Introduction: Adnexal masses represent a spectrum of conditions from a gynecologic or non-gynecologic source and benign or malignant. The most common symptoms are pelvic or abdominal pain, distention, bloating, intestinal obstruction, or lower urinary tract symptoms. Here, we present an unusual presentation of adenocarcinoma of colon cancer presenting with solid/cystic adnexal mass causing extrinsic luminal compression of the sigmoid colon. Case Description/Methods: A 61-year-old woman with a past medical history of COPD, hypertension, hypothyroidism, CAD s/p stents placement, heavy smoking and drinking presented with progressive LLQ abdominal pain for 3 months. Physical examination showed LLQ tenderness. Labs showed elevated CEA 29.6ng/mL (normal < =3.8) otherwise negative other tumor markers. Her family history was significant for colon cancer in her brother. CT abdomen showed a complex solid/cystic mass in the left adnexal area (10cm of solid and 6cm of cystic components) with abutment and possible invasion to sigmoid colon (Figure 1). Colonoscopy was performed and revealed stricture without typical appearance of colon cancer in the sigmoid colon at 50cm from anus, which caused near complete obstruction that scope couldn’t traverse. Her pathology from stricture biopsy showed invasive, moderately differentiated adenocarcinoma with colorectal origin from positive SATB-2 and negative PAX-8, which was consistent with her elevated CEA. She underwent exploratory laparotomy with Hartman's procedure, small bowel resection anastomosis, left SO, and ureteral stent, which revealed pT4bN0M0 stage from final pathology result. Her hospital course was complicated by secondary peritonitis but improved with antibiotics. Discussion: Colorectal cancer is common and one of the 3 leading causes of death in women. Cancers of the left and sigmoid colon are often deeply invasive and annular, patients can be asymptomatic or present with abdominal pain, bowel habit change or obstructive symptoms. Adnexal masses especially in postmenopausal women raise concerns of malignancy which necessitates thorough evaluation. Tumor markers may aid in identifying carcinoma origin but are not sensitive. In this case, the patient had elevated CEA with a mixed solid cystic adnexal mass and was proven to have adenocarcinoma of the sigmoid colon causing intraluminal compression as opposed to gynecologic malignancy. Patients with pelvic masses should receive careful evaluation including applicable endoscopic studies and to minimize the risks of misdiagnosis.Figure 1.: CT abdomen showed a complex solid/cystic mass in the left adnexal area (10cm of solid and 6cm of cystic components) with abutment and possible invasion to sigmoid colon. Colonoscopy showed stricture without typical appearance of colon cancer in the sigmoid colon at 50cm from anus causing near complete obstruction that scope couldn't traverse. SATB-2 image showed positive staining in the glands, supporting colorectal primary H&E 10x image showed infiltrating malignant glands with associated desmoplastic reaction (invasive colon adenocarcinoma).

Abstract Upper gastrointestinal bleeding results in significant morbidity, mortality, and healthcare burden. This study aimed to evaluate inpatient outcomes of nonvariceal upper gastrointestinal bleeding (NVUGIB) during the year 2020 of the COVID-19 pandemic. The National Inpatient Sample databases were used to identify NVUGIB-related hospitalizations. Outcomes of interest for the year 2019 were compared to 2020 and included inpatient mortality, length of stay, mean inpatient cost, odds of getting esophagogastroduodenoscopy (EGD), mean time to EGD, early EGD (within 1 day of hospitalization), endoscopic intervention for hemostasis, and the odds of developing complications. NVUGIB-related hospitalizations increased by 8.1% in 2020. NVUGIB-related hospitalizations in 2020 were also associated with an 11.1% higher mortality (adjusted odds ratio [aOR] = 1.11, confidence interval [CI] = 1.06–1.17, P < 0.01), 0.15-day longer mean time to EGD (aOR = 0.15, CI = 0.08–0.24, P < 0.01), 4% lower odds of getting an EGD (aOR = 0.96, CI = 0.93–0.99, P = 0.02), 8% lower odds of getting an early EGD (aOR = 0.92, CI = 0.89–0.96, P < 0.01), and $6340 higher mean inpatient cost (aOR = 6340, CI = 1762–10919, P = 0.01) compared to 2019. We conclude that there was an increase in NVUGIB-related hospitalizations and mortality in 2020 when the COVID-19 pandemic started.

