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INTRODUCTION:Fecal microbiota transplantation for treatment of IBD is an off-label use since it has not been approved for the FDA. But its use has been approved as one of the treatment options in recurrent C. difficile infection. The efficacy of self-administered home fecal transplant has not been studied in patients with Crohn's disease.CASE DESCRIPTION/METHODS:A 46-year-old woman with history of Crohn’s pancolitis with perianal fistulae diagnosed when she presented with chronic bloody diarrhea, her colonoscopy showed severe colitis characterized by deep ulcers throughout the colon (Figure a-b). Biopsies showed cryptitis and crypt abscesses. She was started on prednisone and azathioprine. She refused biologic treatments because of concerns about side effects. During this time, she developed frequent upper respiratory infections so she self-stopped azathioprine. She initiated a series of self-administered home fecal transplants and continued to do them when she began to feel symptomatic again. She presented to our GI clinic four years later. She denied any abdominal pain, diarrhea, melena, hematochezia, or weight loss. On physical examination her vitals were within normal limits, her abdomen was soft and non-tender. On anal exam, few skin tags were observed, no fistulae. Laboratories were within normal limits, including C-reactive protein. Repeat colonoscopy showed normal terminal ileum, multiple pseudopolyps throughout the colon (Figures 1–4). Random colon biopsies showed quiescent disease.DISCUSSION:There is some evidence that suggests changes in the gut microbiota in patients with IBD. These changes over-activate the mucosa immune system leading to chronic inflammation and mucosal lesions. A substantial proportion of patients do not respond to the currently available drugs, most of them immunosuppressive therapy with potential long-term consequences. Consequently, alternative safer therapies are being studied, such as fecal microbiota transplantation. Despite all the studies and investigation in this regard, the FDA only allows the use of FMT for recurrent C. difficile but has tighter restrictions for IBD. In this scenery, those patients can only get a fecal transplant in a medical setting if they are participating in a clinical trial. A handful of case reports have shown the effectiveness of self-administered home fecal transplant in recurrent C. difficile, and the efficacy of FMT, under monitored environment, in refractory CD unresponsive to current conventional therapy.

INTRODUCTION:Illicit use of anabolic androgenic steroids (AAS) has been growing among athletes and bodybuilders for cosmetic and performance purposes. We report a case of one of the possible hepatic complications of AAS, acute cholestatic syndrome (ACS), in a male with anabolic steroid abuse.CASE DESCRIPTION/METHODS:27-year-old Polish man with no past medical history presented with jaundice, itching of the body, dark-colored urine, clay-colored stools for 5 weeks. No abdominal pain was reported. Patient reported taking for 4 months 4 types of AAS (testosterone, oxandrolone, methasterone and trenbolone) for body building, which he stopped taking 6 weeks prior to initial presentation due to fatigue. Vitals were normal, and on exam he appeared to be a muscular, jaundiced male with scratch marks on his skin. Abdominal exam revealed a non-tender, non-distended abdomen, with difficulty palpating the liver edge due to the muscularity. Laboratory tests were significant for total bilirubin of 34.8 mg/dL with direct of 23.5 mg/dL, AST 55 U/L, ALT 70 U/L, ALP 212 U/L, GGT 57 U/L, INR 1, creatinine 1.1 mg/dL. Liver ultrasound showed hepatomegaly with no biliary dilation and patent hepatic and portal veins. A liver biopsy was obtained showing portal neutrophil predominant inflammation with occasional eosinophils, mild portal fibrosis and cholestasis, suggestive of drug-induced hepatotoxicity. Liver function tests normalized after 4 months of cessation of AAS use, with resolution of his jaundice and pruritis.DISCUSSION:Body builders usually prefer polydrug use of AAS to maximize the desired effects and hypothetically reduce side effects at the same time. But contrary to their belief, the concomitant use of different illicit AAS may be a factor in their toxicity, making difficult to link an adverse effect with a specific substance. Acute cholesta tic syndrome, has been associated with use of the 17α – alkylated anabolic steroids ( i.e. oxandrolone, methasterone), thought related to an increase of reactive oxygen. This leads to prolonged direct toxic effects and intrahepatic cholestasis, though the pathophysiology remains unclear. ACS usually occurs 1-4 months after steroid initiation presenting with nausea, fatigue, pruritis; later, jaundice, dark urine, with significantly elevated total bilirubin and ALP but mild aminotransferase elevation can be seen. Management consists of stopping anabolic steroid use, supportive care and symptomatic treatment of pruritis.

