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Background and Aims: Men are at a higher risk for Barrett's esophagus (BE) and esophageal adenocarcinoma (EAC), but little is known about BE progression to dysplasia and EAC in women. We performed a retrospective, multicenter cohort study to assess risk of BE progression to dysplasia and EAC in women compared with men. We also investigated comorbidities, medication use, and endoscopic features that contribute to sex differences in risk of BE progression. Methods: We collected data from large cohort of patients with BE seen at 6 centers in the United States and Europe, followed for a median 5.7 years. We obtained demographic information (age, sex, ethnicity), clinical history (tobacco use, body mass index, comorbidities), endoscopy results (procedure date, BE segment length), and histopathology findings. Neoplasia was graded as low-grade dysplasia, high-grade dysplasia (HGD), or EAC. Rates of disease progression between women and men were compared using χ2analysis and the Student t test. Multivariable logistic regression was used to assess the association between sex and disease progression after adjusting for possible confounding variables. Results: Of the total 4263 patients in the cohort, 2145 met the inclusion criteria, including 324 (15%) women. There was a total of 34 (1.6%) incident EACs, with an overall annual incidence of 0.3% (95% confidence interval: 0.2%-0.4%). We found significant differences between women and men in annual incidence rates of EAC (0.05% for women vs. 0.3% in men; P=0.04) and in the combined endpoint of HGD or EAC (0.1% for women vs. 1.1% for men; P

Background and study aims Adequate removal of precancerous polyps is an independent factor in colorectal cancer prevention. Despite advances in polypectomy techniques, there is an increasing rate of surgery for benign polyps. We assessed whether surgical resection is properly utilized for benign colorectal polyps. Patients and methods We identified 144 patients with surgical resection for benign colorectal polyps. Polyp location, size and the indication for and type of surgery were obtained. For the purposes of this analysis, we assumed that gastroenterologists should assess polyp size accurately, endoscopically resect polyps Results A total of 118 patients (82 %) were referred to surgery without attempted endoscopic removal. In 26 (22 %) of 118, the macroscopic polyp size was Conclusions Of the patients, 41 % could have potentially avoided surgical intervention (37 polyps

Rationale and objective While COVID-19 infection has been associated with acute kidney injury (AKI), it is unclear whether this association is independent of traditional risk factors such as hypotension, nephrotoxin exposure, and inflammation. We tested the independent association of COVID-19 with AKI. Study Design Multicenter, observational, cohort study. Setting and participants Patients admitted to one of six hospitals within the Yale-New Haven Health System between 3/10/2020 and 8/31/2020 and tested for SARS-CoV-2 via nasopharyngeal PCR test. Exposure Positive test for SARS-CoV-2. Outcome AKI by Kidney Disease: Improving Global Outcomes criteria. Analytic approach Evaluated the association of COVID-19 with AKI after controlling for time-invariant factors at admission (e.g., demographics, comorbidities) and time-varying factors updated continuously during hospitalization (e.g., vital signs, medications, laboratory results, respiratory failure) using time-updated Cox proportional hazard models. Results Of the 22,122 patients hospitalized between, 2,600 tested positive and 19,522 tested negative for SARS-CoV-2. Compared to patients who tested negative, patients with COVID-19 had more AKI [30.6% vs. 18.2%, absolute risk difference 12.5 (95% CI, 10.6, 14.3)%] and dialysis-requiring AKI (8.5% vs. 3.6%) and lower recovery from AKI (58% vs. 69.8%]. Compared to patients who tested negative, patients with COVID-19 had higher inflammatory markers (C-reactive protein, ferritin), and greater use of vasopressors and diuretics. Compared to patients who tested negative, patients with COVID-19 had higher rate of AKI in univariable analysis (HR, 1.84 [1.73, 1.95]). In fully adjusted model controlling for demographics, comorbidities, vital signs, medications, and laboratory results, COVID-19 remained associated with a high rate of AKI (adjusted HR, 1.40 [1.29-1.53]). Limitations Possibility of residual confounding. Conclusions COVID-19 is associated with high rates of AKI not fully explained by adjustment for known risk factors. This suggests the presence of mechanisms of AKI not accounted for in this analysis, which may include a direct effect of COVID-19 on the kidney or other unmeasured mediators. Future studies should evaluate the possible unique pathways by which COVID-19 may cause AKI., One-third of patients hospitalized with COVID-19 experience acute kidney injury (AKI), which is higher than in other hospitalized patients. Patients with COVID-19 carry many well-known risk factors for AKI including severe lung disease requiring mechanical ventilation, shock and significant inflammation. Whether higher rates of AKI in COVID-19 are above what could be expected in patients with similar risk factors is unknown. We compared AKI rates between those with and without COVID-19 after controlling for risk factors for AKI both before and during hospitalization. We found that COVID-19 was independently associated with high rates of AKI. This indicates that some of the AKI risk in patients with COVID-19 is unexplained by traditional AKI risk factors and is unique to this disease.

