Purpose: A 53-year-old male underwent upper endoscopy for Barrett's screening, revealing a smooth, 7-mm subepithelial nodule just proximal to GE junction. Though the diagnostic yield is low for subepithelial lesions with standard biopsies, the lesion was sampled and the patient was counseled that endoscopic ultrasound would likely be needed to define the lesion further. Microscopy demonstrated fiber deposition in the lamina propria suspicious for amyloid, but Congo-red staining was negative. Van Gieson staining was positive, consistent with elastosis (Image 1). Elastosis is typically a degenerative change in the dermal connective tissue that results in the deposition of an increased amount of elastic fibers. Rare cases of elastotic change have been reported within the gastrointestinal (GI) tract, usually within the distal colon appearing as polyps or within the small intestine and stomach, manifesting as ulcers or inflammation. Ours appears to be the first reported case of elastosis involving the esophagus. Though typically sporadic, elastosis in the GI tract is a form of granulomatous inflammation that can result from a genetic predisposition for inherited fibrous tissue abnormalities such as Down's syndrome, Marfan's syndrome, Ehlers-Danlos or Gronblad-Stranberg (Pseudoxanthoma Elasticum). It can be seen with neuroendocrine tumors or elastosis perforans serpiginosa disorder, characterized by the transepidermal elimination of elastic fibers. Elastosis has also been associated with certain medications, such as D-penicillamine. Notably, elastosis carries no known malignant potential. Microscopically elastosis appears as finely granular and/or fibrillar, pale, eosinophilic to gray-tinged amphophilic material. It may have a fibrous component, which can involve the submucosa and muscularis mucosa, and may be centered around submucosal blood vessels. Hematoxylin-Eosin stained sections are similar in appearance to that of amyloidosis. Elastic van Gieson staining reveals increase in elastic fibers that built bandlike formations and ovaloid structures. Unlike amyloid, Congo red staining is negative. Though the yield for standard biopsies of submucosal pathology is low, this case highlights that “low” yield is not “no” yield. The technique is safe, and may be sufficient to make a diagnosis, avoiding additional testing. Further, though rare, gastroenterologists should be aware of elastosis' benign nature and how it may mimic amyloid.Figure: H&E stain.

Purpose: UGB is typically controlled by endoscopic intervention (EI). For the small subset of patients (pts) that fails EI for non-variceal UGB, IRE has become standard when available. Surgery remains the preferred secondary therapy in institutions lacking IRE support, or for those that have failed IRE. Endoscopic and clinical charateristics that predict re-bleeding rates without EI have been defined for nonvariceal UGB. However, no classification addresses the risk of re-bleeding following failed EI and prior to IRE. The aim of this study is to identify endoscopic and clinical predictors of the success or failure of salvage IRE for non-variceal UGB. Methods: We conducted a retrospective review of the charts, from 2009-2012 at two large tertiary hospitals, of all pts who had IRE for control of non-variceal UGB following failed EI. Pts were identified using CPT codes. Data was collected and categorized on pts' age, gender, co-morbid conditions, presenting complaints, medication usage, clinical and lab findings, transfusion requirements and endoscopic findings prior to IRE. Failure of IRE was defined by a need for salvage surgery, the primary endpoint. Secondary outcomes analyzed were post IRE transfusion requirement of >4 units packed RBC, in-hospital mortality, and readmission for UGB. Fisher's exact test was used to correlate endoscopic/clinical characteristics with primary and secondary outcomes. Results: Thirty three pts were identified, 20 were males. Average pt age was 72 years (range 29-102). Eighteen pts had bleeding due to duodenal ulcers (DU), seven had gastric ulcers, seven had unidentified UGB source, with the remainder having angioectasias or Dieulafoy lesions. Five pts (15%) ended up requiring surgery despite IRE, seven pts died and six pts were re-admitted for further GI bleeding control. The only endoscopic predictor for primary IRE failure was the presence of a DU, five out of 18 pts (28%; p=0.04), but a trend towards eventual surgery was seen with those pts with multiple ulcers four out of 14 pts (29%; p=0.14). No statistically significant association was seen between any endoscopic/clinical characteristic and a secondary endpoint. Conclusion: IRE has become a valuable, minimally invasive alternative to urgent surgery for non-variceal UGB that has failed EI. The modality, however, is not universally available, often leading to emergency patient transfers with delay of therapy. We have identified DU as a risk factor for IRE failure, with almost one-third of patients requiring salvage surgery. While this fact alone may not be enough to triage pts directly to surgery, it should certainly be taken into account. Larger cohort studies are needed to further characterize lesions based on size, locations and other endoscopic characteristics as predictors of success for IRE.