Introduction: Endoscopy-related injuries are common for gastroenterologists and can contribute to signi fi cant workplace and quality of life disruption. While standardized ergonomics curricula are important for prevention and education at the fellowship level, this approach may be lower yield for practicing endoscopists who have variable years of experience. We present a pilot practice improvement project to

Key Clinical Messages Behçet's disease (BD) or syndrome is a chronic, recurrent, multisystem, inflammatory vasculitis disorder with findings of oral aphthous ulcers, genital ulcers, and uveitis. Gastrointestinal (GI) involvement can be the initial presentation as presented in this case. Abstract Behçet's disease (BD) or syndrome is a chronic, recurrent, multisystem, inflammatory vasculitis disorder of unknown etiology with classical findings of oral aphthous ulcers, genital ulcers, and ocular involvements including chronic anterior, intermediate, posterior, and even panuveitis. Gastrointestinal involvement in BD usually presents with chronic diarrhea, hematochezia as the disease affects ileocecal area which might be similar to presentation of inflammatory bowel diseases. Here, we report a case of undiagnosed BD who presented with chronic diarrhea for 4 months, leading to the diagnosis of BD and responded well to corticosteroid therapy.

Heparin-induced Thrombocytopenia with Normal Platelet Count: A Cautionary Tale of Delayed DiagnosisAhmed Elkheshen MD1, Marawan Elmassry MD1*, Sierra Sullivan MD1, Ricardo Franco MD1, Abbie Evans MD1, Kavya Bharathidasan MD1, Arunee Motes MD1, Sameer Islam PhD3, Ebtisam Attaya Islam PhD21-Department of Internal Medicine, Texas Tech university Health Sciences Centre, Lubbock, TX, USA.2- Department of Pulmonology and Critical Care Medicine, Texas Tech university Health Sciences Centre, Lubbock, TX, USA.3- Department of Gastroenterology and Hepatology, Texas Tech university Health Sciences Centre, Lubbock, TX, USA.*Corresponding Author: Marawan Elmassry MDTexas Tech University Health Sciences Centre at Lubbock, Texas, USA.3601 4th street, Lubbock, TX 79430.Telephone/ Fax: +1-806-773-2831E-mail: Marawan.elmassry@ttuhsc.eduConflict of interest: The authors have no financial conflicts to disclose.Patient’s consent: Written informed consent was obtained from the patient to publish this report in accordance with the journal’s patient consent policy.Keywords :HIT, Heparin, Thrombocytopenia, Heparin Induced Thrombocytopenia, Platelet Count.

BACKGROUND:Retrograde cricopharyngeus dysfunction (R-CPD), a condition first detailed in 1987 and termed in 2019, refers to the cricopharyngeal muscle's inability to relax to allow the retrograde passage of gas. Limited research exists on the fundamental characteristics of this condition, including its impact on one's life. The purpose of this study is to characterize R-CPD and how the inability to burp affects the social lives of people who suffer from it.METHODS:A Qualtrics survey was distributed on the subreddit "r/noburp," a community of 26,000 individuals sharing information about R-CPD. Adults aged 18-89 experiencing R-CPD symptoms were invited to participate. Participants reported on their experiences with R-CPD and its effects on social life on a 4-point Likert scale (1 = strongly disagree to 4 = strongly agree). Data was analyzed using descriptive statistics.KEY RESULTS:Among the 199 respondents, the mean age was 30.9, and gender identity was 74%/25% female/male. 99% reported inability to burp, 98% reported abdominal bloating, 93% reported socially awkward gurgling noises, 89% reported excessive flatulence, and 55% reported difficulty vomiting. Only half discussed their symptoms with their primary care provider (PCP), and 90% disagreed with receiving adequate help. Average Likert scores indicated embarrassment (3.4), anxiety/depression (3.1), negative impact on relationships (2.6), and work disruption (2.7) due to R-CPD.CONCLUSIONS & INFERENCES:R-CPD is unfamiliar to many healthcare providers, leaving patients underserved. It not only affects daily life but also personal and professional relationships. Raising awareness by understanding disease basic features may increase diagnosis and treatment rates, improving quality of life.

