Background and Aims Periampullary subepithelial lesions are generally removed by surgery. We demonstrate a video of endoscopic resection of a periampullary duodenal paraganglioma. Methods A combination of ERCP and ESD skills were used to facilitate separation of the subepithelial lesion from the ampulla and lesion resection. Results En-bloc resection with negative margins was achieved. Pathology confirmed a gangliocytic paraganglioma. Conclusions Endoscopic resection is a feasible and less-invasive alternative to pancreaticoduodenectomy for select periampullary subepithelial lesions.

Introduction: Biliopancreatic diversion with duodenal switch (BPD/DS) is an uncommon type of bariatric surgery that can rarely lead to bleeding in the biliopancreatic limb. The altered anatomy poses significant diagnostic and therapeutic challenges. Case Presentation: We present an unusual case of a woman status post-BPD/DS nearly a decade ago who presented with gastrointestinal bleeding in the duodenum of the biliopancreatic limb, a rare phenomenon given the unique surgery. Conclusion: We illustrate a promising minimally invasive option of successfully treating the bleeding by interventional radiology (IR) embolization as an alternative to more invasive and challenging options of balloon-assisted enteroscopy, lumen-apposing metal stent placement and surgical intraoperative enteroscopy.

ObjectivesThe objective of this pilot study was to compare the performance of contrast-enhanced EUS (CE-EUS)-guided fine-needle aspiration (FNA) with EUS-FNA for lymph node (LN) staging in esophageal cancer.MethodsThirty-seven subjects with esophageal cancer undergoing EUS staging were enrolled, and 30 completed this institutional review board-approved study. A Prosound F75 US system (Hitachi Medical Systems, Tokyo, Japan) with harmonic contrast imaging software and GF-UCT180 curvilinear endoscope (Olympus, Tokyo, Japan) was utilized. All LNs identified by standard EUS were first noted. Sonazoid (dose: 1 mL; GE Healthcare, Oslo, Norway) was administered peritumorally, and all enhanced LNs were recorded. Fine-needle aspiration was performed on LNs considered suspicious by EUS alone, as well as LNs enhanced on CE-EUS. Performance of each modality was compared using FNA cytology as reference standard.ResultsA total of 132 LNs were detected with EUS, of which 59 showed enhancement on CE-EUS. Fifty-three LNs underwent FNA, and 22 LNs were determined to be malignant. Among the latter, 10 were considered suspicious by EUS, whereas the other 12 LNs underwent FNA only because of CE-EUS enhancement. Contrast-enhanced EUS showed enhancement in 19 of the 22 malignant LNs. The rate of metastatic node identification from EUS was 45% (10/22), and it was 86% (19/22; P = 0.008) for CE-EUS. Eight subjects (8/30 [27% of study total]) had nodal status upgraded by the addition of CE-EUS, which influenced LN staging and clinical management.ConclusionsFine-needle aspiration of LNs identified by CE-EUS may increase metastasis positive rate by ruling out LNs not associated with the tumor drainage pattern. In addition, CE-EUS seems to identify more metastatic LNs that would not be biopsied under the standard EUS criteria.

Syphilis is a common infection that has variable presentations. We report a rare case of a 64-year-old male with 3 weeks of abdominal pain, back pain, and neurologic deficits including memory impairment who was found to have neurosyphilis causing a cholestatic liver injury. Workup included a positive rapid plasma reagin (RPR) and enzyme immunoassay (EIA), a positive cerebrospinal fluid (CSF) venereal disease research laboratory (VDRL), and a liver biopsy, which was compatible with a diagnosis of syphilitic hepatitis. Completion of a 14-day course of penicillin and 1 month of physical therapy resulted in near full-functional and biochemical recovery.

