Methemoglobinemia: A Life-threatening Complication of Topical Pharyngeal Anesthetics.

Drug-induced methemoglobinemia can be caused due to topical anesthetics, dapsone, nitrates (e.g., nitroglycerin), and metoclopramide. Cyanosis in the setting of topical anesthetic use, along with the arterial blood gas results indicating hypoxemia, points towards the diagnosis of methemoglobinemia. We highlight the potential complication with the use of topical pharyngeal benzocaine through this case presentation.

Case series and review of liver dysfunction in COVID-19 patients.

Coronoviraus disease 2019 (COVID-19) has infected over two million people worldwide and the number keeps growing every day. While the pulmonary complications of COVID-19 are obvious, the effect of the virus on the other organs and the chronicity of the organ dysfunction remain unknown. The virus causes a debilitating infection with multiorgan injury and has a high mortality rate estimated to be around 3.70%. Several hypotheses are formulated to explain the liver dysfunction in COVID-19 patients which include collateral damage from cytokine storm, drug-induced liver injury, viral-induced hepatitis and hypoxia-induced damage. Through this case series, we would like to highlight that liver enzyme abnormalities are often seen in COVID-19 patients and would like to highlight that physicians need to serially monitor biochemical testing until the liver enzymes return to baseline. Physicians also need to be vigilant of liver enzyme abnormalities in these patients, especially before starting new medications.

A Therapeutic Approach to Cecal Varices.

Ectopic varices account for 1%-5% of all variceal bleeding episodes. The most common presentation of cecal varices is an acute episode of a massive lower gastrointestinal hemorrhage. However, cecal varices can be found incidentally and can be silent for a prolonged period of time before presenting with a massive gastrointestinal hemorrhage. Through this case of a 63-year-old woman, we would like to highlight the paucity of literature in the treatment of nonbleeding cecal varices.

Emphysematous Gastritis: A Real Indication for Emergent Surgical Intervention?

Emphysematous gastritis is a rare disease with gastric inflammation and intramural gas formation due to gas-forming microorganisms. It is diagnosed based on clinical presentation and imaging findings of gas in the gastric wall. Computed tomography is the preferred imaging modality. Early diagnosis and management are important since emphysematous gastritis is associated with high rates of morbidity and mortality. We present a case of emphysematous gastritis, which was successfully managed conservatively through early diagnosis and prompt treatment.

Patient Satisfaction and Understanding of Moderate Sedation During Endoscopy.

Millions of endoscopic procedures are performed in the US every year and the use of procedural sedation analgesia (PSA) is increasing with more procedures being performed outside the operating theater and gaining popularity due to reduced costs. Patients having endoscopic procedures usually expect that they would be deeply sedated during the procedure despite verbal counseling during pre-procedure clinic visits and are often dissatisfied with procedural awareness and discomfort. In order to better educate patients, written supplementary reading material was provided to the patients, which stated a clear goal of comfort during the procedure rather than deep sedation. The results showed that the written supplementary material did not improve the patient's understanding or remembrance of being counseled about moderate sedation. We emphasize that there is no substitute for a physician's repetitive verbal counseling.

Rare Complication of Interventional Radiology-guided Arterial Embolization of the Gastroduodenal Artery in the Setting of Acute Gastrointestinal Bleed: Migrated Coils in the Duodenum.

A 91-year-old male presented to the emergency room with hemodynamically significant upper gastrointestinal bleeding. The patient underwent an esophagogastroduodenoscopy (EGD), which showed frank blood in the duodenum interfering with the visualization. Hence, the patient underwent urgent interventional radiology (IR)-guided arteriogram and embolization. An EGD done 48 hours later showed a giant, non-bleeding, cratered duodenal ulcer with a visible vessel and vascular coils partially protruding into the duodenal bulb lumen. The patient had no evidence of bleeding post embolization. The patient presented three months later with abdominal pain. Computed tomography (CT) abdomen showed multiple liver abscesses. IR-guided drainage of abscesses was performed, and the culture grew Streptococcus intermedius. Magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), and barium enema were unremarkable. The patient was treated with a prolonged course of intravenous (IV) antibiotics and recovered without any further issues. IR guided arterial embolization can be lifesaving in cases where GI bleeding cannot be controlled endoscopically, however, it can lead to serious complications, including endovascular coil migration into the gastrointestinal (GI) lumen causing infection and re-bleeding. Endovascular coil migration can occur immediately or several years later, which can result in fatal bleeding and infection. The best approach to prevent and manage migrated endovascular coils in the GI lumen remains unclear.

