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.

Malignant rectal strictures are uncommon, but they may pose a diagnostic challenge in clinical practice. We report the case of an 85-year-old male with an initially puzzling presentation of abdominal distention and discomfort. The patient was ultimately diagnosed with a rectal stricture caused by a plasmacytoid variant of urothelial cell carcinoma originating from the bladder. This case emphasizes the necessity of considering unique etiologies when evaluating rectal strictures and the aggressive character of this type of urothelial carcinoma.

Introduction: Non-Hodgkin lymphoma is made from the B-cell lineage and includes Burkitt lymphoma. Burkitt lymphoma is associated with EBV and HIV. Although it is common for other B-cell lymphomas to develop in the stomach, it is less common for Burkitt lymphoma tumors to manifest there. Additionally, primary and/or secondary involvement of the duodenum, pancreas, and intestines is very rare in Burkitt lymphoma. Case Description/Methods: 52-year-old man with a medical history significant for heart failure and multiple comorbidities presented with melena and abnormal weight loss. The patient had history of two months of chronic jaw abscess and osteomyelitis who was being managed by infectious disease and maxillofacial surgery. Patient presented with melena, fatigue, abdominal distension as well as unintentional weight loss of 35-40 lbs. Laboratory investigation showed hemoglobin of 10 g/dl (baseline around 14 g/dl), normal MCV, elevated white cell count at 23.0 K/ul, and normal platelet count. His blood chemistry was remarkable for elevated BUN and elevated LDH >1500 units/L. CT scan of the abdomen showed a thickening of the gastric wall, some irregularity noted in the lateral aspect of the stomach, and mild thickening at the level of the first and second portions of the duodenum. The patient was resuscitated, transfused, and stabilized. EGD was performed and showed evidence of 2 large 4cm deep ulcers (clean based) identified at the lesser curvature of the stomach. Ulcer edge biopsies were taken per protocol. Gastric ulcer biopsy pathology showed high-grade B-cell lymphoma consistent with Burkitt’s lymphoma. Later, the patient’s jaw abscess and lesion were biopsied and also showed evidence of Burkitt’s lymphoma. The patient’s hospital course was complicated by cardiac arrest secondary to tumor lysis syndrome (Figure 1). Discussion: The primary involvement of BL or a small non-cleaved cell lymphoma in the GI tract is rare. Despite gastric lymphomas being more common than intestinal lymphomas, primary gastric involvement is extremely rare in BL. For non-endemic Burkitt’s lymphoma, the gastrointestinal tract is the most common site, followed by the retroperitoneal, kidney, ovary, and testes respectively. Gastric ulcers namely peptic ulcer disease is one of the most common causes of upper GI bleeding, however, the presence of atypical features during endoscopy such as ulcer size and depth should raise the suspicion of neoplastic process and biopsies should be performed per protocol.Figure 1.: Burkitt's histopathology and endoscopic findings.

Introduction: Bladder urothelial carcinoma rarely spreads to the gastrointestinal tract.The occurrence of rectal stricture due to infiltration by bladder cancer is relatively rare. We herein report the case of a patient who presented with aggressive bladder cancer that resulted in rectal infiltration and partial obstruction. Case Description/Methods: 85-year-old man with no significant medical history, who presented with complaints of epigastric discomfort, distention as well as unintentional weight loss of around 25 pounds in 3 months. Physical examination was remarkable abdominal distension, mild tenderness and a tympanic note on percussion with no succession splash was appreciated. Bowel sounds were sluggish. No signs of the acute abdomen were present. The patient declined a digital rectal examination. Initial work-up with CT abdomen showed no evidence of small bowel obstruction, there was marked dilation of the stomach with gas and fluid, there is also thickening of the visualized distal esophagus, and there is a large stool burden. Labs were unremarkable. EGD was performed and was unremarkable. The patient did well for 2 days following the EGD, diet was slowly advanced and was well tolerated. The next day he started experiencing the same symptoms again of abdominal distension and mild discomfort. CT of the abdomen and pelvis with IV contrast was repeated with findings of small and large bowel distension and non-specific circumferential rectal wall thickening. Flexible sigmoidoscopy was performed with findings of a 5 cm long rectal stricture surrounded with what appears to be multiple submucosal nodules, no mucosal masses were identified, and biopsies were obtained (Figure 1). Pathology came back with a plasmacytoid variant of urothelial cell carcinoma. Cystoscopy was performed with findings of non-specific bladder wall thickening, biopsies were obtained, and confirmed the same pathology taken from the rectum. Unfortunately, the patient’s clinical condition deteriorated rapidly, the family declined chemotherapy and surgery was not an option, the palliative/hospice route was elected and the patient passed away a few days later. Discussion: Invasive bladder cancer rarely infiltrates into the rectum and is known for the difficulty of diagnosis by colonoscopy. Furthermore, the secondary rectum tumor due to bladder cancer had a poor record for survival in the literature review.Figure 1.: Endoscopic view of rectal stricture and histopathology.

