Of the four types of hiatal hernias, type IV is the least common. It involves herniation of the stomach and another visceral organ past the hiatus of the diaphragm. Evaluation of the hernia can be through imaging, endoscopy, or manometry. Management of hiatal hernias can either be medical or surgical. Our case involves a 31-year-old male who presented with nausea, vomiting, and decreased oral intake for six days. He underwent robotic assisted Nissen fundoplication six months prior due to intractable gastroesophageal reflux disease and small hiatal hernia. Computed tomography imaging revealed a large hiatal hernia involving most of the stomach and part of the transverse colon. Esophagogastroduodenoscopy was limited due to rotation of the stomach as well as complex hernia. The patient ultimately underwent robotic assisted repair of the hernia with mesh placement and gastropexy.

East Tennessee State University James H Quillen College of Medicine, USA.

Iron deficiency anemia is a concerning finding, particularly in males and post-menopausal females, and can have numerous underlying causes. When evaluating potential sources of gastrointestinal blood loss, bidirectional endoscopy is often necessary. We report the case of an 89-year-old female with multiple comorbidities, including atrial fibrillation treated with apixaban, who presented with symptomatic iron deficiency anemia. Extensive dermatological and radiological assessments ruled out a primary source, and subsequent endoscopy identified a rare etiology: primary gastric mucosal melanoma. This case highlights the importance of thorough evaluation in identifying uncommon causes of iron deficiency anemia such as unsuspected malignancies, hereditary conditions, and different autoimmune conditions amongst other etiologies.

Introduction: Iron deficiency anemia (IDA) is an alarming finding in males and post-menopausal females. A myriad of etiologies could be responsible for the anemia. In evaluation for possible GI blood loss, bidirectional endoscopy is usually warranted to identify a culprit for the anemia. We present a rare etiology of IDA identified on endoscopy in an elderly patient presenting with symptomatic anemia. Case Description/Methods: An 89-year-old female with multiple medical comorbidities including atrial fibrillation on apixaban presented with fatigue, weakness, and exertional dyspnea. Laboratory investigations revealed IDA with a hemoglobin of 8.0 g/dl. Patient denied any overt GI bleeding. She was admitted, and a CT-Angiography of the abdomen revealed a questionable small focus of hemorrhage in the posterior gastric antrum, she was started on IV PPI and after adequate transfusion she underwent bidirectional endoscopy. Endoscopy findings were significant for a 3-4 mm raised umbilicated gastric lesion that was removed with cold forceps. The biopsy revealed a mucosal melanoma, SOX 10, Mart 1, HMB45 and S100 positive. Subsequently, the patient underwent a PET scan for staging which showed focal uptake at a distal esophageal lymph node; and focal uptake associated with a loop of small intestine in the left aspect of the pelvis. She also underwent a complete dermatological, ophthalmological evaluation and a Head CT scan to assess for a primary source, which were nonrevealing. To further evaluate the PET uptake in the small intestine she underwent video capsule endoscopy which revealed 3 small intestinal (likely jejunal) masses (Figure) with a similar mucosal pattern to the identified gastric lesion. Patient was referred to Oncology and eventually underwent 3 rounds of radiotherapy followed by systemic chemotherapy. Discussion: Malignant melanoma involving the GI tract can be either primary or metastatic. Primary GI mucosal melanoma is a rare entity with an annual incidence of 0.58 cases per million, its presentation is variable depending on location of the primary melanoma. Our case highlights the importance of performing a thorough endoscopic examination to identify subtle mucosal abnormalities that can aid in establishing an etiology of IDA in patients with occult GI bleeding who are on anticoagulation. Evaluation of malignant GI tract melanoma includes evaluation for a possible primary cutaneous source, as well as evaluating for metastatic disease.Figure 1

