Recurrent, Multisubtype Posttransplant Lymphoproliferative Disorder Masquerading as Inflammatory Bowel Disease.

Posttransplant lymphoproliferative disorder (PTLD) is a severe posttransplant complication that occurs because of immunosuppression within the first year; however, recurrent PTLD or development of multiple histologic subtypes are rare. Our case demonstrates a renal transplant recipient with rare, recurrent PTLD with multiple histologic subtypes (monomorphic and polymorphic PTLD) despite a previous response to rituximab and resolution of inflammatory changes on endoscopy. It is essential that clinicians maintain a high suspicion for PTLD when caring for patients with previous transplantation and that they have a lower threshold for biopsy with endoscopic findings of nonspecific inflammatory changes.

Use of a Lumen-Apposing Metal Stent for Management of Pouch Outlet Stenosis After Vertical Banded Gastroplasty.

Lumen-apposing metal stents (LAMSs) offer a novel alternative for the treatment of anastomotic strictures or short, benign gastrointestinal strictures. In the bariatric realm, LAMSs provide a potentially safer, efficacious, and nonsurgical approach to surgical revision. Here, we present a case where a LAMS was successfully used to manage pouch outlet stenosis from a previous vertical banded gastroplasty.

Role of microbial dysbiosis in the pathogenesis of esophageal mucosal disease: A paradigm shift from acid to bacteria?

Genomic sequencing, bioinformatics, and initial speciation (e.g., relative abundance) of the commensal microbiome have revolutionized the way we think about the "human" body in health and disease. The interactions between the gut bacteria and the immune system of the host play a key role in the pathogenesis of gastrointestinal diseases, including those impacting the esophagus. Although relatively stable, there are a number of factors that may disrupt the delicate balance between the luminal esophageal microbiome (EM) and the host. These changes are thought to be a product of age, diet, antibiotic and other medication use, oral hygiene, smoking, and/or expression of antibiotic products (bacteriocins) by other flora. These effects may lead to persistent dysbiosis which in turn increases the risk of local inflammation, systemic inflammation, and ultimately disease progression. Research has suggested that the etiology of gastroesophageal reflux disease-related esophagitis includes a cytokine-mediated inflammatory component and is, therefore, not merely the result of esophageal mucosal exposure to corrosives (i.e., acid). Emerging evidence also suggests that the EM plays a major role in the pathogenesis of disease by inciting an immunogenic response which ultimately propagates the inflammatory cascade. Here, we discuss the potential role for manipulating the EM as a therapeutic option for treating the root cause of various esophageal disease rather than just providing symptomatic relief (i.e., acid suppression).

Outcomes of an international multicenter registry on EUS-guided gallbladder drainage in patients at high risk for cholecystectomy.

Background and study aims The aim of the current study was to review the outcomes of a large-scale international registry on endoscopic ultrasound-guided gallbladder drainage (EGBD) that encompasses different stent systems in patients who are at high-risk for cholecystectomy. Patients and methods This was a retrospective international multicenter registry on EGBD created by 13 institutions around the world. Consecutive patients who received EGBD for several indications were included. Outcomes include technical and clinical success, unplanned procedural events (UPE), adverse events (AEs), mortality, recurrent cholecystitis and learning curve of the procedure. Results Between June 2011 and November 2017, 379 patients were recruited to the study. Technical and clinical success were achieved in 95.3 % and 90.8 % of the patients, respectively. The 30-day AE rate was 15.3 % and 30-day mortality was 9.2 %. UPEs were significantly more common in patients with EGBD performed for conversion of cholecystostomy and symptomatic gallstones ( P  < 0.001); and by endoscopists with experience of fewer than 25 procedures ( P  = 0.033). Both presence of clinical failure ( P  = 0.014; RR 8.69 95 %CI [1.56 - 48.47]) and endoscopist experience with fewer than 25 procedures ( P  = 0.002; RR 4.68 95 %CI [1.79 - 12.26]) were significant predictors of 30-day AEs. Presence of 30-day AEs was a significant predictor of mortality ( P  < 0.001; RR 103 95 %CI [11.24 - 944.04]). Conclusion EGBD was associated with high success rates in this large-scale study. EGBD performed for indications other than acute cholecystitis was associated with higher UPEs. The number of cases required to gain competency with the technique by experienced interventional endosonographers was 25 procedures.

Endoscopic ultrasound-guided creation of an enterocolostomy to relieve malignant bowel obstruction.

Background and study aim Malignant bowel obstruction can cause significantly distressing symptoms in patients with end stage cancers, often requiring invasive surgical intervention. With such procedures, risks often outweigh the benefit. We report a novel application of the AXIOS stent and electrocautery-enhanced delivery system to create an enterocolostomy to bypass a small bowel obstruction in the setting of recurrent malignant bowel obstruction. A 72-year-old patient presented with recurrent malignant bowel obstruction and was deemed unfit for surgery. Endoscopic ultrasound was used to deploy an AXIOS stent, creating an enterocolostomy resolving the obstruction.

