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INTRODUCTION:Liver transplant is the most effective treatment to optimize survivorship in severe alcoholic hepatitis which has a six month mortality rate of 70%. In recent years, multi-center data demonstrated a drastic mortality benefit of early liver transplant and questions the six month alcohol sobriety requirement at some transplant centers. The purpose of this study is to determine whether or not community gastroenterology (GI) providers are aware of the survival benefits of early liver transplant in severe alcoholic hepatitis and to examine what factors impact their decision to refer.METHODS:This study was designed as a cross sectional survey targeting GI providers and fellows within the Washington, DC area. The surveys were distributed both in paper and electronic form via email and local academic meetings. Data was analyzed using Chi-Squared analysis and two sample T-test to detect statistically significant differences between groups.RESULTS:Forty-five surveys were completed by GI physicians (34 attendings, 11 fellows). There was a wide range in the number of years since completion of academic training (range = 0-45 years, average = 14 years). Overall, 40% (17/42) of all participants stated that an active drinking status made them less likely to refer for transplant. Participants who completed training >10 years ago overestimated the rate of alcohol recidivism compared to their counterparts (P = 0.005); however, there was no statistically significant difference in their likelihood to refer active alcohol users for transplant. Although not statistically significant, participants who were more likely to refer active drinkers for transplant completed their last academic training more recently than their counterparts (10 vs 17 years ago, P = 0.14). Factors associated with a higher tendency to refer active users for liver transplant included working for a liver transplant center (P = 0.007) and awareness that peak mortality occurs within two months of last drink (P = 0.001).CONCLUSION:Despite the survival benefits of early liver transplant in severe alcoholic hepatitis, 40% of gastroenterologists surveyed state they are less likely to refer active alcohol users for liver transplant. Education regarding low recidivism rates and drastic benefits in survival outcomes even in patients with less than six months of alcohol sobriety should be disseminated to community gastroenterologists, especially at non-transplant centers.

Introduction Timely admission and treatment of critically ill patients to Intensive Care Units (ICU) is shown to reduce premature mortality. However, low- and middle-income countries face many challenges in providing ICU services. This study describes the profile of patients admitted to ICU and their outcomes at the Central Regional Referral Hospital in Bhutan. Method This was an observational study with a review of records of patients from 2021 to 2023. The data were extracted into a pro forma, entered into EpiData Entry 3.1, and analysed in STATA 18. Results There were 287 patients admitted to the ICU. The mean age was 56.53 (SD ± 19.18) years). The highest number of cases were admitted from the Emergency Department (117, 40.77%) and Medicine Department (50, 17.42%). The common indications for admissions were pulmonary disease (91, 31.70%), sepsis/infection (61, 21.25%), cardiovascular diseases (48, 16.72%), and cerebrovascular diseases (38, 13.24%). There were 140 (48.78%) patients who received mechanical ventilation, 27 (9.41%) required positive pressure airway support, 36 patients (12.54%) had central venous access insertion, and 19 patients (6.62%) had haemodialysis line insertion. The mortality rate was 51.22% (147/287 patients); the most common causes of mortality were septic shock (22, 14.97%), stroke (16, 10.88%), and pneumonia (14, 9.52%). Patients with chronic liver disease (adjusted OR 4.32, 95% CI 1.84–10.09, p  = 0.001), and those receiving Ceftriaxone (adjusted OR 2.57, 95% CI 1.31–5.03, p  = 0.006), Piperacillin-Tazobactam (adjusted OR 2.63, 95% CI 1.02–6.77, p  = 0.045), and Cefazolin (adjusted OR 7.57, 95% CI 1.26–44.16, p  = 0.026) had higher odds of mortality. Patients receiving Doxycycline (adjusted OR 0.49, 05% CI 0.25–0.96, p  = 0.036) had lower odds of mortality. Conclusion About half of patients admitted to the ICU ended in mortality and the most common cause was septic shock. This study provides a baseline understanding of critical care service delivery in a resource-limited setting.

INTRODUCTION:Mucosal Schwann cell hammartomas are considered benign and were rarely reported as an incidental finding during colonoscopies. There is a lack of data on outcomes and surveillance guidelines due to the rarity of these unusual polyps. Here we report a case of colonic mucosal Schwann cell hammartoma incidentally found in a patient with intermittent diarrhea to enhance recognition of this rare lesion.CASE DESCRIPTION/METHODS:A 70-year-old-male with history of venous thromboembolism in setting of Factor V Leiden mutation on rivaroxaban had presented to our gastroenterology clinic complaining of chronic intermittent diarrhea without pain, hematochezia, melena, upper GI symptoms, or weight loss. To further evaluate ongoing diarrhea, the patient had a colonoscopy that showed patchy erythematous mucosa of the sigmoid colon with a single polyp measuring 4 mm at the descending colon, which was removed with a cold snare. The polyp showed focal expansion of the lamina propria by a bland spindle cell proliferation (Schwann cells) with no evidence of atypia or mitotic figures. No ganglion cells were noted and by immunostaining the spindle cells were strongly immunoreactive for S100 (Figure 1). Neuron-specific enolase (NSE) and synaptophysin were negative supporting the absence of ganglion cells. The immunoprofile and morphology was consistent with a diagnosis of mucosal Schwann cell hamartoma. Random colon biopsies ruled out microscopic colitis. Follow up visits were suggestive that food intolerances were the likely cause of his intermittent diarrhea.DISCUSSION:Benign nerve sheath tumors are mostly seen in the stomach and are rare in the rest of the gastrointestinal tract. The differential diagnosis is wide including neurofibromas, perineuromas, ganglioneuromas, granular cell tumors, gastrointestinal stromal tumors, carcinoid, and leiomyoma. Although there are common histological features of neural tumors, the immunostaining pattern is necessary to differentiate them from one another. Due to its rare occurrence, the exact incidence and prevalence of mucosal Schwann cell hammartoma is unknown. This distinction is important as this lesion has no association with any inherited polyposis syndrome and has a benign clinical course.

