Background and study aims Peroral endoscopic myotomy (POEM) is increasingly being used as the preferred treatment option for achalasia. The aim of this systematic review and meta-analysis was to compare the efficacy and safety of POEM versus pneumatic balloon dilation (PD). Methods We performed a comprehensive review of studies that reported clinical outcomes of POEM and PD for the treatment of achalasia. Measured outcomes included clinical success (improvement of symptoms based on a validated scale including an Eckardt score ≤ 3), adverse events, and post-treatment gastroesophageal reflux disease (GERD). Results Sixty-six studies (6268 patients) were included in the final analysis, of which 29 studies (2919 patients) reported on POEM and 33 studies (3050 patients) reported on PD and 4 studies (299 patients) compared POEM versus PD. Clinical success with POEM was superior to PD at 12, 24, and 36 months (92.9 %, vs 76.9 % P = 0.001; 90.6 % vs 74.8 %, P = 0.004; 88.4 % vs 72.2 %, P = 0.006, respectively). POEM was superior to PD in type I, II and III achalasia (92.7 % vs 61 %, P = 0.01; 92.3 % vs 80.3 %, P = 0.01; 92.3 %v 41.9 %, P = 0.01 respectively) Pooled OR of clinical success at 12 and 24 months were significantly higher with POEM (8.97; P = 0.001 & 5.64; P = 0.006). Pooled OR of GERD was significantly higher with POEM (by symptoms: 2.95, P = 0.02 and by endoscopic findings: 6.98, P = 0.001). Rates of esophageal perforation (0.3 % vs 0.6 %, P = 0.8) and significant bleeding (0.4 % vs 0.7 %, P = 0.56) were comparable between POEM and PD groups. Conclusions POEM is more efficacious than PD in the treatment of patients with achalasia during short-term and long-term follow-up, albeit with higher risk of abnormal esophageal acid exposure.

BACKGROUND:The "remission theory" is an emerging concept that suggests the presence of human immunodeficiency virus (HIV) results in decreased disease severity in patients with inflammatory bowel disease. This theory is based upon evidence that implicates CD4 T-lymphocytes in the pathogenesis of both Crohn's disease and ulcerative colitis. This study sought to elucidate the legitimacy of this theory.METHODS:A retrospective cohort analysis of all adult inpatient hospitalizations for inflammatory bowel disease (IBD) using the 2016 National Inpatient Sample (NIS) was conducted. Our study population included patients admitted with IBD who were infected with HIV. We compared our study group to patients who also had IBD but were not infected with HIV. Baseline demographic characteristics, resource utilization, and in-hospital mortality rates were extracted for both groups.RESULTS:A total of 58,979 patients were admitted for IBD in 2016. Of those patients, we identified 145 who also had the presence of HIV. We found that patients with ulcerative colitis and HIV had a shorter length of hospital stay (4.1 vs. 5.9 days, p-value < 0.01), lower hospital charge ($35,716 vs $52,893, p-value < 0.01), and lower hospital cost ($7,814 vs. $13,395, p-value < 0.01) than those who did not have HIV. In patients with Crohn's disease, the presence of HIV resulted in decreased colonoscopy rates (0% vs. 17.4%, p-value < 0.01); however, the rate of esophagogastroduodenoscopies was not statistically significant (7.1% vs. 14.7%, p-value 0.106).CONCLUSION:In this retrospective population-based study, we found that patients with ulcerative colitis and concurrent HIV had a milder course of the disease when compared to ulcerative colitis patients that were not infected with HIV. These findings support the remission theory in that HIV may play a role in inflammatory bowel disease.

Goals/Background: Hemospray is a new hemostatic powder recently approved for endoscopic hemostasis in gastrointestinal (GI) bleeding. Data are limited in terms of its clinical outcomes, and its role in the treatment algorithm of GI bleeds. We conducted a systematic review and meta-analysis to study the clinical performance of Hemospray in the management of GI bleeding. Study: We searched multiple databases from inception through March 2019 to identify studies that reported on the clinical outcomes of Hemospray in GI bleeding. The primary outcome was pooled rates of clinical success after the application of Hemospray in GI bleeding. The secondary outcomes were pooled rebleeding rates and adverse events after use of Hemospray. Results: A total of 19 studies, 814 patients, of which 212 patients were treated with Hemospray as monotherapy, and 602 patients were treated with Hemospray with conventional hemostatic techniques. Overall pooled clinical success after the application of Hemospray was 92% [95% confidence interval (95% CI), 87%-96%; I (2)=70.4%]. Overall pooled early rebleeding rates after application of Hemospray was 20% (95% CI, 16%-26%; I (2)=54%). Overall pooled delayed rebleeding rates after the application of Hemospray was 23% (95% CI, 16%-31%; I (2)=34.9%). There was no statistical difference in clinical success (RR, 1.02; 95% CI, 0.96-1.08; P=0.34) and early rebleeding (RR, 0.89; 95% CI, 0.75-1.07; P=0.214) in studies that compared the use of Hemospray as monotherapy versus combination therapy with conventional therapy. Conclusions: Hemospray is highly effective in achieving immediate hemostasis in gastrointestinal bleeding. However, due to significantly high rebleeding rates, Hemospray is not suited for definitive long-term therapy.

