Introduction: Plummer-Vinson Syndrome (PVS), also known as Paterson-Kelly syndrome, presents with a classic triad of dysphagia, iron-deficiency anemia and esophageal webs. Although this triad of disease is increasingly less prevalent, early detection and intervention are imperative to reduce mortality given increased risk of malignant transformation.1 Case Description/Methods: A 22-year-old female with a history of iron deficiency anemia presented to the emergency department with syncope in the setting of palpitations and dyspnea. The patient endorsed alarm symptoms including hematochezia over the past 6 weeks, 20-lb unintentional weight loss and dysphagia. Initial labs were remarkable for a hemoglobin of 11.1 g/dL, and microcytic indices, with an MCV of 72.4 fL. The patient underwent esophagogastroduodenoscopy (EGD) to investigate the etiology of iron deficiency anemia. EGD revealed a prominent esophageal web (Figure A) in the proximal esophagus with associated erythema and mucosal friability. Significant narrowing impeded safe passage of the endoscope and thus serial pneumatic dilations to 10 mm were performed. Following pneumatic dilation, the endoscope was successfully advanced beyond the web (Figure B) to the gastroesophageal junction. The patient tolerated the procedure well and had immediate resolution of dysphagia following EGD with pneumatic dilation. She was then continued on iron supplementation as previously prescribed at discharge. Discussion: Plummer-Vinson Syndrome comprises the pathological triad of dysphagia, esophageal web, and iron deficiency anemia. Other signs and symptoms can include glossitis, angular cheilitis, and koilonychia. The decreased incidence of this syndrome parallels the decreased prevalence of iron deficiency in the developed world. Iron deficiency induces an iron-dependent enzyme dysfunction which causes oxidative stress, mucosal DNA damage and ultimately potentiates the formation of esophageal webs. 2 Without intervention, patients with this syndrome may develop absolute dysphagia, aspiration pneumonia and other complications. Due to increased risk of malignancy, surveillance EGDs are necessary to screen for esophageal carcinoma in patients with PVS.Figure 1.: Esophageal Web pre dilation (a) and post dilation (b).

Obesity is associated with comorbidities such as diabetes, hypertension, dyslipidemia, obstructive sleep apnea, and non-alcoholic fatty liver disease and is known to significantly impair quality of life and reduce the life expectancy

INTRODUCTION: Some chronic immune-mediated diseases like Eosinophilic esophagitis (EoE) and inflammatory bowel disease (IBD) have similar pathogenesis. Recent studies have shown that both the prevalence and incidence of EoE and IBD are rising in developed countries. However, only few case reports on concurrent EoE and IBD were published and only limited data is available describing the epidemiology. Our objective was to evaluate the prevalence and associated comorbidities of concurrent EoE and IBD. METHODS: We performed a population-based study using IBM EXPLORYS, a HIPPA-enabled web platform that includes over 65 million patient data, pooled from multiple healthcare systems with distinct electronic health records. The prevalence of EoE in patients with IBD and in general population without IBD was compared. The IBD patient group was further stratified into Crohn's disease and Ulcerative colitis groups. Prevalence was calculated per 100,000 patients. Patient characteristics like age, gender and co-morbid immune-mediated disorders like celiac disease, asthma, and eczema were compared between patients with and without EoE in Crohn's disease, UC and the general population. Data were analyzed with R statistical software (RStudio, Inc. Boston, MA). RESULTS: A total of 197,050 patients with IBD and 64,095,520 without IBD were identified. Among the 197,050 cohorts with IBD, 100,780 (51%) had CD and 96,270 (49%) had UC. EoE prevalence is significantly higher in the IBD group compared to the general population (533 vs. 47, P < 0.0001). There was a significant difference in the prevalence of EoE between Crohn's disease and UC group (575 vs. 488, P = 0.008). The proportion of patients between age 18–65 years was significantly higher in EoE all 3 groups. A significant association of asthma and eczema with EoE was noted in all three groups. CONCLUSION: The risk of EoE is significantly higher among IBD patients, both Crohn's disease and UC. Concurrent diagnoses of EoE and IBD might modify the risk of IBD- and EoE-related complications. Studies to evaluate the mechanisms underlying the observation are needed.Table 1.: Prevalence and characteristics of patients with Eosinophilic esophagitis (EoE) associated with Crohn's disease, Ulcerative colitis and in general population