BACKGROUND & AIMS: European guidelines recommend different surveillance intervals of non-dysplastic Barrett’s esophagus (NDBE) based on segment length, as opposed to guidelines in the United States, which do recommend surveillance intervals based on BE length. We studied rates of progression of NDBE to high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC) in patients with short-segment BE using the definition of BE in the latest guidelines (length ≥1 cm). METHODS: We collected demographic, clinical, endoscopy, and histopathology data from 1883 patients with endoscopic evidence of NDBE (mean age, 57.3 years; 83.5% male; 88.1% Caucasians) seen at 7 tertiary referral centers. Patients were followed for a median 6.4 years. Cases of dysplasia or EAC detected within 1 year of index endoscopy were considered prevalent and were excluded. Unadjusted rates of progression to HGD or EAC were compared between patients with short (≥1 and

Acute cholangitis is an infection of the biliary system that typically results from obstruction. Common causes include choledocholithiasis, strictures, foreign bodies (such as biliary stents) parasitic worms (e.g. ascarids) and compression from an external structure. Obstruction allows for higher bacterial concentrations and bacterial proliferation. With biliary stasis and increases in intraductal pressure, bacteria migrate into the venous and lymphatic systems with subsequent bacteremia. The rate of gallstone development is 3-4 % annually in those >60 years old with up to a 15% overall prevalence in the US. In the US, 85% of ascending cholangitis cases are a consequence of choledocholithiasis. The gram-negative bacteria E coli, Klebsiella, Pseudomonas and Enterobacter are the most commonly identified pathogens. Anaerobes are less common.Ascending cholangitis is classically diagnosed by the presence of Charcot’s triad – fever, right upper quadrant pain and jaundice. Though very specific, the presence of Charcot’s triad is only 26% sensitive and thus its absence does not rule out the diagnosis. All patients with suspected ascending cholangitis should undergo appropriate fluid resuscitation, be given broad spectrum antibiotics to cover the likely enteric pathogens, and closely monitored for worsening in their clinical condition.Once initial assessment is complete and resuscitative efforts begun, imaging is often helpful in confirming the diagnosis of ascending cholangitis. After the diagnosis has been confirmed, ERCP and biliary drainage is indicated.

Pancreatic cancer is the fourth leading cause of cancer-related death with a median survival of 3–11 months when metastatic. We present a patient with metastatic pancreatic cancer and an exceptional response to initial systemic chemotherapy with FOLFIRINOX (fluorouracil, leucovorin, irinotecan, and oxaliplatin). Despite evidence of disease control on body imaging, he developed symptomatic leptomeningeal disease and brain metastases 29 months into treatment. He received aggressive treatment with capecitabine and irinotecan, intrathecal topotecan, and eventually bevacizumab. He did well for 36 weeks on this regimen until developing sepsis. This patient significantly outlived his expected survival and, moreover, did so with very good quality of life. This case demonstrates the natural history of pancreatic cancer progressing to involve the central nervous system when systemic disease is otherwise responsive to chemotherapy. It is the first case to demonstrate the potential effectiveness of intrathecal topotecan in combination with systemic chemotherapy for the treatment of leptomeningeal metastases of pancreatic cancer.