BACKGROUND:Ischemic colitis (IC) occurs when the blood supply of the large intestine becomes compromised. Several cardiovascular conditions, such as coronary artery disease, congestive heart failure, and atrial fibrillation, are well-established risk factors for the development of IC. The effects of pulmonary conditions, namely chronic obstructive pulmonary disease (COPD), on IC have not been well studied.AIMS:Our aim was to elucidate if the presence of COPD worsened outcomes in patients with IC.METHODS:Retrospective analysis of patients hospitalized with IC in 2016 was evaluated using the National Inpatient Sample database. Baseline demographic data, length of hospital stay (LOS), total hospital cost/charge, rates of colectomy, and in-hospital mortality were extracted from the database. Categorical variables were compared using the chi-square test and continuous variables were compared using the t-test.RESULTS:A total of 25,035 patients with IC were identified while 4482 of these patients also had COPD. We found that IC patients with COPD had a longer LOS (5.8 days vs 4.4 days; P<0.01), higher total hospital charge ($56,682 vs $42,365; P<0.01), higher total hospital cost ($13,603 vs $10,238; P<0.01), higher mortality rate (6.5% vs 3.1%; P<0.01), and higher colectomy rate (5.1% vs 3.7%; P<0.01).CONCLUSIONS:The presence of COPD portends poor outcomes in patients with IC. This was evidenced by increased risk of death and increased risk of undergoing colectomy. Given these findings, patients with COPD warrant closer observation. We advocate that COPD be considered as part of the risk assessment of patients with acute IC who need surgical intervention.

INTRODUCTION: Intramural duodenal hematoma (IDH) is an unusual presentation after blunt abdominal trauma. IDH rarely leads to gastric outlet obstruction (GOO), acute pancreatitis, obstructive cholestasis, and gastrointestinal hemorrhage. We report first case of delayed presentation of large IDH associated with acute pancreatitis and GOO four months after abdominal trauma. CASE DESCRIPTION/METHODS: A 53-year-old man with history of diabetes mellitus, alcohol use disorder presented with upper abdominal pain, nausea and vomiting of 2 days duration. Reports fall on to the edge of bathtub and hitting his abdomen 4 months ago. Abdominal exam revealed a non-tender palpable mass in the epigastrium. Labs were significant for elevated AST-214, ALT-63, ALP- 218, lipase-419, and CA 19-9 -377.8. A CT scan of Abdomen showed a large duodenal intramural mass without enhancement and upstream GOO, which is new compared to prior CT scan done a year ago for other reasons. An MRI of the abdomen showed a large heterogeneous duodenal filling defect, with no internal enhancement likely representing a hematoma (Figure 1). Patient underwent EGD and Endoscopic ultrasound(EUS) that showed a submucosal duodenal mass occupying the entire lumen of the duodenum (Figure 2). FNA showed many inflammatory and necrotic cells and was non-diagnostic. Patient had persistent obstruction despite one week of conservative therapy with Nasogastric decompression and TPN (Figure 3). He underwent surgical hematoma evacuation with a feeding jejunostomy tube placement and was discharged on post-operative day 7 after tolerating oral feeds, normalization of lipase and LFTs. DISCUSSION: Most cases of IDH are secondary to blunt abdominal trauma. Spontaneous IDH occurs in patients with bleeding disorders, anticoagulation therapy, vascular collagen diseases, or after invasive endoscopic procedures. IDH is more frequent among children. Due to its anatomic location and high submucosal vascularity distal duodenum is the most common site involved. Symptomatic patients present with GOO symptoms. Compression of the ampulla or pancreatobiliary ducts can cause acute pancreatitis and obstructive jaundice. Cross sectional imaging aids in diagnosis and to evaluate for complications such as perforation or retroperitoneal hemorrhage. EGD and EUS are helpful when imaging is inconclusive. Most patients improve with conservative management by 1 week. Surgical, image guided or endoscopic drainage is needed in patients who fail conservative management or develop complications.Figure 1.: A: CT scan of abdomen showing large heterogeneous filling defect ( arrow) extending from 1st to 3rd portion of duodenum, measuring at least 13 cm × 5.6 cm resulting in upstream gastric outlet obstruction, as evidenced by distended stomach and contrast not passing in to small bowel. B: MRI of abdomen- Post contrast subtraction films showing large heterogenous filling defect (arrow) with no internal enhancement, likely representing a hematoma.Figure 2.: A: ESD showing large 4-5 cm smooth, subepithelial duodenal mass involving the bulb and the duodenal sweep occupying 99% of the lumen of the duodenum. B: -Linear EUS imaging showing a 37.2 mm × 60.5 mm subepithelial lesion in the duodenal bulb. Due to local inflammation and the large size of the lesion, the layers of the duodenum could not be well defined.Figure 3.: Upper Gastrointestinal series showing filling defect in the lateral aspect of the duodenum with a narrow trail of contrast coursing in the residual medial lumen at 1 week of conservative therapy.