INTRODUCTION: The estimated incidence of neuroendocrine tumors in the United States ranges from 2.5 to 5 cases per 100,000. Although relatively rare, the most common location for them is the small bowel, specifically the ileum. Rarely do they present with hemodynamically significant bleeding or at a young age. The following case is a rare presentation of substantial hematochezia from a small bowel neuroendocrine tumor in a young, otherwise healthy male. CASE DESCRIPTION/METHODS: The patient is a 26 year old male who presented to hospital complaining of bloody stools.His hemoglobin on admission was 6.9 dg/L. Patient underwent a CTA that was read as 1.6 cm mesenteric mass and right colon extravasation, but subsequent angiography was negative for active bleeding. A follow-up Meckel’s scan was also negative. Within 3 days, the patient had 12 bloody stools and required transfusion of 6 units of blood. An EGD and colonoscopy revealed no sources of acute bleed. Decision was then made to transfer the patient to a higher acuity facility for push enteroscopy and video capsule endoscopy. VCE on transfer was remarkable for 3 areas of fresh blood mixed with mucosa in the distal small bowel. Decision was made for a push enteroscopy the next day, however it revealed a normal small bowel from the ileocecal valve to about 100cm into the ileum. The patient was stabilized and a few weeks later underwent an exploratory laparotomy where a mesenteric mass and 2 lymph nodes were biopsied. There was also appreciable denseness to the mid and distal jejunum. Subsequent biopsies were remarkable for a well-differentiated, G2 neuroendocrine tumor likely representing a metastatic tumor from the adjacent small intestine. Since surgery, the patient reports no further episodes of hematochezia. DISCUSSION: The most common site of small bowel neuroendocrine tumors is the ileum, approximately 60-100cm from the ileocecal valve. While abdominal pain is the most common presentation, GI bleeding is the initial symptom in 23-29 percent of cases. One study of neuroendocrine tumors found it took an average of 2.3 tests before a diagnosis was determined. In this case, the patient underwent multiple imaging and endoscopic evaluation before ascertaining a cause for his bleeding. These tumors are typically found in the 6th or 7th decade of life, which is one of the unusual facets of this case. For a tumor of this size, surgery with extensive lymph node resection is associated with low local recurrence.Figure 1.: Mesenteric tumor pathology report.

BACKGROUNDMore than 70 million Americans (23% of the USA population) have non-cardiac chest pain at least once in their lifetime with gastroesophageal reflux disease being the leading cause (37-66%). Current guidelines support the use of a proton pump inhibitor (PPI) prior to invasive or noninvasive testing as a diagnostic, therapeutic and cost-effective method as a part of High Value Care recommendations.METHODSWe performed a chart review of 126 patients admitted to the hospital under observation status who underwent upper gastrointestinal endoscopies in the hospital at 3 different urban community hospitals. This was compared with 260 patients admitted who did not have this procedure done. We calculated the healthcare burden including length of stay, reimbursement and complications from the procedures/extra stay in the hospital.RESULTSThe direct cost per case was almost two times in the group that underwent the procedure as compared to the group that did not. The mean length of stay was higher in the group that underwent the endoscopies. There were no complications and there was no difference in mortality.CONCLUSIONSUpper gastrointestinal endoscopy in patients with atypical chest pain of gastrointestinal origin as an initial step is a significant healthcare burden and contradicts the currently recommended High Value Care recommendations. Our study delineates this large negative financial impact when performing upper endoscopies under observation status. Such patients should be started on an empirical trial of PPI, and endoscopy should be reserved for patients whose symptoms are unresponsive to PPIs or have alarm features.

