Explore the vast range of titles available.

Background. The value of endoscopy in dyspeptic patients is questionable. Aims. To examine the prevalence of significant endoscopic findings (SEFs) and the utility of alarm features and age in predicting SEFs in outpatients with dyspepsia. Methods. A retrospective analysis of outpatient adults who had endoscopy for dyspepsia. Demographic variables, alarm features, and endoscopic findings were recorded. We defined SEFs as peptic ulcer disease, erosive esophagitis, malignancy, stricture, or findings requiring specific therapy. Results. Of 650 patients included in the analysis, 51% had a normal endoscopy. The most common endoscopic abnormality was nonerosive gastritis (29.7%) followed by nonerosive duodenitis (7.2%) and LA-class A esophagitis (5.4%). Only 10.2% had a SEF. Five patients (0.8%) had malignancy. SEFs were more likely present in patients with alarm features (12.6% versus 5.4%, p=0.004). Age ≥ 55 and presence of any alarm feature were associated with SEFs (aOR 1.8 and 2.3, resp.). Conclusion. Dyspeptic patients have low prevalence of SEF. The presence of any alarm feature and age ≥ 55 are associated with higher risk of SEF. Endoscopy in young patients with no alarm features has a low yield; these patients can be considered for nonendoscopic approach for diagnosis and management.

INTRODUCTION:Sharp objects impacted in the esophagus require prompt endoscopic removal. Removal of sharp foreign bodies can be technically challenging and care should be taken to avoid inducing esophageal trauma during retrieval.CASE DESCRIPTION/METHODS:A 69-year-old female presented with sudden onset dysphagia and sharp chest pain for 1 day. While eating cake one day prior to arrival, she reported sudden, sharp, central chest pain followed by a sensation of food being stuck in her esophagus. Her physical examination was unremarkable with no abdominal tenderness. Her laboratory tests revealed normal complete blood count and chemistry. Chest x-ray revealed no acute abnormality. Upper endoscopy showed a sharp star-shaped foreign body (FB) approximately 2 cm in diameter (Figure 1). The FB was lodged in the distal esophagus, causing mucosal trauma. Due to the large size of the FB, insertion of an overtube was not considered to facilitate removal. An attempt was first made to extract the FB with rat-tooth forceps, but it could not be retrieved through the upper esophageal sphincter. Mucosal trauma was seen in the mid and proximal esophagus following this attempt. The FB was then advanced to the gastric antrum using a Roth net. Attempts to break the FB using argon plasma coagulation (APC) and a snare were unsuccessful due to the rigid nature of the FB. Subsequently, a 2T dual channel therapeutic gastroscope was inserted, and a Dormia stone retrieval basket was used to grasp the foreign body. Using the crushing power of the basket, the FB was successfully crushed and pulled inside the large therapeutic channel of the scope. The scope was withdrawn without additional mucosal trauma. The FB consisted of a star-shaped cake decoration with sharp edges (Figure 2). Following the procedure, the patient reported immediate improvement in her chest pain.DISCUSSION:This is a unique case wherein after the failure of conventional foreign body extraction devices, a Dormia stone retrieval basket was used to crush the object within the stomach allowing for safe retrieval. Gastroenterologists should consider this approach when retrieving irregularly-shaped, sharp, but pliable FBs. For the general public, care should be taken when eating food with non-edible decorations and toppers to avoid inadvertently swallowing or aspirating these objects.