Goals/Background: Hemospray is a new hemostatic powder recently approved for endoscopic hemostasis in gastrointestinal (GI) bleeding. Data are limited in terms of its clinical outcomes, and its role in the treatment algorithm of GI bleeds. We conducted a systematic review and meta-analysis to study the clinical performance of Hemospray in the management of GI bleeding. Study: We searched multiple databases from inception through March 2019 to identify studies that reported on the clinical outcomes of Hemospray in GI bleeding. The primary outcome was pooled rates of clinical success after the application of Hemospray in GI bleeding. The secondary outcomes were pooled rebleeding rates and adverse events after use of Hemospray. Results: A total of 19 studies, 814 patients, of which 212 patients were treated with Hemospray as monotherapy, and 602 patients were treated with Hemospray with conventional hemostatic techniques. Overall pooled clinical success after the application of Hemospray was 92% [95% confidence interval (95% CI), 87%-96%; I 2=70.4%]. Overall pooled early rebleeding rates after application of Hemospray was 20% (95% CI, 16%-26%; I 2=54%). Overall pooled delayed rebleeding rates after the application of Hemospray was 23% (95% CI, 16%-31%; I 2=34.9%). There was no statistical difference in clinical success (RR, 1.02; 95% CI, 0.96-1.08; P=0.34) and early rebleeding (RR, 0.89; 95% CI, 0.75-1.07; P=0.214) in studies that compared the use of Hemospray as monotherapy versus combination therapy with conventional therapy. Conclusions: Hemospray is highly effective in achieving immediate hemostasis in gastrointestinal bleeding. However, due to significantly high rebleeding rates, Hemospray is not suited for definitive long-term therapy.

INTRODUCTION: Sarcoidosis is an immune mediated multisystem chronic granulomatous disease that affects almost every tissue in the body. Involvement of the gastrointestinal(GI)tract is rare and seen in about 5–10% of the patients with sarcoidosis. The stomach is the most common site in the GIT. We report a case of diffuse GI tract involvement which is rarely reported in literature. CASE DESCRIPTION/METHODS: A 47-year-old African American man with history of pulmonary and lymphatic sarcoidosis (not on treatment) was evaluated for chronic abdominal pain and watery diarrhea with 25 pounds weight loss in the last 6 months. Physical exam was significant for mild diffuse abdominal tenderness. Extensive stool workup, autoimmune workup including ANA, ASCA, ANCA and Quantiferon gold were negative. ACE levels were normal. Recent CT scan of the abdomen that was performed 3 months prior to presentation showed wall thickening of multiple loops of small bowel and retroperitoneal lymph nodes >1 cm (Figure 1). Colonoscopy showed diffuse moderate inflammation extending from sigmoid colon to Ileocecal valve (Figure 2). Random biopsies from colon and terminal ileum showed non-caseous granuloma formation and villous flattening (Figure 3). He was diagnosed with GI sarcoidosis after infectious and other autoimmune causes of granulomatous disease were excluded. He is planned to start oral steroids given his symptoms and systemic involvement. DISCUSSION: Sarcoidosis of the GI tract can occur in patients with known disease as well as patients who have no history of the diagnosis. It is more frequent in African- Americans and has a predilection towards young women. Clinically symptomatic disease occurs in less than 1% of patients. According to the area of GI tract involvement, symptoms can include GERD, abdominal pain, gastroparesis, chronic diarrhea, weight loss, gastrointestinal hemorrhage, stricture or obstruction. Cross sectional imaging and endoscopic findings are nonspecific and can overlap with other diseases. The characteristic histologic presence of non-caseating granulomas in the absence of other autoimmune, infectious, malignant causes confirms the diagnosis. Asymptomatic or mild symptoms do not need treatment. Immunosuppressants are required if significant symptoms and complications occur. Surgical intervention is required for management of stricture, intestinal obstruction and intussusception. ACE levels are helpful to check for response to therapy, relapse, and disease course.Figure 1.: A- Frontal view of CT abdomen showing thickened loops of small bowel in left upper quadrant. B- Axial views of CT abdomen showing a 2.8 × 1.3 cm enlarged lymph node and splenomegaly.Figure 2.: A, B, C: Colonoscopy views showing diffuse moderate inflammation characterized by congestion (edema), erythema, friability, granularity, and nodularity/pseudo polyps in entire colon extending from sigmoid colon to Ileocecal valve.Figure 3.: A: Terminal ileum biopsy- H&E stain, 40X showing small bowel mucosa with mild active chronic ileitis, flattened villous pattern and noncaseating microgranuloma formation. B: Immunohistochemical stain with CD68 reveal scattered and few small clusters of histiocytes.