Introduction: High no-show rates in outpatient clinics can have negative impacts on longitudinal patient care, clinic efficiency, and may increase reliance on emergency department visits. In our study, we aimed to address the issue of communication-related no-shows among nurse-practitioner (NP) providers in a gastrointestinal (GI) outpatient clinic. By implementing interventions to target communication issues, we sought to reduce the no-show rate for these NPs by 10% over a period of three months. Methods: To understand the reasons behind appointment cancellations and no-show instances, data collection involved on-site personnel manually recording patients' reasons in a free-text format. Subsequently, the collected data was analyzed to identify common patterns and categorize frequently cited reasons. Interventions were then implemented to enhance patient engagement and communication. Statistical analyses were conducted using R statistical software, comparing the proportions of pre-cancellations, no-shows, and total cancellations during the pre-and post-intervention periods. Results: Following the intervention, there were significant improvements in the proportions of pre-cancellations, no-shows, and total cancellations (P = 0.010, P = 0.039, and P < 0.001, respectively). Sensitivity analyses comparing pre- and post-intervention periods further confirmed the significant reduction in pre-cancellations and total cancellations (P < 0.001). When examining specific causes, cancellations due to internal scheduling errors significantly decreased (13.10% vs. 4.25%, P < 0.001). The proportion of patients who could not be contacted also significantly decreased (44.44% vs. 30.79%, P < 0.001). However, the proportion of patients not providing a reason for cancellation significantly increased from 10.91% to 25.48% (P < 0.001) (Table 1). Conclusion: The intervention period resulted in a significant reduction in no-show rates (P = 0.01) while simultaneously increasing the proportion of patients who did not provide a reason for their absence (P < 0.001). This rise in unexplained absences can likely be attributed to an overall decrease in no-show rates due to modifiable factors such as internal scheduling errors and the inability to contact patients. Implementing a standardized data collection system proved to be an effective strategy for addressing attendance issues in this clinic and could be easily implemented in similar settings. Table 1. - Summary and comparison of specific reasons for pre- vs. post-intervention visit cancellations Pre-intervention Post-intervention n (%) n (%) χ2 (df=1) P-value Adjusted P-value Appointment no longer necessary 16 (3.17) 8 (1.7) 1.64 0.201 1 Appointment prep not done 19 (3.77) 24 (5.1) 0.72 0.395 1 Cost 14 (2.78) 10 (2.12) 0.2 0.651 1 Deceased 2 (0.4) 4 (0.85) 0.24 0.622 1 Did not give reason 55 (10.91) 120 (25.48) 34.09 < 0.001 < 0.001 Did not want appointment 16 (3.17) 18 (3.82) 0.14 0.707 1 Emergency 13 (2.58) 14 (2.97) 0.03 0.858 1 Forgot appointment 3 (0.6) 7 (1.49) 1.13 0.288 1 Internal scheduling issues 66 (13.1) 20 (4.25) 22.62 < 0.001 < 0.001 Out-of-town 5 (0.99) 0 (0) 2.95 0.086 1 Schedule conflict 30 (5.95) 42 (8.92) 2.71 0.1 1 Seeing another GI provider 4 (0.79) 5 (1.06) 0.01 0.919 1 Sick 19 (3.77) 33 (7.01) 4.43 0.035 0.706 Transportation 15 (2.98) 14 (2.97) 0 1 1 Unable to contact patient 224 (44.44) 145 (30.79) 18.73 < 0.001 < 0.001 other 1 (0.2) 7 (1.49) 3.51 0.061 1 Not scheduled with preferred provider 1 (0.2) 0 (0) 0 1 1 Childcare issues 1 (0.2) 0 (0) 0 1 1 Each of the pre-and post-intervention periods was compared using a Chi-square test with a Yate’s continuity correction. The P-values were adjusted using a Holm-Bonferroni correction to maintain the family-wise error rate at 0.05.

Despite the growing disease burden of non-alcoholic fatty liver disease (NAFLD), approved medical treatments to improve or prevent liver fibrosis are effective only in a small number of patients. Recent studies have found the new use of antiplatelet agents for antifibrotic benefits in NAFLD, but human studies are still limited. The goal of this meta-analysis was to combine the findings of existing relevant studies to investigate the effects of antiplatelet therapy in reducing or preventing advanced liver fibrosis in patients with NAFLD. We conducted a systematic literature search in PubMed, EMBASE, and Web of Science databases from inception to January 2021 to identify all original studies that investigated the use of antiplatelet agents in patients with NAFLD. We used the National Institutes of Health’s quality assessment tool for observational cohort and cross-sectional studies to assess study quality and risk of bias. The primary outcome was the prevalence of advanced liver fibrosis stage 3–4. Data from each study was combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate pooled odds ratio (OR) and 95% confidence intervals (CIs). Of the 2,498 studies identified, 4 studies involving 2,593 patients with NAFLD were included in this study (949 antiplatelet agent users and 1,644 non-antiplatelet agent users). The use of aspirin and/or P2Y12 receptor inhibitors was associated with a lower pooled OR of advanced liver fibrosis in patients with NAFLD (pooled OR = 0.66; 95% CI: 0.53–0.81, I2 = 0.0%; p < 0.001). This study focuses on the outcome of advanced liver fibrosis in patients with NAFLD. Our study is limited by the small number of studies that were included. Preliminary evidence from this meta-analysis suggests a protective association between antiplatelet therapy and the prevalence of advanced liver fibrosis in patients with NAFLD. Our findings support future research into repositioning an antiplatelet agent as a novel NAFLD treatment.