e16036 Background: Venous thromboembolism (VTE) is associated with significant morbidity and mortality in cancer patients. Our study compares the mortality in hospitalized VTE patients among the five most common Gastrointestinal (GI) malignancies which includes esophageal, gastric, pancreatic, colorectal, and hepatobiliary cancers. Methods: A retrospective study was conducted utilizing the Nationwide Inpatient Sample database (NIS) from 2016 to 2018. Patients with Venous thromboembolism (VTE) were identified using ICD 10 codes from all primary discharge diagnoses. Only deep venous thrombosis (DVT) and pulmonary embolism (PE) were considered. Patients with VTE were further divided into groups: esophageal cancer, gastric cancer, pancreatic cancer, colorectal cancer, hepatobiliary cancer, and compared with patients who did not have these malignancies. Patients younger than 18 years of age or patients with missing age, gender or race were excluded. Among the hospitalized patients with VTE, we investigated the difference in mortality with different gastrointestinal malignancies. Adjusted odds ratio (OR) was calculated using multivariate regression analysis. Results: Among 751,834 patients discharged with a VTE diagnosis, 0.24% had esophageal cancer, 0.25% had gastric cancer, 0.93% had pancreatic cancer, 1.10% had colorectal cancer, 0.35% had hepatobiliary cancer, and the other 97.14% did not have these malignancies. The study shows that adults admitted to the hospitals for VTE have higher mortality when compared to patients who did not have GI malignancies, with esophageal cancer having the highest inpatient mortality with an OR of 2.66 (95% CI 1.78-3.94, P of 0.00). For the remaining GI cancers, gastric cancer had an OR of 1.74 (95% CI 1.141-2.661, P of 0.010), pancreatic cancer had an OR of 1.74 (95% CI 1.402-2.178 P of 0.000), hepatobiliary cancer had an OR of 1.67 (95% CI 1.144-2.439 P-value of 0.002) and colorectal cancer had OR of 1.18 (95% CI 0.930-1.517 P of 0.169), which was not statistically significant. Conclusions: Pancreatic and gastric cancers have a higher risk of VTE and frequently score high in validated VTE risk assessment tools such as the Khorana score. This study shows that VTE in hospitalized patients with esophageal cancer is associated with greater mortality. More research is needed to analyze the outcomes of VTE in cancer patients and to identify those who would benefit from thromboprophylaxis. Due to the nature of the NIS database, one of the study's limitations was the difficulty in identifying patients receiving DVT prophylaxis.

Introduction: Adenocarcinoma of small the bowel is a rare entity with less than 3% of gastrointestinal cancers. The duodenum is the most involved segment of the small bowel followed by the jejunum and ileum. Duodenal bulb adenocarcinoma is, however, an extremely rare finding with very few cases reported. In this case, we present primary duodenal bulb adenocarcinoma that manifested as epigastric pain with nausea. Case Description/Methods: 55 y/o female with history of Diabetes that presented for GI consultation for two months of epigastric pain and nausea. Her endoscopy showed a single 3 cm cratered ulcer in the posterior duodenal bulb. Duodenal bulb biopsy showed poorly differentiated adenocarcinoma. PET CT scan showed a 2.9x1.8cm eccentric mass of the first portion duodenum and non-measurable left lobe hepatic hypodensity. CT Chest Abdomen and Pelvis showed unchanged 3.1cm soft tissue density in the duodenal bulb and interval increase of an hypoehancing mass of the left hepatic lobe. Her biopsy of the left hepatic lesion showed poorly differentiated adenocarcinoma. In the interim, she developed jaundice and PTC showed stenosis in the central region of the posterior branches of the right biliary tree and had internal-external biliary drain placed. Multidisciplinary tumor discussion was conducted with Medical Oncology, Surgical Oncology, Radiation Oncology, Radiology and Pathology with final recommendations proceed with FOLFOX chemotherapy. (Figure) Discussion: Duodenal adenocarcinoma is rare with a very aggressive trajectory. A large population study indicates that majority of Duodenal adenocarcinoma arise in the D2 followed by D3/D4. Presentation in the first portion of the duodenum especially at the duodenal bulb is extremely rare. Patients tend to present with advanced disease due to nonspecific symptoms such as abdominal pain which is the most common presenting symptom. Endoscopy is the favored approach for visualization and biopsy. Contrast enhanced cross-sectional imaging (CT) is a valuable tool for assessing involvement and planning for surgery. Interventions ranges from radical resection (pancreaticoduodenectomy) which has the best outcome to palliative chemotherapy. Primary duodenal bulb adenocarcinoma is an extremely rare finding with only few cases reported. This is an intriguing phenomenon and raises the question if the duodenal bulb mucosa is inherently advantaged environmentally or physiologically to resist to malignant transformation.Figure 1.: A: Endoscopic imaging finding of 3 cm cratered ulcer in the posterior duodenal bulb Figure B: PET CT scan showing 2.9x1.8cm eccentric mass of the first portion duodenum Figure C: PET CT scan showing non-measurable left lobe hepatic hypodensity.

