Explore the vast range of titles available.

INTRODUCTION:Immunotherapies are commonplace in the treatment of many neoplasms, and have an array of commonly reported toxicities. Among the reported gastrointestinal side effects, diarrhea and colitis are most frequently cited. However, there have only been a rare handful of reported cases of Immune-checkpoint modulator toxicity affecting only the upper GI tract. In this paper we report a case of Ipilimumab-Nivolumab associated Gastritis in a patient treated with these medications at our facility.CASE DESCRIPTION/METHODS:The patient is a 78-year-old male with Stage IV Melanoma who presented to the hospital with nausea, vomiting, weight loss, and reduced oral intake for two weeks. The patient had most recently received 2 rounds of Ipilimumab and Nivolumab for his Melanoma 2 weeks prior to his presentation to our hospital, concurrent with the start of his symptoms. There had been no history of NSAID usage during this time, and physical exam was notable for mild epigastric tenderness. A Computed Tomography scan of the Chest/Abdomen/Pelvis showed diffuse thickening of the stomach, compatible with gastritis. Upper Endoscopy revealed diffuse severely erythematous mucosa with bleeding on contact in the entire examined stomach, and patchy, mildly erythematous mucosa without bleeding was found in the duodenal bulb, with the second portion of the duodenum being normal. The pathology report revealed subacute gastritis with acute inflammatory exudate consistent with an area of mucosal ulceration, with other etiologies of gastritis ruled out. The patient was begun on glucocorticoid therapy, with rapid resolution of his symptoms. Repeat endoscopy 2 weeks later revealed resolution of the previously noted gastritis and inflammation. Pathologic examination of biopsies confirmed resolution of the inflammatory process.DISCUSSION:On review of the literature, gastritis resulting from immune-checkpoint modulators has rarely been reported on. Some common side effects associated with these immune modulating medications, colloquially called immune-related adverse events (irAEs), include diarrhea, colitis, and hepatitis. However, there are a few case reports concerning the development gastritis without enterocolitis after Nivolumab treatment alone. Approximately 3 case reports and 1 case series of 20 patients describe such a side effect, To date, there are no reported cases of a patient treated with both Nivolumab and Ipilimumab who developed gastritis as the only adverse event.

IntroductionThe optimal therapy for bleeding-related gastric varices is still a controversial topic. There is a paucity of literature that comprehensively summarizes the available literature regarding safety and efficacy of thrombin in bleeding gastric varices.MethodsFour independent reviewers performed a comprehensive review of all original articles published from inception to October 2020, describing the use of thrombin for management of bleeding gastric varices. Primary outcomes were (1) pooled early and late rebleeding rate, (2) pooled gastric variceal related mortality rate, (3) pooled rescue therapy rate, and (4) pooled adverse event rate with the use of thrombin in bleeding gastric varices. The meta-analysis was performed and the statistics were two-tailed. Finally, probability of publication bias was assessed using funnel plots and with Egger’s test.ResultsEleven studies were included in the analysis after comprehensive search. This yielded a pooled early rebleeding rate of 9.3% (95% CI 4.9–17) and late rebleeding rate 13.8% (95% CI 9–20.4). Pooled rescue therapy rate after injecting thrombin in bleeding gastric varices was 10.1% (95% CI 6.1–16.3). The pooled 6-week gastric variceal-related mortality rate after injecting thrombin in bleeding gastric varices was 7.6% (95% CI 4.5–12.5). There were a total of four adverse events out of a total of 222 patients with pooled adverse event rate after injecting thrombin in bleeding gastric varices was 5.6% (95% CI 2.9–10.6).ConclusionIn summary, the systematic review and meta-analysis on the use of thrombin for bleeding gastric varices suggest low rates of rebleeding and minimal rates of adverse events. While, early and late rebleeding rate and rescue therapy rate are similar to cyanoacrylate-based therapy, the minimal rates of adverse events are perhaps the most important benefit of thrombin. Thus, the current data suggest that thrombin is a very promising therapeutic alternative with low risk of adverse events for bleeding gastric varices.

