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Objective:New York City was the epicenter of the outbreak of the 2019 coronavirus disease (COVID-19) pandemic in the United States. As a large, quaternary care medical center, NYU Langone Medical Center was one of many New York medical centers that experienced an unprecedented influx of patients during this time. Clinical leadership effectively identified, oriented, and rapidly deployed a “COVID Army,” consisting of non-hospitalist physicians, to meet the needs of the patient influx. We share feedback from our providers on our processes and offer specific recommendations for systems experiencing a similar influx in the current and future pandemics.Methods:To assess the experiences and perceived readiness of these physicians (n = 183), we distributed a 32-item survey between March and June of 2020. Thematic analyses and response rates were examined to develop results.Results:Responses highlighted varying experiences and attitudes of our frontline physicians during an emerging pandemic. Thematic analyses revealed a series of lessons learned, including the need to (1) provide orientations, (2) clarify roles/workflow, (3) balance team workload, (4) keep teams updated on evolving policies, (5) make team members feel valued, and (6) ensure they have necessary tools available.Conclusions:Lessons from our deployment and assessment are scalable at other institutions.

BACKGROUND: Coronavirus SARS-CoV-2 affects multiple organs. Studies have reported mild elevations of lipase levels of unclear significance. Our study aims to determine the outcomes in patients with COVID-19 and hyperlipasemia, and whether correlation with D-dimer levels explains the effect on outcomes. METHODS: Case-control study from two large tertiary care health systems, of patients with COVID-19 disease admitted between March 1 and May 1, 2020 who had lipase levels recorded. Data analyzed to study primary outcomes of mortality, length of stay (LOS) and intensive care utilization in hyperlipasemia patients, and correlation with D-dimer and outcomes. RESULTS: 992 out of 5597 COVID-19 patients had lipase levels, of which 429 (43%) had hyperlipasemia. 152 (15%) patients had a lipase > 3x ULN, with clinical pancreatitis in 2 patients. Hyperlipasemia had a higher mortality than normal lipase patients (32% vs. 23%, OR = 1.6,95%CI = 1.2-2.1, P = 0.002). In subgroup analysis, hyperlipasemia patients had significantly worse LOS (11vs.15 days, P = 0.01), ICU admission rates (44% vs. 66%,OR = 2.5,95%CI = 1.3-5.0,P = 0.008), ICU LOS (12vs.19 days,P = 0.01), mechanical ventilation rates (34% vs. 55%,OR = 2.4,95%CI = 1.3-4.8,P = 0.01), and durations of mechanical ventilation (14 vs. 21 days, P = 0.008). Hyperlipasemia patients were more likely to have a D-dimer value in the highest two quartiles, and had increased mortality (59% vs. 15%,OR = 7.2,95%CI = 4.5-11,P

Background The novel Coronavirus (SARS‐CoV‐2) has caused almost 2 million deaths worldwide. Both Food and Drug Administration and European Medicines Agency have recently approved the first COVID‐19 vaccines, and a few more are going to be approved soon. Methods Several different approaches have been used to stimulate the immune system in mounting a humoral response. As more traditional approaches are under investigation (inactivated virus vaccines, protein subunit vaccines, recombinant virus vaccines), more recent and innovative strategies have been tried (non‐replicating viral vector vaccines, RNA based vaccines, DNA based vaccines). Results Since vaccinations campaigns started in December 2020 in both the US and Europe, gastroenterologists will be one of the main sources of information regarding SARS‐CoV 2 vaccination for patients in their practice, including vulnerable patients such as those with Inflammatory Bowel Disease (IBD), patients with chronic liver disease, and GI cancer patients. Conclusions Thus, we must ourselves be well educated and updated in order to provide unambiguous counseling to these categories of vulnerable patients. In this commentary, we aim to provide a comprehensive review of both approved COVID‐19 vaccines and the ones still under development, and explore potential risks, benefits and prioritization of vaccination.