Despite an unmet need for hepatologists in the United States, every year transplant hepatology (TH) fellowship positions remain unfilled. To address this, we investigated factors that influence trainee decisions about pursuing a career in hepatology. We invited current gastroenterology (GI) and TH fellows from all Accreditation Council for Graduate Medical Education-accredited programs for the academic year 2014-2015 to participate in an online survey about factors influencing decisions to train in hepatology. The same paper-based survey was distributed at a nationally recognized GI board review course. The survey was completed by 180 participants of which 91% were current GI or TH fellows and 24% were not aware of the pilot 3-year combined GI and TH training program. A majority of respondents (57%) reported that a shorter time (3 versus 4 years) to become board certification eligible would influence their decisions to pursue TH. The most common reasons for not pursuing hepatology were less endoscopy time (67%), additional length of training (64%), and lack of financial compensation (44%). Personal satisfaction (66%), management of complex multisystem disease (60%), and long-term relationships with patients (57%) were the most attractive factors. Sixty-one percent of participants reported having a mentor, and 94% of those with mentors reported that their mentors influenced their career decisions. Conclusion: We have identified several factors that affect fellows' decision to pursue TH. Shorter training, increased financial compensation, and increased endoscopy time are potentially modifiable factors that may increase the number of trainees seeking careers in hepatology and help alleviate the deficit of hepatologists. (Hepatology Communications 2017;1:347-353).

Worldwide, colorectal cancer (CRC) is the third most commonly diagnosed cancer in males and second in females, with an estimated 1.4 million cases and 693,900 deaths in 2012. The current screening modalities utilized in the USA are examined in this review, along with current colonoscopy quality indicators. The contribution of CRC screening to the rising cost of health care in the USA has warranted recent public interest and has overall been demonstrated to be cost-effective. In addition, numerous barriers to screening are analyzed along with models for risk stratifying CRC risk at both an individual and population level. Recently, recognized risk stratification models from the Netherlands and Asia are compared with those developed in the USA, and the applicability of each to the US population is evaluated. Ultimately, this review presents the challenges and potential solutions in moving forward in the realm of CRC screening.

Emphysematous gastritis (EG) is an uncommon and potentially fatal disease characterized by gastric pneumatosis in the setting of infection. While this disease has been described in the literature, it has not previously been identified as a potential complication of cyclic vomiting syndrome. We describe a patient with a history of cyclic vomiting syndrome who presented acutely ill and was found to have radiographic, endoscopic, and histologic evidence of EG. This case illustrates how an untreated functional bowel disorder can lead to severe and potentially fatal complications.

Most of the malignant pancreatic lesions are primary pancreatic tumors with only a small percentage due to metastases. Pancreatic malignancies often present with symptoms such as jaundice and weight loss. Less commonly, new-onset diabetes mellitus has been seen in the setting of pancreatic adenocarcinomas. Although colon cancer commonly presents with metastatic disease, it typically spreads to the liver, lung, and peritoneum. We present a rare case of colon cancer metastatic to the pancreas presenting as diabetic ketoacidosis.