Introduction: It is well documented that PPI therapy decreases the sensitivity of all common methods of testing for H. pylori infection. This leads to decreased detection of colonization in patients hospitalized for GI bleeding, so routine follow up and re-testing is indicated 1-2 weeks after the withdrawal of PPI therapy. The aim of this study is to evaluate how often adequate follow up occurs in patients who were tested for H. pylori infection by EGD with biopsy during hospitalization for GI bleeding. Methods: A chart review of 240 patients admitted to a large suburban community hospital from January 2017 to April 2018 was conducted in search of individuals whose clinical course met the following criteria: patients had to have an ICD 10 code related to GI bleeding, been on PPI therapy for at least 2.5 hours prior to EGD with biopsy, survived to discharge, and been referred to a provider within the hospital's network. 36 patients met the criteria and we mathematically determined the proportion of patients who received adequate follow up based on records obtained from the outpatient providers. Results: Of the 36 patients included, 6 (16.7%) patients received adequate follow up. 8 (22.2%) were positive for H. pylori infection and of these patients, only 3 (37.5%) received treatment. Of the 28 patients with a negative test as an inpatient, only 3 (10.7%) had any record of ever being retested. Conclusion: The prevalence of H. pylori infection of the adult population in the Western world is estimated to be about 45%, however, studies have shown a prevalence of greater than 70% in patients treated for GI bleeding. Using a modest estimate of 45%, it is likely that several cases of H. pylori were not detected in this study, and most patients were never retested. The most common reason for not retesting was patient non-compliance, 50% of patients never returned for follow up. While patient non-compliance will always be a barrier to delivery of care, improved patient education on the importance of follow up would curb this issue. Of the 8 patients who tested positive for H. pylori, the 3 who sought further evaluation were treated and retested for eradication. Failure to detect H. pylori infection in patients with GI bleeding leads to further episodes of re-bleeding, and thus increased morbidity and mortality as well as increased healthcare costs. More must be done to ensure retesting in as many patients as possible. We are continuing this study across other healthcare networks for more data.

Pseudoaneurysms of the inferior pancreaticoduodenal artery are rare. We report a case of chronic pancreatitis-related inferior pancreaticoduodenal artery pseudoaneurysm that resulted in obstructive jaundice and life-threatening bleeding. This case highlights both of these complications, and it also reflects on the importance of a multidisciplinary and multimodal approach to diagnosis and management. Anticipating potential complications and intervening at the right time can prevent fatal consequences in such patients.

A Choledochocele is defined as a cyst of the intra-duodenal portion of the distal common bile duct. As its prevalence is rare in western population, it is common to be overlooked especially when it presents with non-specific symptoms. We present the case of a patient with recurrent bouts of right upper quadrant abdominal pain who was eventually diagnosed with choledochocele. A 77-year old female without any past medical history presented with recurrent right upper quadrant (RUQ) abdominal pain, 5-6 episodes/month almost for past 2 years. There was no inciting factor and the pain was self-resolving. The patient underwent numerous imaging (ultrasound and CT scans) without any abnormal pathological findings. Blood work including bilirubin, lipase, liver function continued to be within the normal range. Due to multiple episodes of pain and poor quality of life, patient agreed to go for elective cholecystectomy. Pt continued to have similar type of recurrent abdominal pain even after cholecystectomy. CT abdomen was obtained to look for any post- surgical etiology of pain and this time it revealed mild (1 cm) CBD dilation without choledocholithiasis. The patient underwent an endoscopic retrograde cholangiopancreatography (ERCP) which revealed a large 2 cm periampullary polypoid mass, consistent with choledochocele which was snared with cautery. The duct was swept with good bile drainage post procedure. CBD brushings were negative for malignancy. The rarity of type III choledochal cyst or choledochocele presents a diagnostic challenge in biliary pathology especially when presented with normal labs and biliary imaging. As shown in our case, the patient continuously had RUQ pain and the diagnosis of Choldechocele was overlooked and patient unnecessarily had frequent imaging and eventually a cholecystectomy. Despite being a rare diagnosis, this case report could be a learning for our readers to keep choledochocele as one of the differentials in patients with recurrent RUQ pain especially if laboratory and imaging findings are negative. It is imperative to diagnose and treat this clinical entity not only for symptomatic relief but also by virtue of its risk of cholangitis, stone formation, cholangitis, secondary biliary cirrhosis or malignancy in long term. Excision and sphincterotomy with stent placement are the treatment options, although sometimes it may require surgical reconstruction with Roux-en-Y hepaticojejunostomy.

