Gastrointestinal Stromal Tumor Complicated by Fistula Formation.

Gastrointestinal (GI) stromal tumors are mesenchymal tumors that may arise in any portion of the GI tract. Their clinical presentation and complications may vary but do not often present with fistulization. This case is of clinical interest because of the rarity of GI stromal tumor intestinal fistulas.

Etiologies and Outcomes of Transaminase Elevation > 1000 IU/L: A Systematic Review and Meta-Analysis.

BACKGROUND: Among liver injury causes, few result in marked elevation of liver enzymes to a level > 1,000 international units per liter (IU/L). This review summarizes common etiologies of marked transaminase elevation and associated prognostic factors. METHODS: We performed a comprehensive search on PubMed, EMBASE, Cochrane Library, and Google Scholar from inception through December 2022 using MOOSE guidelines for studies reporting frequency of etiologies of marked transaminase elevation. We used a proportion meta-analysis to pool frequencies with corresponding 95% confidence interval (CI). I2 was used to adjudicate heterogeneity. We used CMA software for statistical analysis. RESULTS: Seven relevant studies (n = 1608 patients) were included. The pooled frequency of ischemic hepatitis was 51% (95% CI 42-60%, I2 = 91%), viral hepatitis was 13.1% (95% CI 9.7-17.6%, I2 = 80%), toxins or drug-induced liver injury (DILI) was 13% (95% CI 8-18%, I2 = 85%), and pancreaticobiliary-related injury was 7.8% (95% CI 4.4-13.6%, I2 = 89%). Mortality was significantly higher in ischemic hepatitis versus other causes of marked transaminase elevation, with an odds ratio of 21 (95% CI 9.9-44.8, P value < 0.0001, I2 = 64% Q 11.1). DISCUSSION: This is the first meta-analysis to examine etiologies of marked transaminase elevation > 1000 IU/L. Liver ischemia is the most common cause, while other causes include DILI or toxins, viral hepatitis, and biliary pathologies. We found biliary pathologies to be the fourth most common cause. This is clinically relevant as it has been traditionally linked to a cholestatic pattern of liver injury. Being aware of this presentation may help prevent delayed or missed diagnoses and unnecessary testing.

Prevalence and trends of Clostridioides difficile infection among persons requiring maintenance hemodialysis: A systematic review and meta-analysis.

OBJECTIVE: Clostridioides difficile infection (CDI) is among the most common cause of healthcare-associated infections. Persons requiring maintenance hemodialysis (MHD) are at increased risk of CDI and associated mortality compared to persons not requiring MHD. Given the clinical impact of CDI among persons requiring MHD, we aimed to quantify the burden of CDI and trends over time in this patient population. STUDY DESIGN: A systematic review and meta-analysis of studies reporting rates of CDI among persons requiring MHD in MEDLINE, Embase, Web of Science Core Collection, CINAHL, and Cochrane Central Register of Controlled Trials were performed. Searches were conducted on May 17, 2021, and March 4, 2022. RESULTS: In total, 2,408 titles and abstracts were identified; 240 underwent full text review. Among them, 15 studies provided data on rates of CDI among persons requiring MHD, and 8 of these also provided rates among persons not requiring MHD. The pooled prevalence of CDI among persons requiring MHD was 19.14%, compared to 5.16% among persons not requiring MHD (odds ratio [OR], 4.35; 95% confidence interval [CI], 2.07-9.16; P = .47). The linear increase in CDI over time was significant, increasing an average of 31.97% annually between 1993 and 2017 (OR, 1.32; 95% CI, 1.1-1.58; P < .01). The linear annual increase was similar among persons requiring and not requiring MHD (OR, 1.28; 95% CI, 1.13-1.45; P = .11). CONCLUSIONS: Persons requiring MHD have a 4-fold higher risk of CDI compared to persons not requiring MHD, and rates of CDI are increasing over time in both groups.

Clinical Implication of Drug Resistance for H. pylori Management.