Background & Aims Esophageal adenocarcinoma is believed to result from the progression of gastroesophageal reflux disease to erosive esophagitis and re-epithelialization of the esophagus with a columnar cell population termed Barrett's esophagus (BE). Men develop BE and esophageal adenocarcinoma more frequently than women, yet little is known about the mechanisms of this difference. We assessed whether sex steroid hormones were associated with BE in a male population. Methods We analyzed data from the Barrett's Esophagus Early Detection Case Control Study, based at the Walter Reed National Military Medical Center. Blood samples were collected from 174 men with BE and 213 men without BE (controls, based on endoscopic analysis); 13 sex steroid hormones were measured by mass spectrometry and sex hormone binding globulin was measured by enzyme-linked immunosorbent assay. We also calculated free estradiol, free testosterone, and free dihydrotestosterone (DHT). We used multivariable logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs) adjusted for age, race, smoking status, alcohol consumption, body mass index, heartburn, regurgitation, and gastroesophageal symptom score (excluding heartburn and regurgitation). Results Levels of free testosterone and free DHT were associated positively with BE risk; patients in the highest quartile for these hormones were most likely to have BE (free testosterone: OR, 5.36; 95% CI, 2.21–13.03; P = .0002; free DHT: OR, 4.25; 95% CI, 1.87–9.66; P = .001). Level of estrone sulfate was associated inversely with BE risk ( P for trend = .02). No other hormone was associated with BE risk. Relationships were not modified by age or BMI. Conclusions In an analysis of men, levels of free testosterone and free DHT were significantly associated with BE.

Background & Aims A system is needed to determine the risk of patients with Barrett's esophagus for progression to high-grade dysplasia (HGD) and esophageal adenocarcinoma (EAC). We developed and validated a model to determine of progression to HGD or EAC in patients with BE, based on demographic data and endoscopic and histologic findings at the time of index endoscopy. Methods We performed a longitudinal study of patients with BE at 5 centers in United States and 1 center in Netherlands enrolled in the Barrett's Esophagus Study database from 1985 through 2014. Patients were excluded from the analysis if they had less than 1 year of follow up, were diagnosed with HGD or EAC within the past year, were missing baseline histologic data, or had no intestinal metaplasia. Seventy percent of the patients were used to derive the model and 30% were used for the validation study. The primary outcome was development of HGD or EAC during the follow-up period (median 5.9 years). Survival analysis was performed using the Kaplan-Meier method. We assigned a specific number of points to each BE risk factor, and point totals (scores) were used to create categories of low, intermediate, and high risk. We used Cox regression to compute hazard ratios (HR) and 95% CIs to determine associations between risk of progression and scores. Results Of 4584 patients in the database, 2697 were included in our analysis (84.1% men; 87.6% Caucasian; mean age, 55.4±20.1 years; mean body mass index, 27.9±5.5; mean length of BE, 3.7 cm±3.2). During the follow-up period, 154 patients (5.7%) developed HGD or EAC, with an annual rate of progression of 0.95%. Male sex, smoking, length of BE, and baseline-confirmed low-grade dysplasia were significantly associated with progression. Scores assigned identified patients with BE that progressed to HGD or EAC with a c-statistic of 0.76 (95% CI, 0.72–0.80) ( P P =.99), determined from the validation cohort. Conclusions We developed a scoring system (called progression of BE (PIB) score) based on male sex, smoking, length of BE, and baseline low-grade dysplasia) that identified patients with BE at low, intermediate, and high risk groups for HGD or EAC. This scoring system might be used in management of patients.

It is estimated that over 50,000 people will die from colorectal cancer (CRC) in 2014, making CRC the third leading cause of cancer death in the USA. During the last decade, we gained a better understanding of CRC pathophysiology and improved techniques for CRC prevention. Colonoscopy, as a cancer prevention measure, is essential in this task. Our article will review several aspects of colonoscopy and its use in CRC prevention. In addition, we will cover non-technical aspect such as quality measures, improving colonoscopy uptake, new bowel preparation formulations, sedation, and quality metrics. Next, we will discuss advances in technology and techniques including water immersion, new colonoscopes, and new imaging methods. Finally, we will cover two areas of major recent interest, “resect and discard” and sessile serrated polyps.

