Explore the vast range of titles available.

BackgroundVedolizumab is a monoclonal antibody used to treat inflammatory bowel disease (IBD). There is little known about the safety and comparative efficacy of this agent in the elderly population.AimsHere, we present data on the safety and comparative efficacy of vedolizumab versus tumor necrosis factor α antagonists (anti-TNF) in elderly patients with IBD.MethodsThis retrospective cohort study included IBD patients started on vedolizumab or anti-TNF at age 60 or older at a single tertiary IBD center. Safety was evaluated by assessing for the development of serious infection. The comparative needs for IBD-related surgery, IBD-related hospitalization, and drug discontinuation for any reason were obtained. Efficacy was assessed by comparing changes in endoscopic, histologic, and patient-report outcomes.Results212 cases were identified—108 patients treated with vedolizumab and 104 patients treated with anti-TNF. There were no significant differences between cohorts in serious infection, surgical intervention, or IBD-hospitalization-free survival (p = NS). Drug discontinuation survival was different between anti-TNF and vedolizumab (p = 0.02) with more patients remaining on vedolizumab at the time of last follow-up (51.9% vs. 25.9%). Endoscopic remission and response rates were higher in the vedolizumab versus anti-TNF group (65.7% vs. 45.2%, p = 0.02; 80.0% vs. 59.3%, p < 0.001).ConclusionsIn a cohort of IBD patients over age 60, vedolizumab showed no statistically significant differences in infection, hospitalization, or surgical intervention-free survival as compared to anti-TNF. Vedolizumab was discontinued less frequently than anti-TNF. Patients on vedolizumab had higher rates of endoscopic remission and response.

INTRODUCTION Colloid carcinoma of the pancreas (CCP), is a rare pancreatic neoplasm and represents 1% of all pancreatic tumors. Most common site is head of the pancreas with oftentimes association with intraductal papillary mucinous neoplasms (IPMNs). CCP tumor cells are cuboidal or stellate clusters floating within voluminous amount of mucin. Compared to pancreatic ductal adenocarcinoma, CCP has better prognosis appealing to distinguish it as a recognizable entity. We present a rare case of multifocal colloid (mucinous) carcinoma arising in association with an IPMN. CASE PRESENTATION 71-year-old male with history of weight loss had a CT abdomen showing mixed density 6cm pancreatic head (PH) lesion and dilatation (1.1cm) of the distal pancreatic duct (PD). EUS guided FNA was non-diagnostic and ERCP guided PD brushing showed atypical cells suspicious for high grade dysplasia (HGD). Follow up ERCP with pancreatoscopy showed free mucin exiting the main papilla followed by direct visualization of papillary growth and mucin rich fluid in the proximal PD in the PH. Rest of PD was grossly normal. PD brushing again revealed atypical cells. Due to high suspicion of malignancy and previous findings of HGD, patient underwent Whipples surgery (pancreaticoduodenectomy). Surgical pathology showed invasive moderately to poorly differentiated colloid (mucinous) carcinoma, multifocal, arising in association with an IPMN, predominantly intestinal type with high grade glandular dysplasia. The IPMN involved the main PD as well as multiple branch ducts. Invasive tumor was confined to the pancreas with negative surgical margins. Patient was sent for adjuvant therapy after uneventful post-operative course. DISCUSSION CCP is primarily associated with intestinal type of IPMN. Theory behind better prognosis of CCP is inverse polarization of colloid carcinoma cells with abundant mucin secretion through their base into the interface between the cells and stroma and not towards the lumen, fencing the further cancer cell infiltration although conceding to the overall ample tumor growth. There is a male predilection in seventh decade of life with weight loss as one of the common presenting symptoms. Most often CCP is diagnosed after surgical resection. No guidelines exist for its treatment (due to rare nature). Nevertheless, surgical treatment is recommended. No studies are done to appraise adjuvant therapy, however its still recommended to bolster long-term prognosis.