INTRODUCTION:Endoscopic sleeve gastroplasty (ESG) is a novel procedure that is safe and effective for weight loss that has been shown to have significantly less morbidity than alternative bariatric procedures. We present the first case of Endoscopic ultrasound-guided liver biopsy (EUS-LB) done in the same session as ESG. Both procedures were without complications, and were technically and clinically successful.CASE DESCRIPTION/METHODS:28 year old female with hypertension and morbid obesity presented for elevated liver function tests concerning for NAFLD. In past 20 months patient went from 268 to 293 pounds and failed lifestyle interventions. Medications were Famotidine and Lipitor. Physical Exam was notable for obese female, increased waist circumference, nontender and non distended abdominal exam without rebound or guarding. CBC,BMP,PT/INR were within normal limits. Liver Function: AST 54 U/L, ALT 78U/L, Alkaline Phosphatase 56 U/L, Total Bilirubin 1.0 mg/dL. Ultrasound revealed hepatic steatosis, and FibroScan showed Fibrosis Score F4 consistent with cirrhosis. She did not have physical exam or lab findings consistent with cirrhosis. Patient was planned for ESG for weight loss and given Fibroscan results, same session EUS-LB was performed. EUS-LB was performed first in left lobe with 19 gauge FNB needle with no complications. ESG was performed successfully without complications. Upper GI series the next morning revealed no extravasation, patient tolerated diet and was discharged home. One month later, patient BMI decreased from 51kg/m2à45kg/m2, 298 to 263 lbs. No complaints of abdominal pain, nausea, vomiting and tolerating diet. Pathology from Liver Biopsy showed NAS Score 4/8 consistent with steatohepatitis, Stage 2-3 fibrosis.DISCUSSION:EUS-LB is an effective method for liver biopsy with minimal complications. ESG significantly reduces BMI with low morbidity . With the prevalence of NAFLD and subsequent conversion to NASH and cirrhosis increasing, non-invasive tests are utilized to stage fibrosis in patients with NASH. In cases where there is a discordance between clinical findings and Fibroscan results, liver biopsy can be obtained. This case demonstrates when a liver biopsy is indicated, EUS-LB is a safe and efficient option in a patient undergoing an endoscopy for other reasons. This is also the first reported case of EUS-LB and ESG in the same session. We demonstrate this procedure can be considered simultaneously in patients undergoing ESG to aid in weight loss for fatty liver disease.

INTRODUCTION:Infliximab is an anti-tumor necrosis factor alpha inhibitor commonly used in the treatment of Crohn's disease. It is known to produce mild elevations in liver enzymes, however, severe damage and marked elevations in transaminases related to drug-induced autoimmune hepatitis (AIH) are rare. We present a case of a patient with Crohn's disease who recently began infliximab and presented with severe infliximab-induced autoimmune hepatitis.CASE DESCRIPTION/METHODS:A 37-year-old man with Crohn's ileocolitis, diagnosed at age 28 and recently inducted with infliximab, presented with fatigue, weakness, and epigastric pain. He had previously been on 6-mercaptopurine, adalimumab, and ustekinumab, but had most recently been on azathioprine (AZT) and began infliximab two months prior to presentation. Approximately one month prior to presentation, he developed elevated transaminases with aspartate transaminase (AST) and alanine transaminase (ALT) in the 300s, so AZT was discontinued as this was thought to be the cause. Despite discontinuation of AZT, his liver function tests (LFTs) rose dramatically, prompting hospitalization. Labs on admission revealed a hepatocellular pattern with total bilirubin 7.1, AST 2153, ALT 2931, alkaline phosphatase 156, and international normalized ratio 1.25. Notably, antinuclear antibody was positive 1:1280, smooth muscle antibody was weakly positive, and cytomegalovirus (CMV) IgM was elevated. Hepatobiliary scan and magnetic resonance cholangiopancreatography were consistent with hepatocellular disease. Core liver biopsy revealed active hepatitis with moderate activity (interface moderate), cholestasis, and an infiltrate of eosinophils and plasma cells. CMV staining was negative. Overall, the testing was consistent with drug-induced AIH. Infliximab was stopped and steroids were begun, resulting in normalization of LFTs.DISCUSSION:Infliximab has been implicated in mild cases of hepatotoxicity, and therefore, it is recommended to check LFTs before and after beginning the medication. There are very few reports of severe AIH that have been linked specifically to infliximab, as cases of hepatotoxicity are often secondary to reactivation of viral hepatitis or CMV infections, or related to other biologic therapies. This is a rare case of infliximab-induced AIH, and it is an important consideration in patients with elevated LFTs after starting this drug. Treatment involves cessation of infliximab and treatment with steroids, which usually leads to resolution of the hepatitis.