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

Introduction: Altmetric Attention Score (AAS) is an emerging tool to assess the reach of published literature, with adoption by major scientific journals as a tool in assessing dissemination. The association between citations and AAS has not been extensively studied, especially among highly cited articles. The goal of our study was to assess the correlation between citations and AAS in the American Journal of Gastroenterology and Gastroenterology Journal. Methods: Using the Publish or Perish tool by Harzing, we collected the top 4000 most highly cited articles in the Gastroenterology Journal and the American Journal of Gastroenterology for the years 2009 – 2018 using the data available on google scholar, we then ranked them according to per year citation average. The top one hundred articles from each journal with a total of 200 articles were chosen and we subsequently evaluated the AAS that was available through the attention score reported via Altimetric booklet, which represents a weighted approximation of all the attention and the level of online activity surrounding a research output and is based on 3 main factors: volume, sources, and authors. Spearman correlation coefficient was calculated to assess the correlation between average citations per year for articles and their AAS. Results: Fourteen articles were excluded from analysis as they did not have an AAS, for the remaining 186 articles the Spearman correlation coefficient was 0.437 (P< 0.001), signifying a moderate positive correlation between AAS and citations per year, Figure 1. The mean citations per year was 118 with a standard deviation of 74 and the mean for the attention score was 115. The article that had the highest citations per year average was published in 2012 in Gastroenterology while the highest attention score reported was for an article published in 2013 also in Gastroenterology. Conclusion: Our analysis revealed a moderate positive correlation between average citations per year and AAS, thus, we believe this could potentially be a valid tool when assessing the reach and gained attention of published literature. However, bigger studies must be performed to ensure our results can be generalized to all published literature in different specialties, journals and especially in different parts of the world where social media may not be a contributing factor in spreading literature and published articles.Figure 1.: Spearman correlation coefficient was 0.437 (P<0.001), signifying a moderate positive correlation between AAS and citations per year.

Introduction: Dysphagia secondary to vascular abnormalities is a rare condition, with a prevalence of less than 1%, that occurs through secondary compression of the esophagus posteriorly by an abnormal intrathoracic vascular structure. It commonly presents with dysphagia to solids. Management is usually done with dietary modification; however, more severe, and intractable cases may require surgical intervention. We describe this rare entity in a 56-year-old man presenting with mechanical dysphagia secondary to dilated azygous and hemi-azygous vein resulting from chronic IVC stenosis. Case Description/Methods: A 56-year-old man with a long-standing history of recurrent dysphagia for solids along with other comorbidities including CAD with cardiomyopathy and atrial fibrillation on long-term anticoagulation presents with recurrent debilitating dysphagia associated with weight loss. The patient’s initial evaluation included a barium esophagogram that showed and small size sliding hiatal hernia as well as an esophageal ring, which was followed by went through multiple endoscopic evaluations with an EGD and dilation that did not show evidence of an actual ring and resulted in very minimal improvement in symptoms most recently one week prior to presentation. Cross-sectional imaging was ordered to rule out the possibility of intrathoracic mass or malignancy that showed significant narrowing of the inferior vena cava as it courses above the renal vein and through the liver (Figure 1). There is a significantly dilated azygous and hemiazygous vein that compresses the esophagus between the aorta, left atrium, and azygous vein. The patient underwent a venogram that confirmed the findings mentioned on CT imaging followed by multiple sessions of IVC venoplasty by interventional radiology resulting in significant and steady improvement of the patient’s dysphagia symptoms over time. Discussion: Persistent and recurrent dysphagia mainly for solids with unremarkable endoscopic evaluation and minimal response to dilation should prompt the clinician to either evaluate for a motility dysfunction or extrinsic compression by intrathoracic structure in the right clinical setting. Vascular compression of the esophagus resulting in dysphagia is rare, yet amenable to intervention resulting in symptoms improvement, a high index of clinical suspicion id required for diagnosis.Figure 1.: Cross-sectional imaging.