Post-transplant lymphoproliferative disorder (PTLD) is a rare complication of solid organ transplantation as the result of immunosuppressant medications. Epstein–Barr virus (EBV) has been implicated in most of these cases, specifically with B-cell predominant lymphoma. This case report describes a 24-year-old female who presented with recurrent GI bleed within 6 months post-orthostatic heart transplant. Endoscopic evaluations including video capsule study, push enteroscopy, and colonoscopy revealed multiple ulcerated lesions in duodenum, jejunum, and colon secondary to Epstein–Barr Virus-associated monomorphic PTLD. Despite continuation of rituximab after discharge, she returned to the hospital for recurrent GI bleed requiring additional endoscopic intervention. PTLD is a devastating disease of the post-transplant population. Due to a high risk of recurrent GI bleeding, patients with PTLD may benefit from careful monitoring by gastroenterology as an outpatient with a low threshold for repeat endoscopic evaluation despite being on immunotherapy or chemotherapy.

Endoscopic ultrasound (EUS) guided tissue retrieval is a safe and effective technique in obtaining tissue samples from solid mass lesions. Needle tip designs have evolved with the goals of obtaining a core biopsy to maximize tissue retrieval for efficient and accurate diagnosis, a procedure termed (FNB). Franseen and fork-tip needle designs are used to perform FNB. This study is a randomized prospective comparison of the 22G Sharkcore™ FNB needle to the 22G BNX™ FNA needle in retrieving tissue samples to evaluate solid masses in the pancreas.

Grayscale endoscopic ultrasound (EUS) is standard of care for tumor and nodal staging in patients with esophageal cancer. However, conventional EUS cannot be used for mapping lymphatic drainage or identification of sentinel lymph nodes (SNLs). Our group and others have confirmed that SLNs can be identified with contrast enhanced ultrasound following subcutaneous or peri-tumoral injections of a microbubble based contrast agent around tumor sites. This study investigates CEUS for nodal mapping in patients with primary esophageal malignancy.

Since the discovery of the Hepatitis B Virus (HBV) by Blumberg et al. in 1965, significant progress has been made in understanding the pathogenesis of HBV. The nucleos(t)ide analogues (NAs) have succeeded in decreasing the viral loads to undetectable levels, and reduced the incidence of HCC significantly

In patients with Barrett's esophagus (BE), radiofrequency ablation (RFA) effectively completely eradicates intestinal metaplasia (CE-IM) and dysplasia (CE-D) in the majority of patients. Several factors affect the number of RFA treatments needed to achieve eradication. The purpose of this study is to investigate whether hiatal hernia (HH) size and BE segment length independently predict the number of RFA treatments needed to achieve CE-IM or CE-D in patients with BE. This was a retrospective cohort study of BE patients who underwent RFA at a single tertiary center over a 10 year period. Participating endoscopists had performed RFAs for more than 15 high-grade dysplasia cases per year. The following demographic data were collected from the electronic medical record: Age, sex, race, BMI, and age at BE diagnosis. Endoscopic details were collected including the presence of a nodule, pathology before RFA, presence and size of a HH (small, medium, or large), and BE segment length. Univariate association tests for categorical variables were carried out by Fisher's exact test, ANOVA test, or Kruskal-Wallis tests, as appropriate. Predictors of RFA were evaluated by a multiple linear regression model that adjusted for sex, age at BE diagnosis, BMI, and categorical BE segment length <5 cm, 5-9 cm, and ≥10 cm. The reference levels for sex, HH size, and categorical BE segment length were male, small, and <5 cm, respectively. 317 patients with BE who underwent RFA were assessed and 48 patients were excluded who were still undergoing RFA treatments at the time of data collection or were lost to follow up. Of the 269 patients included, 92% achieved CE-IM and 96.6% achieved CE-D. 85% of the patients had HHs (60% small, 20% medium, and 5% large). HH size was independently associated with requisite number of RFA sessions to achieve CE-IM or CE-D for both large HHs (p<0.0001) which required ∼2 additional sessions (β = 2.12; 95% CI: 1.18, 3.06), and medium HHs (p<0.01) which required ∼1 additional session (β = 0.93; 95% CI: 0.36, 1.50). The number of RFAs needed to achieve CE-IM or CE-D was also independently associated with the length of the BE segment. Compared to patients with BE segments <5 cm, those having BE segments 5-9 cm (p<0.01) required ∼1 additional RFA session (β = 0.8; 95% CI: 0.33, 1.27) as did those with BE segments >10 cm (p<0.01) (β = 1.05; 95% CI: 0.34, 1.76). Sex, age, BMI, and final pathology prior to RFA were not significantly associated with the number of RFA treatments. Larger hiatal hernia size and longer BE segment are each independent predictors of the number of RFA treatments needed to achieve CE-IM or CE-D in patients with BE. This information may help endoscopists and patients establish realistic expectations before embarking on RFA for BE.

