Background and study aims  Post-ERCP pancreatitis (PEP) is a common adverse event in high-risk patients. Current intervention known to reduce the incidence and severity of PEP include pancreatic duct stent placement, nonsteroidal anti-inflammatory drugs per rectum, and intravenous (IV) fluids. We compared aggressive normal saline (NS) vs aggressive lactated Ringer’s (LR) infusion for the prevention of PEP in high-risk patients undergoing ERCP. Patients and methods  Patients were randomized to receive either an aggressive infusion of NS or LR. The infusion was started at a rate of 3 mL/kg/hr and continued throughout the ERCP procedure. A 20 mL/kg bolus was given at the end of the procedure, then continued at a rate of 3 mL/kg/hr. Results  A total of 136 patients were included in our analysis. The incidence of PEP was 4 % (3/72 patients) in the LR group versus 11 % (7/64 patients) in the NS group resulting in a relative risk (RR) of 0.38 (95 % confidence interval [CI] 0.10 to 1.42; P  = 0.19). The relative risk reduction (RRR) was 0.62 (95 % CI –0.41 to 0.90) along with an absolute risk reduction (ARR) of 0.07 (95 % CI –0.025 to 0.17) and an number needed to treat of 15 (95 % CI –41 to 6). Conclusions  To our knowledge, this is the first study comparing aggressive IV NS to aggressive IV LR in high-risk patients. The incidence of PEP was lower in the group receiving an aggressive LR infusion (4 %) compared to NS infusion (11 %). However, the difference was not statistically significant likely due to poor accrual thereby impacting the power of the study.

The prevention of post-ERCP pancreatitis (PEP) has evolved considerably over the years. The use of prophylactic pancreatic duct stents and rectal indomethacin are known to decrease rates of PEP. Recently, there has been increased study on periprocedural intravenous fluid (IVF) hydration during ERCP to prevent PEP. Specifically, the amount and type of IVF may impact the rates of PEP. The purpose of this ongoing, prospective study is to compare the efficacy of high volume lactated ringer’s (LR) to high volume normal saline (NS) given peri-procedurally to prevent PEP, particularly in patients at high risk of developing PEP (i.e. SOD, precut sphincterotomy, >8 cannulation attempts). This is a randomized, double-blinded, controlled trial being conducted at Tampa General Hospital. Enrollment started 8/2017 and is ongoing. Patients with active pancreatitis, clinically volume- overloaded and over the age of 75 were excluded. Patients were randomized (1:1) to receive either NS or LR infusion. The infusion was started pre-procedurally at 3 mL/kg/hr and continued throughout the procedure. A 20 mL/kg bolus was given at the end of the procedure and the infusion was then continued at 3 mL/kg/hr. Hospitalized patients continued this infusion for 8 hours. All patients were given 100mg rectal indomethacin prior to the ERCP. Pancreatic duct stents were placed at the discretion of the endoscopists. Depending on inpatient/outpatient status, patients were evaluated after the procedure either at bedside or via telephone to determine if pancreatitis had occurred. The widely accepted consensus definition of PEP was having 2 of 3 of the following: (1) new or worsening abdominal pain clinically consistent with acute pancreatitis, (2) associated pancreatic enzymes elevation ≥ 3 times the upper limit of normal 24 hours after the procedure, and (3) resultant or prolongation of existing hospitalization of ≥ 2 nights. To date, 38 patients have been included in our study, with 22 patients (58%) in the LR group and 16 patients (42%) in the NS group. 51% of the study population was female, 49% was male, and the average age was 56. Thirty patients (75%) were at high risk for developing PEP based on patient and procedure related risk factors. Indications for ERCP are listed in table 1. The overall rate of PEP was 2.6%. The rate of PEP between the NS and LR group was not statistically significant (6.25% vs. 0%, p=0.24). In those at high risk of developing PEP, again, there was no statistically significant difference in the PEP rate between NS and LR (9.1% vs 0%, p=0.18). In patients receiving rectal indomethacin, both NS and LR are equally effective in prevention of PEP when given at high rates, particularly in those at high risk of developing PEP.Tabled 1Indications for ERCP in Study PopulationIndicationLactated RingerNormal Saline GroupTotalAmpullary adenoma112Evaluation for stricture213CBD and PD dilation123Choledocholithiasis639Stent placement, exchange, or removal8513RUQ pain101Known Sphincter of Oddi dysfunction101Evaluation for cholangiocarcinoma011History of FAP (ampullary screening)101Elevated bilirubin011Past episodes of pancreatitis with unknown etiology022Evaluation for suspected periampullary mass101Total221638 Open table in a new tab Tabled 1Table 1. Comparison of Post-ERCP Pancreatitis Rates in Lactated Ringer's and Normal Saline IVF GroupsAll patients:Occurrence of PEPLactated RingerNormal Saline GroupTotalp-valueNo221537Yes011Total221638p=0.235High risk patient subset analysis:Occurrence of PEPLactated RingerNormal Saline GroupTotalp-valueNo191029Yes011Total191130p=0.181 Open table in a new tab