Introduction Pancreatic pseudocyst is a known complication of acute pancreatitis.Often these are small (< 5 cm) and require no treatment.Cysts more than 10 cm in size are termed as giant and require surgical intervention.Giant cysts are rare and infrequently reported.We describe a case of giant (20cm) Walled off Pancreatic Necrosis (WOPN) causing bilateral deep vein thrombosis and pulmonary emboli that required cystogastrostomy. Case Report A 76 year old male presented with a 2 day history of pain abdomen.Examination revealed severe epigastric tenderness and normal vital signs. He did not have a history of alcohol consumption.Laboratory panel revealed WBC count 14.0K/UL, lipase 3000 U/L (normal range 13U/L- 60U/L) and normal LFTs. CT of the abdomen revealed acute interstitial edematous pancreatitis.There was no evidence of gall stones.Patient was diagnosed with Thiazide induced pancreatitis and treated with aggressive fluid resuscitation.His condition improved and was discharged. Five weeks later he presented with abdominal discomfort, nausea and shortness of breath.CT abdomen with contrast revealed extensive walled-off pancreatic necrosis measuring 22cm x15 cm originating at the body and tail of the pancreas compressing the stomach.In addition there was extensive deep venous thrombosis of bilateral femoral veins and bilateral iliac veins.There was also evidence of bilateral pulmonary emboli.Patient was started on low molecular weight heparin and total parental nutrition since he had significant gastric outlet obstruction. Six weeks later after the cyst had matured he underwent elective open surgical cystogastrostomy and 3 liters of necrotic fluid was drained.His post operative course was uneventful and was discharged home. Discussion According to the Revised Atlanta Classification of acute pancreatitis, WOPN is described as mature encapsulated pancreatic necrosis that develops at least 4 weeks after acute pancreatitis.This may contain solid and liquid materials.The incidence of WOPN is 1%-9% after acute pancreatitis. 40% of WOPN resolve spontaneously.Clinical manifestations depend on the size and location; this often include abdominal pain, infection, biliary obstruction and pseudo aneurysm.Imaging studies to diagnose WOPN include contrast enhanced CT and MRI.Symptomatic WOPN requires drainage either endoscopically or surgically.This often depends on the anatomy and topography of the cyst as well as the surgeons preference.Figure: Red arrow points to Giant WOPN Yellow arrow points to gastric outlet obstruction.

Introduction: It is estimated that more than 70 million Americans (23% of the United States population) suffer from non-cardiac chest pain at least once in their lifetime with gastroesophageal reflux disease (GERD) being the most common cause (37-66%).Recent guidelines support the use of a proton pump inhibitor (PPI) trial prior to any invasive or noninvasive testing as a diagnostic, therapeutic and cost effective method as a part of High Value Care recommendations. Methods: We performed a retrospective chart review of 126 patients admitted to the hospital under observation status for atypical chest pain and/or GERD, who underwent upper GI endoscopies while in the hospital at 3 different urban community hospitals. This was compared with 260 patients admitted for the same diagnoses who did not have this procedure done. Data was used to calculate the healthcare burden including length of stay, reimbursement contribution margin and complications from the procedures/extra stay in the hospital. Results: Demographics are described in table 1. Length of Stay (LOS) results and financial analysis are described in table 2. The direct cost per case was almost two times as compared to the group without endoscopy and the LOS was also increased. There were no complications and there was no difference in mortality between the two groups.Table. DemographicsTable: Table. Length Of Stay And Financial AnalysisConclusion: Upper gastrointestinal endoscopy in patients with atypical chest pain of GI origin, GERD exacerbations without alarm symptoms (dysphagia, odynophagia, unintentional weight loss, hematemesis, or melena) as an initial management step is a significant healthcare burden on the system and contradicts the currently recommended High Value Care (HVC) recommendations. Our study especially reinforces this large negative financial impact to our hospitals when performing inappropriate upper endoscopies under observation status. Such patients should be started on an empirical trial of PPI, and endoscopy should be reserved for patients whose symptoms are unresponsive to PPIs or have alarm features. The data in this study strongly supports the current guideline based recommendations.