Bowel preparation for colonoscopy: what is best and necessary for quality?

PURPOSE OF REVIEW: Colonoscopy is recognizably, the best colon cancer prevention test, provided the quality of the preparation is adequate for detection of precancerous polyps but also allowing for accurate identification of margins, thereby facilitating complete endoscopic resection. As there are many aspects effecting colon prep outcomes, it is timely to review new standards for optimizing outcomes, including product selection based on patient demographics. RECENT FINDINGS: New national guidelines have set a minimum quality threshold for adequacy and also defined a split day delivery for oral options as the "standard of care". Several new prep options have been recently released and these data are discussed. SUMMARY: Optimizing the quality of colon preps has major implications for clinical practice. Clinicians must recognize new targets for standard of care, providing the best approach for each individual patient, considering variable factors which may otherwise compromise success.

A tale of two LAMS: a report of benign tissue ingrowth resulting in recurrent gastric outlet obstruction.

Background and study aims Endoscopic ultrasound (EUS)-guided gastroenterostomy is a novel, off-label, procedure that has been facilitated by availability of a novel lumen apposing metal stent (LAMS) (Axios, Boston Scientific, Marlbourough Massachusetts, United States). The literature suggests its efficacy to be comparable to surgical gastrojejunostomy. In theory, this procedure overcomes the issues associated with woven enteral stents, which are subject to continuous, straightening, axial forces. We report the adverse event of tissue ingrowth in an Axios stent placed as an EUS-guided gastroduodenostomy, resulting in recurrence of gastric outlet obstruction, treated by a stent-inside-stent technique.

Barriers to Lynch Syndrome Testing and Preoperative Result Availability in Early-onset Colorectal Cancer: A National Physician Survey Study.

OBJECTIVE: Although widely recommended, Lynch syndrome (LS) testing with tumor microsatellite instability (MSI) and/or immunohistochemistry (IHC) is infrequently performed in early-onset colorectal cancer (CRC), and CRC generally. Reasons are poorly understood. Hence, we conducted a national survey focusing on gastroenterologists, as they are frequently first to diagnose CRC, assessing testing barriers and which specialist is felt responsible for ordering MSI/IHC. Additionally, we assessed factors influencing timing of MSI/IHC ordering; testing on colonoscopy biopsy, opposed to post-operative surgical specimens, assists decisions on preoperative germline genetic testing and extent of colonic resection (ECR). METHODS: A 21-question web-based survey was distributed through an American College of Gastroenterology email listing. RESULTS: In total 509 completed the survey. 442 confirmed gastroenterologists were analyzed. Only 33.4% felt gastroenterologists were responsible for MSI/IHC ordering; pathologists were believed most responsible (38.6%). Cost, unfamiliarity interpreting results and unavailable genetic counseling most commonly prevented routine ordering (33.3%, 29.2%, 24.9%, respectively). In multivariable analysis, non-academic and rural settings were associated with cost and genetic counseling barriers. Only 46.1% felt MSI/IHC should always be performed on colonoscopy biopsy. Guideline familiarity predicted whether respondents felt surgical resection should be delayed until results returned given potential effect on ECR decisions. CONCLUSION: Inconsistencies in who is felt should order MSI/IHC may lead to diffusion of responsibility, preventing consistent testing, including preoperatively. Assuring institutional universal testing protocols are in place, with focus on timing of testing, can optimize care. Strategies addressing cost barriers and genomic service availability in rural and non-academic settings can enhance testing. Greater emphasis on guideline familiarity is required.

The Effects of Sleep on the Commensal Microbiota: Eyes Wide Open?

Sleep dysfunction is an epidemic, the implications of which have a profound impact on a variety of gastrointestinal disease. Recent data suggests a relationship between sleep dysfunction and intestinal dysbiosis, a known proinflammatory driver. This article evaluates the interplay between sleep dysfunction and gastrointestinal health and disease, with a focus on the impact of circadian rhythm disruption on the commensal microbiota.

Wake-up Call to Clinicians: The Impact of Sleep Dysfunction on Gastrointestinal Health and Disease.

Sleep dysfunction is an epidemic affecting a large portion of the adult population. Recent studies have linked sleep dysfunction with an upregulation of proinflammatory cytokines (eg, tumor necrosis factor-α, interleukin-1 and interleukin-6), the implications of which can have a profound impact on a variety of gastrointestinal disease. In particular, sleep dysfunction seems to accelerate disease states characterized by inflammation (eg, gastroesophageal reflux disease, irritable bowel syndrome and functional dyspepsia, chronic liver disease, inflammatory bowel disease, and colorectal cancer). This article evaluates the complex interplay between sleep dysfunction and gastrointestinal health and disease.

A wolf in another wolf's clothing.