Purpose: A 39-year-old male presented with dyspnea and recurrent hematochezia. Colonoscopy 10 years prior showed vascular lesions and hemorrhoids. He had no follow up since then. Physical exam revealed axillary lymphadenopathy. Laboratory evaluation revealed severe iron deficiency anemia (Hct 16, MCV 52, Iron 12). CT revealed a right hilar mass compressing the right mainstem bronchus and multiple lung nodules. Rectum was diffusely thickened extending into the sigmoid colon, associated with numerous phleboliths. (Figure 1) Several hepatic lesions were seen. Colonoscopy showed increased mucosal vascular pattern from the rectum to distal sigmoid (Figure 2) and a patchy area in transverse colon. Endoscopic ultrasound demonstrated edematous vascular structures in this distribution. A heterogeneous, hypoechoic, circumferential lesion measuring 18 mm in maximal thickness involving all layers was noted. Doppler ultrasound showed vascular flow in the lesion (Figure 3). Calcified phleboliths were seen in the rectal wall. The patient was diagnosed with cavernous hemangiomatosis of the colon and pulmonary non-small cell carcinoma. Colonic cavernous hemangiomatosis is rare and benign, with infrequent simultaneous liver involvement. There is frequent delay in diagnosis. Surgical resection is the preferred treatment modality for diffuse disease.Figure 1: No Caption available.Figure: [1178] Figure 2Figure: [1178] Figure 3

Purpose: Obesity is implicated in the severity and outcome of acute pancreatitis. The role of regional distribution of fat in the severity and outcome of acute pancreatitis (AP) has not been studied. We aim to study the relationship of abdominal adiposity and hepatic steatosis with the severity and outcome of acute pancreatitis. Methods: A retrospective chart review of 108 (mean age 53 yrs, male 52%) of 257 patients with AP seen between January 2002 and December 2009 meeting the inclusion criteria was performed. Ranson's score and CT severity index calculations were performed. Hepatic attenuation index (HAI) was obtained by calculating the ratio of hepatic to splenic attenuation (Hounsfield units) on an unenhanced CT; HAI <0.8 was used to diagnosis moderate to severe macrovesicular steatosis. Total abdominal fat was calculated using sagital and coronal reformation images on CT of the abdomen and pelvis using data from the superior end plate of T10 to the inferior symphysis pubis. Hounsfield units ≤ 200 HU and ≤20 HU were excluded yielding total abdominal fat content; a histogram profile of this remaining volume using a post-processing Workstation (GE AW 4.2, GE Milwaukee, WI) was used to calculate the fat volume. Results: Etiology of AP was alcohol 19(17.6%), ERCP-induced 8(7.6%), gallstone 42(39%) or other etiologies 39(36%). HAI < 0.8 was noted in 23(21.3%) patients. The severity of pancreatitis by Ranson's criteria at 48 hrs (1.91±1.65vs. 1.20±1.26, p=0.04) and by CT severity index criteria (4±3.2vs. 2.2±1.6, p=0.04) were significantly higher in patients with low-HAI (fatty liver) compared to high-HAI (non- fatty liver). Patients with low HAI had longer hospital stay (13.8±11.2 vs. 11.5±17, P=0.02), more frequent ICU admission (47.8 vs. 24.7, P=0.03), more frequent need for antibiotics (69.6 vs. 30.6, P=0.001) and higher in-hospital mortality (13% vs. 1.2%, P= 0.008) compared to patients with higher HAI. Although higher number of patients also had CT evidence of necrosis (21.7% vs. 10.6%, P=0.17) and pseudocyst formation (13% vs. 7.1%, P=0.39), this did not reached statistical significance. Mean total abdominal fat content was not significantly different in patients with severe (score > 3) vs. milder (score < 3) pancreatitis by Ranson's criteria (15.6±6.7 vs. 13±4.7 liters, p=0.14). Conclusion: Lower hepatic attenuation index, a measure for hepatic steatosis on unenhanced CT scan, is a novel non-invasive marker for severe outcomes in patients with acute pancreatitis.

