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Despite the use of safer tubes with high-volume, low-pressure cuffs, post-intubation injury is still the leading cause of benign, acquired, tracheoesophageal fistula (TEF). Cuff pressure, which is their primary pathogenetic driver, is not routinely monitored as a quality metric. To highlight the devastating consequences, we report this case of a fatal, iatrogenic fistula in a 64-year-old Asian male. He had undergone tracheostomy due to amyotrophic lateral sclerosis (ALS) and had a series of hospitalizations due to recurrent episodes of pneumonia. A TEF was eventually diagnosed to be the underlying cause. Esophageal stenting was ineffective. We intend to present teaching points aimed at reducing the risk of TEF in ventilator-dependent patients.

INTRODUCTION: Gastrointestinal (GI) symptoms and liver function test (LFT) abnormalities are increasingly being reported in patients with COVID-19 but there is no reliable data on the real magnitude of GI tract involvement We present the results of our study of 711 patients for GI and liver manifestations of COVID-19 METHODS: We performed a retrospective chart review of the 711 adult patients who visited the Richmond University Medical Center and/or its ambulatory centers in New York City up until May 13, 2020, and tested positive for COVID-19 We analyzed the reported incidence of dysgeusia, anorexia, nausea, vomiting, diarrhea, abdominal pain, and GI bleeding as well as LFT abnormalities In case of deranged LFTs, we looked for preexisting liver disease, alcohol abuse, and anti-retroviral medication use RESULTS: A total of 711 patients were studied using inpatient charts, and laboratory data to identify abnormal findings The mean age of patients was 60 5 years with slight male predominance (n = 395 vs 316) 27 1% (n = 193) reported GI symptom and an additional 56 9% (n = 405) had at least one liver enzyme abnormality Diarrhea was the most common with a frequency of 17 3% (n = 86), nausea 16 2% (n = 80), anorexia/vomiting 13 7% (n = 68), and abdominal pain 5 6% (n = 28) The least reported symptoms were dysgeusia 3 2% (n = 16) and GI bleeding 2 2% (n = 11) Lipase level was elevated in 27 8% patients (n = 138) Among LFTs, AST alone was elevated in 16 6% (n = 118), ALT alone in 15 0% (n = 6), both AST/ALT 15 7% (n = 112), alkaline phosphatase 23% (n = 164), and bilirubin 10% (n = 71) Potential confounders were preexisting liver disease (n = 8), patients taking HIV medications (n = 9) and alcohol abuse However, the enzyme levels in these patients were elevated above their baseline PT/ INR was elevated in 13 4% (n = 95) of patients while only 27 of them were on oral anticoagulant 88 6% (n = 630) of patients were admitted with respiratory failure, and 28 5% (n = 203) died CONCLUSION: GI symptoms were experienced by 27% and hepatic dysfunction was at 57% in this study of 711 COVID-19 patients This reflects a fairly high burden of GI involvement As the covid- 19 pandemic continues its rampage, our understanding of its GI and hepatobiliary aspects is growing This will improve our diagnostic, therapeutic, and preventive armamentarium Other implications for gastroenterlogists include prolonged viral shedding in stools, potential for fecal-oral transmission and risk of exposure during endocsopy (Table Presented)

A 79-year-old African American woman presented with acute hematemesis after progressive dysphagia for 6 weeks and 12-pound weight loss. She had no predisposing immunocompromising comorbidity such as the human immunodeficiency virus or active malignancy. Computed tomography showed air-fluid levels within the esophagus with partial obstruction. Upper endoscopy revealed a 1-cm mass lesion in the midthoracic esophagus, and biopsy results surprisingly showed esophageal actinomycosis. The patient's symptoms resolved on antimicrobial therapy at a one-month follow-up, and the lesion was not seen on repeat endoscopy with biopsy at 3 months. We believe that inhaled corticosteroids for chronic obstructive pulmonary disease may have created the growth milieu by impairing local defenses. Correct inhaler technique, avoiding swallowing the water after mouth rinsing, and a spacer device are recommended to reduce esophageal corticosteroid exposure.

Percutaneous Gastrostomy (PEG) tube is an endoscopic-guided procedure to provide enteral nutrition, medications and/or fluids to patients with oral or esophageal pathologies. PEG tubes are a relatively safe intervention but commonly known to have complications like insertion site infection, tube leakage, and tube blockage. This was an unusual case in which the PEG tube was discovered to be obstructing the third part of the duodenum after migration resulting in mechanical gastric obstruction with septic shock and severe hemodynamic instability. PEG induced gastric obstruction is often misdiagnosed during a triage due to the atypical presentation of this condition leading to aggressive management, testing and consultations. PEG dependent patients have rapidly increased over the years and a complete physical examination of the PEG site should be performed by all physicians in order to prevent related complications.

Introduction: Laparoscopic appendicectomy (LA) is the most commonly performed surgical emergency procedure. The aim of this study was to highlight a series of iatrogenic bladder injuries during LA and suggest a simple method of prevention.Methods: A retrospective review was carried out of all LA performed in a university teaching hospital over a two year period 2012-2013. Iatrogenic visceral injuries were identified and operative notes examined.Results: During the study period 1124 appendicectomies were performed. Four iatrogenic bladder injuries occurred related to secondary trocar insertion. No patient was catheterised preoperatively. One of the injuries was identified intra-operatively, another in the early postoperative period where as two re-presented acutely unwell post-discharge from hospital. Three were repaired by laparotomy and one laparoscopically.Conclusion: Iatrogenic secondary trocar induced bladder injuries are a rare but preventable and potentially serious complication of LA. Urethral catheterisation during LA is a safe and simple method which can prevent this complication.