Introduction: Autoimmune Pancreatitis (AIP) is a rare but increasingly more recognized cause of chronic pancreatitis. AIP can be divided into Type 1 and Type 2, which are characterized by high amounts of IgG4 Plasma Cells and Granulocytic Epithelial Lesions, respectively. Until recently, most AIP was diagnosed in patients who underwent Pancreaticoduodenectomy due to concern for pancreatic cancer. With the advent of Endoscopic Ultrasound (EUS) and Fine Needle Biopsy (FNB), a less invasive realm for diagnosis and management is now utilized. Here we present a case of a patient with acute pancreatitis and a mysterious pancreatic mass. Case report: A 49 year old female presented with abdominal pain and a lipase of 1227. Though the patient had symptoms consistent with acute pancreatitis, she did not have any major risk factors nor familial history. CT Imaging revealed a 4 cm tail of pancreas solid mass. To rule out malignancy, an EUS was performed which showed 3.1 x 3.2 cm hypoechoic and heterogenous mass with poorly formed borders. FNB was successfully done with histopathology revealing storiform fibrosis without granulation, up to 25 IgG4 plasma cells in a high power field, and an IgG4/IgG ratio greater than 40%. The diagnosis of Type 1 AIP was made with a high serum IgG4 level of 109. Ultimately, a corticosteroid taper was initiated which brought resolution of the patients symptomology. Discussion: Criteria for diagnosis of AIP include 5 distinct entities recognized by the mnemonic HISORt (histology, imaging, serology, organ involvement, and response to therapy). Imaging findings typically show a sausage shape of the pancreas, multifocal strictures, and a positive duct penetrating sign. Tissue histology for Type 1 AIP reveals sheets of plasma cells, storiform fibrosis, and positive IgG4 immunostaining of plasma cells. Upon diagnosis, immunoglobulin deposition within the biliary tree and hepatic parenchyma, as well as multi-organ manifestations of the more broadly termed IgG4 related diseases should be taken into clinical consideration. A trucut biopsy was initially indicated since fine needle aspiration (FNA) diagnostic yield was 43%. With the second generation FNB needle the use of trucut biopsy is not needed. First line therapy involves a course of corticosteroids that is typically tapered based on organ responsiveness. More recent case series include depletion of the B cell line with Rituximab for patient's refractory to steroids.

Introduction: Cirrhosis related portal hypertension is a well-known cause of esophageal varices (EVs) and portal hypertensive gastropathy (PHG). Similar mucosal abnormalities have been observed in small intestine (portal hypertensive enteropathy; PHE) and colon (portal hypertensive colopathy; PHC). Nevertheless, to our knowledge, no anomalous hemodynamically altered mucosal abnormality has been described in the esophagus. We present a case of an upper gastrointestinal bleed (UGIB) secondary to esophageal mucosal abnormalities which amended swiftly with changes in hemodynamics and we called it portal hypertensive esophagopathy. Case Report: A 53-year-old female with alcohol related cirrhosis complicated by porto-pulmonary hypertension was admitted with UGIB. An esophagogastroduodenoscopy (EGD) revealed grade-2 EVs, small GVs without any active bleeding or stigmata and PHG. The esophagus showed diffusely abnormal mucosa with severe friability and petechial appearance, covering more than two-third of entire esophagus starting from distal segment. Patient received conservative management with blood products and was discharged. Two weeks later. patient presented again with hematemesis and melena. EGD showed similar findings as prior evaluation. Anon-selective beta-blocker (NSBB) was added with her home pulmonary hypertension treatment (comprising a prostacyclin and phosphodiesterase-5 enzyme inhibitor). Follow up EGD after one month, showed significant improvement in esophageal mucosal abnormalities while esophageal varices remained stable. Discussion: PHG, PHE and PHC are common in cirrhosis and their severity parallels the stage of liver disease. Reduction in portal pressure, results in improvement in gastrointestinal (GI) mucosal appearance. While the pathophysiology of PHG is not clearly understood, involvement of multiple factors such as tumor necrosis factor (TNF) inhibitors, nitric oxide (NO), EGF, and prostaglandins have been reported. The treatment of PHG involves reduction in portal pressures, with non-selective beta blockers or TIPS, which result in a resolution of mucosal changes and improvement in bleeding risk. Esophageal mucosal abnormalities in our case resembled PHG and showed a similar treatment response due to hemodynamic changes induced by NSBB justifying the fact that portal hypertension was the cardinal etiology for its appearance. We coin the term \"portal hypertensive esophagopathy\" for this esophageal mucosal transformation.