30% received early EGD.Patients receiving higher-quality pre-endoscopic care had significantly higher rate of early EGD (35%) than patients receiving lower-care (23%)(p=0.01).After adjustment for pre-specified variables, the odds of receiving early EGD were 78% higher in patients with higher quality of care than those with lower quality (OR=1.78,95%CI=1.13-2.8).In addition, presentation during weekdays (OR= 1.98, 95% CI=1.14-3.42)and at night (OR=1.91,95%CI=1.18-3.10)were associated with receipt of early EGD.Conclusion Quality of pre-endoscopic care in NVUGIH leaves room for improvement.Better quality of care is independently associated with a higher likelihood of receipt of early endoscopy.Given these findings, improving pre-endoscopic care processes may eventually be translated into better clinical outcomes in NVUGIH by fulfilling the promise of endoscopic treatment in patients with NVUGIH.Delphi

Purpose: Obesity is implicated in the severity and outcome of acute pancreatitis. The impact of abdominal fat and the influence of hepatic steatosis on the severity and outcome of the acute pancreatitis (AP) have not been studied. Hepatic dysfunction associated with obesity might enhance the systemic inflammatory response by altering the detoxification of inflammatory mediators. We aim to study the relationship of abdominal adiposity and hepatic steatosis with the severity and outcome of acute pancreatitis. Methods: A retrospective chart review on 108 (mean age 53 yrs, male 52%) of 257 patients with AP seen between January 2002 and December 2009 meeting the inclusion criteria were included. Ranson's and CT severity index score calculations were performed. Hepatic attenuation index (HSA) was obtained by calculating the ratio of hepatic to splenic attenuation (Hounsfield units); HSA < 1.0 was used to diagnose moderate to severe macrovesicular steatosis. Total abdominal fat was calculated using sagital and coronal reformation images on CT of the abdomen and pelvis using data from the superior end plate of T10 to the inferior symphysis pubis. Hounsfield units < - 200 HU and > -20 HU were excluded yielding total abdominal fat content; a histogram profile of this remaining volume using a post processing Workstation, GE AW 4.2 (GE Milwaukee, WI) was used to calculate the fat volume. Results: Etiology of AP was alcohol in 19 (17.6%), ERCP-induced 8 (7.4%), gallstone 42 (38.9%) and other etiologies 39 (36.1%). Based on Ranson's score at 48 hrs, 22 (20.4%) had severe AP (score ≥3), and of the 87(80.6%) subjects whose CT severity index was available 20 (23%) had severe AP (score ≥3). HSA < 1.0 was noted in 44 (40.7%) patients. The severity of pancreatitis on Ranson's criteria at 48 hrs (1.57±1.43 vs. 1.20±1.3, p=0.14) and by CT severity index (3.13±2.51 vs. 2.15±1.75, p=0.08) trended to be higher in patients with low-HSA (with fatty liver) compared to high-HSA (without fatty liver). When patients with ERCP induced pancreatitis were excluded, subjects with low-HSA had significantly more severe AP on CT severity index (3.21±2.5 vs. 2.12±1.8, p=0.04). Mean total abdominal fat content was not significantly different in patients with severe (score > 3) vs. milder (score < 3) pancreatitis by Ranson's criteria (15.6±6.7 vs. 13±4.7 liters, p=0.14). No significant difference was noted in the need for ICU admission (31.8% vs. 28.1%), fraction of patients with necrosis (13.6% vs. 12.5%) or pseudocyst formation (9.1 vs. 7.8%), or length of hospital stay (11.6±9.4 vs. 12.2±19.2, p=0.07) in patients with low-HSA and high-HSA. Conclusion: Patients with hepatic steatosis may be predisposed to more severe acute pancreatitis.