Introduction: Rarely, an aortoenteric fistula (AEF) is identified as the source of a herald bleed, or one that precedes a catastrophic hemorrhagic event such as abdominal aortic aneurysm rupture. AEFs are abnormal communications between the GI tract and aorta that arise most commonly secondary to aortic vascular procedures. In contrast, primary AEFs have much lower incidence and are felt to arise spontaneously from erosion. Case Description/Methods: We present a 69 year old female with prior history of an abdominal aortic aneurysm who presented with multiple bouts of hematemesis and abdominal pain. CT showed an irregular shaped infrarenal abdominal aortic aneurysm with dimensions 9.6 x 7.5 cm with evidence of contained rupture. The patient developed hemorrhagic shock with both hematemesis and brisk hematochezia. With stabilization, the patient underwent percutaneous endovascular aneurysm repair with stent placement over aortic bifurcation. Following vascular intervention, no further hematemesis or clinical GI bleeding occurred. Push enteroscopy was performed revealing a defect in the distal third portion of the duodenum with extravasation of both debris and blood (image 1). The ampulla was excluded as a bleeding source. This mucosal defect was concerning for AEF and hemoclips were deployed to mark its location. Following this hospitalization, the patient later died from chronic respiratory failure. Discussion: This case presents a “herald” GI bleed secondary to a primary aortoenteric fistula. A classic triad of abdominal pain, pulsating mass and gastrointestinal bleeding has been described, however all 3 components are present in a minority of cases. Primary AEFs have a commonly cited incidence of 0.07%. Identification of both primary and secondary AEF demands a high index of suspicion, particularly in the setting of acute aneurysm. (Figure) Endoscopically confirming aortoenteric fistula is technically challenging and often inconclusive, thus CT with contrast is preferred with sensitivity 94% and specificity 85%. Presence of air bubbles or intravascular air on CT is often confirmatory. With an estimated mortality rate of primary AEF of approximately 36%, surgical management is usually required. Surgical options include utilizing an in situ graft versus direct closure of the mucosal defect in the GI tract. Endovascular techniques including aortic stent and graft placement are increasingly used.Figure 1.: Defect in duodenal mucosa representing primary aortoenteric fistula.

Background and study aims Current guidelines conditionally recommend performing early colonoscopy (EC) (< 24 hours) in patients admitted with acute lower gastrointestinal bleeding (LGIB). It remains unclear whether this practice is implemented widely. Therefore, we used the Nationwide Inpatient Sample to investigate trends for timing of colonoscopy in patients admitted with acute LGIB. We also assessed trend of hospitalization and mortality in patients with LGIB. Patients and methods Adult patients with LGIB admitted from 2005 to 2014 were examined. ICD-9-CM codes were used to extract LGIB discharges. Trends were assessed using Cochrane-Armitage test. Factors associated with mortality, cost of hospitalization, and length of stay (LOS) were assessed by multivariable mixed-effects and exact-matched logistic, linear regression, and accelerated-failure time models, respectively. Results A total of 814,647 patients with LGIB were included. The most common etiology of LGIB was diverticular bleeding (49 %) and 45 % of patients underwent EC. Over the study period, there was no change in the trend of colonoscopy timing. Although admission with LGIB increased over the study period, the mortality rate decreased for patients undergoing colonoscopy. Independent predictors of mortality were age, surgery (colostomy/colectomy) during admission, intensive care unit admission, acute kidney injury, and blood transfusion requirement. Timing of colonoscopy was not associated with mortality benefit. However, cost of hospitalization was $ 1,946 lower and LOS was 1.6 days shorter with EC. Conclusion Trends in colonoscopy timing in management of LGIB have not changed over the years. EC is associated with lower LOS and cost of hospitalization but it does not appear to improve inpatient mortality.