Contains fulltext : 205162.pdf (Publisher’s version ) (Open Access) BACKGROUND AND AIMS: Colorectal cancer (CRC) is largely preventable with routine screening and surveillance colonoscopy; however, interval cancers arising from precancerous lesions missed by standard colonoscopy still occur. An increased adenoma detection rate (ADR) has been found to be inversely associated with interval cancers. The G-EYE device includes a reusable balloon integrated at the distal tip of a standard colonoscope, which flattens haustral folds, centralizes the colonoscope's optics, and reduces bowel slippage. The insufflated balloon also aims to enhance visualization of the colon during withdrawal, thereby increasing the ADR. METHODS: In this randomized, controlled, international, multicenter study (11 centers), patients (aged >/=50 years) referred to colonoscopy for screening, surveillance, or changes in bowel habits were randomized to undergo either balloon-assisted colonoscopy by using an insufflated balloon during withdrawal or standard high-definition colonoscopy. The primary endpoint was the ADR. RESULTS: One thousand patients were enrolled between May 2014 and September 2016 to undergo colonoscopy by experienced endoscopists; 803 were finally analyzed (standard colonoscopy n = 396; balloon-assisted colonoscopy n = 407). Baseline parameters were similar in both groups. Balloon-assisted colonoscopy provided a 48.0% ADR compared with 37.5% in the standard colonoscopy group (28% increase; P = .0027). Additionally, balloon-assisted colonoscopy provided for a significant increase in detection of advanced (P = .0033) flat adenomas (P < .0001) and sessile serrated adenomas/polyps (P = .0026). CONCLUSION: Balloon-assisted colonoscopy yielded a higher ADR and increased the detection of advanced, flat, and sessile serrated adenomas/polyps when compared with standard colonoscopy. Improved detection by the G-EYE device could impact the quality of CRC screening by reducing miss rates and consequently reducing interval cancer incidence. (Clinical trial registration number: NCT01917513.).

The COVID-19 pandemic has had a profound impact on provision of endoscopy services globally as staff and real estate were repurposed. As we begin to recover from the pandemic, a cohesive international approach is needed, and guidance on how to resume endoscopy services safely to avoid unintended harm from diagnostic delays. The aim of these guidelines is to provide consensus recommendations that clinicians can use to facilitate the swift and safe resumption of endoscopy services. An evidence-based literature review was carried out on the various strategies used globally to manage endoscopy during the COVID-19 pandemic and control infection. A modified Delphi process involving international endoscopy experts was used to agree on the consensus statements. A threshold of 80% agreement was used to establish consensus for each statement. 27 of 30 statements achieved consensus after two rounds of voting by 34 experts. The statements were categorised as pre-endoscopy, during endoscopy and postendoscopy addressing relevant areas of practice, such as screening, personal protective equipment, appropriate environments for endoscopy and infection control precautions, particularly in areas of high disease prevalence. Recommendations for testing of patients and for healthcare workers, appropriate locations of donning and doffing areas and social distancing measures before endoscopy are unique and not dealt with by any other guidelines. This international consensus using a modified Delphi method to produce a series of best practice recommendations to aid the safe resumption of endoscopy services globally in the era of COVID-19. ispartof: GUT vol:69 issue:11 pages:1915-1924 ispartof: location:England status: published

Colorectal cancer remains the second‐leading cause of cancer death in the United States—but efforts over the past two decades have resulted in tremendous progress in understanding the biology of how this disease develops, increasing screening rates, and decreasing incidence and mortality in those age 50 years and older. The drivers of this movement have been outstanding leadership, innovation, and collaboration. As we move forward to tackle issues such as the increasing incidence of this disease in younger adults, the need to address disparities in care and outcomes, and our shared goal to reach 80% screening rates, it's important to understand and appreciate the story of our past success in order to advance our future efforts.