INTRODUCTION:Endoscopic ultrasound (EUS) is an important diagnostic and therapeutic modality in the field of gastrointestinal endoscopy1. Therapeutic EUS has found a role in management of pancreatic fluid collections, biliary and pancreatic duct drainage, and drainage of mediastinal and intra-abdominal abscesses and collections1. We present a case of a mediastinal abscess drainage after esophagectomy using a Lumen-apposing metal. To our knowledge, this is the second case using a Lumen-apposing metal stent for mediastinal collections2.CASE DESCRIPTION/METHODS:Case Summary: This is a case of a 75-year-old man with esophageal adenocarcinoma s/p transhiatal esophagectomy complicated by recurrent pleural effusions, ischemic colitis requiring right hemicolectomy and end ileostomy who presented to the ED from rehab because of abnormal lab findings of hypernatremia and leukocytosis. During his hospital stay, the patient developed persistent fevers and leukocytosis. A CT scan of the chest revealed a large posterior mediastinal collection adjacent to the gastric pull-through that coursed inferiorly into the peritoneum. The collection measured 8 cm × 4.1 cm x 12 cm in size and was presumed to be the source of infection. The case was discussed amongst the surgical oncologist, thoracic surgeon, interventional radiologist, and advanced endoscopists. Options for drainage included repeat surgery, percutaneous drain placement, and endoscopic drainage. The consensus opinion was to drain the collection internally by endoscopic ultrasound. The patient underwent a successful EUS-guided abscess drainage with a lumen apposing metal stent. The patient drastically improved after internal drainage with the lumen apposing metal stent. Fevers and leukocystosis resolved. Follow-up CT scan of the chest 10 days later demonstrated a resolution of the mediastinal collection.DISCUSSION:Conclusion: Although developed for drainage of pancreatic fluid collections, this case demonstrates that lumen apposing metal stents can be safely used to drain mediastinal collections. Our literature review identified one other case that utilized a lumen-apposing metal stent to drain a mediastinal abscess2. This stent seems to be useful and safe for mediastinal drainage. We recommend a multidisciplinary discussion with surgeons and radiologists when dealing with large mediastinal collections that require drainage.

Cholecystectomy (CCY) is the gold standard treatment of acute cholecystitis (AC). Nonsurgical management of AC includes percutaneous transhepatic gallbladder drainage (PT-GBD) and endoscopic ultrasound-guided gallbladder drainage (EUS-GBD). This study aims to compare outcomes of patients who undergo CCY after having received EUS-GBD vs PT-GBD. A multicenter international study was conducted in patients with AC who underwent EUS-GBD or PT-GBD, followed by an attempted CCY, between January 2018 and October 2021. Demographics, clinical characteristics, procedural details, postprocedure outcomes, and surgical details and outcomes were compared. One hundred thirty-nine patients were included: EUS-GBD in 46 patients (27% male, mean age 74 years) and PT-GBD in 93 patients (50% male, mean age 72 years). Surgical technical success was not significantly different between the 2 groups. In the EUS-GBD group, there was decreased operative time (84.2 vs 165.4 minutes, P < 0.00001), time to symptom resolution (4.2 vs 6.3 days, P = 0.005), and length of stay (5.4 vs 12.3 days, P = 0.001) compared with the PT-GBD group. There was no difference in the rate of conversion from laparoscopic to open CCY: 5 of 46 (11%) in the EUS-GBD arm and 18 of 93 (19%) in the PT-GBD group ( P value 0.2324). Patients who received EUS-GBD had a significantly shorter interval between gallbladder drainage and CCY, shorter surgical procedure times, and shorter length of stay for the CCY compared with those who received PT-GBD. EUS-GBD should be considered an acceptable modality for gallbladder drainage and should not preclude patients from eventual CCY.

INTRODUCTION:Perivascular epithelioid cell neoplasms (PEComas) are a rare type of mesenchymal tumor that can be found in various visceral and soft tissues in the body. Approximately fifty cases have been reported in the gastrointestinal (GI) tract. Typically, management of these lesions is laparoscopic or open surgical resection followed by chemotherapy if there is metastatic disease. The majority of GI PEComas are benign, colonic masses in middle-aged females. This case describes a malignant, colonic PEComa in a 16-year-old male. To the best of our knowledge, this is the largest malignant, colonic PEComa in an adolescent, and this is the first case to demonstrate successful endoscopic mucosal resection (EMR) of a PEComa.CASE DESCRIPTION/METHODS:A 16-year-old male with history of IgA vasculitis during childhood presented with acute onset of bilious emesis in the setting of severe, intermittent, left lower quadrant abdominal pain and constipation for one month. Lab testing was unremarkable. Computed tomography revealed a non-obstructing, nodular mass in the transverse colon. The patient underwent colonoscopy, during which the 6-cm large, semi-sessile, broad-based polyp was removed by piecemeal EMR. EMR was technically challenging due to the size, broad base, and location of the mass. Histology of the tissue showed a predominance of fascicular spindled cells, scattered areas with epithelioid morphology, and prominent vasculature, consistent with a PEComa. The tissue stained positive for HMB-45, MART-1, and cathepsin. Based on the size (>5 cm), nuclear atypia, and high mitotic activity, the lesion was defined as malignant. Though the lesion was removed to the submucosa, there was concern for deeper extension, so he underwent laparoscopic transverse colectomy with primary anastomosis. Pathology confirmed there was not any residual tumor in the resected colon or metastasis to lymph nodes. Positron emission tomography did not show metastasis. Fifteen months have elapsed and the patient has not had recurrence on imaging.DISCUSSION:There are few cases of GI PEComas. This case demonstrates a rare presentation of a large, malignant GI PEComa in a young male and is the first case of successful endoscopic removal of a malignant PEComa. The surgical specimen revealed no evidence of residual PEComa, and the patient has not had evidence of recurrence on imaging, verifying successful removal of his PEComa. This supports the notion that EMR should be considered for definitive management in patients with these lesions.