Introduction: Fecal immunochemical test (FIT) utilizes antibodies to detect the globin (protein) part of hemoglobin. Indications for FIT include screening for colorectal cancer (CRC) and in cases of anemia without any overt gastrointestinal (GI) bleeding. An abnormal FIT could suggest the presence of CRC, polyps, hemorrhoids, or ulcers and should be pursued with a colonoscopy for evaluation. Despite these indications for FIT, we realized there were numerous instances at the VAMC in which FIT was obtained inappropriately inpatient, such as in overt GI bleeding. This quality improvement (QI) project aimed to identify and reduce the situations of inpatient FIT usage, to educate on the proper indications for FIT, and to evaluate the impact on patient outcomes. Methods: A retrospective chart review was performed of 1 year of inpatient FIT usage. Subsequently, weekly pre-intervention questionaire surveys were distributed over 3 months to various VA healthcare providers to gauge baseline understanding of FIT. Then, teaching and educational handouts were provided (Figure 1). Data post intervention was collected over a 3 month period and analyzed. Results: A total of 400 FITs (on average 33/month) were ordered pre-intervention with 20% done on patients with active GI bleeds: abdominal pain and diarrhea were other reasons. Pre-intervention surveys were obtained from 74 individuals; 13% of respondents thought FIT was for GI bleeding while 7% were unsure of FIT indication. Post educational intervention, 89 FITs (on average 30/month) were collected, with the majority of ordering providers of medicine specialty. Anemia was the most common indication for FIT at 64% (Table 1). Of the +FITs, GI was only consulted on 76% of these cases post intervention in which colonoscopy was performed in 38% of these cases. 31% of inpatients with +FITs were critically ill with multiple comorbidities, had no overt GI bleeding, and thus colonoscopy was deferred. Among the FIT+ patients whom did not undergo endoscopic evaluation, about 40% had died from non GI related causes by completion of the study. Conclusion: FIT is overutilized in the hospital setting and it's inpatient role is limited. Despite the lack of difference in the number of FITs ordered pre and post educational intervention, our data suggests +FITs did not affect patient outcome or clinical management. We propose decreased usage of FIT in the acute inpatient setting with a plan for continued educational intervention and setting forth limitations to ordering providers.Figure 1.: Educational handouts on FIT usage were provided to healthcare providers.Table 1.: Reasons for Ordering FIT pre vs post intervention.