INTRODUCTION: Telehealth involves the use of electronic information and telecommunications to promote healthcare Physician experience is critical in assessing the impact of telehealth on clinical outcomes and utilization Gastroenterologists' use and attitudes towards telehealth are largely unknown We aimed to identify gastroenterologists' professional attitudes towards their use of telehealth and its effect on patient care during the COVID-19 pandemic METHODS: We performed a cross sectional survey of outpatient gastroenterologists and hepatologists at a single tertiary academic medical center in June 2020 Clinicians were invited to participate in an electronic survey Survey questions involved either single or multiple categorical responses RESULTS: A total of 46 respondents (51 ± 14 years old) participated, 70% of which were male 44 (96%) respondents had no telehealth experience prior to the pandemic Clinicians conducted 19 ± 13 visits weekly with a mean length of 24 ± 9 minutes 88% of providers reported telehealth allowed for increased flexibility, both in patient scheduling and their personal lives Telehealth was always or usually effective in addressing patients' clinical needs 91% of the time 29 (63%) respondents estimated that 10% or fewer patients required in-person follow-up Clinicians estimated 93% of patients desired the continued option of telehealth, and 42 (91%) providers wanted to continue telehealth in some capacity, conditional on reimbursement Those interested would use telehealth for follow-up visits (28%), on a patient-by-patient basis (23%), or for new visits (20%) While 21 (46%) respondents felt that telehealth and in-person visits required equal effort, 16 (35%) felt telehealth required more effort Reasons cited for telehealth requiring more effort included coordination of care (30%), technical difficulty for the patient (20%), and more charting (17%) CONCLUSION: While most clinicians had no telehealth experience before the pandemic, a majority were interested in using telehealth in the future, citing increased flexibility for both provider and patient Physicians felt that telehealth was effective in addressing patients' needs However, many felt that telehealth required more effort, particularly in regard to coordination of care and technical difficulties Newer telehealth platforms should address connectivity issues Future studies should focus on patients' attitudes towards telehealth, and the effect of telehealth on healthcare outcomes, utilization and costs

Background and Aims The advent of capsule endoscopy has revolutionized evaluation of the small bowel. Capsule endoscopy has become the criterion standard as the initial examination to diagnose small-bowel abnormalities, but does not allow for tissue sampling or therapeutic intervention. Deep enteroscopy can be performed by using a balloon-assisted device or a spiral overtube for both diagnostic and therapeutic interventions of the small bowel. Deep enteroscopy is time-consuming and requires special endoscopes and accessories to perform the examination. We studied a novel through-the-scope balloon catheter system used for deep enteroscopy that uses a conventional colonoscope and standard accessories. Methods We performed a 9-center, retrospective study using a novel TTS balloon system for small-bowel evaluation. The new through-the-scope device is an on-demand balloon catheter that is inserted through the instrument channel of a standard colonoscope and enables deep advancement into the small bowel in either the anterograde or retrograde approach. It consists of a balloon inflation/deflation system and a single-use balloon catheter designed for anchoring in the small bowel. The balloon is inflated to an anchoring pressure in the small intestine, and a repetitive push-pull technique is performed, with the endoscope sliding over the guiding catheter to the inflated balloon. The catheter may be removed and reinserted to allow for therapeutic intervention while maintaining the endoscope position. Results A total of 98 patients were included; 52% were male, and the mean age was 55 years old (range 15-94 years). Indications included abdominal pain, iron-deficiency anemia, occult GI bleeding, diarrhea, abnormal capsule endoscopy, weight loss, protein losing enteropathy, retained foreign body, altered anatomy ERCP, and small-bowel strictures. Anterograde enteroscopy was performed in 65 patients. The average depth of insertion was 158 cm (range 50-350 cm) from the pylorus. Retrograde enteroscopy was performed in 33 cases. The average depth of insertion was 89 cm (range 20-150 cm) beyond the ileocecal valve. Overall, diagnostic yield was 44%. The average advancement time for the anterograde and retrograde enteroscopy cases was 15.5 minutes. There were no procedural adverse outcomes reported in the 98 cases. Conclusions The TTS advancing balloon is a safe and effective way to perform deep enteroscopy by using a conventional colonoscope without the need for an overtube. Procedure time is shorter than that of other forms of deep enteroscopy. Diagnostic yield and depth of insertion are on par with other forms of deep enteroscopy. This is the largest reported study using this novel technology to diagnose and treat small-bowel disease.