INTRODUCTION: Data on time trends of dysplasia and esophageal adenocarcinoma (EAC) in Barrett’s esophagus (BE) during the index endoscopy (ie, prevalent cases) are limited. Our aim was to determine the prevalence patterns of BE-associated dysplasia on index endoscopy over the past 25 years. METHODS: The Barrett’s Esophagus Study is a multicenter outcome project of a large cohort of patients with BE. Proportions of patients with index endoscopy findings of no dysplasia (NDBE), low-grade dysplasia (LGD), high-grade dysplasia (HGD), and EAC were extracted per year of index endoscopy, and 5-yearly patient cohorts were tabulated over years 1990 to 2010+ (2010-current). Prevalent dysplasia and endoscopic findings were trended over the past 25 years using percentage dysplasia (LGD, HGD, EAC, and HGD/EAC) to assess changes in detection of BE-associated dysplasia over the last 25 years. Statistical analysis was done using SAS version 9.4 software (SAS, Cary, NC). RESULTS: A total of 3643 patients were included in the analysis with index endoscopy showing NDBE in 2513 (70.1%), LGD in 412 (11.5%), HGD in 193 (5.4%), and EAC in 181 (5.1%). Over time, there was an increase in the mean age of patients with BE (51.7 ± 29 years vs 62.6 ± 11.3 years) and the proportion of males (84% vs 92.6%) diagnosed with BE but a decrease in the mean BE length (4.4±4.3 cm vs 2.9±3.0 cm) as time progressed (1990–1994 to 2010–2016 time periods). The presence of LGD on index endoscopy remained stable over 1990 to 2016. However, a significant increase (148% in HGD and 112% in EAC) in the diagnosis of HGD, EAC, and HGD/EAC was noted on index endoscopy over the last 25 years (P < .001). There was also a significant increase in the detection of visible lesions on index endoscopy (1990–1994, 5.1%; to 2005–2009, 6.3%; and 2010+, 16.3%) during the same period. CONCLUSION: Our results suggest that the prevalence of HGD and EAC has significantly increased over the past 25 years despite a decrease in BE length during the same period. This increase parallels an increase in the detection of visible lesions, suggesting that a careful examination at the index examination is crucial. (Gastrointest Endosc 2019;89:257–63.)

The Angelchik prosthesis is an antireflux device that was popular in the 1980s for treatment of refractory gastroesophageal reflux disease (GERD). We present a patient who developed a gastroesophageal fistula 17 years after Angelchik prosthesis placement. The incidence of late complications continues to grow, and clinicians should consider device malfunction in patients with history of Angelchik placement presenting with abdominal symptoms.

It is not clear whether length of Barrett's esophagus (BE) is a risk factor for high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC) in patients with nondysplastic BE. We studied the risk of progression to HGD or EAC in patients with nondysplastic BE, based on segment length.We analyzed data from a large cohort of patients participating in the BE Study-a multicenter outcomes project comprising 5 US tertiary care referral centers. Histologic changes were graded as low-grade dysplasia, HGD, or EAC. The study included patients with BE of documented length without dysplasia and at least 1 year of follow-up evaluation (n = 1175; 88% male), and excluded patients who developed HGD or EAC within 1 year of their BE diagnosis. The mean follow-up period was 5.5 y (6463 patient-years). The annual risk of HGD and EAC was plotted in 3-cm increments (≤3 cm, 4-6 cm, 7-9 cm, 10-12 cm, and ≥13 cm). We calculated the association between time to progression and length of BE.The mean BE length was 3.6 cm; 44 patients developed HGD or EAC, with an annual incidence rate of 0.67%/y. Compared with nonprogressors, patients who developed HGD or EAC had longer BE segments (6.1 vs 3.5 cm; P.001). Logistic regression analysis showed a 28% increase in risk of HGD or EAC for every 1-cm increase in BE length (P = .01). Patients with BE segment lengths of 3 cm or shorter took longer to develop HGD or EAC than those with lengths longer than 4 cm (6 vs 4 y; P = nonsignificant).In patients with BE without dysplasia, length of BE was associated with progression to HGD or EAC. The results support the development of a risk stratification scheme for these patients based on length of BE segment.