INTRODUCTION:An isolated colonic stricture is a rare sequela of recurrent pancreatitis, but may present a diagnostic challenge as it presents similarly to more common etiologies of isolated colonic stricture, such as inflammatory bowel disease (IBD) and malignancy.CASE DESCRIPTION/METHODS:A 48-year-old man with a history of alcohol–induced recurrent necrotizing pancreatitis requiring multiple debridements presented with a week of colicky right- sided abdominal pain and constipation. CT abdomen revealed markedly distended cecum and ascending colon, a 13-cm mid-transverse colonic stricture with marked associated stranding, and a 6-cm intra-pancreatic fluid collection. The isolated colonic stricture was thought to be due to either colonic ischemia secondary to his history of multiple episodes of severe necrotizing pancreatitis, or extrinsic compression by the pancreatic fluid collection on the transverse colon. Initial workup showed mildly elevated inflammatory markers and ascitic fluid cytology, which was negative for malignancy. On imaging, it was unclear if the stranding in the bowel was contiguous from the peri-pancreatic inflammation. See Figures 1 and 2. Colonoscopy was attempted but the colonoscope could not be passed beyond 50 cm due to marked tortuosity. The visualized portions of the mucosa appeared normal. The patient underwent a laparoscopic diverting loop ileostomy, during which narrowing of the mid-transverse colon was noted to be grossly consistent with cicatricial reaction to prior severe necrotizing pancreatitis, with adherence to the pancreatic head and neck. No neoplastic process was noted, and there was no necrotic tissue or abscess visualized. The strictured area was thought not to be amenable to resection given the frozen nature and presence of large peri-gastric and peri-colic varices and thus diverting loop ileostomy was performed along with adhesiolysis.DISCUSSION:Colonic stricture is a rare sequela of acute or chronic pancreatitis, which is thought to occur as a consequence of diffusion of ischemia and necrosis through the mesentery to the colon. Alternatively, it has also been suggested that pancreatitis may lead to colonic stricture by way of extrinsic compression on the colon by a pancreatic pseudocyst. Although rare, in the appropriate clinical context, clinicians may consider acute and chronic pancreatitis as possible etiologies of isolated colonic stricture along with more common etiologies.

INTRODUCTION:The location of an esophageal stricture often provides clues for its etiology. Upper esophageal strictures are most commonly associated with previous mediastinal radiation, caustic ingestion, or bullous dermatologic disorders. They are rarely attributed to infectious etiology. We present a case of an upper esophageal stricture that we believe is secondary to candida infection.CASE DESCRIPTION/METHODS:A 52-year-old female with past medical history significant for diabetes mellitus type 2 and invasive ductal carcinoma of right breast status post mastectomy and chemotherapy, now in remission and only on hormonal therapy, had presented to our gastroenterology clinic complaining of dysphagia with associated unintentional weight loss. Dysphagia had been present for several months prior and was progressive, with near inability to tolerate solids, and not associated with regurgitation or acid reflux symptoms. She had also reported a 15-pound weight loss during this time. Initial esophagogastroduodenoscopy revealed an upper esophageal stricture approximately 15cm from the incisors, preventing initial passage of standard upper endoscope. Neonatal scope was used which both traversed and dilated to 9mm. Past the stenosis, friable and desquamative- appearing mucosa was found. Upper esophageal biopsies were consistent with Candida esophagitis. Gastric cardia biopsy incidentally noted Helicobacter pylori. Patient was subsequently treated with oral fluconazole, triple therapy, and proton-pump inhibitor. Repeat follow-up esophagogastroduodenoscopy again demonstrated the initial upper esophageal stenosis, which could now be traversed with a standard upper endoscope. A Savary dilator was used to dilate the stricture to 39 Fr. Repeat esophageal and stomach biopsies were negative for Candida and H. Pylori, respectively. Subsequently, the patient reported improved symptoms without any dysphagia to solids or liquids.DISCUSSION:Candidal esophagitis is fairly common, however it is not typically known to cause upper esophageal strictures. This case highlights the need for physicians to maintain a broader differential and consider candida as a risk factor for developing stenotic lesions, even in immunocompetent patients and especially in the absence of other more well-known etiologies. Correct identification of etiology is necessary for appropriate treatment and preventing recurrence.