The advent of direct acting antiviral (DAA) agents has redefined the treatment landscape for hepatitis C virus (HCV) within the past decade, with achievement of high HCV eradication rates.However, several reports have suggested an increased incidence of tumor recurrence following DAA treatment compared with interferon treatment.In adding to the evolving literature, we herein present a case of a 73-year-old female with long term follow up at our center, who had recurrence of previously treated HCC after 4 years and 7 months on maintenance interferon therapy and subsequent development of a new HCC after 14 months on DAA therapy.Tumor ablation consisted of successful trans-arterial chemoembolization and microwave ablation.

Epstein-Barr virus (EBV) is a member of the herpesvirus family that is associated with various disease manifestations, including EBV-associated colitis. There are few case reports describing hemorrhage associated with EBV colitis. We report a 61-year-old woman with acute gastrointestinal bleeding due to EBV colitis after initiation of methylprednisolone and enoxaparin for spinal cord infarction. To our knowledge, there are only a few case reports of hemorrhagic EBV colitis. Perhaps we need to have a higher suspicion for EBV in cases of colitis associated with hemorrhage even in relatively immunocompetent patients.

Background: Barrett’s esophagus is a premalignant condition for esophageal adenocarcinoma. Endoscopic treatment is recommended for dysplastic Barrett’s given its increased risk of malignant transformation. The aim of this study was to evaluate the efficacy, durable response, and safety of radiofrequency ablation and identify risks for disease progression and reduced eradication. Methods: A retrospective cohort study was conducted of patients with Barrett’s esophagus undergoing radiofrequency ablation at a single tertiary care center over a 10-year period. The electronic medical record was reviewed to collect patients’ demographics and medical history regarding the diagnosis, treatment, and post-procedural follow-up of Barrett’s esophagus. Results: 273 patients with BE who underwent RFA were assessed. 228 patients (83.5%) were male and 252 were Caucasian (92.3%). The mean age at BE diagnosis was 62.4 years. The average BE segment length was 4.73 cm (range 1 cm to 18 cm). 118 (43.2%) patients progressed to a higher risk pathology prior to or during endoscopic therapy including 8 undergoing esophagectomy for EAC. 155 (56.8%) patients underwent ≤ 3 RFA sessions, 108 (39.6%) underwent 4-6 RFA sessions, and 10 (3.7%) underwent ≥ 7 RFA sessions. 91.2% (249 of 273) achieved complete eradication of intestinal metaplasia (CE-IM) and 96.7% (264 of 273) achieved complete eradication of dysplasia (CE-D). 20 (7.3%) patients had procedure related complications, including stricture (5.3%), bleeding (1.0%), and aspiration (0.3%). The average length of follow up at our institution was 36.3 months. Conclusion: At our tertiary center, radiofrequency ablation was confirmed to be an effective and safe ablative technique eradicating dysplastic Barrett’s esophagus. Complications rates were low with development of stricture being most common.

