Dysphagia with an identifiable stricture occurs frequently following chemoradiation therapy for head/neck cancer patients, some developing complete obliteration of the esophageal lumen. Combined Antegrade Retrograde Dilation (CARD) is designed to restore luminal patency. This paper reports how experience at one institution shaped a more effective strategy for the long-term management of this difficult patient population. Twenty patients, mean age 62.6 years, initially undergoing CARD procedure, subsequently required a total of 278 dilation sessions (average 13.9 sessions/patient) performed on average every 8.2 weeks (range 2.7–12.6). All patients achieved luminal patency. Complications occurred in 7 patients (35.0

Because dysphagia occurs when the esophageal luminal diameter is < 13 mm, the traditional goal of dilation is set at 14–16 mm (42–48 Fr) to relieve symptoms. This study was designed to determine whether increasing the size of dilators further would improve durability of response to bougienage. Patients with severe or non-severe esophageal stricture and dysphagia were randomized to two different sizes of dilators. Diet and Dysphagia scores were calculated before and after index dilation, then every 4–8 weeks by phone for 12 months. Of 35 patients (mean age 63.1 yrs, 37.1

The purpose of this article is to review available literature on management of persistent ostomy following PEG tube removal. We will discuss the incidence of persistent gastrocutaneous fistula (GCF) following PEG tube removal, risk factors for their development, and management strategies that have been proposed and their efficacy. The use of over the scope clips (OTSC) have evolved recently in the management of gastrointestinal bleeding, perforation, and fistula closures. OTSC has become more readily available and proven to be effective and safe. Suturing devices have shown promising results. Persistent gastrocutaneous fistula following PEG removal is a rare yet serious complication that can lead to continuous skin irritation and leakage of gastric contents and acid. There are several postulated risk factors but the most important of these is duration of placement. Management can include medical therapy which has recently been shown to be somewhat effective, endoscopic therapy and surgery as a last resort. Overall, the data on GCFs is limited and further study with larger sample size is needed.

Clay is a native building material in Sudan and is utilized by most low-income people. The radiation shielding characteristics of clay and cement were tested with a specific thickness to explore the behavior of gamma radiation through these materials. The results were compared and estimated by the Phy-X, XCOM, and Py-MLBUF software packages. Mass Attenuation Coefficient (MAC), Linear Attenuation Coefficient (LAC), Half-Value Layer (HVL), Tenth-Value Layer (TVL), Mean Free Path (MFP), and equivalent atomic number (Zeq), which describe the shielding properties of the examined materials, were all determined and compared. The comparison of calculations by software and experimental data of all selected samples showed a high degree of agreement, with discrepancies ranging between 0.01 and 5%. The experiments were carried out in a chamber close to 137Cs and 60Co sources at energies of 662, 1173, and 1332 keV.

The early provision of soluble/insoluble fiber to the patient who is critically ill has been controversial in the past. Especially in the setting of hemodynamic instability, dysmotility, or impaired gastrointestinal transit, fear of inspissation of formula with precipitation of nonocclusive mesenteric ischemia (NOMI)/nonocclusive bowel necrosis (NOBN) limited its utilization by medical and surgical intensivists. The incidence of NOMI/NOBN has been estimated at 0.2%-0.3% for all intensive care unit (ICU) patients receiving enteral nutrition (EN), and the occurrence of inspissated formula is even less. The science supporting a benefit from providing fiber has recently increased exponentially. The fermentation of soluble fibers leading to the production of short chain fatty acids supports gut barrier function, modulates immune responses, and promotes refaunation of commensal organisms. The "butyrate effect" refers to local (gastrointestinal tract) and systemic anti-inflammatory responses mediated by the M2 polarization of macrophages, inhibition of histone deacetylase, and stimulation of ubiquitous G protein receptors. Both soluble and insoluble fiber have been shown to promote intestinal motility, reduce feeding intolerance, and shorten hospital length of stay. The benefit of providing dietary fiber early upon admission to the ICU outweighs its minimal associated risk. The point at which the intensivist determines that is safe to initiate EN, both soluble and insoluble fiber should be included in the enteral formulation.