Shergill and McQuaid1Shergill A.K. McQuaid K.R. Ergonomic endoscopy: an oxymoron or realistic goal?.Gastrointest Endosc. 2019; 90: 966-970Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar explore the very important topic of ergonomics in endoscopy. Indeed, the current endoscope design is suboptimal, and manufacturers should improve ergonomics to mitigate endoscopic-related injuries. However, equally important, an endoscopist’s ergonomic approach to handling the endoscope (as it is currently designed) is pivotal, yet is seldom addressed in any systematic way during training in the United States. Importantly, the 2 most recent ASGE documents related to training do not even mention the issue.2Adler D.G. Bakis G. Coyle W.J. et al.Principles of training in GI endoscopy.Gastrointest Endosc. 2012; 75: 231-235Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar,3Sedlack R.E. Coyle W.J. Obstein K.L. et al.ASGE's assessment of competency in endoscopy evaluation tools for colonoscopy and EGD.Gastrointest Endosc. 2014; 79: 1-7Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar What can we do to bring ergonomics in endoscopy to the forefront? Ergonomics should be formally incorporated in the American Society for Gastrointestinal Endoscopy (ASGE) endoscopy training guidelines, including the “Principles of training in GI endoscopy” and the “Assessment of competency evaluation tool.”2Adler D.G. Bakis G. Coyle W.J. et al.Principles of training in GI endoscopy.Gastrointest Endosc. 2012; 75: 231-235Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar,3Sedlack R.E. Coyle W.J. Obstein K.L. et al.ASGE's assessment of competency in endoscopy evaluation tools for colonoscopy and EGD.Gastrointest Endosc. 2014; 79: 1-7Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar The way we teach and perform endoscopic procedures should focus not only on safely achieving the procedure goal (from a patient’s perspective) but also on proper ergonomics, thus minimizing the risk of endoscopy-related injuries.4Siau K. Anderson J.T. Ergonomics in endoscopy: should the endoscopist be considered and trained like an athlete?.Endosc Int Open. 2019; 7: E813-E815Crossref PubMed Google Scholar Each procedure should be dissected into its components and taught in a standardized manner. This may not necessarily be the only or “best” way to perform the procedure but would be a mutually agreed-upon way to teach the procedure in a standardized fashion during training. We should implement a standardized approach of teaching endoscopy, which requires “buy-in” from endoscopy trainers. Fortunately, we can tap into the wealth of experience from the programs in training the trainers (TTT) and colonoscopy skills improvement that have been successfully run for many years in the United Kingdom, Canada, and other countries.5Waschke K.A. Anderson J. Macintosh D. et al.Training the gastrointestinal endoscopy trainer.Best Pract Res Clin Gastroenterol. 2016; 30: 409-419Crossref PubMed Scopus (32) Google Scholar,6Coderre S. Anderson J. Rostom A. et al.Training the endoscopy trainer: from general principles to specific concepts.Can J Gastroenterol. 2010; 24: 700-704Crossref PubMed Scopus (17) Google Scholar The TTT programs emphasize formal training of endoscopy trainers toward conscious competence, rather than considering an endoscopy trainer’s personal ability to perform endoscopy as a surrogate of his or her ability to effectively teach endoscopy.5Waschke K.A. Anderson J. Macintosh D. et al.Training the gastrointestinal endoscopy trainer.Best Pract Res Clin Gastroenterol. 2016; 30: 409-419Crossref PubMed Scopus (32) Google Scholar,6Coderre S. Anderson J. Rostom A. et al.Training the endoscopy trainer: from general principles to specific concepts.Can J Gastroenterol. 2010; 24: 700-704Crossref PubMed Scopus (17) Google Scholar Furthermore, these programs go beyond the mechanics of endoscope handling; they also aim to identify essential endoscopy teaching competencies,7Kumar N.L. Smith B.N. Lee L.S. et al.Best practices in teaching endoscopy based on a Delphi survey of gastroenterology program directors and experts in endoscopy education.Clin Gastroenterol Hepatol. 2020; 18: 574-579Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar,8Anderson J.T. Optimizing ergonomics during endoscopy training.Tech Gastrointest Endosc. 2019; : 143-149Abstract Full Text Full Text PDF Scopus (5) Google Scholar including how to effectively provide feedback to the trainee during training.8Anderson J.T. Optimizing ergonomics during endoscopy training.Tech Gastrointest Endosc. 2019; : 143-149Abstract Full Text Full Text PDF Scopus (5) Google Scholar,9Dilly C.K. Sewell J.L. How to give feedback during endoscopy training.Gastroenterology. 2017; 153: 632-636Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar Skills programs are taught by TTT-trained endoscopists and place a significant emphasis on teaching the manual techniques and manipulation of the endoscope (eg, where to place the endoscope umbilicus, hand and finger positioning at the head of the endoscope, preferably using torque steering rather than wheel steering). Importantly, the techniques that are endorsed during training pay special attention to ergonomics and minimizing tension. A standardized, ergonomically centered approach to endoscopy training in the United States is warranted to improve both patient and endoscopist outcomes. Ultimate implantation of this approach will require ASGE involvement from the top. Dr Yang is a consultant for Boston Scientific, Lumendi, and Steris. Dr Draganov is a consultant for Olympus, Cook Medical, Boston Scientific, MicroTech, Lumendi, and Fuji Film. The other authors disclosed no financial relationships. Ergonomic endoscopy: An oxymoron or realistic goal?Gastrointestinal EndoscopyVol. 90Issue 6PreviewThe current endoscope design is not ergonomic. There is a high prevalence of endoscopy-related injury reported in the literature, and studies have demonstrated high-risk biomechanical exposures during the performance of routine colonoscopy. Endoscopy ergonomics focuses on understanding the endoscopist’s interaction with the endoscope and the endoscopy unit and re-designing these tasks to minimize the risk of endoscopy-related injury. The discussion to date has focused on what the endoscopist can do to minimize his or her risk of injury. Full-Text PDF

We reviewed the literature in order to determine the best system to develop a training program for third space endoscopic procedures in the West. There has been a steady growth in the number and type of advanced endoscopic procedures over the past several decades, including the expansion of “third-space” or submucosal endoscopy. Most of our knowledge on training in third-space endoscopy stems from the East, with a lack of consensus regarding the optimal training model for Western endoscopists. We review the current literature and provide insight into a potential training algorithm that can be adopted in the West. A multipronged, stepwise training approach, involving self-directed learning, exposure courses, hands-on explant models, observation of experts, followed by performing cases with gradually increasing difficulty preferably under direct supervision, is the foundation for third-space endoscopy training in the West. Learning and performing third-space endoscopy in the West will continue to be facilitated by the ongoing development of dedicated devices and accessories and the establishment of training benchmarks.