Rates of antimicrobial-resistance among H. pylori strains are increasing worldwide, resulting in declining eradication rates with current therapies, especially those containing clarithromycin or levofloxacin. To improve H. pylori management, a paradigm shift is needed, from the empiric approaches formerly employed, to regimen selection based upon knowledge of local and patient-level antimicrobial susceptibility data. We review the mechanisms of H. pylori antimicrobial resistance and the available worldwide pattern of resistance to key antimicrobials used in H. pylori therapy. The practicalities and challenges of measuring susceptibility in clinical practice is discussed, including not only conventional culture-based techniques but also novel sequencing-based methods performed on gastric tissue and stool samples. Though clinical trials of "tailored" (susceptibility-based) treatments have yet to show the clear superiority of tailored over empiric regimen selection, the ability to measure and modify treatment based upon antimicrobial susceptibility testing is likely to become more frequent in clinical practice and should lead to improved H. pylori management in the near future.

Helicobacter pylori Antibiotic Resistance in the United States Between 2011 and 2021: A Systematic Review and Meta-Analysis.

INTRODUCTION: Antimicrobial resistance among Helicobacter pylori strains has been rising globally, leading to declining eradication rates. We performed a systematic review and meta-analysis of the resistance patterns of H. pylori strains in the United States between 2011 and 2021. METHODS: Ovid MEDLINE, Embase, CINAHL, and Cochrane CENTRAL databases were searched for manuscripts and conference abstracts published between 2011 and 2021 reporting H. pylori antibiotic resistance. A mixed-effects model estimated pooled rates of resistance to clarithromycin, amoxicillin, metronidazole, tetracycline, rifabutin, levofloxacin, or a combination of these, with 95% confidence intervals (CIs). RESULTS: A total of 19 studies including 2,660 samples, met inclusion criteria. The pooled rate of resistance to metronidazole was 42.1% (95% CI 27.3%-58.6%), levofloxacin 37.6% (95% CI 26.3%-50.4%), clarithromycin 31.5% (95% CI 23.6%-40.6%), amoxicillin 2.6% (95% CI 1.4%-5.0%), tetracycline 0.87% (95% CI 0.2%-3.8%), rifabutin 0.17% (95% CI 0.00%-10.9%), and dual clarithromycin and metronidazole 11.7% (95% CI 0.1%-94.0%). Considerable data heterogeneity was evident for pooled resistance prevalence rates (I 2 > 50%), with the exception of rifabutin resistance. DISCUSSION: Metronidazole, levofloxacin, and clarithromycin resistance rates each exceed 30%; thus, choosing an empiric antibiotic regimen without knowledge of the likely pattern of antibiotic resistance is not appropriate. Resistance to tetracycline, rifabutin, and amoxicillin remains low. Given the scarcity of available data with considerable heterogeneity among studies, continued surveillance, ideally with a more systematic approach to data collection, is an increasingly important goal in H. pylori management.

Analysis of Decreasing Adverse Events with Endoscopic Ultrasound in a New Advanced Endoscopy Program Over Time.

OBJECTIVE: New innovations and increasing utility of endoscopic ultrasound (EUS) are associated with rare but serious risks. We investigate the rates and risk factors for post-procedural complications over a four-year period at a new advanced endoscopy program. METHODS: We conducted a retrospective review of all adult patients who underwent upper EUS at an academic level-1 trauma center between April 2015 and November 2019. The primary outcome was the incidence of adverse events within 1 week of EUS. Secondary outcomes included emergency department visits and mortality within 30 days after EUS. Chi-square test, t test, and multivariable logistic regression were used to assess risk factors for post-procedural complications. RESULTS: A total of 968 EUS procedures were performed on 864 patients (54% female; 79% Caucasian; mean age 61 years). The overall incidence of post-procedural adverse event with EUS was 5.6%. The probability of an adverse event decreased by an average of 22% per year (p =0.01, OR 0.78). The risk for adverse events were 3.3% acute pancreatitis, 1.9% clinically significant bleeding, 0.3% bacteremia, 0.2% perforation, and 2.4% 30-day mortality. The adverse event rate was highest among low volume proceduralists (p =0.04). The 30-day mortality was more than threefolds among patients who had an adverse event within 7 days after EUS. CONCLUSION: The overall incidence of post-procedural adverse events at a new EUS program was 5.6%, with an average of 22% relative decrease in adverse events per year in the first 4 years.