Introduction: Pancreatic pseudocysts are known complications of acute and chronic pancreatitis. However, subsequent infection of pseudocyst is uncommon. We present a rare case of chronic pancreatitis with pancreatic pseudocyst complicated by a candida infection. Case report: A 42-year old African American female with alcoholic chronic pancreatitis, presented with complaints of abdominal pain, nausea and vomiting over 2 weeks. Computed tomography (CT) scan of abdomen revealed an acute on chronic pancreatitis with a large (91x48 mm) multiloculated pancreatic pseudocyst involving body and tail of the pancreas without signs of necrotizing pancreatitis. Initially she was managed conservatively, she began to spike fevers with worsening abdominal pain. She was therefore started on IV Meropenem but showed no clinical improvement. Given the lack of an endoscopic ultrasound in our institution, she underwent CT guided percutaneous drainage and aspirate cultures grew Candida albicans and antibiotics were switched to IV Fluconazole. Her fevers and poor appetite persisted. Repeat CT abdomen showed no change in the size of her pseudocyst. Subsequently, she again underwent percutaneous drainage; this time, a drainage catheter was left in place, and again, the fluid cultures grew C. albicans. Meropenem was resumed to cover for common pathogens. Despite all this, her condition did not improve. She therefore underwent exploratory laparotomy and several pockets of pus with significant amount of necrotic tissue were found. These pockets were debrided and her abdomen was left open with wound-vac drainage. Meropenem and Fluconazole were continued and underwent several peritoneal washings until eventually her abdomen was closed. She was later discharged with close outpatient follow up. Conclusion: Although most pancreactic pseudocysts are managed expectantly and resolve on their own, 10% of pseudocysts can get infected and carry a high morbidity and mortality. The most common pathogens isolated from pancreatic pseudocysts are bacterial including Escherichia coli, Klebsiella pneumonia, Enterococcus faecalis, Staphylococcus aureus, Pseudomonas aeruginosa, Proteus mirabilis. Isolation of Candida albicans is extremely rare and only a few cases are reported in literature. Aggressive therapy is necessary with surgical drainage and antimicrobials. We suggest a high level of suspicion for Candida infected Pancreatic Pseudocyst for patients with persistent or worsening symptoms.

Introduction: Bowel perforation following colonoscopy is a dreaded but rare complication. We report a case of jejunal perforation in a male patient following a screening colonoscopy. Case Report: A 77-year-old male with a past history of congestive heart failure cholecystectomy underwent a routine colonoscopy which revealed two 5 mm polyps in the rectum which were subsequently biopsied.The remainder of the colon was normal except for mild diverticulosis on the left side.Patient tolerated the procedure well without complications and was discharged. Within 24 hours he presented to the emergency room with diffuse abdominal pain, nausea and vomiting.Vital signs showed a blood pressure of 90/50mmHG and heart rate of 84 beats/min.Physical exam of the abdomen was consistent with diffuse tenderness, guarding and rigidity. Laboratory panel revealed a WBC count of 20,100/mm3 and creatinine of 2.7 mg/dL. Chest X-ray revealed no free air under the diaphragm, however non contrast CT of the abdomen revealed pneumoperitoneum and scattered foci of extra luminal gas consistent with perforation of the small bowel .Urgent exploratory laparotomy was performed which revealed small bowel perforation in the jejunum, extensive small bowel diverticulosis and a large abscess in the left paracolic gutter. 65 cm of small bowel was resected and end to end anastomosis was performed. His post-operative course was uneventful and was discharged.Histopathology was consistent with diffuse small bowel diverticulosis and acute serositis. Discussion: Colonic perforation is an uncommon but well documented complication of colonoscopy. In contrast perforation of the small bowel following a routine colonoscopy is rare. Perforation of the Ileum have been described in a few case reports1, however jejunal perforation is exceedingly rare. The mechanisms postulated includes excessive air insufflation and/or thermal injury during biopsy causing transmission of current across the cecal wall to the small bowel. The presence of jejunal diverticuli has been identified as a risk factor, as with this patient. Small bowel perforation often warrants surgical consultation and intervention. The physician must have a high index of suspicion to diagnose this dreaded complication since timely intervention can reduce mortality.Figure: Axial non contrast CT of the abdomen( soft tissue window) demonstrates multiple small bowel diverticula (yellow arrow).Figure: Non contrast CT demonstrates inflammation around the small bowel and omental fat stranding consistent with perforation (asterisk).Figure: Non-contrast axial CT of the abdomen( lung window) demarcates a small foci of free air (yellow arrow).