A 42-year-old woman with a history of cholangiocarcinoma on adjuvant chemotherapy with capecitabine presented with painless haematochezia. She was found to have an isolated twenty-five mm ulcer in the ascending colon. Biopsies of the ulceration demonstrated typical cytomegalovirus (CMV) inclusions and her peripheral blood CMV PCR was significantly elevated. This is an unusual case of a solitary proximal colon ulcer. Non-steroidal anti-inflammatory drugs, inflammatory bowel disease and malignancy, are the most frequent causes of isolated ulcers in the proximal colon. Gastrointestinal (GI) CMV disease most commonly causes CMV colitis and is considered rare outside of the transplant population and other severely immunosuppressed patient groups. Patients who have received chemotherapy may also be at risk for GI CMV disease. The diagnosis should be suspected in patients who present with haematochezia or watery diarrhoea within a broad window of time after receiving chemotherapy.

Background Endoscopic dilation of postlaryngectomy strictures (PLS) is safe and effective; however, PLS are often refractory and require serial dilations. Long-term outcomes of dilation in patients with refractory PLS are not well reported. Materials and Methods Seven patients with dysphagia and refractory PLS underwent serial endoscopic dilation therapy during a 4.5-year period. Dilation characteristics, technical success, clinical success, and diet advancement (as assessed by Diet/GT scale) were measured. Results. All strictures were complex, and there were no reported complications. The median number of dilations per patient was 12 (range 7 to 48). The average interval in between dilations was six weeks. Technical success was achieved in 6/7 patients, and clinical success was achieved in 2/7 patients. 6/7 patients had advancements in Diet/GT scores. Conclusions Dilation of refractory PLS is safe and effective and frequently requires the use of a retrograde approach, fluoroscopic guidance, and/or lumen patency strings. Serial dilations are required to maintain luminal patency, relieve dysphagia, and advance oral diet. The definition of clinical success of dilation in these patients should avoid the use of a specific time interval between dilations to characterize success.

Background: After inpatient management of upper gastrointestinal bleeding (GIB) due to peptic ulcer disease (PUD), oral proton pump inhibitor (PPI) therapy is recommended at discharge to decrease re-bleeding risk and improve ulcer healing. Our aim is to determine whether once-daily oral PPI dosing at hospital discharge is associated with inferior 30-day rebleeding outcomes as compared to twice-daily dosing. Methods: We retrospectively identified 233 patients admitted with signs and symptoms of upper GIB found to be due to PUD on upper endoscopy. After inpatient management, patients discharged on once-daily oral PPI were compared to those discharged on twice-daily therapy. We utilized propensity score matching based on Rockall scores to ensure the two groups were closely matched in terms of their baseline rebleeding risk. Primary outcome was the incidence of rebleeding within 30 days. Secondary outcomes were all-cause mortality, blood transfusion requirement, requirement for interventional radiology or surgery. Results: Overall, 49 patients were discharged on once-daily and 184 on twice-daily PPI. Recurrent bleeding occurred in 18 patients (7.7%) within 30 days. There was no statistically significant difference in recurrent bleeding rates between once-daily (n = 7, 14.3%) as compared to twice-daily PPI (n = 11, 6%) (P = 0.053). In a 1:1 propensity score matched analysis, there was no statistically significant difference in 30-day recurrent bleeding rate between groups (14% once-daily vs. 4% twice-daily, P = 0.159). There were no differences in secondary outcomes. Conclusions: Once-daily oral PPI dosing at hospital discharge was not associated with inferior outcomes compared to twice-daily dosing in patients hospitalized for upper GIB due to PUD.