Many patients with a1 cm segment of columnar metaplasia in the distal esophagus, also called an irregular Z line, are encountered. These patients, often referred to as patients with Barrett's esophagus (BE), are enrolled in surveillance programs. However, little is known about their risk of high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC). We aimed to determine the incidence of HGD and EAC in patients with irregular Z line with intestinal metaplasia.We performed a prospective, multicenter cohort study of patients who underwent endoscopic examination for BE at tertiary care referral centers in the United States and Europe. We analyzed data from 1791 patients (mean age, 56 ± 17 years) found to have non-dysplastic BE at the index endoscopy and after 1 year or more of follow-up. Patients were followed for a median of 5.9 years (interquartile range, 3.1-8.3 years). We calculated rates of progression to HGD or EAC between groups of patients with irregular Z line (n = 167) and those with BE of ≥ 1 cm (n = 1624).A higher proportion of patients in the irregular Z-line group were female (26.3%) than in the BE group (14.8% female BE) (P.001). A lower proportion of patients in the irregular Z-line group were smokers (33.5%) than in the BE group (52.6% smokers). None of the patients with irregular Z line developed HGD or EAC during a median follow-up period of 4.8 years (interquartile range, 3.2-8.3 years). All 71 incident cases of HGD or EAC developed in patients with BE of ≥1 cm in length. On multivariate analysis, patients with irregular Z line and patients with BE of ≥ 1 cm did not differ significantly in age, race, or duration of follow-up.In a prospective, multicenter cohort study, we found that patients with irregular Z line do not develop HGD or esophageal cancer within 5 years after index endoscopy.

Colorectal cancer (CRC) is the third most common cause of cancer-related death in the United States (U.S.), with estimates of 143,460 new cases and 51,690 deaths for the year 2012. Numerous organizations have published guidelines for CRC screening; however, these numerical estimates of incidence and disease-specific mortality have remained stable from years prior. Technological, genetic profiling, molecular and surgical advances in our modern era should allow us to improve risk stratification of patients with CRC and identify those who may benefit from preventive measures, early aggressive treatment, alternative treatment strategies, and/or frequent surveillance for the early detection of disease recurrence. To better negotiate future economic constraints and enhance patient outcomes, ultimately, we propose to apply the principals of personalized and precise cancer care to risk-stratify patients for CRC screening (Precision Risk Stratification-Based Screening, PRSBS). We believe that genetic, molecular, ethnic and socioeconomic disparities impact oncological outcomes in general, those related to CRC, in particular. This document highlights evidence-based screening recommendations and risk stratification methods in response to our CRC working group private-public consensus meeting held in March 2012. Our aim was to address how we could improve CRC risk stratification-based screening, and to provide a vision for the future to achieving superior survival rates for patients diagnosed with CRC.

Colorectal cancer (CRC) is the second leading cause of cancer death in the United States. Many, if not most, cases arise from premalignant lesions (adenomas) which may be identified and removed prior to becoming frankly malignant. For over a decade, colonoscopy has been the preferred modality for both CRC screening and prevention in the US. Early reports suggested that colonoscopic screening imparted a 90% risk reduction for colorectal cancer. Subsequent studies showed that estimate to be overly optimistic. While still an outstanding CRC screening and detection tool, colonoscopy has several important limitations. Some of these limitations relate to the mechanics of the procedure such as the risk of colonic perforation, bleeding, adverse consequences of sedation, and the inability to detect all colonic polyps. Other limitations reflect issues with patient perception regarding colonoscopy which, at least in part, drive patient non-adherence to recommended testing. This review examines the literature to address several important issues. First, we analyze the effect of colonoscopy on CRC incidence and mortality. Second, we consider the patient-based, periprocedural, and intraprocedural factors which may limit colonoscopy as a screening modality. Third, we explore new techniques and technologies which may enhance the efficacy of colonoscopy for adenoma detection. Finally, we discuss the short and long-term future of colonoscopy for CRC screening and the factors which may affect this future.