Sandifer syndrome is an uncommon pediatric disorder characterized by abnormal dystonic movements of the head, neck, eyes, and trunk associated with gastroesophageal reflux disease (GERD) or hiatal hernia. The pathophysiology remains unclear but it is hypothesized that dystonic posturing relieves abdominal discomfort caused by acid reflux. Early recognition and prompt treatment ensure better therapeutic response and prognosis. The following is the case of a complex patient whose condition did not take the expected course despite early surgical intervention. A 19 year-old white male with Asperger and Sandifer syndromes presented for evaluation of worsening dysphagia and regurgitation. His symptoms began at age 5 after spica cast placement with dystonias of the neck and trunk that temporally correlated with perceived post-meal discomfort. He was diagnosed with Sandifer syndrome and underwent Nissen fundoplication at age 7. Initially he experienced 50% improvement in symptoms but developed recurrence of bloating, aerophagia, dysphagia to solids and liquids, and regurgitation. Treatments thereafter including relaxation therapy, diaphragmatic breathing exercises, and acid blocking agents provided partial relief. Neurological evaluation was unremarkable for sensory tics. Routine labs were within normal limits. Previous studies, including CT chest and several endoscopies and colonoscopies, last 1 year ago, were normal. To further investigate, we performed a timed barium swallow and high resolution manometry. Results suggested pseudo-achalasia with delayed esophageal emptying at 1 and 5 minutes (Figure 1) and absent contractility with normal integrated relaxation pressure (Figure 2). The etiology of the worsening dysphagia and regurgitation was determined to be disease progression with initial esophageal dysmotility that evolved into failed contractility after tight Nissen fundoplication. Sandifer syndrome represents dystonic movements often misdiagnosed as neurologic disease, resulting in unnecessary workup, ineffective treatment, and adverse effects. Response to medical and behavioral therapies varies and these patients may require surgical fundoplication for GERD. Research favors partial over complete fundoplication in such patients due to less risk of dysphagia. Our patient underwent a fundoplication, but was found to have absent esophageal contractility years later. This case highlights the need to maintain a broad differential including surgical complications.1724_A Figure 1. Barium swallow at 1,5, and 10 minutes1724_B Figure 2. High resolution esophageal manometry