Anasua Deb: NO financial relationship with a commercial interest | Malak Faragallah: NO financial relationship with a commercial interest | Sebastian Sanchez: NO financial relationship with a commercial interest | Thanita Thongtan: NO financial relationship with a commercial interest | Marawan Elmassry: NO financial relationship with a commercial interest | Busara Songtanin: NO financial relationship with a commercial interest | Sameer Islam: NO financial relationship with a commercial interest

removed from the left lower lobe using flexible fiberoptic bronchoscopy under general anesthesia. The patient tolerated the procedure well and had no complications. Capsule endoscopy is a device that is less inva-sive than EGD and colonoscopy to evaluate patients for gastrointestinal bleeding, but it is a costly diag-nostic tool. It is an FDA-approved for the evaluation of obscure gastrointestinal bleeding and allows visu-alization of inaccessible parts of the gastrointestinal tracts. Video capsule endoscopy adverse event rates are generally low. Our patient qualified for this procedure with a history of melena and negative finding of esophagogastroduodenoscopy. Common compli-cations include retention of the capsule in the small bowel which has been reported in 1.4% of procedures and can result in small bowel obstruction. Aspiration occurs in about 0.001% of the cases. Management of VCE aspiration includes urgent removal of the capsule by bronchoscopy. Radiographic studies may not be necessary in these patients since the capsule video should demonstrate the location.

Rectal bleeding in a patient with a history of hemorrhoids should not be ignored. It is often benign and resolves spontaneously without treatment. Here we present a case of anorectal malignant melanoma that presented with rectal bleeding and a prolapsed rectal mass.

Collagenous gastritis is a rare cause of heartburn in adults. Histopathological examination of gastric mucosal biopsy from the stomach shows submucosal collagen deposition. The pathophysiologic mechanism is unknown, and collagenous gastritis cases have been associated with certain drugs, such as olmesartan and non-steroidal anti-inflammatory drugs, and certain medical conditions, such as common variable immunodeficiency, primary IgM deficiency, autoimmune disorders, and psoriatic arthropathy. Here we report a case of collagenous gastritis in a 29-year-old woman with psoriatic arthropathy who presented with persistent heartburn. She was successfully treated with oral pantoprazole. Key words: heartburn, collagenous gastritis,

Introduction: Bravo wireless capsule is a catheter-free pH monitoring system used to diagnose GERD in patients who fail anti-secretory therapy. Several adverse events have been reported in the literature; these include nose or throat discomfort and dislocation from positioned sites. Case Description/Methods: A 72-year-old man with a history of GERD, prostate cancer, hypothyroidism, obstructive sleep apnea, presented for esophagogastroduodenoscopy (EGD) with Bravo™ placement due to persistent esophageal reflux symptoms despite appropriate therapy. The Bravo™ capsule (Medtronic, Minneapolis, MN) with a delivery system was introduced through the mouth and advanced into the esophagus. The device was placed with visual confirmation; however, the patient had severe a coughing fit. Suction was applied and the delivery system was then withdrawn. Repeat EGD was performed and no Bravo™ was seen in esophagus, stomach, or duodenum. Due to suspicion of dislodgement, a chest x-ray was performed and Bravo™ was seen in the left lung (figure 1, panel A). The patient was admitted to the hospital, and the pulmonology service was consulted for device removal. Bronchoscopy was performed successfully with the extraction of a capsule from the left main bronchus (Figure 1, panel B). After 24 hours observation, the patient did not have any symptoms or signs of aspiration pneumonitis and was discharged home. Discussion: We present a case of an adult patient with aspiration of the capsule into the lungs. This is an unusual complication with pH monitoring techniques(3). Given the limited number of cases of Bravo™ aspiration, there are no definite guidelines or gold-standard treatment up to date. A patent airway and good oxygenation must be maintained. The initial diagnostic evaluation includes chest radiographs, since the Bravo™ capsule is radiopaque(4).Once located, bronchoscopic tools can usually reveal the capsule, as was done with our patient.Figure 1.: Panel A, left: X-ray showing bravo capsule in left lung panel B, right: bronchoscopy showing reveals bravo capsule in left main bronchus.