Patients with inflammatory bowel disease (IBD) commonly require surgery despite the availability of an increasingly large repertoire of powerful immunosuppressive medications for the treatment of IBD. Optimizing patients' care preoperatively is crucial to obtaining good surgical outcomes. This review discusses preoperative assessment and management principles including assessing disease location and activity with cross-sectional or endoscopic imaging, addressing modifiable risk factors (i.e., stopping smoking, weaning steroids, and correcting anemia), and properly managing medications. The major focus of our literature review is the evaluation for malnutrition, a common finding that affects up to 70% of patients with IBD and a well-known, independent risk factor for adverse postoperative outcomes. Our review confirms that whenever feasible, oral or enteral nutrition (EN) is the preferred method of nutritional support; parenteral nutrition (PN) should be reserved for nutritionally deficient IBD patients unable to tolerate EN. In selected patients, recent data demonstrated that the use of preoperative PN resulted in improved nutritional status, fewer postoperative complications, and reduced disease severity. Our review highlights the need for well-designed, prospective trials investigating perioperative nutritional support in patients with IBD. Future studies should perform modern nutritional assessment, standardize for diet, and include patients with UC since this subset of patients is underrepresented in existing studies. In addition, relevant outcome of interest specific to Crohn's disease (CD) patients such as length of small bowel resected, number of anastomoses, and need for an ostomy should be included as these patients may require repeated small bowel resections.

A 71-year-old woman who had previously undergone cholecystectomy several years prior presented with nausea, vomiting, and right upper quadrant abdominal pain.Computed tomography of her abdomen revealed a dilated common bile duct measuring 11 mm in diameter.She underwent endoscopic retrograde cholangiopancreatography (ERCP) for evaluation.A sphincterotomy with balloon extraction revealed several white stones as the cause of her choledocholithiasis (Figure 1).Her symptoms resolved, and she fully recovered to her previous state of health.

Endoscopic dilation of proximal esophageal strictures that develop after head and neck cancer treatment is safe and effective; however, these strictures are often refractory and require serial dilations. Long-term outcomes of dilation in patients with refractory post-laryngectomy esophageal anastomotic strictures (PLEAS) are sparse. We investigated the safety and success of frequent serial endoscopic dilation in this population and attempted to identify possible risk factors associated with the development of refractory PLEAS. We performed a retrospective study of 7 patients with dysphagia and refractory PLEAS that were dilated during a 4.5-year period (118 dilations; median follow-up period, 11 months; average follow-up period, 17.6 months). A stricture was refractory if luminal patency of ≥14 mm could not be achieved after ≥5 dilation sessions at intervals of 2 to 4 weeks. Technical success was achieved when a stricture could be dilated at least 3 mm during initial dilation. Clinical success was defined as ability to advance diet consistency (ie. from liquids to solids) from baseline diet at start of study period and the need for repeat dilation being no fewer than every 12 weeks. All 7 patients underwent total laryngectomy (TL) for treatment of SCC of the larynx (Table 1). Bougie dilators were used for dilation in all patients. All strictures were complex. Retrograde approach and fluoroscopic guidance were used in 5 and 4 patients, respectively. A lumen patency string was placed in 4 patients (average time of string kept in place 26 weeks). Average diameter of esophageal stenosis at time of first dilation was 4.3 mm (median 3 mm). Maximum caliber dilator passed was 18 mm in 6 of 7 patients. Mean number of dilations per patient was 17 (range 7 to 48) and average interval in between dilations was 6 weeks. Of the 7 patients, 6 had advancements in their best tolerated diet (Table 2). At study end, 4 of 5 patients who were G-tube dependent at start of study still had their G-tube in; however, 2 were not using their G-tube at all and 3 were tolerating a soft-regular diet. Technical success was achieved in 6/7 patients and clinical success was achieved in 2/7 patients. There were no complications. Endoscopic dilation of refractory PLEAS is safe and effective. Dilation of these strictures frequently requires use of retrograde approach, fluoroscopic guidance, and/or luminal patency strings. Serial dilations are required to maintain luminal patency, relieve dysphagia, and advance a patient's best tolerated diet. Given this, the need arises to modify the definition of clinical success in these patients, specifically avoiding the use of a specific time interval between dilations to characterize success. In addition, due to the anatomy and proximal nature of PLEAS, use of stents is not well tolerated.Tabled 1Table 1: Patient Characteristics and Dilation ResultsPatient #AgeSexMalignancy treatmentTime since laryngectomy at study end, weeksSize of stenosis at time of first dilation, diameter in mm(*) Max luminal diameter achieved by study end, mmMax caliber dilator passed, mm (Fr)Number of dilations at study endAverage time interval between dilations, weeksTechnical success?Clinical success?160MPrimary total laryngectomy with left radial forearm free flap with post-op chemoradiation4051018 (54)123.9YesNo269FSalvage total laryngectomy with left pectoral and right sternocleido-mastoid flaps; chemoradiation prior to surgery852618 (54)143.8YesNo358FSalvage total laryngectomy with initial XRT prior to surgery, then also post-op chemoradiation3382616 (48)156YesNo458MSalvage total laryngectomy with left pectoral flap; chemoradiation prior to surgery1023618 (54)124.5YesNo561MPrimary total laryngectomy with post-op chemoradiation212101218 (54)1013YesYes650FSalvage total laryngectomy with left pectoral flap; XRT prior to surgery2370 ("complete lumen occlusion")1118 (54)483.5NoNo764MPrimary total laryngectomy with post-op XRT7098918 (54)78.5YesYes Open table in a new tab