INTRODUCTION: Opioids, one of the potent yet addictive pain management tools, are often prescribed in Inflammatory Bowel Disease (IBD). It is important to reassess the prevalence of opioids use among IBD patients. We conducted a retrospective study to assess the trends of opioid use (OU) among hospitalized IBD patients in the US from the year 1998 to 2014. We also identified factors associated with opioid use in this patient population. METHODS: We utilized the Nationwide Inpatient Sample database from the year 1998 to 2014. Adult patients with a diagnosis of IBD, including Crohn’s disease and ulcerative colitis, were identified using ICD-9-CM codes. Patients with IBD were then further classified into OU vs. non-OU after identifying OU with ICD9-CM code. The trend in prevalence was calculated after adjusting for age, gender, and co-morbidities. Multivariable logistic regression analysis was used to identify factors associated with OU. RESULTS: A total of 3,876,583 patients with IBD were included in the study. Out of those, 1.6% of patients had OU. The prevalence of OU in IBD patients increased steeply from 0.89% to 2.41% over 17 years (Figure 1). After adjusting for age, gender, and co-morbidities, the prevalence in the year 2014 was 3.3 times higher compared to the year 1998 (OR: 3.3; P < 0.0001). OU was more prevalent in the age group 35-49 years (38.2%), female gender (56.7%), and white patients (82.6%). Crohn’s patients had a higher prevalence of OU compared to Ulcerative colitis (78.3% vs. 21.7%, P < 0.0001). The prevalence of concurrent alcohol and marijuana use with OU was 9.2% and 6.4%, respectively. Patients <50 years had 27 times high odds of OU compared to >80 years (Table 2). Patients with Medicare and Medicaid also had a two-fold higher likelihood of OU compared to private insurance. Patients with concomitant cannabinoid (OR: 3.31; <0.0001 and alcohol use (OR: 2.08; <0.0001) were associated with three and two-fold higher OU, respectively. We also found that patients with a diagnosis of mood disorder had three times more likely to have OU (OR: 3.26; P < 0.0001), while anxiety disorder had nearly two times higher OU (OR: 1.89; P < 0.0001). CONCLUSION: From 1998 to 2014, the prevalence of opioid use in patients with IBD has tripled. IBD patients with age less than 50 years are more likely to have opioid use compared to older patients. Patients with psychiatric conditions and other substance use, such as alcohol and cannabinoid, are associated with higher opioid use.Figure 1.: Prevalence of opioid use in IBD patients from year 1998 to 2014 with adjusted odds ratio showing 3-fold increase in prevalence in 17 years.Table 1.: Baseline study population characteristics Table 2. Factors associated with opioid use in IBD patients