A rare anatomical variation complicating a diffuse abdominal pain presentation: A case report of colonic perforation in situs inversus totalis.

INTRODUCTION: Situs inversus totalis (SIT) is a rare anatomical variation of the thoracic and abdominal organs. It is a congenital anomaly with an incidence of 1:10,000 to 1:20,000. Patients with SIT do not have a decreased survival rate as compared to patients without SIT because SIT generally does not have a pathophysiologic significance. However, the anatomical variations in SIT can cause some challenges when assessing intraabdominal and intrathoracic symptoms or performing operations. CASE PRESENTATION: We report a case of a 93-year-old woman with a past medical history of hypertension, hyperlipidemia, atrial fibrillation, and situs inversus totalis who presented with diffuse abdominal pain for 4 days. Abdominal exam was significant for diffuse tenderness. Computed tomography (CT) imaging was significant for pneumoperitoneum. She emergently underwent an exploratory laparotomy, descending hemicolectomy and left in discontinuity with an open abdomen. On postoperative day 2 she underwent a stamm feeding gastrostomy tube, incisional hernia repair, and maturation of end colostomy. Her remaining hospital course was complicated by a pelvic collection, which was managed by a percutaneous guided drain placement. She was ultimately discharge to rehab on hospital day 15. DISCUSSION: SITS can present a particularly challenging situation to clinical diagnoses and surgical procedures. However, when identified, these patients should warrant special considerations prior to proceeding with surgical intervention. This includes radiologic imaging and proper planning prior to the operating room, when possible. CONCLUSION: We herein present a case of colonic perforation in a patient with situs inversus totalis. Proper planning, thorough imaging, and careful execution are necessary to ensure patient safety and care in patients with SIT. However, in the case of emergency this should not delay definitive management.

Prevalence and risk factors of steatosis and advanced fibrosis using transient elastography in the United States' adolescent population.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is the leading cause of chronic liver disease in children and adolescents. AIM: To determine the prevalence and risk factors of steatosis and advanced fibrosis using transient elastography (TE) in the United States' adolescent population. METHODS: Using the National Health and Nutrition Examination Survey 2017-2018, adolescent participants aged 13 to 17 years who underwent TE and controlled attenuation parameter (CAP) were included in this study. Forty-one factors associated with liver steatosis and fibrosis were collected. Univariate and multivariate linear regression analysis were used to identify statistically significant predictors. RESULTS: Seven hundred and forty participants met inclusion criteria. Steatosis (S1-S3), based on CAP, and advanced fibrosis (F3-F4), based on TE, were present in 27% and 2.84% of the study population, respectively. Independent predictors of steatosis grade included log of alanine aminotransferase, insulin resistance, waist-to-height ratio, and body mass index. Independent predictors of fibrosis grade included steatosis grade, non-Hispanic black race, smoking history, and systolic blood pressure. CONCLUSION: This study demonstrated a high prevalence of steatosis in the United States' adolescent population. Almost 3% of United States' adolescents had advanced fibrosis. These findings are concerning because a younger age of onset of NAFLD can lead to an earlier development of severe disease, including steatohepatitis, cirrhosis, and liver decompensation.

Whipple's Disease Mimicking Common Digestive Disorders.