Primary adrenal leiomyosarcoma (PAL) is an extremely rare mesenchymal tumor with only a few isolated case reports in the medical literature. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) or endoscopic ultrasound-guided core biopsy (EUS-CB) is a safe, effective modality for sampling lesions in the gastrointestinal tract and adjacent organs, including the adrenal glands. We describe the case of a 50-year-old male presenting with abdominal pain and unintentional weight loss over the course of one year. CT imaging revealed an 8.1 cm heterogeneous left adrenal mass with PET-confirmed metastases to the liver and lung. Pheochromocytoma was ruled out. Adrenal cortical carcinoma was the other critical differential diagnosis. As the patient was not a candidate for surgery, an EUS-FNA and CB were performed on this left adrenal mass revealing a spindle cell neoplasm with extensive necrosis confirming the diagnosis of primary leiomyosarcoma. The patient was treated with chemotherapy with palliative radiation. This case demonstrates the utility of EUS-FNA or CB as modalities that can aid in the diagnosis of adrenal lesions in specific circumstances.

We present the case of a 56-year-old woman with a contained esophageal perforation caused by ingestion of a chicken bone. Esophageal perforation is a life-threatening event that requires prompt diagnosis and treatment. Overall mortality can range from 20% to 30% but may increase as time passes without intervention. Common causes of esophageal perforation include medical instrumentation, foreign-body ingestion, and trauma. Most foreign-body perforations are due to either fish or chicken bones. They puncture the esophageal wall directly or can cause perforation by pressure necrosis, ultimately leading to perforation. The usual esophageal sites affected are the 3 natural anatomic narrowings: the cricopharyngeus, the crossing of the left main stem bronchus or aortic arch, and the gastroesophageal junction.1Nandi P. Ong G.B. Foreign body in the oesophagus: review of 2394 cases.Br J Surg. 1978; 65: 5-9Crossref PubMed Scopus (457) Google Scholar Management depends on several factors, including the cause, site, and size of perforation; the time elapsed between perforation and diagnosis; any underlying esophageal disease; and the overall health status of the patient.2Tsalis K. Blouhos K. Kapetanos D. et al.Conservative management for an esophageal perforation in a patient presented with delayed diagnosis: a case report review of the literature.Cases J. 2009; 2: 6784-6786Crossref PubMed Google Scholar A 56-year-old woman presented to the emergency department with odynophagia and associated vomiting with attempts of oral intake after ingesting a chicken bone 4 days earlier. CT of the chest with intravenous (IV) contrast material (Fig. 1) revealed a linear density, 2.5 cm in length, below the larynx with a small air pocket at the right lateral aspect of the esophageal wall, concerning for a contained perforation. She was given IV fluids and empiric antibiotics for sepsis and transferred to a tertiary care center. Upper endoscopy (Video 1, available online at www.VideoGIE.org) revealed a 3-cm chicken bone lodged horizontally at the upper third of the esophagus, 13 to 14 cm from the incisors (Fig. 2). The endoscope was removed, and a transparent endoscopic cap was placed over the tip of the endoscope to help with tissue movement. The chicken bone was then grasped at its end with a Raptor grasping device (US Endoscopy, Mentor, Ohio) (Fig. 3), withdrawn into the distal endoscopic cap, and extracted. The cap allowed for protection from further esophageal injury related to the sharp end of the chicken bone. The site of the bone impaction was investigated further, with the identification of 2 localized severe mucosal changes, characterized by ulceration in the upper third of the esophagus (Fig. 4).Figure 3Forceps removal of bone in distal cap.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 4Ulcer at site of bone impaction.