Endoscopic management of benign biliary disease in patients with surgically altered anatomy is challenging despite recent advancements in Endoscopic retrograde cholangiopancreatography (ERCP). With the advent of endoscopic ultrasound (EUS) guided procedures, internal biliary drainage (BD) is possible in cases where ERCP is technically challenging. This study aimed to perform a systematic review and meta-analysis to evaluate the efficacy and safety of EUS-BD for the treatment of benign biliary disease in patients with altered surgical anatomy. Individualized search strategies from inception to November 2019 were used, and studies were selected using PRISMA and MOOSE guidelines. Pooled effects were calculated using a random-effects model. The primary outcome was technical success defined as successful balloon dilation for the anastomotic stricture and or successful removal of the bile duct stones. Secondary outcomes included adverse events and procedure-related mortality. Heterogeneity was assessed with I2 statistics. Ten studies (n=132 patients, 51.5% females) evaluating EUS-BD for benign biliary disease in patients with surgically altered anatomy were included in the final analysis. The mean age was 67.6 years. The most common indication for EUS-BD was biliary stone disease (58.3%), while biliary duct strictures accounted for 41% of patients. The overall pooled technical success after EUS-BD was 85% (95% CI 73.5-91.8, I2=26%). In studies with prior failed Balloon enteroscopy directed-ERCP (8 studies, n=84 patients), the pooled technical success of EUS-BD was 87.7% (95% CI 78.7-93.2, I2=0). In 6 studies, EUS-BD was performed as a one-stage procedure versus a two-stage procedure in 4 studies, involving Hepatico-gastrostomy (HGS)/ Hepaticojejunostomy (HJS) followed by Antregrade (AG) approach. The pooled adverse events after EUS-BD was 19.7% (95% CI 11.7-31.2, I2=32%). Mild abdominal pain was the most reported adverse event (5.3%). There was no procedure-related mortality. EUS-guided bile duct drainage appears to be safe and effective for treating anastomotic stricture and common bile duct stones in patients with surgically altered anatomy. Further randomized trials are needed to evaluate the efficacy and safety of this procedure in comparison to traditional modalities.

INTRODUCTION: Killian–Jamieson diverticulum (KJD) is a false pulsion diverticulum that arises in the pharyngoesophageal area of weakness called Killian-Jamieson area. It is located inferolateral to cricopharyngeus muscle in the cervical esophagus and should be considered in the evaluation of dysphagia or globus. Annual incidence of KJD is 1/ 200,000 population and thus far less than 100 cases have been reported. We report a case of KJD who presented after chicken bone struck in diverticulum. CASE DESCRIPTION/METHODS: 59-year-old man with history of GERD presented with acute onset odynophagia and globus localized to the left neck after eating chicken wings the previous night. He did not complaint of dysphagia, regurgitation or cough and was able to tolerate secretions. Physical examination and laryngoscopy was normal. Labs and X-ray of the neck were unremarkable. A CT scan of the neck showed an esophageal diverticulum below the cricoid ring containing foreign body [Figure 1]. Esophagogram revealed normal esophageal motility and left lateral upper esophageal diverticulum measuring 1.5 × 0.8 centimeters consistent with Killian Jamieson Diverticulum(KJD) [Figure 2]. Subsequent EGD revealed a medium sized nonbleeding diverticulum with debris, a small piece of chicken bone and calcified rim adhering to the wall of the diverticulum [Figure 3]. Contents were removed by forceps and biopsies were not performed due to risk of esophageal perforation. Symptoms resolved and patient was referred to a tertiary care center for further management. DISCUSSION: KJD is relatively rare compared to Zenkers diverticulum ( ZD), which is the most common pharyngoesophageal diverticulum. KJDs are unilateral, more frequent on the left side and common among females in the 5th and 6th decades of life. Patients present with aerodigestive symptoms, most common symptoms being dysphagia, Globus, neck pain and odynophagia . A third of the patients are asymptomatic and found incidentally on imaging. Barium swallow is the gold standard for diagnosis and shows a lateral diverticulum in cervical esophagus. Persistently symptomatic diverticula require intervention and transcervical surgical diverticulectomy is the preferred option to restore normal anatomy, reduce the risk of recurrence and carcinogenesis. Diverticulopexy and endoscopic diverticulotomy is an alternative. Endoscopic interventions are gaining popularity because of faster recovery and tolerability.Figure 1.: CT scan of the neck frontal views shows focus of air abutting the lateral aspect of the upper esophagus, just below the level of the cricoid ring measuring 7 × 10 × 12 mm containing hyperdense foci along the inferior aspect, likely representing esophageal diverticulum containing ingested material/foreign body.Figure 2.: Barium swallow esophagogram showing left lateral upper esophageal diverticulum measuring 1.5 × 0.8 centimeters, compatible with a Killian Jamieson diverticulum.Figure 3.: EGD showed a medium sized nonbleeding diverticulum with debris, a small piece of chicken bone and calcified rim adhering to the wall of the diverticulum, just below the upper esophageal sphincter.