The Current Topics in Military Tropical Medicine series provides focused reviews addressing specific questions faced by operational military medical personnel. This issue in the series explores the diagnosis and management of persistent diarrhea in deployed service members.

Background & Aims Guidelines recommend that patients with symptoms of nonconstipated irritable bowel syndrome (NC-IBS) undergo testing for celiac disease (CD). We evaluated the prevalence of CD antibodies, and biopsy confirmed CD among patients with NC-IBS in a large US population. Methods In a study conducted at 4 sites, from 2003 to 2008, we compared data from 492 patients with symptoms of NC-IBS to 458 asymptomatic individuals who underwent colonoscopy examinations for cancer screening or polyp surveillance (controls). All participants provided blood samples for specific and nonspecific CD-associated antibodies. Additionally, patients with IBS were analyzed for complete blood cell counts, metabolic factors, erythrocyte sedimentation rates, and levels of C-reactive protein and thyroid-stimulating hormone. Any subjects found to have CD-associated antibodies were offered esophagogastroduodenoscopy and duodenal biopsy analysis. Results Of patients with NC-IBS, 7.3% had abnormal results for CD-associated antibodies, compared with 4.8% of controls (adjusted odds ratio, 1.49; 95% confidence interval: 0.76–2.90; P = .25). Within the NC-IBS group, 6.51% had antibodies against gliadin, 1.22% against tissue transglutaminase, and 0.61% against endomysium ( P > .05 vs controls for all antibodies tested). CD was confirmed in 0.41% of patients in the NC-IBS group and 0.44% of controls ( P > .99). Conclusions Although CD-associated antibodies are relatively common, the prevalence of CD among patients with NC-IBS is similar to that among controls in a large US population. These findings challenge recommendations to routinely screen patients with NC-IBS for CD. More than 7% of patients with NC-IBS had CD-associated antibodies, suggesting that gluten sensitivity might mediate IBS symptoms; further studies are needed.

Background and Objective: Accessory spleen (AS) may be encountered as an intrapancreatic lesion on EUS. This can look similar to other pancreatic pathologies and may lead to unnecessary interventions. The goal of this study was to evaluate the accuracy of EUS in distinguishing intrapancreatic AS (IPAS) from other pancreatic lesions. Materials and Methods: Twelve sets of endoscopic images of the spleen and various pancreatic lesions confirmed on histology or cytology were gathered. Ten endosonographers were asked to characterize and identify the lesions. The responses were analyzed via Excel and the interobserver agreement was analyzed using Gwet's agreement coefficient statistic via Stata I/C v15. Results: In our sample, the interobserver agreement was 0.37 (−+1–1; 0–0.2 poor, 0.2–0.4 fair, 0.4–0.6 moderate, 0.6–0.8 substantial, and 0.8–1.0 almost perfect) for determining whether or not the pancreatic lesion is IPAS. The reviewers were able to correctly determine IPAS endosonographically with a sensitivity of 77%, specificity of 74%, and positive and negative predictive values of 50% and 92%, respectively. Conclusion: There is a moderate-to-substantial interobserver agreement in describing the sonographic characteristics of the pancreatic lesions, such as the shape, echogenicity compared to spleen, echotexture, and border of the lesions. However, the interobserver agreement is only fair when deciding if the pancreatic lesion is an IPAS. The similar profile of IPAS and pancreatic neuroendocrine tumor could confound the diagnosis of IPAS, thus contributing to the decreased interobserver agreement. This study demonstrates that EUS criteria alone are not accurate for IPAS diagnosis. Fine-needle aspiration (FNA) may be required for a confirmatory diagnosis.