INTRODUCTION: GI bleeding remains one of the most common reasons for GI consultation, with top causes including peptic ulcer disease, erosive disease, angiodysplastic lesions, varices, Mallory Weiss tears, dieulafoy lesions, and malignancy. Obscure GI bleeding (OGIB), defined as recurrent or persistent bleeding or anemia despite negative endoscopic evaluation, makes up 5% of all GI bleed cases. Approximately 75% of OGIB are found to have small bowel lesions. We outline a case of a rare cause of OGIB. CASE DESCRIPTION/METHODS: A 78-year-old female with history of HTN, HLD, CAD, STEMI s/p DES placement, biliary colic s/p cholecystectomy, is referred to GI clinic for symptomatic anemia. She was found to have a hemoglobin of 8 g/dL from baseline 11–12 g/dL. She had been on dual antiplatelet therapy with ticagrelor until 3 months ago, now on aspirin 81 mg. Anemia workup revealed iron deficiency. CT scan negative. Started on po iron with improvement in symptoms. Denied abdominal pain, weight loss, or overt bleeding. No NSAID use. No prior endoscopy or colonoscopy. No family history of GI malignancy. An upper endoscopy and colonoscopy were done. There was antral erythema, otherwise normal EGD. Duodenal and gastric biopsies were negative. Colonoscopy only notable for extensive diverticulosis and a small tubular adenoma. Capsule endoscopy identified active bleeding in the proximal small bowel and a potential submucosal mass. Push enteroscopy revealed a long polypoid lesion extending from the third to fourth portion of the duodenum, approximately 15 mm in width and at least 100 mm in length with visible ulcerated tip. Mucosa was otherwise normal. Endoloop was applied and tissue removed with a hot snare. Pathology resulted in a submucosal lipoma. She was followed with serial blood counts and continued on iron therapy. She is doing well with continued GI follow up. DISCUSSION: This case of an ulcerated lipoma as the cause of an OGIB is among a handful of other case reports and seem to be similarly found in patients on antiplatelet or anticoagulation therapy. Other cases have undergone surgical resection for symptomatic lipomas, however our case suggests that perhaps in those that are able to stop antiplatelet therapy and have a lesion within reach of an enteroscope, resection of the ulcerated portion may be sufficient treatment and may avoid invasive surgery.

Hepatitis B virus (HBV) is one of the most significant hepatocarcinogens. The ultimate goal of anti-HBV treatment is to prevent the development of hepatocellular carcinoma (HCC). During the last two decades, with the use of currently available anti-HBV therapies (lamivudine, entecavir and tenofovir disoproxil fumatate), there has been a decrease in the incidence of HBV-associated HCC (HBV-HCC). Furthermore, several studies have demonstrated a reduction in recurrent or new HCC development after initial HCC tumor ablation. However, during an observation period spanning 10 to 20 years, several case reports have demonstrated the development of new, subsequent new and recurrent HCC even in patients with undetectable serum HBV DNA. The persistent risk for HCC is attributed to the presence of covalently closed circular DNA (cccDNA) in the hepatocyte nucleus which continues to work as a template for HBV replication. While a functional cure (loss of hepatitis B surface antigen and undetectable viral DNA) can be attained with nucleos(t)ide analogues, these therapies do not eliminate cccDNA. Of utmost importance is successful eradication of the transcriptionally active HBV cccDNA from hepatocyte nuclei which would be considered a complete cure. The unpredictable nature of HCC development in patients with chronic HBV infection shows the need for a complete cure. Continued support and encouragement for research efforts aimed at developing curative therapies is imperative. The aims of this minireview are to highlight these observations and emphasize the need for a cure for HBV.

Background The significance of a family history of esophageal adenocarcinoma in the progression to esophageal adenocarcinoma in patients with Barrett’s esophagus has not been thoroughly evaluated. The purpose of this study is to evaluate the presence of esophageal adenocarcinoma in a first-degree relative in patients with Barrett’s esophagus. Methods A retrospective cohort study was conducted of patients with Barrett’s esophagus at a tertiary care center undergoing radiofrequency ablation. Family history, demographics, and pathology and endoscopy reports were assessed in all patients. Findings Three hundred and one patients with Barrett’s esophagus were assessed. Nineteen patients who had a diagnosis of esophageal adenocarcinoma on index endoscopy were excluded. Nineteen (6.7%) patients had a first-degree relative with esophageal adenocarcinoma. Four (21.1%) of these patients progressed to esophageal adenocarcinoma. Of patients without first-degree relative with esophageal adenocarcinoma 22/263 (8.7%) progressed to esophageal adenocarcinoma. In a logistic regression model adjusted for sex and the number of radiofrequency ablation treatments, we found that family history of esophageal adenocarcinoma was a significant independent predictor of progression to esophageal adenocarcinoma (odds ratio = 5.55, 95% confidence interval: 1.47–20.0). Conclusion Our study indicates that Barrett’s esophagus patients with a first-degree family member with esophageal adenocarcinoma are at 5.5-fold higher risk for disease progression to esophageal adenocarcinoma. Family history of esophageal adenocarcinoma in Barrett’s esophagus patients should be considered in patient surveillance and radiofrequency ablation treatment, beyond recommended guidelines.