INTRODUCTION:Acute pancreatitis (AP) is a frequent cause of hospitalization in the United States. The major etiologies of AP are alcohol, choledocholithiasis, and drug-induced. We aim to describe demographic, clinical, and admission characteristics of AP hospitalizations according to etiology. In addition, we compared in-hospital and 30 day mortality and readmission outcomes among the three major AP subtypes.METHODS:We performed a retrospective analysis of the 2016 National Readmission Database. Hospital admissions of adults (>18 years of age) with the primary or secondary discharge diagnosis of AP. Specific ICD-10 codes were used to classify AP into biliary pancreatitis (K851), alcoholic pancreatitis (K852), and drug-induced pancreatitis (K853). Patients with nonspecific AP codes were classified as biliary pancreatitis if they had a concomitant diagnosis of cholelithiasis and as alcoholic AP if they had a diagnosis of alcohol abuse. Non-specific AP admissions were excluded. Characteristics and 30-day outcomes of the three groups were compared using the X-square test for categorical variables and the one-way analysis of variance (ANOVA) for continuous variables.RESULTS:A total of 81,382 admissions met the inclusion criteria: 32,459 had biliary AP, 46,438 alcoholic AP, and 2,485 drug-induced AP. Patients with alcoholic AP were more likely to be male (69.1%) and younger (mean age 46.6) compared to the other groups. Patients with biliary AP were more likely to develop cholangitis (1.8%) compared to the other groups (≤0.2%). HIV was more associated with drug-induced pancreatitis (1.4%) compared to the other groups (≤0.4%). Mean length of stay was longest (5.9 days) and mean costs were highest ($15,367) in biliary AP. These were lowest in drug induced AP (4.2 days and $9413, respectively). In-hospital mortality (0.9%) and 30-day mortality (1.3%) was highest in biliary AP compared to the other groups. Thirty day- readmissions were highest in alcoholic AP (14.3%) compared to drug induced AP (11.5%) and biliary AP (10.1%).Table 1CONCLUSION:In this large, nationally representative patient sample, drug induced AP had the lowest length of stay and costs, while alcoholic AP had the highest 30-day readmission rates (14.3%). Biliary pancreatitis was associated with the highest in-hospital and 30-day mortality. Knowledge of these findings may allow us to design and target future studies to mitigate the high readmission rates in alcoholic pancreatitis, and the complications and mortality in biliary pancreatitis.

INTRODUCTION:Patients with acute cholecystitis (AC) often present with laboratory and imaging findings suggestive of choledocholithiasis (CDL). There are no population studies to assess the incidence of CDL and its impact on outcomes in patients with AC. In this nationwide study, we examine the frequency of CDL in patients with acute cholecystitis, and examine the effect of choledocholithiasis on in hospital mortality, costs, and 30-day outcomes.METHODS:We analyzed the nationwide readmission database (NRD) from 2010 through 2014. We identified all admissions of adult patients with the principal diagnosis of acute cholecystitis. We compared hospitalizations with acute cholecystitis and choledocholithiasis (AC + CDL), with those with cholecystitis alone (AC group). Bivariate analysis was performed to compare the demographics, characteristics, and in-hospital and 30-day outcomes between the two groups.RESULTS:There were total of 552,207 hospitalizations for acute cholecystitis, of which 408,847 (74%) had acute cholecystitis alone (AC group) and 143,360 (26%) had coexistent choledocholithiasis (AC + CDL group). Characteristics of the groups are shown in Table 1. Patients with AC + CDL were more likely males and older than 65 (P < 0.0001). Patients with AC+CDL were more likely to have abnormal liver enzymes (1% vs. 0.7%), cholangitis (4.4% vs. 1.1%), acute pancreatitis (11.6% vs. 7.7%) and septic shock (1.7% vs. 1.1%, all comparisons P < 0.0001). ERCP was performed more commonly in AC + CDL group compared to the AC group (26.7 vs. 3.7%, P < 0.0001). Same admission cholecystectomy was more common in AC group (84% vs 38% P < 0.0001). Patients with AC + CDL had longer length of stay (4.9 vs. 4.1 days, P < 0.0001) and higher hospital costs ($15,966 vs $15,202, P < 0.0001). The AC + CDL group had higher in hospital and 30 day post-discharge mortality (4.5% vs. 1.2%, P < 0.0001) and 30-day readmission (13.6% vs. 8%, P < 0.0001), compared to the AC group.CONCLUSION:Approximately one in four patients with acute cholecystitis has coexistent choledocholithiasisPresence of choledocholithiasis in acute cholecystitis patients is associated with increased length of stay, hospitalization costs, in-hospital and 30-day mortality and readmissions. Further studies are needed to develop predictor models to identify coexisting CDL in patients with AC for timely diagnosis and optimizing management aimed at improving outcomes in this high risk subset of patients.Table 1.Comparison of outcomes in acute cholecystitis group vs. acute cholecystitis + choledocholithiasis group