Esophageal Adenocarcinoma Causing Nonbacterial Thrombotic Endocarditis.

Nonbacterial thrombotic endocarditis (NBTE) is a rare condition that causes noninfectious vegetative lesions of heart valves. NBTE is generally seen in association with advanced malignancy. The patient in this case is a 54-year-old Caucasian male with a history of rate-controlled atrial fibrillation on rivaroxaban and morbid obesity post sleeve gastrectomy in 2021, who was admitted for atrial flutter. Transesophageal echocardiogram (TEE) cardioversion was planned due to difficulty in controlling the heart rate. During the procedure, cardioversion was aborted due to TEE findings of large mobile vegetation on the left atrial side of the posterior mitral valve leaflet. The patient was afebrile for the entirety of his 10-day hospital stay, and four sets of blood cultures were negative. Further workup with esophagogastroduodenoscopy (EGD) revealed a large partially obstructing ulcerated mass in the middle and lower third of the esophagus arising in the setting of Barrett's esophagus which was biopsy positive for esophageal adenocarcinoma. The patient was found to have advanced malignancy with metastases to the liver, adrenal glands, and perirectal lymph nodes. This case emphasizes the utilization of a TEE prior to cardioversion and also highlights the importance of EGD prior to and post gastric sleeve surgery to evaluate for esophageal cancer.

Practice patterns and adherence to society guidelines for suspected choledocholithiasis: A comparison of academic and community settings from a large US healthcare system.

Background: The American Society of Gastrointestinal Endoscopy (ASGE) has proposed practice guidelines for evaluating patients with suspected choledocholithiasis. This study aims to assess and compare practice patterns for following ASGE guidelines for choledocholithiasis in a large academic vs. community hospital setting. Methods: A total of one thousand ER indicated for choledocholithiasis were randomly selected. Patients' demographics, total bilirubin, imaging studies including magnetic resonance cholangiopancreatography (MRCP), intraoperative cholangiogram (IOC), endoscopic ultrasound (EUS), and ERCP results were retrospectively collected. Patients with prior sphincterotomy were excluded. We examined the following practice deviations from the current ASGE guidelines; (1) ERCP was potentially delayed in high probability cases while awaiting additional imaging studies, (2) ERCP was performed without additional imaging studies in cases of low/intermediate-risk, or (3) ERCP was performed in low/intermediate-risk cases when additional imaging studies were negative. Results: A total of 640 patients with native papilla who underwent ERCP were included in the final analysis. Overall, the management of 43% (275) of patients was deviated from the applicable ASGE guidelines. Academic and community provider rates of non-adherence were 32 vs. 45%, respectively (p-value: < 0.01). Of 381 high-risk cases, 54.1% had additional imaging before ERCP. (Academic vs. community; 11.7 vs. 88.3%, p-value: < 0.01). In 26.7% (69/258) of low/intermediate risk cases, ERCP was performed without additional studies; academic (14.5%) vs. community (85.5%) (p-value: < 0.01). Finally, in 11.2% (19/170) of patients, ERCP was performed despite intermediate/low probability and negative imaging; academic (26.3%) vs. community (73.7%) (p-value: 0.02). Conclusion: Our study results show that providers do not adhere to ASGE practice guidelines in 43% of suspected choledocholithiasis cases. The rate of non-adherence was significantly higher in community settings. It could be due to various reasons, including lack/delays for alternate studies (i.e., MRCP, EUS), concern regarding the length of stay, patient preference, or lack of awareness/understanding of the guidelines. Increased availability of alternate imaging and educational strategies may be needed to increase the adoption of practice guidelines across academic and community settings to improve patient outcomes and save healthcare dollars.

Current and emerging pharmacological approaches for treating diarrhea-predominant irritable bowel syndrome.

Introduction: Irritable bowel syndrome with diarrhea (IBS-D) is among the most common functional gastrointestinal (GI) disorders and is associated with impaired quality of life, increased health-care utilization, and significant costs to patients and society. The treatment of IBS is typically hierarchal with initial therapies consisting of dietary and lifestyle modifications. Pharmacotherapy with over-the-counter and prescription medications is also commonly used for symptomatic control in the course of therapy.Areas covered: Three medications are approved by the United States Food and Drug Administration (FDA) for IBS-D, with all of them demonstrating efficacy in randomized, placebo-controlled trials. In this review, the authors discuss the clinical trial data applicable to the current FDA approved IBS-D therapies as well as review data related to new and emerging therapies for this condition.Expert opinion: Clinicians should be familiar with emerging therapies for IBS-D as they may provide benefit to some IBS-D patients. The exact mechanisms of action of many of the emerging agents for IBS-D remain unknown. Despite substantial differences and limitations in the design and quality of supporting studies, there is an increasing body of evidence suggesting that emerging agents may promote meaningful symptom improvement in patients with IBS-D.

Update on Pharmacotherapy for Irritable Bowel Syndrome.