The American College of Gastroenterology and the 80% by 2018 Colorectal Cancer Initiative: A Multifaceted Approach to Maximize Screening Rates

75-year-old woman with a remote history of sigAmoidectomy for perforated diverticulitis, as well as benign colonic polyps found during colonoscopy 4 years prior, presented for surveillance colonoscopy. During colonoscopy, an isolated, 3 cm in length, pedunculated, worm-like polyp was discovered at 40 cm proximal to the anus (Figure A). Initial hot snare polypectomy, set at 25 W, cut through the outermost layer of stalk tissue but failed to cut through the central fibrous-appearing core. Of note, the stalk of the polyp was noted to contract with application of current. By using the autocut function set at 180 W, the central core was successfully cut (Figure B). The polyp was retrieved, and hemostatic clips were placed to prevent post-polypectomy bleeding. Pathologic examination revealed a finger-like polyp lined by benign reactive colonic epithelium and containing a central fibrovascular core, which was negative for dysplasia (Figure C). There were no post-procedural adverse events. Filiform polyps are most commonly associated with inflammatory bowel disease but may also be seen with diverticulitis and malignancy. Differing from this case, filiform polyps more commonly are found as a group of polyps or even as mass-like agglomerations. Histologic examination of filiform polyps reveals nonspecific inflammation of colonic mucosa with a core that is often fibrovascular but can also contain disordered smooth muscle fascicles and nerves. These muscle fascicles are believed to be the cause of polyp contraction with application of current during this case. Filiform polyps generally are not thought to have malignant potential. However, endoscopists should consider polypectomy or biopsy if the polyp is of uncertain histology. This was an atypical, isolated filiform polyp found during colonoscopy, and thus the endoscopists chose to proceed with polypectomy. A previous report suggested a snare and cautery technique for removal of suspected filiform polyps. However, because of the fibrovascular and muscular core of these polyps, autocut may be more successful for polypectomy of a suspected filiform polyp.

Regional enteritis may present in the setting of a variety of clinical symptoms. These symptoms range from mild to severe.Here we describe two different presentations of regional enteritis (Crohn's disease): one in the setting of Clostridium perfringens sepsis and the second in association with hemolytic-uremic syndrome. Both presentations resulted in life-threatening multiple organ dysfunction syndrome.Following appropriate surgical management and intensive physiologic support, both patients recovered, despite a MODS-predicted risk of mortality of 100% and 91%, respectively.Fulminant presentations of regional enteritis of this magnitude are rare, and highlight the resolution of severe multiple organ dysfunction for each presentation.

Clinical histories, endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) material, and immunohistochemical stains performed on cell block samples of 6 solid-pseudopapillary tumors of the pancreas (SPTPs) were reviewed in the cases of 5 females (13–58 years) and 1 man (57 years); all had abdominal pain. Preliminary cytologic diagnoses at endoscopy included 1 SPTP, 2 low-grade neoplasms, and 3 pancreatic endocrine tumors. Variable numbers of branching fragments with central capillaries and myxoid stroma were seen in the smears of 5 of 6 cases but were more apparent in the cell block material of all cases. The cells had bland nuclear features and rare grooves. Extensive necrosis was noted in 1 case and rare mitotic figures in 1. SPTPs showed strong cellular immunoreactivity for vimentin and focal weak keratin reactivity. Neuron-specific enolase, α1-antitrypsin, and α1-antichymotrypsin stains performed in 2 cases were strongly positive. Subsequent surgical resection confirmed all diagnoses. EUS-guided FNA diagnosis of SPTP is accurate. The characteristic branching papillae with myxoid stroma are best seen in cell block slides. Clinical setting, cytomorphologic features, and immunostains of the cell block help distinguish SPTP from pancreatic endocrine tumors, acinar cell carcinoma, and papillary mucinous carcinoma.