INTRODUCTION: Esophageal squamous papilloma (ESP) is a rare benign epithelial tumor characterized by finger like projections of fibrovascular core lined by increased number of squamous cells. ESP is usually asymptomatic and an incidental finding in mid-distal esophagus on upper endoscopy. Uncertainty exists regarding its malignant potential and management. We report a rare case of upper esophageal ESP, in a patient that presented with food impaction. CASE DESCRIPTION/METHODS: 63-year-old man with history of intermittent dysphagia to solids and GERD presented with globus sensation after eating chicken. Patient denied any respiratory symptoms or difficulty to tolerate secretions. Physical examination and labs were unremarkable. CT neck showed 1.7 × 2.3 × 6.1 cm impacted food bolus in the cervical esophagus [Figure 1]. Upper endoscopy revealed a large impacted piece of chicken in the upper esophagus that was morselized using biopsy forceps and eventually fell through the esophagus. A partially circumferential ring was then visualized at the site of food impaction [Figure 2]. Biopsy from the ring showed ESP that was negative for malignancy, eosinophilic esophagitis, and HPV [Figure 3]. Given the associated risk of malignant and suboptimal visual field at the time of food disimpaction, patient is scheduled for a second look upper endoscopy. DISCUSSION: ESPs are small, solitary and usually asymptomatic. Intermittent dysphagia, epigastric pain or heart burn are associated with large or multiple ESPs. Our case is unique in that ESP presented as an esophageal ring causing food impaction. Its prevalence the general population varies from 0.01% to 0.45% and is more frequent in middle aged white men. Etiology is thought to be chronic mucosal irritation from chemical, viral, or mechanical factors leading to hyper regeneration. The prevalence of squamous cell carcinoma (SCC) in patients with ESP at 2 years is 1.3%. The risk of dysplasia and SCC should prompt resection of ESP, even if asymptomatic. Majority of ESPs can be removed using a biopsy forceps or snare. Endoscopic laser, radio-frequency ablation or cryotherapy have been reported in treating multiple lesions. Surgery is reserved for ESP with malignant transformation or extensive squamous papillomatosis. No surveillance is required once ESP is completely removed.Figure 1.: A and B representing sagital and axial CT images of neck showing 1.7 × 2.3 × 6.1 cm impacted food bolus ( arrows) in the cervical esophagus.Figure 2.: A- Upper endoscopy showing a large impacted piece of chicken in the upper esophagus that was morselized using biopsy forceps. B- A partially circumferential ring / stenosis visualized at the site of food impaction (18 cm from incisors), from which biopsies were obtained.Figure 3.: Hematoxylin and eosin stain of the biopsy from esophageal ring, ×40 magnification, showing projections of fibrovascular core lined by benign squamous epithelium suggesting squamous papilloma.

INTRODUCTION: Inflammatory bowel disease (IBD) is thought to occur secondary to inappropriate host immune responses, resulting in gastrointestinal inflammation. On that basis, many studies have established an association between IBD and opportunistic infections. No studies however have evaluated its association with influenza virus, a commonly seen pathogen. METHODS: We retrospectively analyzed patients hospitalized with the diagnosis of IBD, consisting of Crohns disease and Ulcerative Colitis, and patients with the diagnosis of influenza virus via ICD-9 codes in the year 2014 using the Nationwide Inpatient Sample (NIS) database. Our primary endpoint was to evaluate the morbidity and mortality associated with IBD and superimposed influenza virus. We looked at multiple variables including incidence, length of hospital stay (LOS), and mortality rate. Logistic regression models were developed using STATA software version 15. RESULTS: A total of 1,027,740 patients with IBD, 523,190 patients with influenza virus, and 358,400 patients with IBD and influenza virus were included in our study population. We found that patients with IBD were 111% more likely to have influenza virus than patients without IBD (OR: 112.772, CI: 108.778-116.808, P-value: 0.000). In addition, patients with IBD and influenza virus presented at a statistically significant younger age when compared to patients with IBD alone (56.31 years vs 58.47 years, P-value: 0.000). On the contrary, patients with IBD and influenza virus had statistically significant shorter LOS (4.4 days vs 4.7 days, P-value: 0.000) and lower mortality rate (1.5 vs 1.9, P-value: 0.004) than patients with influenza virus alone. Similarly patients with IBD and influenza presented at a later age than patients with influenza alone (56.31 years vs 55.99 years, P-value: 0.385), but these findings were not statistically significant. CONCLUSION: We conclude that IBD patients are more susceptible to develop infection with influenza virus than patients without IBD. Although this association is clear, the mortality rate and LOS were lower in IBD patients with influenza compared to patients with influenza virus alone. Limitations such as our retrospective study design, and sample size may explain this paradoxical finding. Conversely there may exist an age-related bias, in that older more frail patients with influenza virus are more likely to seek medical attention when compared to their younger counterparts.