Enteral feeding is commonly used to provide patients with nutrition. Access via feeding tubes can be attained by multiple medical specialties through a variety of methods. There are limited data available on direct comparisons amongst gastroenterologist, interventional radiologists and surgeons, although there appears to be similar rates of complications. Fluroscopically and surgically placed feeding tubes may have a higher technical success rate than endoscopically placed tubes. The preferred specialty for feeding tube placement varies per institution, often due to logistical matters over technique or concern for complications. Ideally, a multidisciplinary team should exist to determine which approach is best in a patient-specific manner.

Enteral feeding plays a critical role in the management of hospitalized patients, especially in intensive care units. In addition to delivering important nutrients, it also maintains the integrity of the gut and microbiota. Enteral feeding is also associated with complications and adverse events, some are related to access placement, metabolic and electrolytes disturbances, and aspiration pneumonia. In tube-fed patients, aspiration pneumonia has a prevalence ranging from 4% to 95% with a mortality rate of 17%-62%. Our review has not showed any significant difference in the incidence of aspiration pneumonia between gastric and postpyloric feeding and, given the ease of gastric access, we therefore suggest using gastric feeding as an initial strategy for the delivery of nutrition unless postpyloric access is otherwise indicated for other clinical reasons.

This article presents data collected by measurements of lead (Pb) and iron (Fe) and their combination as heavy shielding materials. Measurements were performed using gamma photon energies of 662, 1173, and 1332keV for the Cs-137 and Co-60 sources. The theoretical data part was calculated using WinXCom, Phy-X, and Py-MLUBF software packages. Tables and graphs of the photon Mass Attenuation Coefficient (MAC), Linear Attenuation Coefficient (LAC), Half Value Layer (HVL), Tenth Value Layer (TVL) and Mean Free Path (MFP) are presented for both heavy metals and their combination to study the shielding properties experimentally and theoretically. The results will contribute to the ongoing research as a database for future use.

Trace elements (TEs) have significant effects on both dental health and human health. Toxic effects are caused by deficiency or excess of TEs. This study was performed to determine levels of toxic and trace elements in incisor and molar teeth sampled from male and female participants residing in the north and south regions of Sudan. The tooth enamel of 18 extracted human teeth was analyzed using particle-induced x-ray emission (mu-PIXE) to determine its elemental profile and distribution. GeoPIXEII software package was used for the analysis of mu-PIXE data. The main elements determined were Na, Mg, P, S, Cl, K, Ca, Mn, Fe, Zn, Co, and Sr which were homogeneously distributed in the areas of the tooth enamel mapped with micro-PIXE.

Introduction: We describe a case of severe abdominal pain following an uneventful upper endoscopy, which led to a diagnosis of hereditary angioedema (HAE). Given symptoms, recent procedure, and pertinent family history, testing was pursued and diagnostic of HAE. Case Description/Methods: Patient is a 27-year-old woman with history of asthma, who presented to an outpatient Gastroenterology appointment due to nausea, bloating, and intermittent abdominal pain. Celiac disease and gastroparesis were ruled out. Patient had an upper endoscopy with normal esophagus, stomach, and duodenum. Biopsies were taken to evaluate for Helicobacter pylori infection and celiac disease. One day post-procedure, patient reported significant epigastric pain, nausea, and emesis. On presentation to the hospital, computed tomography (CT) imaging of the chest, abdomen and pelvis with intravenous contrast demonstrated thickening of gastric antrum and duodenum (Figure 1). Six days post-procedure, patient re-presented to the hospital for ongoing abdominal pain, nausea, emesis and inability to tolerate oral intake. Repeat CT imaging of abdomen and pelvis demonstrated less pronounced gastric thickening, ongoing small bowel thickening, suggestive of enteritis. She was admitted to the hospital. Patient described a family history significant for hereditary angioedema (HAE) in her father, 2 paternal uncles, and paternal grandmother. Testing for HAE was pursued, and revealed low C4 complement, C1 esterase inhibitor, and C1 esterase inhibitor function, which is diagnostic. Patient followed-up with an Allergist who initiated icatibant injection, a bradykinin B2 receptor antagonist, for future symptomatic attacks. Discussion: HAE is an autosomal dominant disease, an estimated 1 in 50,000 people are affected. Tissue swelling in HAE occurs due to a vascular reaction with increased blood vessel permeability, with primary mediator of bradykinin. Intermittent recurrent abdominal pain complaints and family history should prompt consideration of the diagnosis in the differential. HAE management guidelines describe increased risk of angioedema with upper endoscopy, with symptoms typically occurring within 48 hours of procedure. Prophylactic administration of a plasma-derived human C1-inhibitor concentrate is recommended pre-procedurally if diagnosis is known. Our case highlights a patient with intermittent abdominal pain, pertinent family history, and post-procedure symptoms, which ultimately led to the diagnosis of HAE.Figure 1.: CT images with gastric thickening following endoscopic biopsies.