INTRODUCTION: Schwannoma of the esophagus is usually a benign submucosal tumor that arises from the perineural elements of the schwann cell in the peripheral nerves and only 46 cases have been reported to date. It is usually managed surgically. We present the first case of benign asymptomatic esophageal schwannoma in the existing literature which was treated conservatively. CASE DESCRIPTION: A 60-year-old man with a history of barrett's esophagus was found to have mild extrinsic compression of the thoracic esophagus on surveillance EGD in 2011 (Fig 1). The patient was lost follow-up for 2 years. In 2013, an endoscopic ultrasound (EUS) with core biopsy showed a solid 22x22 mm mass arising from the middle third of the esophagus (Fig 2) and the histopathology revealed spindle-shaped cells in a fasciculated and disarrayed pattern positive for S-100 on immunohistochemistry and negative for CD 117, CD34, desmin and smooth muscle actin consistent with schwannoma (Fig 3). As the tumor was small and the patient was asymptomatic, surgical management for esophageal schwannoma was deferred and we planned to manage it conservatively with regular surveillance imaging. The repeat EUS in 2016 demonstrated that its size remained stable. The patient remained asymptomatic the entire time.Figure: Endoscopy showed a mass causing mild extrinsic compression of the mid-esophagus.Figure: Endoscopic Ultrasound showing a well-defined 22x22 mm-round mass from the muscularis propria of the middle third of the esophagus (as pointed).Figure: Histopathology and Immunohistochemistry: Spindle-shaped cells in a fasciculated and disarrayed architecture and nuclei in a palisading pattern (a - hematoxylin and eosin stain, ×400 and b - Immunohistochemical study: S100 protein positivity, ×400).DISCUSSION: Most patients diagnosed with esophageal schwannoma will initially present with symptoms of neck discomfort or dysphagia and dyspnea depending on the size of the lesion. An asymptomatic presentation is rare (only six case reports in the existing literature). Diagnosis is challenging given a relatively lower prevalence as compared with more commons tumors e.g. leiomyoma or gastrointestinal stromal tumor. Definitive diagnosis is made by histological and immune histochemical exams on tissue samples extracted by either CT-guided biopsy, fine needle aspiration or core biopsy. All the patients in the existing English literature, symptomatic or asymptomatic, regardless of their size have been managed surgically. However, in this case, the patient was asymptomatic, the tumor was small and benign on histopathology. Hence, we opted for conservative management with regular surveillance imaging. Our patient is being followed up with regular endoscopic ultrasound and has remained asymptomatic 5 years after the initial diagnosis. Conservative management with regular surveillance with EUS/CT scan may be considered for small, benign, asymptomatic esophageal schwannomas.

Metastatic melanoma is an aggressive disease that can spread to many organs of the body. In rare cases, it can spread to the gallbladder causing secondary lesions, yet presenting with little to no symptoms. Therefore, most cases of metastatic melanoma lesions to the gallbladder go undiagnosed. Here, we present the case of a 41-year-old male with a four-month history of melanoma of the face, with a postresection status, who presented with right upper quadrant abdominal pain. Doppler ultrasound and computed tomography confirmed the presence of a mass on the gallbladder. Laparoscopic excision along with liver wedge resection was performed. Pathology staining revealed the presence of a malignant metastatic melanoma lesion of the gallbladder.