Although colonoscopy is the "gold standard" for colorectal cancer screening, a significant number of adenomas are still missed during standard colonoscopy, often because they are hidden behind colonic folds and flexures. The aim of this study was to assess the ability of a novel balloon colonoscope (G-EYE endoscope; Smart Medical Systems, Ra'anana, Israel) to increase adenoma detection and reduce the miss rate compared with standard colonoscopy.This was a multicenter, randomized, prospective, controlled study in patients (age ≥ 40 years) undergoing colonoscopy for screening or diagnostic work-up (including surveillance). Patients underwent same-day, back-to-back tandem colonoscopy. Patients in Group A underwent standard colonoscopy followed by balloon colonoscopy, and patients in Group B underwent balloon colonoscopy followed by the standard technique. The adenoma detection and miss rates were compared between the two colonoscopy procedures.A total of 126 patients were enrolled and randomized into Group A (n = 60) or Group B (n = 66). The adenoma miss rate of balloon colonoscopy was significantly lower than that of standard colonoscopy (7.5 % vs. 44.7 %; P = 0.0002). The detection of additional adenomas by balloon colonoscopy was significant (81.0 %; P = 0.0002), in particular, the relative amount of adenomas detected in the ascending colon by balloon colonoscopy was 41 % versus 14 % for standard colonoscopy.A novel balloon colonoscopy technique detected significantly more adenomas than standard colonoscopy, and missed fewer adenomas. Balloon colonoscopy has the potential to increase the effectiveness of colorectal cancer screening and surveillance colonoscopy.

Since the first description by Frantz in 1959 of a papillary cystic tumor of the pancreas, solid pseudopapillary tumors have been increasing in incidence. However, management of these lesions remains controversial. Patients under the age of 20 years more often undergo local excision than do their older counterparts, resulting in increased recurrence rates. The cause of this discrepancy is not clear but may be related to an inability to make a definitive preoperative diagnosis. The authors report a case of a solid pseudopapillary tumor of the pancreas in a 13-year-old girl in which the diagnosis was established preoperatively by endoscopic ultrasound scan with fine-needle aspiration (EUS-FNA). EUS-FNA represents a diagnostic technique commonly used in adults that may be useful in identifying the rare pediatric patient with pancreatic malignancy.

Background & Aims The incidence and predictors of non-gastrointestinal (GI) adverse events (AEs) after colonoscopy are not well-understood. We studied the effects of antithrombotic agents, cardiopulmonary comorbidities, and age on risk of non-GI AEs after colonoscopy. Methods We performed a retrospective longitudinal analysis to assess the diagnosis, procedure, and prescription drug codes in a United States commercial claims database (March 2010–March 2012). Data from patients at increased risk (n = 82,025; defined as patients with pulmonary comorbidities or cardiovascular disease requiring antithrombotic medications) were compared with data from 398,663 average-risk patients. In a 1:1 matched analysis, 51,932 patients at increased risk, examined by colonoscopy, were compared with 51,932 matched (on the basis of age, sex, and comorbidities) patients at increased risk who did not undergo colonoscopy. We tracked cardiac, pulmonary, and neurovascular events 1–30 days after colonoscopy. Results Thirty days after outpatient colonoscopy, non-GI AEs were significantly higher in patients taking antithrombotic medications (7.3%; odds ratio [OR], 10.75; 95% confidence interval, 10.13–11.42) or those with pulmonary comorbidities (1.8%; OR, 2.44; 95% confidence interval, 2.27–2.62) vs average-risk patients (0.7%) and in patients 60–69 years old (OR, 2.21; 95% confidence interval, 2.01–2.42) or 70 years or older (OR, 6.45; 95% confidence interval, 5.89–7.06), compared with patients younger than 50 years. The 30-day incidence of non-GI AEs in patients at increased risk who underwent colonoscopy was also significantly higher than in matched patients at increased risk who did not undergo colonoscopy in the anticoagulant group (OR, 2.31; 95% confidence interval, 2.01–2.65) and in the chronic obstructive pulmonary disease group (OR, 1.33; 95% confidence interval, 1.13–1.56). Conclusions Increased number of comorbidities and older age (older than 60 years) are associated with increased risk of non-GI AEs after colonoscopy. These findings indicate the importance of determining comorbid risk and evaluating antithrombotic management before colonoscopy.