Failure to regain consciousness after general anesthesia has a multitude of life-threatening causes, including neurological injury, metabolic derangements, or drug effects. Failure to promptly recognize the cause of unconsciousness after anesthesia can result in significant patient morbidity or mortality, costly laboratory and radiographic evaluation, and physician anxiety. Rarely, patients fail to awaken after anesthesia due to a psychiatric cause. The early recognition of psychogenic coma can result in reduced iatrogenic complications, hospital cost, and physician anxiety.We present a case of a 28-year-old female who became unresponsive after general anesthesia for an upper endoscopy. Physical, laboratory, and radiographic examination after the procedure revealed no apparent organic cause for her failure to awaken. The patient spontaneously awoke after 16 hours without neurological deficit.We reviewed the literature and identified 10 previously reported cases of postanesthesia psychogenic coma. We have compared and contrasted our case with the 10 previous reports and propose bedside clues to assist the physician with diagnosing this unusual condition.

Alternatives to the traditional, but possibly toxic mercury sphygmomanometer are needed for accurate blood pressure measurements in the medical workplace. We compared the performance of two commercially available potential replacements for the mercury column; an anaeroid manometer (BaumCo) and an automated oscillometric device (Omron HEM-907), using the mercury sphygmomanometer as a standard, in the same participants.Two independent observers performed simultaneous triplicate blood pressure readings for 512 participants. The average difference and standard deviation of the difference comparing the mercury column vs. the anaeroid and automated devices were calculated for each of the three paired systolic and diastolic blood pressure readings.Both devices met the Association for the Advancement of Medical Instrumentation criteria for sphygmomanometers (5 mmHg average difference,8 mmHg standard deviation of the difference) for all three readings. Compared with the mercury standard, there were no significant differences (by paired t-test) with the anaeroid device (-0.83/0.73 mmHg, P=0.25/0.09), but the automated device slightly overestimated systolic blood pressure (by 2.12 mmHg, P=0.002) and underestimated diastolic blood pressure (by 2.36 mmHg, P=0.0002). The first reading was significantly higher and had a larger standard deviation than the second or third readings across all manometers.The automated device performed as well as an anaeroid manometer operated by well trained, experienced observers. The two alternative devices to the mercury sphygmomanometer examined in this study may be potential replacement devices for blood pressure measurement.

Background and study aim: Data are limited on the natural history of patients with Barrett’s esophagus with a diagnosis of “indefinite for dysplasia” (IND). The aims of this study were to: (i) determine rates of progression to high grade dysplasia (HGD) or esophageal adenocarcinoma, and compare these with rates for low grade dysplasia (LGD); and (ii) determine the proportion of patients whose histological IND diagnosis changed on follow-up endoscopy. Patients and methods: Demographic, endoscopic, and histologic information of patients with diagnoses of IND and LGD and at least 12 months of follow-up were extracted from the database of a multicenter Barrett’s esophagus study. Rates and times for progression to HGD and esophageal adenocarcinoma and regression to nondysplastic epithelium were calculated. Proportions of diagnoses upgraded to HGD/esophageal adenocarcinoma or downgraded to nondysplastic epithelium at first follow-up endoscopy were evaluated. Results: Amongst 2264 patients, 83 with a diagnosis of IND (mean age 60 years, 95 % men, 95 % white; mean follow-up 5.6 years) and 79 with diagnosis of LGD were identified. In the IND group, annual incidences of esophageal adenocarcinoma and HGD were 0.21 % and 0.64 %, respectively, representing a combined incidence of 0.8 %. Mean time to progression was 4.72 years. Within the IND group 55 % patients showed regression to nondysplastic epithelium at first follow-up endoscopy and the overall regression rate was 80 %. Corresponding rates in LGD patients were similar. Conclusions: Lesions diagnosed as IND and LGD show similar biological behavior and can be treated as a single category with respect to surveillance and follow-up.

Over the past several years, a number of studies have addressed the role of specific strains of bacteria, or combinations thereof, to alleviate certain symptoms of irritable bowel syndrome (IBS). More importantly, the precise factors that contribute to this therapeutic effect, such as modulations in cytokine levels and alterations in colonic motility, are being clarified. This review serves to summarize the evidence for the use of probiotics in the treatment of IBS and to place this information in clinical context. Potential future developments and areas of possible research are also discussed.