Pseudoaneurysm of the inferior pancreaticoduodenal artery (IPDA) is very rare. We report the case of a patient with hemorrhagic shock secondary to a bleeding pseudoaneurysm of the IPDA, also causing obstructive jaundice by virtue of its size and location. To our knowledge, this is the first such reported case in the United States. A 45-year-old male with history of iron deficiency anemia, chronic pancreatitis and alcohol abuse presented with severe right upper quadrant (RUQ) abdominal pain for 1 week. On presentation, vitals were stable and physical examination revealed RUQ abdominal tenderness and scleral icterus. Laboratory study showed hemoglobin 6.1 g/dl, alkaline phosphatase 416U/L, GGT 230 U/L, AST 76 U/L, ALT 132 U/L, total bilirubin 4.4 mg/dl, and direct bilirubin 3.4 mg/dL. Computed tomography (CT) of the abdomen with intravenous contrast showed a pseudoaneurysm arising from the IPDA (6.5x4.1x4.3 cm), acute on chronic pancreatitis and obstruction of biliary tree due to mass effect from pseudoaneurysm, marked intra and extrahepatic biliary dilation with the common bile duct measuring 17 mm and distended gallbladder. Mesenteric angiography also revealed the aneurysm but not amenable to embolization. The patient's abdominal pain worsened and developed hemorrhagic shock requiring additional resuscitation. Stat CT angiography showed increased size of the pseudoaneurysm, and a new hyperdense material within the small bowel loops. Exploratory laparotomy revealed large amount of intraluminal blood in second part of duodenum and a large pseudo aneurysm entering second part of duodenum that was ligated. Distal gastrectomy with duodenotomy with lysis of adhesions was done. LFTs trended down and jaundice resolved after procedure. Pseudoaneursym of IPDA is a rare complication of chronic pancreatitis. The mortality is 90-100% with acute hemorrhage in untreated patients and 12-50% even with aggressive treatment. Even though, most common presentation of pseuodaneusym is acute GI bleed, other presentations should not be overlooked. As shown in this case, our patient presented with obstructive jaundice. Direct pressure over the pancreaticobiliary ducts can cause recurrent pancreatitis and jaundice. Mesenteric angiography is the gold standard diagnostic test. Treatment options include angiographic embolization and surgical treatment. Early multidisciplinary approach with diagnostic and therapeutic interventions is needed to improve the outcome and decrease mortality.Figure: CT abdomen with contrast: Pseudoaneursym of inferior pancreaticoduodenal artery (arrow).Figure: Mesenteric Angiography:Pseudoaneursym of inferior pancreaticoduodenal artery(arrow).

Background: Direct Access Colonoscopy (DAC) allows for the direct scheduling of colonoscopies by both non-gastroenterologist physicians and gastroenterologist physicians without prior formal gastroenterology office visit in selected patients.It is believed to improve patient satisfaction, adherence, and decrease wait time.In DAC, bowel preparations are assigned to the patients by trained registered nurses during telephone interviews.There is a paucity of data on quality of bowel preparation between DAC and Conventional Colonoscopy (CC).Aim: To examine the differences in the quality of bowel preparation, and thus compare polyp detection rates (PDR) and adenoma detection rates (ADR) between DAC and CC.Methods: Retrospective chart review was done in all patients who underwent outpatient colonoscopies at Mercy Fitzgerald Hospital, PA from January 2014 to March 2015.Individual charts were reviewed and demographic and clinical data were obtained.Patients were devided into two groups depending on their type of colonoscopies: CC and DAC.All patients had received split dose polyethylene glycol-E (moviprep) for their bowel preparation.The procedures were performed by the same physician to eliminate observer bias.Each patient received a score for the quality of bowel preparation using validated Aronchick Bowel Preparation Score (ABPS).Bowel prepearation was considered adequate if they had score 0 or 1 on ABPS scale and inadequate bowel prepeartion if they had score 2, 3, or 4 on ABPS scale.Colonoscopy findings, such as PDR, ADR, angiodysplasia, diverticulosis and cecal intubation rate were recorded.The differences in findings of each group was analyzed.Age, sex, medication history, history of diabetes, prior colonoscopies were all accounted for.Results: A total of 819 colonoscopies were analyzed.Of those, 194 (23.68%) were DAC and 625 (76.31%) were CC.Using ABPS, 185/194 (95.36%) were noted to have adequate