INTRODUCTION: Radio frequency ablation (RFA) role is established in the treatment of solid tumors. However, its application in biliary system is novel. A novel endoscopic RFA (ERFA) device is available now to manage malignant biliary obstruction (MBO). We are presenting our experience with this novel device. CASE PRESENTATION: Case is a 79 year old male with diagnosis of incidental gallbladder adenocarcinoma (stage IIB;T2bNxM0) after cholecystectomy for symptomatic cholelithiasis. He refused further work up and returned three months later with obstructive jaundice. Imaging showed biliary outflow tract obstruction. ERCP showed bilateral 2.5cm long right and left hepatic duct strictures (RLHDS) extending to common hepatic duct (CHD). Brushing and biopsies were negative. Two plastic biliary stent were placed in hepatic ducts. One month later, jaundice had resolved, nevertheless due to abdominal pain and suspicion for malignant biliary stricture (BS), ERFA of BS and placement of uncovered self-expanding metallic stents (USEMS) was planned for palliative care. ERCP with cholangioscopy confirmed RLHDS biliary strictures. The novel ERFA catheter with 8 F bipolar probe and two ring electrodes (8 mm long and 6 mm apart), providing local coagulative necrosis over a length of 25mm ± 3mm was advanced over the guidewire under fluoroscopic guidance to the hepatic duct stricture. Total 6 RFA ablations (bipolar energy of 7-10 watts above and below the bifurcation respectively; 90 seconds ablation time, 1 minute stability time) were performed sequentially in RLHDS and in CHD successfully. Post RFA, successful biliary ablation appearance and improved lumen patency was noted. Two novel laser cut USEMS with simultaneous deployment device were placed in right and left hepatic ducts with excellent bile drainage. DISCUSSION: USEMS has application in MBO. However, tissue in growth remains a challenge. ERFA before stent placement can delay tumor ingrowth and frequency of re-intervention. Potential complications include thermal injury followed by late bile leak, duodenal leak, or late bleeding. However, a recent clinical trial with 65 patients by Jianfeng Yang etal showed ERFA combined with stenting can significantly prolong survival and stent patency period without increase in adverse events. Large-scale, prospective multicenter trial with a long-term follow-up may reinforce the benefits of RFA on stent patency and survival rates.

Introduction Pancreatic pseudocyst (PP) is a common complication of chronic pancreatitis. PP is a fibrous wall that surrounds a fluid collection comprised of enzymes, blood and necrotic tissue with no true epithelial lining. PP persists in roughly 10% of patients six weeks after initial insult. We present a rare case of an enlarged pancreatic pseudocyst that tracked down the inguinal canal and into the scrotum. Case Presentation A 60 old man with a history of alcoholic pancreatitis presented with signs of peritonitis. Due to clinical concern for ischemic colitis, he was taken to the operating room, where exploratory laparotomy revealed viable colon, but severe pancreatitis. Follow-up imaging showed extensive pancreatic necrosis and possible retroperitoneal hemorrhage requiring aggressive supportive care. One month later he re-presented with sepsis and purulent drainage from his left scrotum. CT Abdomen and Pelvis revealed a 13.3 x 13.8 x 26.1 cm intervally organized multilobulated peripherally enhancing collection extending from the pancreatic tail through the left retroperitoneum into the left inguinal canal and scrotum. Aspirate showed high lipase with Klebsiella pneumoniae isolated from cultures. The diagnosis of infected pancreatic pseudocyst was made. The 1 cm PD stone in the pancreatic body likely eroded through the PD wall and led to extensive leakage of pancreatic fluid. PP was effectively drained with intravenous antibiotics, two percutaneous drains and high-volume irrigation. Distal pancreatectomy was subsequently performed to remove the pancreatic duct stone. Endoscopic cystgastrostomy and ERCP with PD stenting was performed to manage post-operative recurrence of smaller PP and a small postoperative pancreatic fistula. Discussion Most PP spontaneously resolves, only symptomatic PP after six weeks should have percutaneous, endoscopic or surgical intervention. Surgical management has fallen out of favour with a 16% morbidity and 2.5% mortality rate, leading to initial endoscopic management (mortality 0.7%) becoming standard practice. The PP can be approached transmurally, transpapillary or combined via endoscopic methods such as endoscopic ultrasound (EUS) or endoscopic retrograde cholangiopancreatography (ERCP). Because the PP in our patient extended through the inguinal canal and into the scrotum, we also employed percutaneous intervention at bedside to help with PP drainage.

Tofacitinib has been approved for moderate-to-severe ulcerative colitis and studied in Crohn's disease. Understanding medication adherence to oral medications in severe disease is essential. We retrospectively reviewed adherence and real-world outcomes of inflammatory bowel disease patients who initiated tofacitinib at a single care center. Adherence was measured by proportion of days covered. Sixty-three patients were identified. All patients failed at least one prior biologic therapy. Mean proportion of days covered was 95.7% for ulcerative colitis and 93.1% for Crohn's disease. Significant clinical and endoscopic response was seen. Adherence was high in a cohort with highly refractory disease.