Background: Baseline impedance (BI) is a novel esophageal metric that can segregate erosive and non-erosive GERD from functional heartburn and healthy controls.Mean nocturnal BI (MNBI) can be extracted from 24-hour pH-impedance tracings, but can also be acquired from esophageal high-resolution impedance manometry (BI-HRiM).In this study, we investigated BI-HRiM and MNBI values among symptomatic patients with physiologic distal esophageal acid exposure time (AET), on and off proton pump inhibitor (PPI) therapy, to determine correlations between the two methods and to assess relationships with presumed functional symptoms.Methods: Esophageal function studies performed for persisting symptoms over 1 year at a single academic center were reviewed.Patients completed both HRiM and 24hour pH-impedance monitoring (Sandhill Scientific, Highlands Ranch, CO), on or off PPI.Physiologic AET (<4%) was required for inclusion, implying a potential functional basis for symptoms.Patients completed symptom questionnaires; dominant symptom intensity (DSI) was the product of severity and frequency rated on 5-point Likert scales, and global symptom severity (GSS) was rated on 10-cm visual analog scales.BI-HRiM was extracted from HRiM studies as the average from 5 and 10 cm above the lower esophageal sphincter (LES) during quiet rest.MNBI was extracted from 6 channels (3,5,7,9,15, and 17 cm above the LES) at three stable nocturnal 10-min time periods (1,2, and 3 AM), and averaged to yield MNBI at each channel.Data were analyzed to compare on vs off PPI groups, and to assess concordance between BI-HRiM, MNBI, and symptom burden.Results: 22 patients met inclusion criteria (60.6±2.2 yrs, 18.2% F, BMI 31.7±1.2,AET 0.9±0.2%,GSS 64.4±4.5, DSI 8.3±1.2).Dominant symptoms included heartburn (54.5%), regurgitation (4.5%), chest pain (18.2%), and cough (13.6%).14 (63.6%) had testing performed off PPI.Esophageal body motor patterns were normal in 18 (81.8%),and similar by PPI status (p=0.25).Although the off-PPI group had higher AET than on-PPI (1.2±0.3%vs 0.4±0.2%,p=0.045), they shared similar BI-HRiM, MNBI, GSS, and DSI (p $0.27;Table 1).BI-HRiM correlated with distal MNBI at 3,5,7, and 9 cm (p #0.02), as well as their average (p=0.002),but not with MNBI at 15 or 17 cm (p>0.5).BI-HRiM and MNBI were not associated with symptom burden (GSS: p$0.13,DSI: p$0.29).BI-HRiM and MNBI did not differ by dominant symptom (p$0.58).With dominant heartburn (i.e.functional heartburn), BI-HRiM and MNBI were similar on and off PPI (p $0.16).Conclusions: BI-HRiM correlates with MNBI acquired from distal channels on 24-hour pH-impedance testing in patients with physiologic AET.As BI values (BI-HRiM and MNBI) appear similar regardless of method of acquisition or PPI status, persisting heartburn on PPI therapy may share pathophysiologic similarities with functional heartburn.

Complementary and alternative medicines (CAMs) are being used at increasing rates within the U.S. population. Though readily available, these products are possible precipitants of acute liver failure (ALF). This is a case of acute liver failure in a patient taking herbal supplements. Case Report: A 41 year-old female vegan with a history of iron deficiency anemia presented with subacute yellowing of the eyes, nausea, and confusion. The patient took 27 herbal supplements, including Chaparral and Valerian, known precipitants of ALF. Initial labs included Alb 1.8, T Bili 17.1, INR 7.2, Alkaline Phosphatase 177, AST 444, ALT 250, and NH4 119. Consistent with history, toxicology screen was negative for serum acetaminophen, ethanol, and salicylates. Doppler ultrasound revealed patent hepatic vessels. Patient was transferred to a tertiary care center for evaluation for liver transplant. Evaluation for alternative causes was not suggestive of autoimmune or infectious etiologies. Patient and family expressed that medications were “chemicals” and they requested holistic interventions only. Psychiatric evaluation confirmed patient had capacity. Family supported patient's refusal of liver transplant. Integrative Medicine consultation was sought, however, therapeutic contribution was limited. Patient and family preemptively refused the use of immunosuppressive medications post-liver transplant. After multiple discussions regarding the severity of her acute illness, and limitations of alternative treatment options, patient declined being listed for liver transplant. Four days after initial presentation, patient and husband declined hospice referral and was discharged home at her request. Patient re-presented to the OSH two days after discharge with progression of encephalopathy. Although patient required ICU monitoring and intubation, family declined liver transplant evaluation, and 14 days after initial presentation, the patient expired. CAMs have become a significant cause of acute liver failure. Respecting a patient's belief structure is an important part of the practice of medicine. In this case, the patient's belief in herbal supplements precipitated acute liver failure and the patient's belief against western medicines created barriers to the recommended therapy. This combination directly contributed to the patents death. Given the increased utilization of CAM this may represent an increasingly common clinical challenge.