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The superior area of mucosal damage 13 cm from the incisors on the right medial side revealed pus draining from the site (Fig. 5). The inferior ulceration 14 cm from the incisors appeared to be superficial mucosal damage. Because of concern for an underlying abscess and after collaboration with trauma surgery during the case, no further intervention was performed and conservative management was deemed best for her care. Figure 6 shows the chicken bone measured at 3 cm. The patient remained nil per os until repeated CT. The patient remained nil per os until repeated CT esophagram without IV contrast and with oral contrast was performed. This revealed no sign of extravasation of contrast material. The patient was discharged safely a few days later.Figure 6Chicken bone measured at 3 cm.View Large Image Figure ViewerDownload Hi-res image Download (PPT) This case illustrates that EGD can be performed with therapeutic intent even in cases of esophageal perforation. Each patient with esophageal perforation should be treated on an individual basis. In this case, conservative management with IV antibiotics and imaging was indicated, inasmuch as placing a wall stent would have risked worsening of the abscess from lack of drainage or spilling of pus into the intrathoracic space. A CT should always be part of the initial management, and empiric antibiotics should be initiated because of the risk of sepsis.3Li N. Manetta F. Iqbal S. Endoscopic management for delayed diagnosis of a foreign body penetrating the esophagus into the lung.Saudi J Gastroenterol. 2012; 18: 221-222Crossref PubMed Scopus (3) Google Scholar If there is concern for perforation, gastrograffin should be used as oral contrast material for imaging. Carbon dioxide should be used for insufflation during EGD, and a cap should be used to protect the esophagus from the sharp end of the bone during extraction. A multidisciplinary team including surgery, gastroenterology, pulmonology, and medicine should be part of the treatment of such patients. Dr Draganov is a consultant for Boston Scientific, Cook Medical, Olympus America, and Conmed. All other authors disclosed no financial relationships relevant to this publication. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJmM2Q4YjdjMGIyYjM5ODI1NDhiMjBmYWZhMjZlNzZjZiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4NTk4ODgwfQ.mwnYpKJUBWy5ozg262tOwn-ekMGPKfEb93WwbSl3SmNJf-PZlghAwsb_FpEAAmHPwaWnB_cGfKLZDCCfs7YZqaeg13PDNlgECaHCzgURS6T-tXvh6q2_GZkj18xqS-VbkrhZXTJYBx0JEBOQqlG-TpX3lNgWZwKAV9V_zuQlxZ3UZmI0X--RpWNelthANjoxL3E0_76-BYh8AMV9R5ISLRRSa4UFt5gAJMeZuMIJuDzm5-joYbvzO4ijtvJ9_URIR2k3HSmfQuvMLAg6ugUq_yLYALbVOKiLVlPf2e4MXGjMznmV6vpwl9ZrkFUNI7aur4h3THjWRjsXM7E8p442Bg Download .mp4 (21.32 MB) Help with .mp4 files Video 1Contained esophageal perforation. Endoscopic removal of chicken bone. Download .docx (.01 MB) Help with docx files Video Script

Colonic inflammation seen in inflammatory bowel disease (IBD) predisposes to the development of colorectal adenocarcinoma. In contrast, colorectal neuroendocrine carcinomas (NECs) have rarely been reported in the setting of IBD, and no definitive relationship between these tumours and IBD has been established. Dysplasia from chronic inflammation leading to neuroendocrine cell differentiation may be responsible for NEC development, though this finding has not been seen consistently. We present a case of large-cell neuroendocrine carcinoma of the sigmoid colon in a 65-year-old woman with long-standing ulcerative colitis. Although she underwent regular endoscopic follow-ups and was receiving the tumour necrosis factor alpha inhibitor infliximab, her tumour was large and aggressive, with metastases to the liver discovered at time of diagnosis. This case highlights the aggressive nature and poor prognosis of NECs and stresses the need to identify patients at high risk of developing NECs and develop improved surveillance guidelines for detecting them.

Foreign body ingestion is a commonly encountered problem and can cause significant morbidity and mortality. When removal of a foreign body from the upper gastrointestinal tract is indicated, endoscopy is the modality of choice and has a high reported success rate. However, in less than 1% of cases, endoscopic removal of a foreign body is unsuccessful and surgical intervention is necessary. We report a unique case of a large, sharp metallic spring swallowed by an incarcerated patient which subsequently became lodged in his upper thoracic esophagus. This spring was unable to be removed endoscopically due to risk of perforation and cervical esophagotomy was needed for its successful removal, illustrating the limitations of endoscopic techniques in removal of foreign bodies and the role surgical intervention has in these rare instances.