Achalasia is a motility disorder of the esophagus that is characterized by loss of ganglionic neurons within the myenteric plexus of the lower esophageal sphincter (LES) resulting in failure of the LES to relax. Clinically this disorder presents with simultaneous dysphagia to solids and liquids, and if left untreated, leads to esophageal dilation, which can give rise to many adverse consequences. Extrinsic compression of respiratory structures is one such consequence, and rarely, cases of tracheal compression secondary to achalasia have been reported. However, cases of extrinsic bronchial compression are yet rarer. Here, we present a case series comprised of two patients with achalasia who presented with extrinsic bronchial compression by a dilated esophagus secondary to achalasia.

Gastric small cell carcinoma (GSCC) is a rare entity in the western hemisphere. GSCC's typically arise in the upper one-third of the stomach and have histologic features similar to those of small-cell lung carcinoma (SCLC). They have an aggressive natural history that is characterized by early and widespread metastases. Prognosis is dismal with an overall survival of less than 12 months. We present the case of a 79-year-old African-American woman who presented with two weeks of progressive dysphagia associated with nausea, vomiting and a foreign body sensation in the throat. Computed tomography (CT) imaging showed multiple hepatic and lymph node lesions but revealed no gastric thickening. Endoscopy revealed a large ulcer on the lesser curvature of the stomach. Biopsy proved the diagnosis of pure-type GSCC. Bone scan identified multiple focal bony lesions at the thoracolumbar vertebrae, ribcage, bilateral scapulae, pelvic bones and right proximal femur. Treatment was started with cisplatin and etoposide. To our knowledge, this is the one of the first reported cases of gastric small cell cancer with bone metastases in the western hemisphere. Our report shows the importance of doing a full metastatic workup in these patients to identify sites of metastases.

INTRODUCTION: Intrahepatic Portosystemic Venous Shunts (IPSVS) are rare vascular malformations between the hepatic and portal veins. Most of the porto-venous shunts are asymptomatic and found incidentally on radiology imaging. These can be either congenital or acquired. Acquired shunts are typically less than 2 mm in size. Occasionally, complications such as encephalopathy, heart failure, pulmonary hypertension and elevated ammonia levels can occur. We report a case of incidental IPSVS in a patient who presented with complaints of fatigue and failure to thrive. CASE DESCRIPTION/METHODS: 82-year-old African American male with hypertension, diabetes mellitus and prostate cancer (treated) presented with complaints of fatigue and loss of appetite for one-month. Laboratory work up showed a hemoglobin of 11.6 g/dl, normal platelet count, and elevated aspartate aminotransferase of 45 U/L and decreased albumin of 2.0 g/dl. Serum ammonia level was normal. He was immune to hepatitis A, non immune to hepatitis B and hepatitis C antibody was negative. A computed tomography scan of the abdomen showed a contrast enhanced tubular shaped vascular connection between middle hepatic vein and the anterior branch of the right portal vein. The size of the shunt was approximately 10 mm (Figure 1). Liver appeared normal except for small calcifications within the parenchyma. Ultrasound Doppler of hepatic and portal veins were performed, and the porto-hepatic shunt was visualized (Figure 2). Patient had a complicated hospital course secondary to sepsis; however, he did not develop hyperammonemia or hepatic encephalopathy during the hospital stay. DISCUSSION: IPSVS in our patient was likely a congenital anomaly given the presentation, size and lack of related symptoms. IPSVS is divided into 4 types; Type 1- Shunt between portal vein and IVC; Type 2- connections between peripheral branches of portal and hepatic veins in one hepatic segment; Type 3- Aneurysmal connection between portal and hepatic vein; Type 4- multiple communications of portal and hepatic veins in both major lobes of the liver. Doppler sonogram with pulse doppler is highly sensitive and specific to evaluate for IPSVS. In symptomatic IPSVS, shunt closure has shown improvement in symptoms and correction of hyperammonemia. Clinicians should consider this rare vascular malformation in patients presenting with hepatic encephalopathy or hyperammonemia in the absence of cirrhosis where shunt closure can be curative.