This article provides an overview of FDA's regulatory processes for drug development and approval, and the estimated costs associated with the development of a drug, and also examines the issues and challenges facing the FDA in the near future.A literature search was performed using MEDLINE to summarize the current FDA drug approval processes and future directions. MEDLINE was further utilized to search for all cost analysis studies performed to evaluate the pharmaceutical industry RD productivity and drug development cost estimates.While the drug approval process remains at high risk and spans over multiple years, the FDA drug review and approval process has improved, with the median approval time for new molecular drugs been reduced from 19 months to 10 months. The overall cost to development of a drug remains quite high and has been estimated to range from $868M to $1,241M USD. Several new laws have been enacted, including the FDA Safety and Innovation Act (FDASIA) of 2013, which is designed to improve the drug approval process and enhance access to new medicines.The FDA's improved processes for drug approval and post-market surveillance have achieved the goal of providing patients with timely access to effective drugs while minimizing the risk of drug-related harm. The FDA drug approval process is not without controversy, as a number of well-known gastroenterology drugs have been withdrawn from the US market over the past few years. With the approval of the new FDASIA law, the FDA will continue to improve their processes and, working together with the ACG through the FDA-Related Matters Committee, continue to develop safe and effective drugs for our patients.

The diagnosis of protein-losing enteropathy (PLE) should be considered in all patients with hypoalbuminemia and edema without other known causes, and established by plasma alpha(1)-antitrypsin (alpha(1)-AT) clearance or nuclear studies. The therapy for PLE should focus principally on the treatment of the underlying disease after it has been identified. Therapeutic goals should include improvement of hypoalbuminemia, edema, and lymphopenia. The existing primary literature for therapy of PLE syndromes consists mainly of case reports and expert opinions, subject to substantial reporting bias and unknown rates of spontaneous remission; the rarity of and the diversity among this set of diseases make future large randomized trials unlikely. Therapeutic choices, therefore, must involve clinical acumen, empiricism, and understanding of the pathophysiology of the underlying disease process, and must be tailored to each individual patient's syndrome. Dietary interventions including hypolipidic, high-protein regimens, supplemented by medium-chain triglycerides (MCTs), are extremely useful, particularly in protein loss due to increased lymphatic pressure. Corticosteroids can be very useful in certain cases of PLE (though not without substantial long-term toxicity) when clinical serologic or histologic markers of inflammatory disease are present. Octreotide is a well tolerated drug that has been demonstrated to improve PLE in some patients, and is worth consideration. Octreotide is a well tolerated drug that has been demonstrated to improve PLE in some patients, and is worth consideration. Surgery finds its best role in treating gastrointestinal protein loss from neoplasia, inflammatory bowel disease, and hypertrophic gastritis. Most other PLEs are distributed too widely for surgical intervention. Protein-losing gastropathy (PLG) behaves somewhat differently from the general group of PLE, marked by excellent responses to elimination of Helicobacter pylori, antisecretory therapy, and surgical resection. Protein-losing enteropathy stemming from cardiovascular disease is best treated by medical or surgical cardiovascular interventions; however, some patients may respond to mucosa-directed therapy.

Obscure gastrointestinal bleeding is a common clinical scenario. In the upper gastrointestinal tract, gastric varices can be frequently overlooked on endoscopy, particularly if not suspected or volume depleted. We report a case of suspected gastrointestinal bleeding in a patient with a childhood history of pancreatitis, who also experienced severe epigastric pain while in hospital. After transfer to an academic medical centre, the presence of gastric varices was identified and presumed to be due to splenic vein thrombosis. Pancreatitis is the most common cause of splenic vein thrombosis and accords with the patient's history, even though it occurred many years previously. This case highlights the importance of recognising pancreatitis-induced splenic vein thrombosis as a possible aetiology for upper gastrointestinal bleeding.

Although standard colonoscopy is considered the optimal test to detect adenomas, it can have a significant adenoma miss rate. A major contributing factor to high miss rates is the inability to visualize adenomas behind haustral folds and at anatomic flexures.To compare the diagnostic yield of balloon-assisted colonoscopy versus standard colonoscopy in the detection of simulated polyps in a colon model.Prospective, cohort study.International gastroenterology meeting.A colon model composed of elastic material, which mimics the flexible structure of haustral folds, allowing for dynamic responses to balloon inflation, with embedded simulated colon polyps (n = 12 silicone "polyps").Fifty gastroenterologists were recruited to identify simulated colon polyps in a colon model, first using standard colonoscopy immediately followed by balloon-assisted colonoscopy.Detection of simulated polyps.The median polyp detection rate for all simulated polyps was significantly higher with balloon-assisted as compared with standard colonoscopy (91.7% vs 45.8%, respectively; P.0001). The significantly higher simulated polyp detection rate with balloon-assisted versus standard colonoscopy was notable both for non-obscured polyps (100.0% vs 75.0%; P.0001) and obscured polyps (88.0% vs 25.0%; P.0001).Non-randomized design, use of a colon model, and simulated colon polyps.As compared with standard colonoscopy, balloon-assisted colonoscopy detected significantly more obscured and non-obscured simulated polyps in a colon model. Clinical studies in human participants are being pursued to further evaluate this new colonoscopic technology.