Background & aims: Chronic intestinal failure (CIF) has been long-recognized, however the underlying etiology and risk factors have not been historically well-studied. We aim to study the underlying etiologies of CIF and predictive factors for long-term parenteral support (PS). Methods: We retrospectively identified patients with newly diagnosed CIF who received PS to maintain nutrition at the Cleveland Clinic between 2000 and 2017. Long-term PS was defined as a duration of more than 3 months. Univariable and multivariable logistic regression analyses were performed to identify the predictors of the need for long-term PS. Results: We identified 350 patients with CIF, 150 (43%) and 200 (57%) were diagnosed before and after 2010, respectively. The most common etiology was Crohn's disease (CD) in both cohorts (34.7% versus 30.5%, p = 0.41). Graft-versus-host-disease (GVHD) was a less frequent cause of CIF after 2010 (12.7% versus 2.5%, p = 0.0002). The type of PS was mostly total parenteral nutrition before and after 2010, 95% and 96%, respectively (p = 0.55). On univariable analysis, absence of ileocecal valve (p < 0.0001), ischemic bowel disease (p = 0.009), and whole colon resection (p = 0.033) were associated with the need for long-term PS. On multivariable analysis, absence of ileocecal valve (OR 2.19, p = 0.011) and ischemic bowel disease (OR 3.04, p = 0.003) remained statistically significant predictors of long-term PS. Conclusion: In our cohort of patients with CIF, CD remains the leading etiology over the last 20 years, whereas GVHD is less common after 2010. The absence of ileocecal valve and ischemic bowel disease were reliable predictive factors for requiring long-term PS. (C) 2020 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.

Background and study aims: It has been suggested that smoking may be associated with microscopic colitis (MC) in some studies; however, there are conflicting results in the current literature with many of these studies having significant limitations. Our study aims to offer a meta-analysis evaluating the association between MC, including both its subtypes, and smoking. Patients and methods: A systemic review was conducted in PUBMED, Embase, PubMed Central, and ScienceDirect databases from inception through December 2019. Effect estimates from the individual studies were extracted and combined using the random effect, generic inverse variance method of DerSimonian and Laird and a pooled odds ratio (OR) was calculated. Forest plots were generated, and publication bias was assessed for using conventional techniques. Results: Eight observation studies with a total of 1461 patients with MC were included in this study, 383 of whom were active smokers (26.2%). Current smoking was significantly associated with MC (OR 3.58, 95% CI, 2.51-5.11), lymphocytic colitis (LC) (OR 3.64, 95% CI, 2.46-5.38), and collagenous colitis (CC) (OR 4.43, 95% CI, 2.68-7.32). Gender-specific subgroup analysis showed a significant association with smoking was found for CC in men (OR 4.53, 95% CI, 1.59-12.85), CC in women (OR 3.27, 95% CI, 2.35-4.54), LC in women (OR 2.27, 95% CI, 1.27-4.06) and MC in women (OR 2.93, 95% CI, 2.09-4.10). We found no publication bias as assessed by the funnel plots and Egger's regression asymmetry test. Conclusion: Our meta-analysis found a statistically significant association between smoking and both subtypes of MC. (C) 2020 Pan-Arab Association of Gastroenterology. Published by Elsevier B.V. All rights reserved.

Background Capsule endoscopy (CE) is a non-invasive imaging modality designed to evaluate various small bowel pathologies. Failure to reach the cecum within the battery lifespan, termed incomplete examination, may result in inadequate testing and possibly delayed therapy. Several studies have attempted to evaluate the association between CE completion and opioid use. However, their results are conflicting. The aim of this meta-analysis is to evaluate the previously published literature on the association between opioid use and CE completion. Methods We performed a comprehensive literature search in PubMed, PubMed Central, Embase, and ScienceDirect databases from inception through June 1, 2018, to identify all studies that evaluated the association between CE completion and opioid use. We included studies that presented an odds ratio (OR) with a 95% confidence interval (CI) or presented the data sufficient to calculate the OR with a 95% CI. Statistical analysis was performed using the comprehensive meta-analysis (CMA), version 3 software. Results Five studies with a total of 1,614 patients undergoing CE in the inpatient (IP) and outpatient (OP) setting were included in this study, 349 of which had an incomplete CE (21.6%). The pooled OR for CE completion is 0.50 (95% CI: 0.38-0.66, I2=36.9%) in opioid users compared to non-users. No publication bias was found using Egger's regression test. Conclusions Our results indicate that patients on opioids are significantly less likely to have a complete CE examination compared to non-users. To our knowledge, this study represents the first meta-analysis to assess this association.

Diverticular hemorrhage is the most common etiology for hospital admission with lower gastrointestinal bleeding. Colonoscopy is recommended as the first-line diagnostic study. But because bleeding is usually self-limited, endoscopic localization and hemostasis is achieved in a minority of patients. The aim of our study was to evaluate the impact of inpatient colonoscopy on prevalence of 30-day readmission for lower GI bleeding in patients with diverticular hemorrhage.