Bouveret syndrome as a rare cause of gastric outlet obstruction.

Biliary-enteric fistula is a rare complication of cholelithiasis that can lead to gallstone ileus. Gallstone impaction in the duodenum and pylorus is extremely rare and can lead to gastric outlet obstruction, a condition known as Bouveret syndrome. Bouveret syndrome needs to be diagnosed and managed in a timely fashion, as it has a high mortality rate. We describe a case of an elderly patient who presented with Bouveret syndrome secondary to impaction of the biliary calculus in the first part of duodenum.

Black speckled duodenal mucosa.

Pseudomelanosis duodeni is a rare incidental finding seen on endoscopy and has the characteristic appearance of flat, black-speckled pigmented mucosa. We present the case of an 83-year-old woman who presented with gastrointestinal bleeding and was found to have pseudomelanosis duodeni. The finding has no diagnostic or prognostic significance. Therapeutic chelation or endoscopic follow-up is not recommended.

Outcomes of Upper Gastrointestinal Bleeding Based on Time to Endoscopy: A Retrospective Study.

Introduction Non-variceal upper gastrointestinal bleeding (UGIB) is a major burden on the health care system. The timing of endoscopy has been an ongoing debate and data on the association of early endoscopy with a better or worse clinical outcome are conflicting. In our study, we aimed to identify the benefits versus the risks of performing an urgent endoscopy in regards to the number of endoscopic interventions, length of hospital stay, number of packed red blood cells (PRBCs) transfused, and mortality.  Methodology This is a retrospective record-based study. A total of 806 charts were reviewed and 251 patients with the signs and symptoms of UGIB on presentation were included in the study. Patients with variceal bleeding, lower gastrointestinal bleeding, insignificant bleeds with no drop in H/H, GI bleed not being the presenting complaint on admission, and patients on anticoagulation were excluded. Results Out of the patients who underwent an urgent esophagogastroduodenoscopy (EGD), 26.2% needed a second-look EGD 48 hours after the first EGD when compared to 4% and 2% in the early (12-24 hours) and late (>24 hours) endoscopy groups, respectively. In patients who underwent urgent EGD, 23% had active bleeding and it was statistically significant when compared to the other groups. The active bleeding limited the visualization during the endoscopy, which led to a repeat EGD in the urgent EGD group. If an endoscopic intervention was received, patients having EGD >24 hours received a smaller number of interventions. There was no statistical difference in the Blatchford scores between the three groups, indicating that the groups were similar in morbidity. No difference in mortality, hospital length of stay, or number of blood transfusions received, surgical or interventional radiology-guided interventions was found between the three groups. Conclusion Patients who underwent urgent endoscopy had more procedures, with no difference in mortality, number of units of blood transfused, or length of hospitalization when compared to the early or late endoscopy groups.

Relation of viscous lidocaine combined with propofol deep sedation during elective upper gastrointestinal endoscopy to discharge.

Fusing topical pharyngeal anesthetics (TPAs) to intravenous sedation during esophagogastroduodenoscopy (EGD) has been controversial. This double-blind, randomized, placebo-controlled trial assessed the association of TPA with patient recovery time, post-EGD to discharge. Supplementary aims were to determine the association of TPA with patient and practitioner satisfaction (both measured on a 100-mm visual analog scale), total propofol dose, and side effects. The study included 93 patients (mean age 53.8 years, range 44-67; 37 men and 56 women) undergoing elective EGD at a single academic medical center from September 2015 to October 2016. Urgent or therapeutic EGDs were excluded. Interventions were 7.5 mL 2% lidocaine viscous solution and 7.5 mL placebo solution (3% methylcellulose). There were no statistically significant differences between the lidocaine (n = 46) and placebo (n = 47) groups with respect to recovery time (42 ± 17.8 vs 39 ± 15.9 minutes; P = 0.23), procedure time (6.5 ± 2.7 vs 7 ± 3.6 minutes; P = 0.77), endoscopist satisfaction (83.2 ± 24.4 vs 77 ± 27.7, P = 0.23), patient discomfort (16.6 ± 19.8 vs 24.0 ± 29.7, P = 0.37), or total propofol administered (2.3 ± 1.3 vs 2.3 ± 1.0 mg/kg, P = 0.55). Compared to placebo, topical viscous lidocaine does not appear to delay recovery time or adversely affect sedation-related outcomes.