Purpose: Ingestion of small foreign bodies rarely results in complications and the presenting symptoms are usually vague abdominal pain and the diagnosis remains a challenge. It is important to identify the risk factors for patients that require admission and intervention. The objective was to look at the incidence of complication of the small foreign bodies found in the distal gastrointestinal tract and to evaluate the risk factors for these complications. Methods: A retrospective chart review was done for data from consecutive patients for the year 2008 with ICD-9 billing code for foreign body. Patients with foreign bodies that have passed the duodenum were included in the case series. Records were reviewed for patient's age, sex, prior abdominal surgeries, co-morbid conditions, foreign body type, initial location, presenting symptoms, intervention required, as well as length of stay, morbidity and mortality. Patients under age 18 were excluded. Results: Of the 24 patients with swallowed foreign body, only seven cases were identified to have passed the duodenum. Foreign bodies identified included fish bones, soda can lid and an orthodontic device. Foreign bodies were located as follows: one in the jejunum, two in proximal and three in terminal ileum, one in the sigmoid diverticulum. Patient's age ranged from 24 to 80 with a mean of 57. 40% (3pts) had prior abdominal surgery. Only one patient had a history of psychiatric disorder that contributed to the ingestion. 60% (4 of 7) were male. Length of stay ranged from 2-12 days, with the mean of 6. Four patients required interventions: two colonoscopies and three surgeries. First patients had perforation of the gastrointestinal tract from the foreign body at the site of diverticulum. Second patient had a fish bone impacting into the wall of jejunum, without perforation. The third patient had surgery as the object could not pass a stricture. The length of stay was longer in the four patients that required intervention. Only 3 patients remembered swallowing the object. Conclusion: Impaction and perforation usually occurs at the site of narrowing, i.e. terminal ileum. Majority of the swallowed distal foreign bodies ultimately will need intervention, although an expectant conservative management may be warranted as 40% of them may pass the object spontaneously.

Purpose: NA Methods: 30 year old Indian male with no known prior medical history was admitted for total colectomy with ileorectal anastomosis for FAP syndrome. His father was diagnosed with colon cancer (ca) at the age of 52, prompting a colonoscopy in his brother that demonstrated multiple (>50) colonic polyps. The patient's colonoscopy found over 100 polyps ranging from 2 mm to 3 cm, tubular with tubular-villous adenomas on pathology. A presumed diagnosis of attenuated FAP was made. Results: Genetic testing for FAP was positive while mismatch repair gene was negative. Post surgery, the patient had nausea and abdominal pain. An upper endoscopy demonstrated esophagitis, gastric erosions, and clean-based duodenal ulcers, with subtotal villous blunting on biopsy. Celiac markers were found to be positive: anti-tissue transglutaminase antibody (AB)(TTG IgA) 65–100 units, anti-endomysial IgA AB positive (1:20). Antigliaddin AB IgG/IgA were negative. Patient was found to have microcytic anemia (H/H 11/36 with MCV 75) due to iron deficiency (iron 15, iron saturation 4%) and diarrhea (nonbloody, loose, 5–6 BM/day). HLA DQ8 was detected while HLA DQ2 was not present. The patient was instructed to go on a gluten-free diet. A repeat upper endoscopy demonstrated an atrophic duodenum with preserved villi architecture and focal mild intraepithelial lymphocytic infiltrate. On follow-up, the patient had improvement of diarrhea (2 BM/day). Conclusion: This case presents a patient with attenuated FAP syndrome and celiac sprue, both known for their strong genetic predisposition. There have been no known documented cases reported from an extensive literature search. Celiac disease (CD) is an under diagnosed problem that has a 95% genetic predisposition. It can be associated with other autoimmune conditions. 95% of patients with CD have a particular HLA class II genotype – encoded by chromosome 6: 6p21.3. The disease is genetically complex. A recent study (1) indicated that CD is more prevalent in females and has a strong paternal inheritance of predisposing haplotypes. It also found that HLA negative patients were more likely to be male. FAP is an autosomal dominant inherited disease that has a strong association with the APC gene located on chromosome 5, between p21 and p22. Attenuated FAP is characterized by a significant risk for colon ca, but fewer polyps (avg. 30) than classic FAP, more proximally located polyps, and diagnosis of colon ca at a later age; management may be substantially different. (2) It would be interesting to know if both diseases were transmitted through paternal transmission and if there is a role of disease accumulation or co-transmission. The immunologic bases for the co-conditions are not evident and this could represent a random occurrence.