Whipple's disease is a rare infectious disease caused by the bacterium Tropheryma whipplei. The prevalence of Whipple's disease is 3/1,000,000 in Western populations. It most often causes a malabsorption disorder with weight loss and diarrhea as common presenting symptoms. In one-third of patients, however, there are no gastrointestinal symptoms at presentation; patients instead report a wide variety of non-specific extraintestinal complaints, potentially involving every organ system. We report a case of a 37-year-old man who presented with a 3-month history of non-bloody diarrhea and 15-pound weight loss. He was ultimately diagnosed with biopsy-confirmed Whipple's disease. Despite its rarity, Whipple's disease remains an important clinical entity and should be included on the differential diagnosis for selected patients presenting with an array of non-specific symptoms.

P055 Sociodemographic Differences in Fecal Enteropathogen Testing Patterns in Adults Hospitalized for Inflammatory Bowel Disease Flares.

BACKGROUND: Adults with inflammatory bowel disease (IBD) have increased risks for gastrointestinal infections. Single-center studies in Michigan and New York report 17-31% positive enteropathogen tests in patients with symptomatic IBD. Population-based studies are lacking, particularly on factors that determine who undergo testing. Health inequities may exist in the care of patients with IBD where certain groups systematically experience social and/or economic disparities. We aim to assess sociodemographic and healthcare factors associated with enteropathogen testing of hospitalized IBD patients. METHODS: In this retrospective cohort study, we identified 770 patients with IBD who had 1,189 hospital admissions for primary symptoms consistent with IBD flares/enteric infections at 3 hospitals (tertiary referral teaching, community, and county) in the largest healthcare system in Rhode Island from January 2017-March 2019. Using modified Poisson regression to estimate relative risks (RR) and 95% Confidence Intervals (CIs), we assessed enteropathogen testing status as a function of sociodemographic and clinical characteristics in separate models. RESULTS: Patients with IBD hospitalized with symptoms consistent with IBD flares or enteric infections disproportionately had Crohn's disease (69% vs. 31% UC). Patients were 47 years old on average, 60% women, 79% non-Hispanic white, 13% Hispanic, and 7% non-Hispanic Black. Over half (55%) were privately insured, 42% publicly insured, and 2% uninsured. Over half (55%) of patients were treated with glucocorticoids within 1 week of hospitalization while 35% were on biologics. The top 5 primary symptoms for hospitalization were abdominal pain (63%), GI bleeding (8%), fever (8%), vomiting (7%), and diarrhea (7%). Enteropathogen testing (may be >1) was obtained in 46% of hospitalizations: 42% tested for C. difficile; 23 % tested for Salmonella spp., Shigella spp./enteroinvasive E. coli, Campylobacter spp., and Shiga toxin-producing organisms; and 15% had extensive testing for 22 enteropathogens (13 bacteria, 5 viruses, and 4 parasites). 10% of the tests were positive, most commonly for C. difficile (5%), E. coli spp (0.6%), Campylobacter spp (0.5%), Salmonella (0.3%), and Norovirus (0.3%). While gender differences in testing were not observed (female 45%, male 46%, F:M, RR 1.01, 95% CI 0.90,1.15), Hispanic patients were more likely to undergo enteropathogen testing than non-Hispanic white patients (58% vs 44%; RR 1.21, 95% CI 1.02-1.43). Relative to patients hospitalized at the tertiary referral teaching hospital, patients at the county hospital were 29% less likely (95% CI, 0.54-0.93) and those at the community hospital were 22% (95% CI 0.78-1.01) less likely to have enteropathogen testing. Enteropathogen testing occurred most frequently among the privately insured 48%, while uninsured were comparatively 20% less likely and publicly insured were 10% less likely to undergo testing, though neither comparison was statistically significant. CONCLUSION: Racial/ethnic (Hispanic vs non-Hispanic White) and healthcare settings (county vs tertiary referral teaching hospital) differences in enteropathogen testing patterns were observed in adults with IBD hospitalized primarily for GI symptoms at the state of Rhode Island's largest healthcare system. Further studies to assess health inequities, including sociodemographic and organizational differences, in the healthcare delivery in IBD are warranted.

Association Between Obstructive Sleep Apnea and Barrett's Esophagus: A Systematic Review and Meta-Analysis.