Introduction: The WallFlex Esophageal Stent from Boston Scientific is a self-expanding metal stent used to maintain esophageal lumen patency in esophageal strictures caused by intrinsic and/or extrinsic malignancies and the occlusion of concomitant esophageal fistulas. While data on the efficacy and safety of esophageal stents exist, comprehensive evaluation of adverse events are limited. The aim of this study is investigate the reported adverse events and device failures associated with WallFlex esophageal stents using the FDA's Manufacturer and User Facility Device Experience (MAUDE) database. Methods: Data were analyzed from post-marketing surveillance data for the WallFlex Esophageal Stent (both fully and partially covered) using the FDA's MAUDE database from January 2014 to May 2023. The primary outcomes were patient-related adverse events and intrinsic device malfunctions and/or failures. Secondary outcomes included the management of adverse events. Statistical analysis was performed using Microsoft Excel 2010. Pooled numbers and percentages were calculated for each adverse event on the device and patient. Results: Over the timeframe of 10 years, only 140 device failures and 191 patient-related adverse events were reported. Device failures (Figure 1A) were predominantly due to activation, positioning, or separation problems (n=52, 27.2%) and device detachment or migration (n=38, 19.9%). Most device failures were managed by removal of the stent and placing another WallFlex stent (n=41, 35.7%). The majority (n= 78, 55%) of patient-related adverse events (Figure 1B) were asymptomatic (no harm or consequences to the patient). This is followed by no unviable codes (n=21, 15%), and dysphagia/odynophagia (n=12, 8.6%). Subgroup analysis comparing covered and partially covered stents revealed that covered stents had a higher frequency of activation, positioning, or separation problems (37.4% vs 17%, P-value = 0.04). In comparison, partially covered stents had a higher frequency of device migration or detachment (23.4% vs 19.2%, P-value = 0.07). Conclusion: The WallFlex stent has proven to be an effective device for the palliation and treatment of esophageal strictures with an overall low number of voluntary reported patient related adverse events or device malfunctions. This information should allow endoscopists to be more cognizant of device related malfunctions/failures and could potentially be used to optimize device design for future iterations.Figure 1.: A: Device Failures associated with WallFlex Esophageal Stents. B: Patient-related adverse Events associated with WallFlex Esophageal Stents. Device or Use Problems (Adverse Event Without Identified Device or Use Problem, Human-Device Interface Problem, Use of Device Problem), Activation, Positioning or Separation Problem (Activation Failure, Activation, Difficult or Delayed Positioning, Positioning or Separation Problem, Positioning Failure, Positioning Problem), Material or Component Problems (Break, Material Deformation, Material Integrity Problem, Material Puncture/Hole), Device Detachment or Migration (Detachment of Device or Device Component, Migration), Device Markings or Packaging Problems (Device Markings/Labelling Problem, Device Packaging ), Difficulties with Device (Difficult to Advance, Difficult to Remove. Pain related, Bleeding-related (hematemesis/ Bleeding/hemorrhage), Problems with No Impact or Consequence (No Impact or Consequence, No Clinical Signs, Symptoms or Conditions, No Consequences Or Impact To Patient) others (erosion, perforation, sedation, injury).