This case of infective endocarditis masquerading as mixed cryoglobulinemia in a man with a history of intravenous drug use (IVDU) and hepatitis C virus (HCV) highlights the importance of maintaining a broad differential and continually re-evaluating the working diagnosis as new information presents itself. The patient presented to an outside hospital and was treated for presumptive mixed cryoglobulinemia with corticosteroid therapy. When the patient did not improve, he was transferred to a tertiary care center for possible Rituximab and/or plasmapheresis. Further investigation revealed Enterococcus bacteremia with subsequent workup consistent with infective endocarditis (IE). This case highlights a diagnostic dilemma and demonstrates the importance of a thorough evaluation as it pertains to overlapping features of IE and mixed cryoglobulinemia.

The "Scope" of Post-ERCP Pancreatitis.

Pancreatitis is the most common adverse event of endoscopic retrograde cholangiopancreatography, with the potential for clinically significant morbidity and mortality. Several patient and procedural risk factors have been identified that increase the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). Considerable research efforts have identified several pharmacologic and procedural interventions that can drastically affect the incidence of PEP. This review article addresses the underlying mechanisms at play for the development of PEP, identifying patient and procedural risk factors and meaningful use of risk-stratification information, and details current interventions aimed at reducing the risk of this complication.

Cemento-ossifying fibroma of mandible mimicking complex composite odontome.

Cemento-ossifying fibroma (COF) is a fibro-osseous lesion or non-odontogenic tumour that affects craniofacial bones. These lesions are included in the spectrum of fibro-osseous lesions arising from periodontal ligament cells, which can deposit combination of cementum and bone surrounded by fibrous tissue. It clinically, macroscopically and radiologically resembles complex composite odontome and can be differentiated only on the basis of histopathology. They usually occur solitarily as a painless and expansile spherical or ovoid jawbone mass that may displace the roots of adjacent teeth. They predominantly occur in females in third and fourth decades of life. We present a case report of a 20-year-old man, with a mildly painful swelling in the mandible which was successfully treated with enucleation and diagnosed as COF. Its resemblance to complex composite odontome and unique surgical approach are highlighted in this paper.

Dexlansoprazole: delayed-release orally disintegrating tablets for the treatment of heartburn associated with non-erosive gastroesophageal reflux disease and the maintenance of erosive esophagitis.

INTRODUCTION: Gastroesophageal reflux disease (GERD) is a common condition afflicting millions of patients, whose prevalence continues to rise owing to the aging population and increasing burden of comorbid conditions, such as obesity. Currently, the mainstay of therapy for GERD is treatment with proton pump inhibitors (PPIs), which have proven efficacy, safety, and tolerability. Despite this, a considerable number of patients have refractory symptoms to PPI therapy. Dexlansoprazole is a new addition to the class of PPIs, which has a unique dual delayed drug release system, which aims to address the current limitations of acid suppressive therapy by offering extended acid suppression and improved ease of administration. Areas covered: This manuscript covers the pharmacokinetics, pharmacodynamics, clinical efficacy, and regulatory approval of dexlansoprazole. Additionally, there is further discussion concerning the current market settings and the potential future impact of dexlansoprazole. Expert commentary: Overall, dexlansoprazole offers benefits in its ease of administration and proven efficacy in the healing, maintenance of erosive esophagitis, and symptomatic non-erosive GERD. Long-term, dexlansoprazole will likely find a niche market among patients who fail other acid suppressive therapy or who desire simplified administration for compliance concerns, but will likely come at a higher out of pocket expense than comparable generic PPIs.

The Role of Gut Microflora and the Cholinergic Anti-inflammatory Neuroendocrine System in Diabetes Mellitus.

The obesity epidemic has drastically impacted the state of health care in the United States. Paralleling this epidemic is the incidence of diabetes mellitus, with a notable shift toward a much younger age of onset. While central to the pathogenesis of diabetes associated with obesity is the role of inflammation attributed to "adiposopathy." Emerging data suggest that changes in sympathetic/parasympathetic balance regulated by the brain precede changes in the inflammatory cascade. It has now been established that the gut microflora contributes significantly to the activation and inhibition of autonomic control and impact the set of the neuroinflammatory inhibitory reflex mediated by the cholinergic nervous system. There has been a paradigm shift toward further investigating commensal bacteria in the pathogenesis of obesity and diabetes mellitus and its complications, as dysbiosis is thought to play a pivotal role in diabetic-associated disorders. This paper is intended to evaluate the role of intestinal dysbiosis in the pathogenesis of diabetes mellitus and examine the potential for restoration of balance via use of probiotics.

Current Strategies to Reduce Gastrointestinal Bleeding Risk Associated with Antiplatelet Agents.

Antiplatelet agents remain the cornerstone in the primary and secondary therapeutic intervention for cardiovascular disease. Some patients may be subjected to a year or more of dual antiplatelet therapy to reduce the risk of subsequent cardiovascular events. Patients on antiplatelet therapy have an increased risk of gastrointestinal bleeding; however, not all patients benefit from concomitant acid suppressive therapy. This review will provide an overview of the pharmacology of antiplatelet agents and outline patient risk profiles that ought to be considered when considering prophylactic therapy to reduce gastrointestinal toxicity. In addition, we discuss the current risk-reduction strategies intended to mitigate against the potential for related gastroduodenal injury.