INTRODUCTION: Granular Cell Tumors (GCTs) are tumors arising from Schwann cells of the nerve sheath. They occur at an incidence of about 0.03% and have a predilection for the skin, oral cavity, and breasts. Only 6-8% of all GCTs occur in the GI tract with the esophagus (65%) being the most common site, followed by the colorectum (25%). Less than 20 cases of cecal GCTs have been reported so far. Owing to its rarity, we report a case of an asymptomatic cecal GCT found incidentally during screening colonoscopy. CASE DESCRIPTION/METHODS: A 58-year-old male with no known past medical history presented to the Gastrointestinal (GI) clinic for screening colonoscopy. History was negative for alarm symptoms, including no family history of GI cancers. He had no prior Upper endoscopy or colonoscopy. Physical examination and labs were unremarkable. Colonoscopy revealed an 8mm yellowish, sessile, subepithelial nodule with normal overlying mucosa in the cecum (Figure 1). Biopsy showed clusters of cells with granular cytoplasm that was Periodic acid–Schiff (PAS) positive suggestive of GCT (Figure 2). Immunohistochemical staining was positive for S100, CD 68, calretinin thus confirming the diagnosis of GCT (Figure 3). The patient has since been scheduled for Endoscopic ultrasound (EUS) for further evaluation. DISCUSSION: Colorectal GCTs account for up to 25% of all GI GCTs, with most affecting the right sided colon (cecum and ascending colon). Mostly benign and solitary, but about 2% are known to have malignant potential with poor prognosis. More common in females and in African Americans between ages 40-60 years. Generally asymptomatic and found incidentally during a screening colonoscopy, however in a few cases, patients have presented with hematochezia, abdominal pain, and change in bowel habits. EUS is invaluable in differentiating GCTs from other subepithelial tumors, in determining the size, and depth of invasion. Definitive diagnosis is by histopathology and immunohistochemical staining. There is no general consensus on the management of colorectal GCTs. Conservative management is recommended for tumors < 1cm, asymptomatic, with no deep tissue invasion or malignancy. However, resection is warranted for symptomatic tumors, tumors >1 cm in size, deep tissue invasion or malignancy. Endoscopic removal is preferred over surgery for tumors without deep tissue infiltration or malignancy. Endoscopic and histologic surveillance every 1-2 years is recommended.

Peroral endoscopic myotomy (POEM) has emerged as an effective and safe treatment for achalasia in recent years and is considered an endoscopic alternative to pneumatic dilatation (PD). Comparative outcome data of the two techniques are limited.

INTRODUCTION : Endoscopic hemostasis in patients with non-variceal bleeding (NVGIB) with standard therapy has improved outcomes. However, persistent bleeding and re-bleeding continues to drive morbidity and mortality. Use of over-the-scope clips (OTSC) is an emerging treatment modality for managing gastrointestinal (GI) bleeding. We performed a systematic review and meta-analysis to evaluate the ability of OTSC to achieve primary hemostasis and re-bleeding rates as primary therapy and rescue endoscopic interventions in patients with NVGIB. EVIDENCE ACQUISITION : We searched articles in PubMed, Ovid Medline In-Process & Other Non-Indexed Citations, Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus from inception to July 2017 using keywords such as "OTSC "and "NVGIB." EVIDENCE SYNTHESIS : A total of 16 studies which involved 475 patients met the inclusion criteria. 288 patients were treated with OTSC as primary therapy while 187 patients were treated with OTSC as rescue therapy. Primary hemostasis rate achieved with primary endoscopic therapy with OTSC was 0.93 (95% CI : 0.89-0.96). Similarly, primary hemostasis rate achieved with rescue endoscopic therapy with OTSC was 0.91 (95% CI : 0.84-0.95). Re-bleeding rates after primary endoscopic therapy with OTSC was 0.21 (95% CI : 0.08-0.43) and 0.25 (95% CI : 0.17-0.34) with rescue therapy. There was a decreased risk of re-bleeding in patients treated with OTSC as primary therapy versus rescue therapy. RR = 0.52 (95% CI : 0.31-0.89). CONCLUSIONS : This meta-analysis demonstrates success on the use of OTSC as primary and rescue therapy in the management of NVGIB. Further trials should clarify the ideal setting for the use of OTSC and assess the cost of these devices as compared to standard therapy.

Hepatic herniation through an abdominal incisional hernia is a rare phenomenon that has been seldom reported in the medical literature. When present, this may cause patients significant distress and is associated with complications such as hepatic encephalopathy and Budd-Chiari syndrome. Most cases can be managed conservatively through observation, but many cases require surgical intervention to preserve hepatic function. Our case consists of a 54-year-old man who presented with asymptomatic herniation of the left hepatic lobe through an abdominal incisional hernia.