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Focal endoscopic mucosal resection (f-EMR) followed by radiofrequency ablation (f-EMR+RFA), stepwise/complete EMR (c-EMR), and endoscopic submucosal dissection (ESD) are used to manage Barrett's esophagus (BE)-related high-grade dysplasia (HGD) and early adenocarcinoma (EAC). We present a systematic review and meta-analysis evaluating these modalities' cumulative and comparative efficacy and safety. We evaluated studies reporting efficacy and safety of ESD, f-EMR+RFA, and c-EMR for BE-related early neoplasia management. Primary outcomes were recurrence of HGD or EAC and risk of strictures, perforation, and bleeding. Secondary outcomes were en bloc and R0 resections for ESD and complete eradication of neoplasia for f-EMR-RFA and c-EMR. Thirty-eight studies with 2,434 patients (684 ESD, 938 f-EMR+RFA, 812 c-EMR) were included. Weighted pooled rates (WPR) for recurrence were 10.3% (ESD), 5% (f-EMR+RFA), and 7.4% (c-EMR). There was no difference in recurrence with any endoscopic modality (p>0.05). WPR for strictures was 9.5% (ESD), 11.5% (f-EMR+RFA), and 29% (c-EMR). ESD and f-EMR+RFA were associated with lower stricture formation compared to c-EMR (p<0.05), while there was no difference seen between ESD and f-EMR+RFA. WPR for perforation was 3.7% (ESD), 1.6% (f-EMR+RFA), and 2% (c-EMR). F-EMR+RFA was associated with a lower risk of perforation compared to ESD (p=0.01), while no difference was found between ESD and c-EMR. WPR for bleeding was 3.5% (ESD), 3% (f-EMR+RFA), and 6% (c-EMR). There was no difference in the recurrence of neoplasia with any endoscopic modality. f-EMR+RFA appears to be the preferred endoscopic modality for the management of BE-related neoplasia.

Dietary supplements do not need prior Food and Drug Administration (FDA) approval before they are sold to the public per Dietary Supplement Health and Education Act of 1994 (DSHEA). Reporting serious dietary supplement related adverse reactions is voluntary. Hydroxycut is a brand of dietary supplements that are marketed as a popular weight loss product that contains multiple herbal constituents. Due to its potential hepatotoxic effects, FDA issued a warning in 2009 and recommended that consumers discontinue use of Hydroxycut. Hydroxycut was recalled from the market but a reformulated herbal mix is now available again. We are presenting a case of acute liver injury associated with Hydroxycut. The prominent pattern of liver injury is severe hepatocellular injury with the striking elevation of the aminotransferase levels and minimal abnormalities in alkaline phosphatase levels. It can sometimes cause severe hepatocellular necrosis.

Colonoscopy remains the primary method for preventing colorectal cancer. Traditionally, hot snare polypectomy (HSP) was the method of choice for removing polyps larger than 5 mm. Yet, for polyps smaller than 10 mm, cold snare polypectomy (CSP) has become the favored approach. Lately, the use of CSP has expanded to include the removal of sessile polyps that are between 10 and 20 mm in size. Our systematic review and meta-analysis aimed to evaluate the safety of cold snare polypectomy (CSP) compared to hot snare polypectomy (HSP) for resecting polyps measuring 10-20 mm. We searched the Medical Literature Analysis and Retrieval System Online (MEDLINE), Embase, and Cochrane databases up to April 2020 to find studies that directly compared CSP to HSP for polyps larger than 10 mm. Our main focus was on assessing the risk of delayed bleeding after polypectomy; a secondary focus was the incidence of any adverse events that required medical intervention post procedure. Our search yielded three comparative studies, two observational studies, and one randomized controlled trial (RCT), together encompassing 1,193 polypectomy procedures. Of these, 485 were performed using CSP and 708 with HSP. The pooled odds ratio (OR) for post-polypectomy bleeding (PPB) was 0.36 (95% confidence interval {CI}: 0.02, 7.13), with a Cochran Q test P-value of 0.11 and an I of 53%. For the risk of any adverse events necessitating medical care, the pooled OR was 0.15 (95% CI: 0.01, 2.29), with a Cochran Q test P-value of 0.21 and an I of 35%. The quality of the two observational studies was deemed moderate, and the RCT was only available in abstract form, preventing quality assessment. Our analysis suggests that there is no significant difference in the incidence of delayed post-polypectomy bleeding or other adverse events requiring medical attention between CSP and HSP for polyps measuring 10-20 mm.

Eluxadoline is a mixed opioid receptor agonist and antagonist approved for the treatment of diarrhea-predominant irritable bowel syndrome (IBS). It is believed to decrease visceral hypersensitivity without completely inhibiting intestinal motility. Pooled safety data from two phase three randomized trials have reported few cases of pancreatitis especially in patients with sphincter of Oddi (SO) dysfunction and cholecystectomy patients. We present a rare case of eluxadoline-induced recurrent pancreatitis in a 31-year-old female without a gallbladder. Her medical history was significant for irritable bowel syndrome with diarrhea (IBS-D), cholecystectomy, and depression. She was started on 75 mg of eluxadoline (the recommended dose for IBS-D patients without a gallbladder) three weeks prior to the first episode of pancreatitis. She had a recurrent episode of pancreatitis after few weeks and her symptoms and lipase levels improved significantly two days after stopping eluxadoline. The exact mechanism of eluxadoline to cause pancreatitis is unknown but it is believed to increase SO contractions. The absence of gallbladder prevents cholecystokinin mediated relaxation of the SO thus contributing more to spasms with eluxadoline. Few cases of severe pancreatitis and death have been reported even with the reduced dose of eluxadoline recommended for cholecystectomy patients. This case highlights the importance of considering drug-induced pancreatitis and avoidance of eluxadoline even in reduced doses in patients without a gallbladder.

Thymoma is the most common neoplasm originating in the anterior mediastinum and accounts for a quarter of all mediastinal tumors. A pericardial effusion is an uncommon initial manifestation present in approximately 20% of patients. However, our patient had hemorrhagic pericardial effusions causing a cardiac tamponade with bilateral pleural effusions, nodular left pleural based masses, and ascites. In this report, we describe the unique features of our case and its management.