Sclerosing mesenteritis is a rare autoimmune disease that eventually evolves into fibrotic changes that usually affect the adipose tissue around the mesenteric vessels. It can present through a myriad of gastroenterological as well as constitutional symptoms, including but not limited to abdominal pain, diarrhea, fever, nausea, or vomiting. Although the exact etiology of the disease is yet to be determined, there are several predisposing factors, the most common of which is a previous history of abdominal trauma and/or surgery. Several case series have reported the association of sclerosing mesenteritis with prior abdominal surgery ranging from as low as 24% to as high as 53%.

INTRODUCTION: Ceftriaxone has been shown to cause transient biliary and cholecystic sludge evident on imaging in asymptomatic subjects. This sludge may result in obstruction, and hence, acute pancreatitis and cholecystitis. Here we report a case of acute pancreatitis presenting three days following treatment with ceftriaxone which may be attributed to this phenomenon. No other risk factors could be identified. CASE DESCRIPTION/METHODS: A 34-year-old male patient with no past medical history presented to the hospital with the complaint of stabbing epigastric abdominal pain radiating to the back with associated nausea and vomiting of one day duration. He was seen by his primary care doctor three days prior to presentation for urethral discharge and was given an intramuscular injection of 250 mg ceftriaxone in addition to 1 g oral azithromycin with complete resolution of symptoms. Physical examination was notable for epigastric tenderness without rebound tenderness or guarding and was otherwise normal. Laboratory work up was remarkable for WBC 15200 per microliter and lipase 1961 U/L. Liver function test, serum calcium, triglycerides, and IgG4 were all within normal limit. Computed tomography (CT) scan of the abdomen confirmed findings of acute pancreatitis with well-defined pancreatic borders. This was followed by a right upper quadrant ultrasound which showed biliary and cholecystic sludge. Upon further questioning the patient denied alcohol and tobacco use, recent travel, or any prior history of mumps and herpes simplex virus infections. Furthermore, no family history of acute pancreatitis was reported. The time frame of symptoms and the absence of other risk factors point towards a drug adverse reaction. The patient was managed conservatively and discharged the following day with significant clinical improvement. DISCUSSION: Younger patients, patients receiving a prolonged or larger dose and patients with impaired gallbladder emptying are at a greater risk for developing sludge secondary to ceftriaxone use. This is often asymptomatic with discontinuation of the drug usually resulting in resolution of this phenomenon. This case highlights the fact that ceftriaxone induced biliary sludge may rarely result in potentially serious adverse events including acute cholecystitis and pancreatitis.

INTRODUCTION: Irritable bowel syndrome (IBS) is a common disease that affects between 10-15% of the population globally. A growing body of research is attempting to further understand the underlying pathophysiology of IBS and its association with other extra-intestinal manifestations with reports suggestive of sleep disturbances and obstructive sleep apnea (OSA) being implicated. This study aims to explore the available literature for the prevalence of IBS in OSA patients. METHODS: A systematic review was conducted in PudMed, MEDLINE, EMBASE, and Cochrane databases from inception through June 2019 to identify the studies that explored the prevalence of IBS in OSA patients. We included studies that presented event rates with a 95% confidence interval (CI) or presented the data sufficient to calculate the event rate with a 95% CI. Effect estimates from the individual studies were extracted and combined using the random-effect, generic inverse variance method of DerSimonian and Laird and a pooled prevalence was calculated. Forest plots were generated, and publication bias was assessed for using conventional techniques. RESULTS: Four studies with a total of 792 patients with OSA were included in this study. The mean age was 52.94 years and 557 (73.09%) patients were men. The pooled event rate of IBS in OSA patients was 23.90% (95% CI: 20.8%-27.3%) (Figure 1). The pooled event rates of IBS in male and female patients with OSA were 26.4% (95% CI: 22.5%-30.8%) and 19.8% (95% CI: 14.6% - 26.2%) respectively (Figures 2 and 3). CONCLUSION: These results suggest a higher prevalence of IBS in OSA patients compared to the general population. Further research might be needed to evaluate the prevalence of OSA in IBS patients and whether the treatment of OSA would affect the IBS disease course in these patients. Furthermore, health care providers should also screen patients with OSA for gastrointestinal symptoms.