BACKGROUND: Obstructive sleep apnea (OSA) has gastrointestinal implications as it is associated with gastroesophageal reflux disease. Less certain is an independent association between OSA and Barrett's esophagus. We performed a systematic review and meta-analysis to evaluate the association between OSA and Barrett's esophagus. METHODS: A systematic search of Ovid MEDLINE, Embase, Web of Science, CINAHL, and the Cochrane Central Register of Controlled Trials was performed. Inclusion criteria were observational studies (retrospective and case-control) assessing the association between OSA and Barrett's esophagus in adult subjects. Data from the included studies were extracted and used to calculate the pooled odds ratio of OSA with 95% confidence interval (CI) between patients with Barrett's esophagus and those without, using a random-effects model. RESULTS: Altogether six studies involving 2333 subjects met the inclusion criteria and were included in this meta-analysis. The pooled analysis found a significantly increased risk of OSA, high risk of OSA, and patient-reported OSA symptoms among patients with Barrett's esophagus versus those without Barrett's esophagus, with a pooled odds ratio (OR) of 2.19 (95% CI 1.53-3.15). A subgroup analysis for cases of definite OSA (formally diagnosed via polysomnography) and Barrett's esophagus (n = 2 studies) also demonstrated significant association (OR 2.59, 95% CI 1.39-4.84). CONCLUSION: A significantly increased risk of OSA among patients with Barrett's esophagus was demonstrated in this meta-analysis. Further investigation is warranted to determine the pathophysiology and clinical implications of this association.

How curricular changes influence medical students' perceptions of basic science: A pilot study.

THEORY: The perceived value of study material may have implications on learning and long-term retention. This study compares the perceived value of basic science of medical students from schools with a traditional "2+2" curriculum and the USMLE Step 1 placed before core clerkships to those from medical schools that have undergone curricular revisions, resulting in shortened pre-clerkship curricula and administration of the USMLE Step 1 after core clerkships. HYPOTHESIS: We hypothesize that differences in curricula, particularly duration of pre-clerkship curriculum and timing of the USMLE Step 1, affect medical students' perceived value of basic science. METHODS: A twenty item anonymous questionnaire using a 5-point Likert scale was developed to assess medical students' perceptions of basic science. The questionnaire was distributed to third-year medical students across four medical schools. Generalized linear models and p-values were calculated comparing the perceived value and use of basic science between medical schools with the USMLE Step 1 before clerkships and 2-years of basic science (BC) and medical schools with the USMLE Step 1 after core clerkships and 1.5-years of basic science (AC). RESULTS: The questionnaire was distributed to 695 eligible students and completed by 287 students. Students at BC schools tended to view basic science as more essential for clinical practice than students at AC schools across both outcomes (rating independence of basic science and clinical practice, AC school mean = 2.97, BC school mean = 2.73, p = 0.0017; rating importance of basic science to clinical practice, AC school mean = 3.30, BC schools mean = 3.50, p = 0.0135). CONCLUSIONS: Our study suggests that students who have a longer basic science curriculum tend to value basic science greater than students with a shorter basic science curriculum. The timing of the USMLE Step 1 may also influence this relationship. Curricular decisions, such as reductions in pre-clerkship curricula and administration of the USMLE Step 1 after clerkships, may impact medical students' perceptions of the value of basic science to clinical practice. This can have implications on their future engagement with basic science and should be considered when modifying curriculum.

Jejunal Diverticulosis Complicated by Diverticulitis and Small Bowel Obstruction.

Diverticular disease is common in the Western population and can cause considerable morbidity. The prevalence of colonic diverticulosis reaches 60% by the age of 60 years. Small bowel diverticulosis is much rarer and, when present, most commonly occurs in the duodenum. We herein report an elderly woman with jejunal diverticulosis complicated by diverticulitis and small bowel obstruction, who subsequently underwent small bowel resection and primary anastomosis. As demonstrated by this case, jejunal diverticulitis can cause serious complications and given the possibility of recurrence and serious complications, surgical options should be discussed early in the course of medical care.