Introduction: Irritable bowel syndrome with diarrhea (IBS-D) is a chronic, functional gastrointestinal disorder with symptoms of abdominal pain and diarrhea that significantly impact health-related quality of life (HRQoL).Eluxadoline is an investigational, locally active, mixed mu opioid receptor agonist and delta opioid receptor antagonist that significantly improved both pain and diarrhea in two Phase 3 IBS-D trials (IBS3001 and IBS3002).Aim: To evaluate the impact of eluxadoline treatment on HRQoL in patients with IBS-D in two Phase 3 trials.Methods: Adults meeting Rome III criteria for IBS-D were randomized to twice-daily oral treatment with eluxadoline (75 or 100 mg) or placebo for 26 weeks in IBS3002 and 52 weeks in IBS3001.The Irritable Bowel Syndrome Quality of Life (IBS-QOL) questionnaire, which consists of 34 items, each with a 5-point response scale (1=not at all, 5=extremely or a great deal), was completed at baseline and Weeks 4, 8, 12, 18, and 26 in both trials, and at Week 30 in IBS3002 and Weeks 36, 44, and 52 in IBS3001.Mean IBS-QOL overall scores were evaluated for trends by treatment groups by employing a longitudinal mixedeffects polynomial model fitted to pooled data to estimate treatment effects of eluxadoline.Cumulative distribution functions for changes from baseline to Weeks 12, 26, and 52 in IBS-QOL overall scores were plotted.Results: The longitudinal mixed-effects model showed a significant treatment main effect (t=4.45, p<0.0001) for the eluxadoline 100 mg treatment group.Similar results were observed for the 75 mg treatment group.Patients treated with eluxadoline 100 mg showed consistently higher IBS-QOL scores over 52 weeks of treatment compared with patients who received placebo (Figure 1).Cumulative distribution function plots of change from baseline scores confirmed that patients treated with eluxadoline 100 mg showed consistently higher increases in IBS-QOL overall scores compared with patients who received placebo over a range of improvement levels for Weeks 12, 26, and 52 (Figure 2).Conclusions: Compared with placebo, twice-daily eluxadoline treatment significantly improved overall HRQOL among IBS-D patients over the course of the treatment periods in two Phase 3 trials as measured by the IBS-QOL, with patients treated with eluxadoline 100 mg showing particularly strong effects.

Introduction: Metastases of cutaneous melanoma to the gallbladder are unlikely and usually asymptomatic. Here, we report a rare case of symptomatic metastatic melanoma of the gall bladder. Case report: A 41 year old male admitted to the hospital with 3 weeks history of right upper quadrant (RUQ) abdominal pain, nausea, alternate bowel movements and 15 pounds of weight loss. He was recently diagnosed with stage IIC (T4N0M0) cutaneous melanoma of face 4 months prior to admission. He underwent excision of melanoma and was started on interferon therapy. His positron emission tomography (PET-CT) was negative for any metastatic lesion 3 months prior to admission. His physical examination revealed RUQ tenderness otherwise unremarkable. His WBC, amylase, lipase were normal. Liver function test revealed aspartate transaminase 62 U/L, alanine transaminase 96 U/L, alkaline phosphatase 76 U/L, and total bilirubin 0.3 mg/dL. An abdominal computed tomography and liver ultrasound showed 1.1X1 cm gallbladder lesion concerning for mass. Ultrasound guided gallbladder biopsy was attempted but it was unsuccessful. Patient underwent laparoscopic cholecystectomy with hepatic wedge resection. It revealed no evidence of gallbladder mass, intraoperatively or on back table inspection (image 1). Frozen section of gallbladder was also negative for tumor. Interestingly, pathology suggested metastatic melanoma of the gallbladder with positive V600K mutation. His symptoms were improved post-surgery. His 1 month follow up PET-CT scan was negative for any metastasis. Patient is scheduled for close outpatient follow up visit for subsequent PET-CT scan. Discussion: Melanoma tends to metastasize extensively with most common sites of metastases are liver, brain and lung. Although gallbladder involvement is seen in 4-20% of patients with metastatic melanoma as suggested by autopsy report, it is unlikely for metastatic gallbladder melanoma to present with symptoms. The most common presentations of symptomatic metastatic gallbladder melanoma are acute cholecystitis followed by jaundice, hemobilia, biliary fistula and intractable abdominal pain as seen in our patient. Despite advancement in chemotherapy and immunotherapy, the prognosis of metastatic melanoma to the gallbladder is very poor with a median survival of 6-9 months. Isolated, resectable gallbladder metastases can be treated with cholecystectomy and hepatic wedge resection, and can achieve longer survival as indicated in our patient.Figure 1Conclusion: Our case emphasizes on close investigation of hepatobiliary lesion when the patient has a previous history of cutaneous malignant melanoma. Active screening and early detection is the key to achieve longer survival in malignant melanoma of the gallbladder.