This is a case report of a 23-year-old Caucasian male with overlapping granulomatosis with polyangiitis (GPA) and Crohn's disease (CD). He presented with a 6-month history of recurrent nasal, oropharyngeal and aural lesions with associated epistaxis and odynophagia and 1-week history of diffuse, painful and ulcerating skin lesions. Infectious workup was negative. Autoimmune workup revealed elevated C-reactive protein along with +cANCA and autoantibodies to proteinase-3 (PR3-ANCA+). Skin biopsy of chest and thigh ulcers showed intraepidermal vesicular dermatitis. He was diagnosed with cutaneous-limited GPA as he had no renal or pulmonary findings. Methotrexate (MTX) and high-dose prednisone led to improvement in mucosal and skin lesions. Two months later, he returned with bloody diarrhea and severe generalized abdominal pain. Labs showed elevated erythrocyte sedimentation rate and iron deficiency anemia; liver chemistries were normal. CT abdomen revealed circumferential long-segment thickening of the cecum and ascending colon. Colonoscopy showed severe inflammation with cobblestoning, contact friability and deeply cratered linear ulcerations extending from mid-transverse colon to cecum. Histology showed moderately active chronic colitis with cryptitis, crypt abscesses and erosions; no granulomas, vasculitis, infection or ischemic changes were seen. Findings were consistent with inflammatory bowel disease (IBD) favoring CD. Mesenteric angiogram to exclude ischemic colitis in the setting of known vasculitic disease was negative. IBD serology was positive for atypical p-ANCA with negative ASCA. Patient was initiated on infliximab for GPA-IBD overlap and showed dramatic positive response to infusions in combination with MTX. Overlap of GPA and CD is a rare occurrence. Almost all published cases describe IBD presenting before GPA; the opposite is true of our case. This patient had onset and progression of CD while initial presenting GPA manifestations were controlled. As up to 10% of patients with systemic vasculitis can present with colorectal ulcerations, it was important to discriminate between GPA-associated colitis and IBD. Two ANCA profiles helped to further distinguish a diagnosis of PR3-ANCA+CD, a particularly unique subtype, as PR3-ANCA appears more common in UC versus CD and has been linked to extensive UC. We hope that this report can contribute to the limited study of this rare presentation and may help future practitioners approach similar cases.

Little is known about the clinical features, radiology and manometry findings, and treatment outcomes of patients with functional and mechanical esophagogastic junction outflow obstruction (EGJOO). Between November 2011 and February 2015, a total of 1443 high-resolution manometries were reviewed and 49 patients (3.4%) met the manometric criteria for EGJOO. Then, we performed a retrospective chart review, collecting data from manometric studies, timed barium esophagram findings (TBEs), endoscopic reports, and clinical records. Twenty-seven patients had functional EGJOO and 22 patients had an anatomic esophageal obstruction. Common causes of anatomic EGJOO included strictures (36% of patients) and hiatal hernias (31% of patients). There were no differences between groups in manometric or radiographic metrics. Each group had increased basal lower esophageal sphincter and intrabolus pressures, compared with individuals without EGJOO, and most patients had abnormal findings on TBE analysis. Two patients with functional EGJOO progressed to type 3 achalasia. We conclude that patients diagnosed with EGJOO based on manometry findings can have anatomic obstruction or functional EGJOO; high-resolution manometry and TBE do not distinguish between disease causes.

Background: A 48-hour wireless capsule results often vary from the first to second day. Previous investigations comparing discrepant acid reflux readings have yielded variable results. In this study we investigated differences in data obtained on day 1 versus day 2, and the effect of time of capsule placement on discrepancies. Methods: We performed a retrospective cohort study. Patients undergoing a 48-hour wireless capsule study between January 2012 through November 2013 were eligible for inclusion. We collected reflux data for each patient and calculated the proportion of patients in four groups based on abnormal DeMeester score groups (+/+, −/+, +/−, −/−). We placed patients into morning placement or afternoon placement categories and calculated the proportions of patients with various DeMeester score discrepancies. Key Results: This study evaluated 229 patients. The mean day 1 DeMeester score was 28.38 and the mean day 2 DeMeester score was 23.24 (P<0.0001). The mean day 1 DeMeester score in the morning group was 24.9 and 31.7 in the afternoon group (P<0.05). The mean total DeMeester score in the morning placement group was 23.1 and 30.6 in the afternoon group (P<0.05). Twenty-five percent of afternoon patients had a +day 1/−day 2 DeMeester discordance, whereas only 12% of morning placement patients had this discordance (P=0.26). Conclusions: Afternoon capsule placement is associated with a significantly increased amount of acid reflux on day 1. Approximately 10% of 48-hour esophageal wireless monitoring studies may falsely overestimate reflux when the capsule is placed in the afternoon. Capsule placement should ideally be performed in the morning.