INTRODUCTION: Prior authorizations (PAs) are intended to control prescription drug expenditures. METHODS: One hundred fifty-six physician and advanced practice provider members of the American College of Gastroenterology completed a national survey to assess PA burden and impact. RESULTS: One-half of PA requests relate to prescription refills. Greater than 50% of the respondents choose inferior treatments at least weekly because of perceived PA burden for preferred agents. One-half of the respondents reported a patient who experienced serious adverse events due to PA-related care delays. DISCUSSION: PA is an administrative burden that exhausts practice resources and may have a negative impact on patient care.

Background: Even though patients with inflammatory bowel disease (IBD) are not at increased risk of COVID-19 infection, patients with post-acute COVID-19 have been reported to have de novo IBD or a new diagnosis of IBD. Objective: This article reviews the presentation, diagnosis, and clinical course of patients described in the literature to have new-onset IBD after the diagnosis of COVID-19 infection as well as discusses the possible pathophysiological mechanism. Methodology: Extensive literature review by compiling information from case reports and original studies identified by a Pubmed and EMBASE search from inception to May 2021. Results: We identified 4 cases of de novo IBD that were reported in the literature, 2 weeks – 5 months after acute COVID-19 infection. Patients presented with persistent bloody diarrhea, abdominal pain, and anemia. Three patients were diagnosed with ulcerative colitis and one patient was diagnosed with Crohn's disease. Available evidence indicates that COVID-19 infection can instigate an intestinal inflammation and trigger de novo IBD, potentially through intestinal barrier leakage, alterations in gene expression, gut microbiota dysbiosis, and exaggerated immune response. Conclusion: The presence of the SARS-CoV-2 virus in the gut can cause de novo IBD through complex multiple factors. Further studies need to be done to confirm a causal link and the underlying mechanism. Clinicians should be vigilant about the possibility of IBD in patients present with anemia, abdominal pain, or chronic bloody diarrhea after a short interval of COVID-19 infection that warrant a referral to a gastroenterologist.

Introduction: Splenosis is defined as transplantation of splenic tissue in to surrounding structures like the peritoneal, intrathoracic surfaces and rarely in to the Liver. Most cases of hepatic splenosis (HS) are asymptomatic and usually found incidentally. Radiographic findings of HS are nonspecific and mimics other liver masses. We report a rare case of isolated HS in a 38-year-old male who presented with right upper quadrant (RUQ) pain and Liver mass mimicking Hepatoma. Case Description/Methods: A 38-year-old male with asplenia comes to the outpatient with complaint of worsening RUQ pain of 2 years duration. Pain was described as dull aching, non-radiating, 3/10, constant and without aggravating or remitting factors. He underwent splenectomy at the age of 4 for traumatic splenic rapture following a fall down accident from a stair. He denied fever, chills, night sweating, nausea, vomiting, diarrhea, constipation, melena, hematemesis, anorexia or weight loss. On exam; abdomen was soft, without direct or rebound tenderness. On work up- complete blood count, complete metabolic panel, liver function test including coagulation panel are all with in normal limits. Computed Tomography (CT) of the abdomen showed a lobular exophytic mass of the liver measuring 6.7cmx3.6cm (figure -1). Histopathology of the liver mass revealed hemorrhagic splenic parenchyma. Patient was treated conservatively and he is currently doing well. Discussion: Splenosis is the autoimplantation of splenic tissue to surrounding structures which was initially named by Buchbinder and Lipkoff in 1939. Even though splenosis is generally a common occurrence in patient who had history of splenic rapture or following elective splenectomy, hepatic splenosis (HS) is rare. Patients with HS are usually asymptomatic but some may present with nonspecific abdominal pain, nausea, vomiting or mechanical compression of surrounding structures. Imaging modalities are nonspecific because HS mimics liver adenomas, hepatocellular carcinoma or liver secondaries.Treatment is usually conservative for patients without compressive symptoms. Laparotomic removal of the spelonosis is only indicated in these with mechanical complications or if splenectomy was done for hematologic disorders.In Conclusion, isolated intrahepatic splenosis is a rare encountered but it should be strongly considered in the differential diagnosis of a liver lesion, especially if the patient has history of splenic trauma or splenectomy.Figure 1.: White arrows: CT scan of abdomen- a lobular exophytic mass of the liver measuring 6.7cmx3.6cm

Colon cancer generally presents with lower gastrointestinal symptoms, such as diarrhea, constipation, and general abdominal discomfort; it is rare for the primary presentation to have upper gastrointestinal symptoms. We report a patient with coloduodenal fistula secondary to colon malignancy who presented with incessant vomiting and dramatic weight loss as the chief complaint. It is important to consider colon cancer as part of the differential in patients with atypical presentations of upper gastrointestinal symptoms who have known colon cancer risk factors.