Diospyrobezoars are a subtype of phytobezoars caused by excessive consumption of persimmons, which contain large amounts of tannins. In contrast to phytobezoars, diospyrobezoars have a harder consistency than other bezoars, making them more difficult to break up both chemically and endoscopically. We have previously reported successful dissolution of phytobezoars with diet soda and cellulase. A review of the literature found low efficacy of soda in dissolving diospyrobezoars compared to other phytobezoars. We report a case of successful dissolution of a diospyrobezoar after a failed attempt with diet soda alone.

Quality Commitment: The Newly Established American College of Gastroenterology Quality Council to Meet the Needs of Clinical Gastroenterology

The PathfinderTG biomarker panel is useful in the evaluation of pancreatic cysts that have clinical features suspicious for malignancy, but its utility in classifying fine-needle aspiration biopsies from small pancreatic cystic lesions is yet to be proven. We used morphology to classify 20 pancreatic cyst cytology aspirates, all of which met radiographic criteria for close observation. Cases were cytologically classified as consistent with pseudocyst, serous cystadenoma, or mucinous neoplasm with low-grade, intermediate-grade, or high-grade dysplasia and analyzed for carcinoembryonic antigen. Redpath Integrated Pathology Inc. rendered diagnoses of nonmucinous (reactive/indolent or serous) or mucinous (low-risk or at risk) cyst on the basis of results of the PathfinderTG panel (KRAS mutations, DNA content, and loss of heterozygosity at microsatellites linked to tumor suppressor genes). Cytologic and commercial laboratory diagnoses were concordant in only 7 (35%) cases. Seven cysts classified as mucinous with low-grade dysplasia by cytology were interpreted as nonmucinous on the basis of the PathfinderTG panel, 2 of which were resected mucinous cysts. Two pancreatitis-related pseudocysts were misdiagnosed as low-risk mucinous cysts; 1 mucinous cyst with low-grade dysplasia was considered at risk for neoplastic progression using the PathfinderTG panel. Only 1 cyst misclassified as pseudocyst by cytology, but low-risk mucinous cyst by molecular analysis, proved to be a mucinous cystic neoplasm with low-grade dysplasia after surgical resection. We conclude that the PathfinderTG panel may aid the classification of pancreatic lesions, but is often inaccurate and should not replace cytologic evaluation of these lesions.

The incidence of rectal cancer in the United States in young patients is considered to be low. Underestimating this incidence may result in a failure to diagnose younger patients with rectal cancer in a timely manner.The authors conducted a retrospective cohort study using Surveillance, Epidemiology, and End Results (SEER) cancer registry data. A total of 7661 patients with colon, rectal, and rectosigmoid cancer who were diagnosed at age40 years were identified between 1973 and 2005. The change in incidence over time for colon and rectal/rectosigmoid cancer was calculated and the annual percent change for anatomic subsites of colorectal cancer compared.SEER data demonstrated an increase in the incidence of rectal cancer without any increase in colon cancer (annual percent change of 2.6% vs -0.2%). The difference was statistically significant and extended to rectosigmoid cancer, but not cancer of the sigmoid colon or descending colon (annual percent change of 2.2% vs 0.4% and -2.8%, respectively). Joinpoint analysis of the slope of the curve of rectal and rectosigmoid cancer incidence identified the beginning of the increase to be 1984. All races and both sexes demonstrated similar statistically significant increases in the incidence of rectal and rectosigmoid cancer.The incidence of rectal and rectosigmoid cancer appears to be increasing in patients aged40 years. Patients presenting with rectal bleeding or other alarming signs or symptoms should be evaluated with this finding in mind.