Mesenteric vascular disease has been diagnosed increasingly over the past 25 years. This rise in incidence has been attributed to the advanced mean age of the population, an increasing number of critically ill patients and a greater clinical recognition of the condition. Although surgical revascularization and resection has long been the standard of treatment, medical management can also play an important adjunctive role. Early diagnosis before irreversible bowel damage, which may occur within 6-8 hours after the insult, is necessary to improve survival and reduce morbidity. Even in the presence of irreversible bowel ischemia, perioperative medical treatment may reduce disease progression, enabling more limited bowel resection. This article outlines the appropriate pharmacologic management of ischemic disorders of the intestine, with an emphasis on the pharmacologic treatments presently being used in clinical practice and those being studied in the laboratory.

Purpose: Clostridium difficile Associated Diarrhea (CDAD) is a leading cause of nosocomial diarrhea, creating a major economic burden in Health Care. At a major teaching tertiary care center, a preliminary epidemiological survey revealed a striking discrepancy in the distribution of nosocomial CDAD in Medicine (73.8%) and Surgery (8%). Thus, we proposed to compare the distribution of the risk factors for CDAD in Medicine and Surgical Services. Methods: A retrospective random sampling review of 94 Medicine and 76 Surgery charts of patients discharged between March 2004-July 2006 was conducted. We studied the distribution of various risk factors for CDAD in Medicine and Surgery patients: age, length of stay (LOS), admission source (community vs. skilled nursing facilities-SNF), readmission to hospital within 90 days, discharge disposition, prior history of CDAD, albumin level, use of antibiotics and Proton Pump Inhibitors (PPIs), immunosuppression, chemotherapy and hemodialysis. Results: Patients admitted to Medicine were significantly older than in Surgery (mean age:79.7 v.75.1, P < .001), though their LOS were similar (6.5 days v.5.1, P= 0.178). There was a remarkable difference between admission sources, with SNF transfers accounting for 15.7% of medical admissions versus only 1.3% of surgical (P= .001). Similarly, 29.2% of Medicine patients were discharged to SNF compared to 9.2% of surgical patients (P= .001). Readmissions within 90 days accounted for 31.5% of Medicine patients, compared with 11.1% of Surgical patients (P= .002). Serum albumin levels were lower in Medicine (3.7 g/dl) than in Surgery (3.9 g/dl, P= .045). Almost half (44.7%) of Medical patients were prescribed PPIs, compared to 37.1% of surgical patients (P= .022). Finally, antibiotics were prescribed to 47.9% of medical and 60% of surgical patients, most of whom receiving single dose prophylaxis (P < .001). Prior history of CDAD, immunosuppresion, chemotherapy and hemodialysis were not significant risk factors in either group. Conclusion: These results support age, low serum albumin and use of PPIs as known risk factors for CDAD. In addition, this study outlines socio-demographic risk factors, namely the role of SNF for both admission and discharge sites, as strong predictors of CDAD.