regurgitation (P=0.048) and weight loss (P=0.000) in all achalasia patients.And it was correlated with weight loss in typeIachalasia (P=0.000).No correlation was found between Eckardt scores and other HRM metrics.Twenty-five patients (10 patients with type I and 15 patients with type II achalasia) were treated with POEM, and their total Eckardt scores and scores of each symptom were decreased after surgery (vs before POEM, all P<0.05).Eckardt scores changes (Eckardt scores before POEM minus Eckardt scores after POEM) were no difference between type I and type II achalasia.Eckardt scores and weight loss changes were positively correlated with IRP at baseline (all P<0.05).No correlation was found between other HRM metrics at baseline and Eckardt scores changes.Twelve patients (4 patients with type I and 8 patients with type II achalasia) underwent HRM after POME.IRP was changed significantly after POEM (vs before POEM, P=0.005), and so were DEP changes in type II achalasia (vs before POEM, P=0.010).IRP changes (IRP before POEM minus IRP after POEM) were positively correlated with Eckardt score changes (P=0.029).CONCLUSION: IRP correlates with symptoms and symptomatic outcomes of POEM in achalasia patients.HRM is an effective way to assess the severity of achalasia, and can be used to predict the efficacy of POEM.Correlation between HRM metrics and Eckardt scores at baseline (P value) *: P value < 0.05.Correlation between HRM metrics and Eckardt score changes after POEM (P value)

increasing severity of mucosal damage (EE Conclusions: Baseline impedance levels measured during esophageal impedance-manometry have been associated to the diagnosis of GERD in patients with typical reflux symptoms.In patients with limited compliance this may represent an alternative method in order to investigate GERD.However, due to the complexity of this disorder, the miscellaneous manifestations and inconstant benefit of treatment, MII-pH study remains crucial in the management of patients referred to tertiary centers.

A 48 year old male with HIV presented with epigastric pain of 2 weeks duration and odynophagia of 6 days duration. He described the epigastric pain as acute in onset, intermittent, and exacerbated with food. The odynophagia was with solids and to a lesser extent with liquids. The HIV was diagnosed 20 years ago and his home medications were abacavir, lopinavir-ritonavir, tenofovir, dapsone, and azithromycin, although he was later found to be non-compliant. On exam, there was thrush in the back of the throat and slight tenderness to palpation in the epigastrium. Laboratory testing was significant for CD4+ count 6 and WBC 1.48 × 109/L. Chest x-ray was unremarkable. EGD revealed a linear, ulcerated, firm nodule 35mm from the incisors. There was also a single, medium-sized, non-bleeding, deep ulcer in the duodenal bulb (Figure 1). Biopsies from the esophagus and duodenal bulb ulcer revealed fungal esophagitis and fungal duodenitis, consistent with histoplasmosis infection. Intracellular fungal yeast forms measuring 2 to 4 microns were present in the esophageal and duodenal biopsies, highlighted by GMS and PASF histochemical stains (Figure 2).Figure 1Figure 2With regards to treatment, as there is a significant interaction between ritonavir and itraconazole, HAART therapy was held and itraconazole was started. Gastrointestinal histoplasmosis (GIH) is an under-diagnosed entity. A lack of symptoms and/or nonspecific symptoms is common. Ninety-percent of GIH lesions occur in the lower GI tract, likely due to increased amounts of lymphoid tissue in the ileocecal bowel region. Immunocompromised people often suffer from the disseminated form of histoplasmosis. Our case is interesting because of the location of the histoplasmosis infection within the GI tract. It is rare for histoplasmosis to directly infect the esophagus, although the esophagus can be involved in mediastinal adenitis or mediastinal fibrosis, which are separate entities from what we describe. Duodenal disease is rare as well. Infection in the small intestine usually occurs in the ileal region due to the abundant lymphoid tissue there. Assi et al performed a case series review on 18 cases of GIH in AIDS; they found duodenal disease in less than 4% of cases. As far as treatment, for mild-to-moderate cases of progressive disseminated histoplasmosis itraconazole can be used and is effective in preventing relapses. However, potential drug interactions do exist with ART therapy and itraconazole, which must be kept in mind. This case illustrates the importance of maintaining a wide differential in immunocompromised patients. Histoplasma, in particular, can affect many organ systems when disseminated. This organism should always be considered as a cause of nonspecific symptoms in AIDS patients.