Histologic and Endoscopic Similarity between Nodular Gastric Antral Vascular Ectasia and Gastric Hyperplastic Polyps Potentially Causing Treatment Delays.

INTRODUCTION: Gastric antral vascular ectasia (GAVE) is the underlying cause for 4% of nonvariceal upper GI bleeding. Nodular GAVE and gastric hyperplastic polyps have similar appearance on upper GI endoscopy (EGD) as well as histology, which could delay specific targeted therapy. We herein, through this case, would like to highlight that high clinical suspicion is required to diagnose nodular GAVE. CASE REPORT: A 70-year-old male with a past medical history significant for coronary artery disease s/p drug-eluting stent placement on Plavix, coronary artery bypass grafting, mechanical aortic valve replacement on warfarin, and iron deficiency anemia on replacement was admitted for the evaluation of fatigue and melena for a month. Physical examination was positive for black stool. The only significant lab was a drop in hemoglobin/hematocrit (Hg/dl/H%) of 10/32 to 4/12.5. Fibrosure was sought which suggested that the patient had an F4 cirrhosis. Endoscopy showed nodules in the gastric antrum which were presumptively treated as GAVE with argon plasma coagulation (APC). Surgical pathology showed reactive gastropathy and gastric polyps. Review of the past histology suggested that because of the overlap in the histopathological features of hyperplastic polyps and GAVE, they were misinterpreted as hyperplastic polyp rather than nodular GAVE. DISCUSSION: GAVE can be classified endoscopically as punctate, striped, nodular, or polypoidal form. The light microscopic findings considered specific to GAVE are vascular hyperplasia, mucosal vascular ectasia, intravascular fibrin thrombi, and fibromuscular hyperplasia. However, these findings do not differentiate GAVE from hyperplastic gastric polyp. The first line of treatment for GAVE is endoscopic ablation with Nd:YAG laser or argon plasma coagulation. Response to therapy was seen with a mean of 2.6 treatment sessions. There is not a lot of evidence supportive of pharmacological treatment of GAVE with estrogen-progesterone, tranexamic acid, and thalidomide. Serial endoscopic band ligation as well as detachable snares in the management of nodular GAVE refractory to argon plasma coagulation has also been tried. CONCLUSION: Oftentimes, there is a delay in the diagnosis and treatment of nodular GAVE as the histopathological appearance could be similar to gastric polyps. The diagnosis of GAVE especially nodular GAVE requires a high level of clinical suspicion. Misdiagnosis of nodular GAVE can delay targeted therapy and have fatal outcomes.

Effects of Helicobacter pylori eradication on insulin resistance and metabolic parameters: a systematic review and meta-analysis.

INTRODUCTION: Previous studies have shown a close relationship between Helicobacter pylori (H. pylori), insulin resistance, and altered metabolic parameters. However, the effects of H. pylori eradication on these conditions remain controversial. We carried out a systematic review and meta-analysis to evaluate the effects of H. pylori eradication on insulin resistance and metabolic parameters. METHODS: We searched CENTRAL, MEDLINE, and EMBASE databases from their inception to July 2016. Insulin resistance (HOMA-IR), body weight (BW), BMI, waist circumference, triglycerides (TG), high-density and low-density lipoprotein-cholesterol (HDL-C and LDL-C), and fasting blood glucose (FBG) were compared between patients with and without H. pylori eradication using a random-effects model. We reported pooled mean differences (MD) and 95% confidence intervals (CI) for the change in outcomes. RESULTS: Data from five studies showed no difference in HOMA-IR after H. pylori eradication (pooled MD=-0.52, 95% CI: -1.47 to 0.42). Eradication significantly increased BMI (MD=0.36, 95% CI: 0.11-0.60) and BW (MD=1.1, 95% CI: 0.8-1.5), but had no significant effects on TG, LDL-C, HDL-C, or FBG. CONCLUSION: H. pylori eradication does not improve insulin resistance, TG, HDL-C, LDL-C, or FBG, but may increase BW and BMI. Further studies are needed to clarify the effect of H. pylori eradication on metabolism.