (secondary to abdominal trauma) presented after being found down. She complained of a recent history of diarrhea 2 days ago. Blood pressure was 80/60 mmHg and temperature was 101 degrees F at presentation. She was found to have elevated liver enzymes and Klebsiella oxytoca bacteremia (found on Verigene multiplex PCR testing) and was started on broad-spectrum antibiotics. CT of the abdomen in the emergency room revealed a 3x2x5 cm hypodense lesion in the left lobe of the liver. She underwent ultrasound-guided removal of 35 cc dark brown colored fluid, which was positive by culture for Raoultella ornithinolytica. Her antibiotics were narrowed to cefazolin, and the infection was thought to be related to recent diarrhea (of unknown etiology) resulting in intestinal mucosal damage leading to translocation of the bacterium across the intestinal wall into the liver. Of note, on high specificity microbiological testing using matrix assisted desorption-time of flight (MALDI-Tof) technology, the organism recovered from the blood was confirmed to be Raoultella ornithinolytica. Discussion: Incidence of Raoultella ornithinolytica infection has been on the rise in the past decade, and our patient is the second reported case of Raoultella ornithinolytica liver abscess. In humans, it usually causes skin flushing, vomiting, diarrhea, and headache. While the first case, as reported by Surani et al in 2020, had a long-standing liver cyst that was thought to be infected with Raoultella ornithinolytica, our patient did not have any nidus in the liver that could harbor this bacterium. However, she had a history of splenectomy, possibly putting her at higher risk of infection with encapsulated bacteria. In addition, Raoultella ornithinolytica is closely related to Klebsiella oxytoca, but is not recognized in the multiplex PCR database which accounts for the discrepancy in initial identification as seen in our case. Our case adds to the growing literature regarding Raoultella ornithinolytica as an increasing virulent pathogen in humans.

Introduction: Impedance planimetry endoscopically assesses tissue wall distensibility by pressure and cross-sectional area and assesses dynamic muscle and passive wall properties in the GI tract. Pyloric Functional Luminal Imaging Probe (pFLIP) may reveal many abnormalities in pts. with the symptoms (Sx) of gastroparesis (Gp) . We hypothesized that pts. with Gp Sx may have anatomic and physiologic abnormalities of the stomach and/or pylorus in pts. with both delayed and non-delayed gastric emptying (GE). Methods: We evaluated 69 pts. with a history of Gp who underwent a pFLIP. Pts. had baseline and follow-up measures of GI Sx by a traditional FDA compliant patient reported outcomes (TradPRO) pre and post temporary gastric electrical stimulation placement. All pts. underwent EGGs, mucosal and serosal EGs, proximal/liquid and distal/solid gastric emptying (GET) and underwent bio-electric TGES for provocative effects on proximal and distal gastric function over at least 5-days. Most pts. underwent full thickness gastric biopsies during subsequent GES placement and tissue samples were analyzed by neuromuscular stains. At a later date, pts. underwent pyloric function compliance measurements by pFLIP. Pyloric distensibility values at 40 cc volume distension were analyzed. Results were compared by t-tests and correlations using ‘R’ statistical software. Results: Distensibility Index (DI) 40cc was higher in the non-delayed group (5.1 vs. 5.6). CD 4 and CD 8 values were lower in the delayed GE group (0.8 and 1.0), respectively. S100 (neural fiber cells) were lower in the delayed GE group in both inner and outer muscle layers (8.0, 4.4 respectively). CD117/ Cajal cells were also lower in the delayed GE group (2.0, 1.0). Cutaneous EGG amplitude (by manual and computerized analysis) negatively correlated with gastric emptying and frequency amplitude ratio (FAR) had a positive correlation with GE. Conclusion: In this group of pts. with Gp symptoms, we found several differences in gastric microscopic anatomy and upper GI Sx responses between pts. with delayed vs. non-delayed gastric emptying. Distensibility index, at 40cc baloon volume, was often abnormal in the non-delayed GE group, which implies FLIP measurement might be useful irrespective of gastric emptying results. Using various measurement techniques, along with baseline symptoms, anatomy, and physiologic testing abnormities, may allow for more rational therapeutic plans for pts. with Gp.Table 1.: Correlations and Comparisons of FLIP with Gastric Emptying.