Objectives Diagnostic and therapeutic colonoscopy is performed using conscious sedation. Excessive alcohol users, chronic benzodiazepine and opioid users, and polysubstance users are commonly cited as difficult to sedate. Few studies have compared and analyzed medication dosages to achieve sedation in these groups.Methods The endoscopic database was searched for patients who underwent colonoscopy. A retrospective chart review was performed to determine whether each patient was an abuser/chronic user of opioids, benzodiazepines, marijuana, alcohol, or a combination of the above. The mean dose of fentanyl and versed administered in each group was compared.Results A total of 239 patients were enrolled. Compared with the alcohol and control groups, the opioid group used a statistically higher mean medication dosage to achieve sedation. The mean dose of fentanyl in the opioid group was 124 g, the mean dose in the alcohol group was 101 g, and the mean dose in the control group was 101 g. The mean dose of midazolam in the opioid group was 4.1 mg, the mean dose in the alcohol group was 3.3 mg, and the mean dose in the control group was 3.3 mg.Conclusions Identifying patients who are difficult to sedate before colonoscopy is important because adequate sedation is associated with better adenoma detection, a better procedural completion rate, and patient satisfaction. In patients using daily opioids, it is important to anticipate the need for higher doses of medication to achieve adequate sedation.

Introduction: Diagnostic and therapeutic colonoscopy is performed employing conscious sedation. Inadequate sedation during colonoscopy results in suboptimal examinations, dissatisfied patients, and aborted procedures. Excessive alcohol users, chronic benzodiazepine and opioid users, and poly-substance abusers are commonly cited as being difficult to sedate. Few studies have compared and analyzed medication dosages to achieve sedation in these groups. The aim of this study was to compare the medication dosages to achieve conscious sedation during colonoscopy among patient groups deemed difficult to sedate. Methods: The endoscopic database was searched for patients who underwent colonoscopy. Then, a chart review was performed to determine if each patient was either an abuser/chronic user of opioids, benzodiazepines, marijuana, alcohol, or combinations of the above. The mean dose of fentanyl and versed administered in each group were compared. Results: There were 239 patients enrolled in the study. Table 1 describes the demographic data for the six different groups. The opioid group, as compared to both the alcohol group and the group with no substance use, used a statistically higher mean medication dosage to achieve sedation, detailed in table 2.Table 1: Demographics for Study GroupConclusion: Identifying patients who are difficult to sedate prior to colonoscopy is important because adequate sedation is associated with better adenoma detection, procedural completion rate, and patient satisfaction. In our study, daily opioid users required an increased amount of sedation compared to nonsubstance users and alcohol users in patients deemed difficult to sedate. Therefore, in patients using daily opioids, it is important to anticipate the need for higher doses of medication to achieve adequate sedation during colonoscopy.Table 2: Mean Medication Dosage and Statistical Analysis of Study Groups

Introduction: A 76-year-old male presented to our medical center complaining of indigestion, epigastric pain, and regurgitation, which started after consuming venison the day prior. The patient had dysphagia to solids, but tolerated liquids. Evaluation in the emergency room revealed a distal esophageal calcific mass measuring 3 cm in diameter on plain films and CT (Figures 1 and 2). With endoscopy, a large food bolus impaction coated with bismuth subsalicylate was visualized in the distal esophagus. This correlated with the radiographic finding of a distal esophageal calcific mass, since bismuth is a known radio-dense substance. Also found during endoscopy were a hiatal hernia and a partially occluding distal esophageal stricture. Interestingly, in the past, bismuth was widely utilized as a gastrointestinal radiographic contrast agent, although now barium sulfate has taken its place. After the procedure the patient tolerated clear liquids and soft foods. He was discharged on protonix, carafate, and a course of levofloxacin. Follow-up upper endoscopy one week after discharge showed improvement of mucosal injury and confirmed resolution of the food bolus. This case presents a unique example of food bolus impaction with radiographic images not previously reported in the literature.Figure 1: Abdominal plain film with a peripherally enhancing 3.0-cm mass at the level of the distal esophagus. This mass was not present on a prior film taken 9 months earlier.Figure 2: Abdominal CT image showing a 3.0 x 2.9 cm peripherally calcified mass at the gastroesophageal junction.