INTRODUCTION:Esophageal disease is common during HIV/AIDS infection and varies from esophagitis due to opportunistic infections as candida, cytomegalovirus and herpes simplex, to idiopathic ulcerations and non-specific motility disorders, but it has been suggested also that HIV infection itself can be the culprit of esophageal symptoms. We are presenting a case report of likely achalasia that was discovered in a patient newly diagnosed with HIV-1.CASE DESCRIPTION/METHODS:A 46-years-old male with no significant past medical history presented with 1 month history of recurrent attacks of nausea and non-bilious, non-projectile vomiting, 30-60 minutes following meals associated with anorexia, dysphagia and non-intentional weight loss of 10 lb. He did not have any fever, abdominal pain, diarrhea, constipation, hematemesis or melena. He was in a heterosexual relationship with no known contact to HIV infected patients. Examination was not evident of abdominal tenderness or any body swellings. Labs showed normocytic anemia with hemoglobin of 11.8 g/dl in addition to positive HIV-1 serology with viral load of 151,000 and CD4 count of 153. CT Chest was done showing sub-stantial dilation of the lower cervical, mid and distal esophagus with solid and gaseous contents. After 24 hours of “Nothing by mouth,” upper endoscopy was performed showing markedly dilated esophagus with esophageal mucosa covered with adherent food and secretions in addition to LA grade C esophagitis in the distal esophagus. Esophageal biopsy showed candida esophagitis with negative immunostains for CMV and HSV. He was started on HAART therapy and is awaiting manometry for confirmation of Achalasia diagnosis.DISCUSSION:It is accepted that HIV is aneuropathic virus and it has been related to loss of autonomic nerves in different parts of the body. Motor abnormalities have been identified in the esophagus, stomach and small intestine. The case report highlight that HIV maybe considered as possible infectious cause of achalasia.

Background and AimsSeveral criteria have been described to noninvasively predict the presence of high-risk esophageal varices in patients with compensated advanced chronic liver disease (cACLD). However, a recent study showed that treatment with β blockers could increase decompensation-free survival in patients with clinically significant portal hypertension, thereby making it important to predict the presence of any esophageal varices. We aimed to develop a simple scoring system to predict any esophageal varices.MethodsWe retrospectively reviewed patients who had vibration-controlled transient elastography (VCTE) at Cook County Hospital, Chicago, USA. Patients with cACLD and liver stiffness measurement (LSM) ≥ 10 kPa with esophagogastroduodenoscopy performed within one year of VCTE were analyzed. We generated a novel score to predict esophageal varices, using the beta coefficient of predictive variables. The score was validated in an external cohort at the University of Iowa Hospital, USA.ResultsThere were 372 patients in the development cohort and 200 patients in the validation cohort. LSM, platelet count, and albumin were identified as predictors of esophageal varices and were included for generating the Cook County score as “platelet count * − 0.0155872 + VCTE score * 0.0387052 + albumin * − 0.8549209.” The area under receiver operating curve for our score was 0.86 for any varices and 0.85 for high risk varices and avoided more endoscopies than the expanded Baveno VI criteria while maintaining a very low miss rate (negative predictive value > 99%).ConclusionWe propose a new, highly accurate, and easy-to-use scoring system to predict the presence of not only high-risk but any esophageal varices in patients with cACLD.

INTRODUCTION:Chronic pancreatitis (CP) does not currently have a cure and it leads to multiple complications (pain, exocrine pancreatic insufficiency, steatorrhea, bone disease), its management is still a challenge. There is evidence that stimulating the endocannabinoid system may reduce inflammation and fibrosis in pancreatic stellate cells. Cannabis is the most frequently used recreational drug in the US and in recent years its legalization has increased. There are currently multiple States in the US that have approved medical cannabis for CP. We investigate the prevalence and outcomes of CP-related complications amongst cannabis-exposed (CE) and non-cannabis-exposed (non-CE) CP patients.METHODS:The National Inpatient Sample (NIS) database from 2005 to 2014 was queried for all patients with a primary or secondary discharge diagnosis of chronic pancreatitis as per the International Classification of Diseases 9th revision (ICD-9) code 577.1 and a complication related to chronic pancreatitis. Active exposure to cannabis was ascertained based on ICD-9 code 304.3X and 305.2X. We compared CE vs. non-CE patients. Outcomes included pancreatic cancer diagnosis, biliary stricture, pancreatic duct stricture, cholangitis, endoscopic retrograde cholangiopancreatography (ERCP) use for either diagnostic or therapeutic purpose. Propensity match analysis for age, gender, race, median income quartile, hospital characteristics and Elixhauser comorbidity index and multivariable logistic regression models were performed using SAS software (STATA 14).RESULTS:109,326 patients with CP were analyzed (Figure 1). Prevalence of CE was 2.2% (2360 patients). The mean age of CP patients was 49. When comparing CE vs. non-CE, the CP-related complications amongst matched cohorts were as follows chronic abdominal pain 5.2% vs 0.3% (P < 0.001), steatorrhea/diarrhea 1.2% vs 13.5% (P < 0.001), biliary stricture 0.3% vs. 7.1% (P < 0.001), pancreatic cancer 0.4% vs. 11.8% (P < 0.001), cholangitis (0.1% vs 2.6%; P < 0.001), pancreatic cancer (0.4 vs 11.8; P < 0.001). Cannabis users also required less diagnostic ERCP (1.4% vs 5.5%; P < 0.001) and therapeutic ERCP (3.5% vs 9.3%; P < 0.001) (Figure 2).CONCLUSION:In CP patients admitted to the hospital, CE patients had lower rates of CP-related complications and importantly pancreatic cancer. These effects could possibly be through the effect of cannabis in the endocannabinoid system as previously shown in mice studies in Germany. More studies are needed to corroborate our findings.