Introduction: Hemosuccus pancreaticus (HP) occurs when there is bleeding from the pancreatic duct through the Ampulla of Vater into the small intestine. This syndrome is typically seen in patients 32-36 years old with a history of chronic pancreatitis, pancreatic tumors, or pancreatic pseudocysts. Patients present with abdominal pain, gastrointestinal (GI) bleeding, and high amylase levels. Here, a case is presented demonstrating HP secondary to a pseudoaneurysm in the gastroduodenal or pancreaticoduodenal arterial branches. Case Description/Methods: A 39-year-old female with a history of May Thurner Syndrome, on anticoagulation, chronic pancreatitis, and alcohol use disorder with a chief complaint of hematemesis. On presentation, she endorsed abdominal pain and generalized weakness. She had a blood pressure of 83/60 and heart rate of 123 beats per minute. She had guarding and diffuse tenderness to palpation on physical exam. CT abdomen and pelvis was concerning for hemorrhagic pancreatitis. She had a hemoglobin of 10.7 g/dl and a platelet count of 91,000. Three days after admission, she developed melena and an acute hemoglobin drop to 7.4 g/dl. She had a CT angiogram which revealed a large pseudoaneurysm centered near the head and neck of the pancreas. Hyperdense clots and induration surrounded the pseudoaneurysm, suggesting active or chronic bleeding. Interventional radiology (IR) successfully performed urgent embolization of the area distal to the gastroduodenal pseudoaneurysm. She stabilized after IR embolization, with no further episodes of GI bleeding. Discussion: This patient was diagnosed with HP via CT angiogram. The etiology was secondary to erosion of the pseudoaneurysm in the gastroduodenal or pancreaticoduodenal arteries located in the head and neck of the pancreas which led to bleeding into the pancreatic duct through the Ampulla of Vater. This is a rare cause of HP with approximately 6-17% incidence of intracystic bleeding in the setting of chronic pancreatitis. IR procedures such as coil embolization, stent graphing, and balloon tamponade are first line therapy with coil embolization being preferred with an overall 67% success rate. Due to coil embolization being performed with complete resolution of GI bleeding, her case is most consistent with HP. When diagnosing HP, it is imperative to stress urgency in treatment of these patients as bleeding is unlikely to stop without procedural or surgical intervention and heralds a 9.6% mortality rate.

Introduction: Leser-Trelat sign, characterized by a sudden-onset explosion of seborrheic keratoses, is a rare cutaneous paraneoplastic syndrome indicative of an internal malignancy, most commonly rectal, gastric, and colon cancers, with gastric being the most frequent. We present a case of Leser-Trelat sign in the setting of no known malignancy and a periampullary tubulovillous adenoma. Case Description/Methods: Patient is a 77-year-old male with atrial fibrillation (on Apixaban), moderate cognitive impairment, type II diabetes, 57 pack-year smoking history, and prostate cancer (s/p resection in 2009) who presented with low energy, loss of appetite and a 20-pound unintentional weight loss over 1 month. On exam, he did not have any signs of overt bleeding, however, he had periumbilical hyperpigmented ill-defined patches and numerous diffuse warty hyperpigmented lesions throughout his back. Patient was uncertain how long the periumbilical darkening had been present; however, he stated that the lesions on his back developed suddenly 1 year ago. His labs on admission were notable with a hemoglobin of 4.8 (10.6 two months ago) and ferritin of 17. EGD and subsequent endoscopic ultrasound with fine needle aspiration showed a 3 cm non-bleeding, fungating periampullary duodenal mass consistent with a tubulovillous adenoma. Discussion: Patient presented with iron deficiency anemia, unintentional weight loss, Leser-Trelat sign, and acanthosis nigricans. This was concerning for a malignancy, however only a benign periampullary duodenal tubulovillous adenoma was found. Colonoscopy, CMP, CXR, SPEP and UPEP were normal. Patient is planning complete his malignancy and iron deficiency work-up with an outpatient CT scan and capsule endoscopy. Although further work-up is imperative to fully exclude a cancer given these classic malignancy associated skin findings, if no malignancy is found, this may be the first case of a tubulovillous adenoma demonstrating Leser-Trelat sign and acanthosis nigricans.Figure 1.: Leser-Trelat Sign.