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.

Mohamed Eisa: NO financial relationship with a commercial interest | Vincent Nguyen: NO financial relationship with a commercial interest | Thomas Bierman: NO financial relationship with a commercial interest | Matthew Heckroth: NO financial relationship with a commercial interest | Benjamin Rogers: NO financial relationship with a commercial interest | Paul Tennant: NO financial relationship with a commercial interest | Stephen McClave: NO financial relationship with a commercial interest | Endashaw Omer: NO financial relationship with a commercial interest

Mohamed Eisa: NO financial relationship with a commercial interest | Vincent Nguyen: NO financial relationship with a commercial interest | Matthew Heckroth: NO financial relationship with a commercial interest | Mia Jusufbegovic: NO financial relationship with a commercial interest | Benjamin Rogers: NO financial relationship with a commercial interest | Paul Tennant: NO financial relationship with a commercial interest | Endashaw Omer: NO financial relationship with a commercial interest | Stephen McClave: NO financial relationship with a commercial interest

Cetuximab is an epidermal growth factor receptor (EGFR) inhibitor, which is used to treat patients with metastatic head and neck cancer. Dermatological reactions are the most serious adverse events associated with cetuximab treatment including an acne-like rash, xerosis, and pruritus. Other adverse effects include infections, hypomagnesemia, mucositis, conjunctivitis, nausea, and diarrhea. Mucositis is not only restricted to the oral mucosa, however, can affect any part of the gastrointestinal tract. The duration of treatment-related mucositis has been associated with stricture formation. We describe a case of chronic duodenal and jejunal strictures attributed to cetuximab use.

Vincent Nguyen: NO financial relationship with a commercial interest | Mohamed Eisa: NO financial relationship with a commercial interest | Matthew Heckroth: NO financial relationship with a commercial interest | Mia Jusufbegovic: NO financial relationship with a commercial interest | Benjamin Rogers: NO financial relationship with a commercial interest | Endashaw Omer: NO financial relationship with a commercial interest | Stephen McClave: NO financial relationship with a commercial interest | Paul Tennant: NO financial relationship with a commercial interest

The COVID-19 pandemic has had an unprecedented challenge to the critical care providers caring for those patients, including the delivery of nutrition. This review will address the challenges of gastric versus post gastric feeding in patients in COVID-19 disease. Many societies, including American, British, and Australian recommend initiating of enteral feeding in COVID-19 patients as soon as 24 h of ICU admission or within 12 h after intubation. Consideration for post-pyloric feeding if there is evidence of intolerance to gastric feeding. The same principle for non-COVID-19 critically ill patients applies to COVID-19 patients when it comes to the route of nutritional delivery. Gastric feeding should be initiated as soon as 24 h of admission to the ICU, and post gastric feeding should be reserved to patients who demonstrate gastric feeding intolerance.

The COVID-19 pandemic is a unique disease process that has caused unprecedented challenges for intensive care specialists. The hyperinflammatory hypermetabolic nature of the disease and the complexity of its management create barriers to the delivery of nutritional therapy. This review identifies the key differences which characterize this pandemic from other disease processes in critical illness and discusses alternative strategies to enhance success of nutritional support. Prolonged hyperinflammation, unlike any previously described pattern of response to injury, causes metabolic perturbations and deterioration of nutritional status. High ventilatory demands, hypercoagulation with the risk of bowel ischemia, and threat of aspiration in patients with little or no pulmonary reserve, thwart initial efforts to provide early enteral nutrition (EN). The obesity paradox is invalidated, tolerance of EN is limited, intensivists are reluctant to add supplemental parenteral nutrition (PN), and efforts to give sufficient nutritional therapy remain a low priority. The nature of the disease and difficulties providing traditional critical care nutrition lead to dramatic deterioration of nutritional status. Institutions should not rely on insufficient gastric feeding alone but focus instead on redoubling efforts to provide postpyloric deep duodenal/jejunal EN or re-examine the role of supplemental PN in this population of patients with such severe critical illness.