Since the discovery of the hepatitis B virus (HBV) by Blumberg et al. in 1965, its genome, sequence, epidemiology, and hepatocarcinogenesis have been elucidated. Globally, hepatitis B virus (HBV) is still responsible for the majority of hepatocellular carcinoma (HCC). HCC is the sixth-most common cancer in the world and the second-most common cancer death. The ultimate goal of treating HBV infection is the prevention of HCC. Fortunately, anti-HBV treatment with nucleos(t)ide analogues (NAs), which began with lamivudine in 1998, has resulted in remarkable improvements in the survival of patients with chronic hepatitis B and a reduced incidence of HCC. These results were documented with lamivudine, entecavir, and tenofovir. Nonetheless, as the duration of antiviral treatment increases, the risk for HCC still remains despite undetectable HBV DNA in serum, as reported by different investigators with observation up to 4–5 years. In our own experience, we are witnessing the development of HCC in patients who have received antiviral treatment. Some have enjoyed negative serum HBV DNA for over 12 years before developing HCC. Current treatment with NAs can effectively suppress the replication of the virus but cannot eradicate the covalently closed circular DNA (cccDNA) that is within the nucleus of hepatocytes. There still remains a great need for a cure for HBV. Fortunately, several compounds have been identified that have the potential to eradicate HBV, and there are ongoing clinical trials in progress in their early stages.

Introduction: The risk for esophageal adenocarcinoma (EAC) increases as nondysplastic Barrett's esophagus (NDBE) progresses to Barrett's esophagus (BE) with low grade dysplasia (LGD) and high grade dysplasia (HGD). Several factors, including characteristic of the BE segment, may increase the risk for progression to EAC. The purpose of this study is to evaluate BE length as an independent risk factor for the development of EAC. Methods: A retrospective cohort study was conducted of patients at a tertiary care center with BE undergoing radiofrequency ablation (RFA) over a 10 year period. The electronic medical record was reviewed to collect the following data: age, sex, age at diagnosis of BE and EAC, pathology, and length of BE segment at initiation of treatment. Results: 301 patients with BE who underwent RFA were assessed. 249 (82.7%) were male. The mean age at BE diagnosis was 62.1 years. The average BE segment length, at initiation of treatment, was 3.52cm (range <1cm to 18cm). 19 patients with intramucosal adenocarcinoma on index endoscopy were excluded. 26 (9.2%) patients progressed to EAC; 5 from NDBE to EAC, 2 from indefinite for dysplasia to EAC, 5 from LGD to EAC, 14 from HGD to EAC. In patients that progressed to EAC, the average BE segment length was 6.08cm (±4.48) compared to 4.72cm (±3.25) in patients that did not develop EAC. In a logistic regression model adjusted for sex and the number of RFA treatments, we found that length of BE segment was a significant independent predictor of progression to adenocarcinoma (OR=1.16, 95%CI: 1.03-1.30). Conclusion: BE is a known risk factor for EAC. BE with LGD and HGD carries a higher risk for EAC than NDBE. Our study suggests that patients with longer segments of BE, regardless of the presence of dysplasia, are at increased risk for progression to EAC. For every 1cm increase in length of BE, the risk for progression to EAC increases by 16%. We suggest that the length of BE along with dysplasia are both important risk factors for EAC and should be carefully surveyed and considered for treatment with RFA.