PURPOSE OF REVIEW: Irritable bowel syndrome (IBS) is a functional GI disorder that affects a large percentage of the population and presents a significant socio-economic burden on the society. In this article, we reviewed the evidence supporting various pharmacological treatment options for IBS. RECENT FINDINGS: Rifaximin, eluxadoline, and alosetron have demonstrated that they reduce symptom severity improving quality of life in patients with IBS-diarrhea. Ramosetron is a promising agent in development. Peppermint oil has also demonstrated a positive impact on some symptoms of IBS. For IBS with constipation, traditional laxatives have failed to demonstrate significant benefit. However, lubiprostone, linaclotide, and plecanatide have demonstrated improvement of IBS with constipation in large, placebo-controlled trials. Tenapanor, a sodium/hydrogen exchanger 3 inhibitor, appears to be a promising treatment option in the pipeline. There are multiple pharmacologic agents with a variety of mechanisms that have demonstrated efficacy in IBS with diarrhea and constipation. There are no established pharmacologic agents for IBS with a mixed bowel pattern. There is a promising pipeline for additional novel therapies for IBS.

Levamisole-Adulterated Cocaine-Induced Skin Lesions: A Case Report and Literature Review.

Levamisole is used as an agent to increase the total weight of street cocaine. We report the case of a 28-year-old female who presented with multiple painful, ulcerating lesions. She tested positive for cocaine and levamisole. Her skin lesions improved with abstinence from cocaine. Patients with levamisole-induced toxicity most often present with skin manifestations or joint pain. Leukopenia, neutropenia, and agranulocytosis are common lab abnormalities seen in these patients. Complete resolution of the skin lesions are observed approximatelythree weeks after abstinence. Patients known to use street drugs, who present with unexplained skin rash, neutropenia, and multiple immunological abnormalities, should be tested for both cocaine and levamisole. Urine toxicology screen is positive for cocaine approximately 72 hours after ingestion. Levamisole requires specialized testing that is not readily available commercially andis positive forless than 48 hours after exposure.

A Case of Mysterious Impacted Duodenal Foreign Body Presenting with Halitosis.

The majority of gastrointestinal (GI) foreign bodies (FBs) discovered in adults are the result of intentional ingestion, most of which are found in patients with a preexisting psychiatric illness, with substance abuse disorders, or in people seeking secondary gain. No similar case of internal injuries following unintentional ingestion of a barbecue grill cleaning brush bristle has been reported. A 58-year-old Caucasian male with no significant history presented with complaint of halitosis, not improving after oral care and dental hygiene measures. He denied any other symptoms. After ruling out oral causes of halitosis, an esophagogastroduodenoscopy was performed, which revealed a black wire-shaped metallic FB embedded in the duodenum. The FB was identified as a silver metallic flexible wire resembling the bristle of a barbecue grill cleaning brush. The halitosis resolved completely within 3 weeks of the removal of the FB. To the best of our knowledge, this is the first case of duodenal impaction of a barbecue grill cleaning brush bristle atypically presenting with halitosis. Physicians' awareness of this potential injury from grill cleaning brush bristles would lead to a quick diagnosis after a focused history. Also avid grillers must be made aware of this potential hazard and should be encouraged to carefully examine the barbecue grill surface for any remnant bristle of the grill cleaning brush. Appropriate history taking, considering GI causes as potentially inducing halitosis, and an awareness of this entity among providers are important to facilitate prompt diagnoses and prevent major adverse outcomes.

Dermatologic Extrahepatic Manifestations of Hepatitis C.

Hepatitis C virus (HCV) affects millions of people worldwide, and an estimated 3.2 million people in the United States. HCV is a hepatotropic and lymphotropic virus that causes not only liver disease, but also a significant number of extrahepatic manifestations (EHMs). Up to 74% of patients affected by HCV will have HCV-related EHMs of some severity in their lifetime. The EHMs vary from simple cutaneous palpable purpura to complex lymphoproliferative disorders, including lymphomas and immune-complex deposit diseases causing local and/or systemic complications. Mixed cryoglobulinemia (MC) is manifested by multiple systemic organ involvement, mainly skin, kidney, peripheral nerves, and salivary glands, and less frequently causes widespread vasculitis and malignant lymphoma. MC affects up to 3% of HCV-infected patients with cryoglobulinemia of clinical significance, i.e. >6%. Severe disease requires immunosuppressive or plasma exchange therapy. HCV prevalence in the United States in patients with porphyria cutanea tarda (PCT) was reported to be 66%, much higher than that in general population. Therefore, all patients with PCT should be screened for HCV. The skin rash of PCT varies from large blisters to small vesicles and/or milia on the hands. Skin manifestations due to PCT usually respond to anti-HCV treatment together with reducing skin sun exposure, avoiding triggers, having routine phlebotomy (especially for people with chronic iron overload states), and using chloroquine. Lichen planus (LP), which typically affects both the skin and oral mucosa is a chronic inflammatory disease of squamous cell origin affecting about 1% of the worldwide population. The prevalence of HCV in patients with LP varies based on geographic location. We review here the basic pathophysiology, clinical features, and management of dermatologic manifestations of HCV.