Nutritional Calorie Labeling and Menu Ordering Practices Among US Adults With Chronic Illnesses

BACKGROUND

The relationship between diet and the management of chronic illnesses is well established. However, it is unknown the extent to which people with chronic illnesses pay attention to nutritional information and act upon the information obtained. We evaluated the menu ordering practices of adults with chronic illnesses.

METHODS

We analyzed the 2018 Health Information National Trends Survey (HINTS 5 Cycle 2). Our analytic cohort included 3,154 respondents (weighted population size=228,464,822) who answered questions regarding a personal history of diabetes, hypertension, heart disease, and obesity. They also answered questions about their nutritional habits regarding whether they noticed caloric information at fast-food or sit-down restaurants and how that information influenced their dietary choices.

RESULTS

Among respondents with these chronic illnesses, only obese patients were significantly more likely to pay attention to caloric information (OR=1.56; 95%CI: 1.06-2.31). However, noticing the calorie information was not associated with ordering less calories among all categories of respondents with chronic illnesses.

CONCLUSION

US adults with chronic illnesses do not pay sufficient attention to the calorie information of their diet. Furthermore, awareness of the calorie information did not influence their dietary choices. Healthcare professionals should incorporate dietary counseling into the management of chronic illnesses of their patients.

Incidentally Discovered Mucosal Prolapse of the Colon During Colorectal Cancer Screening: A Case Report

Colonic mucosal prolapse syndrome is a rare type of non-neoplastic non-inflammatory colorectal polyps that can mimic neoplastic lesions. We present a case of a 65-year-old man with mucosal prolapse syndrome, incidentally, discovered during colorectal cancer screening. The patient was asymptomatic, and his physical exam and laboratory test results were unremarkable. During a colonoscopy, the physician removed three small tubular adenomas and two pedunculated polyps suspicious of neoplasms. Retroflexion revealed small internal hemorrhoids. The histology of the larger polyps revealed mucosal prolapse features, while the smaller polyps displayed features consistent with tubular adenomas. Management involves the removal of associated polyps during colonoscopy, followed by surveillance colonoscopy to detect any recurrent polyps or early signs of colorectal cancer. Accurate diagnosis is crucial to avoid unnecessary interventions and ensure appropriate management.

Symptomatic, clinical and biomarker associations for mortality in hospitalized COVID-19 patients enriched for African Americans

BACKGROUND AND AIMS

Initial reports on US COVID-19 showed different outcomes in different races. In this study we use a diverse large cohort of hospitalized COVID-19 patients to determine predictors of mortality.

METHODS

We analyzed data from hospitalized COVID-19 patients (n = 5852) between March 2020- August 2020 from 8 hospitals across the US. Demographics, comorbidities, symptoms and laboratory data were collected.

RESULTS

The cohort contained 3,662 (61.7%) African Americans (AA), 286 (5%) American Latinx (LAT), 1,407 (23.9%), European Americans (EA), and 93 (1.5%) American Asians (AS). Survivors and non-survivors mean ages in years were 58 and 68 for AA, 58 and 77 for EA, 44 and 61 for LAT, and 51 and 63 for AS. Mortality rates for AA, LAT, EA and AS were 14.8, 7.3, 16.3 and 2.2%. Mortality increased among patients with the following characteristics: age, male gender, New York region, cardiac disease, COPD, diabetes mellitus, hypertension, history of cancer, immunosuppression, elevated lymphocytes, CRP, ferritin, D-Dimer, creatinine, troponin, and procalcitonin. Use of mechanical ventilation (p = 0.001), shortness of breath (SOB) (p < 0.01), fatigue (p = 0.04), diarrhea (p = 0.02), and increased AST (p < 0.01), significantly correlated with death in multivariate analysis. Male sex and EA and AA race/ethnicity had higher frequency of death. Diarrhea was among the most common GI symptom amongst AAs (6.8%). When adjusting for comorbidities, significant variables among the demographics of study population were age (over 45 years old), male sex, EA, and patients hospitalized in New York. When adjusting for disease severity, significant variables were age over 65 years old, male sex, EA as well as having SOB, elevated CRP and D-dimer. Glucocorticoid usage was associated with an increased risk of COVID-19 death in our cohort.

CONCLUSION

Among this large cohort of hospitalized COVID-19 patients enriched for African Americans, our study findings may reflect the extent of systemic organ involvement by SARS-CoV-2 and subsequent progression to multi-system organ failure. High mortality in AA in comparison with LAT is likely related to high frequency of comorbidities and older age among AA. Glucocorticoids should be used carefully considering the poor outcomes associated with it. Special focus in treating patients with elevated liver enzymes and other inflammatory biomarkers such as CRP, troponin, ferritin, procalcitonin, and D-dimer are required to prevent poor outcomes.

The Impact of Nonalcoholic Fatty Liver Disease on the Outcomes of Coronavirus Disease 2019 Infection

Content available: Audio Recording.

COVID-19 among African Americans and Hispanics: Does gastrointestinal symptoms impact the outcome?

BACKGROUND

The coronavirus disease 2019 (COVID-19) disproportionately affected African Americans (AA) and Hispanics (HSP).

AIM

To analyze the significant effectors of outcome in African American patient population and make special emphasis on gastrointestinal (GI) symptoms, laboratory values and comorbidities.

METHODS

We retrospectively evaluated the medical records of 386 COVID-19 positive patients admitted at Howard University Hospital between March and May 2020. We assessed the symptoms, including the GI manifestations, comorbidities, and mortality, using logistic regression analysis.

RESULTS

Of these 386 COVID-19 positive patients, 257 (63.7%) were AAs, 102 (25.3%) HSP, and 26 (6.45%) Whites. There were 257 (63.7%) AA, 102 (25.3%) HSP, 26 (6.45%) Whites. The mean age was 55.6 years (SD = 18.5). However, the mean age of HSP was the lowest (43.7 years vs 61.2 for Whites vs 60 for AAs). The mortality rate was highest among the AAs (20.6%) and lowest among HSP (6.9%). Patients with shortness of breath (SOB) (OR2 = 3.64, CI = 1.73-7.65) and elevated AST (OR2 = 8.01, CI = 3.79-16.9) elevated Procalcitonin (OR2 = 8.27, CI = 3.95-17.3), AST (OR2 = 8.01, CI = 3.79-16.9), ferritin (OR2 = 2.69, CI = 1.24-5.82), and Lymphopenia (OR2 = 2.77, CI = 1.41-5.45) had a high mortality rate. Cough and fever were common but unrelated to the outcome. Hypertension and diabetes mellitus were the most common comorbidities. Glucocorticoid treatment was associated with higher mortality (OR2 = 5.40, CI = 2.72-10.7). Diarrhea was prevalent (18.8%), and GI symptoms did not affect the outcome.

CONCLUSION

African Americans in our study had the highest mortality as they consisted of an older population and comorbidities. Age is the most important factor along with SOB in determining the mortality rate. Overall, elevated liver enzymes, ferritin, procalcitonin and C-reactive protein were associated with poor prognosis. GI symptoms did not affect the outcome. Glucocorticoids should be used judiciously, considering the poor outcomes associated with it. Attention should also be paid to monitor liver function during COVID-19, especially in AA and HSP patients with higher disease severity.

A Comprehensive Meta-Analysis of COVID-19 in Latin America

BACKGROUND

Latin America has become the epicenter of the coronavirus disease 2019 (COVID-19) pandemic. We aim to perform a systematic comparative review of the clinical characteristics that are associated with this disease in Latin American countries.

METHODS

We conducted a systematic review of published articles, journal and/or epidemiological reports of confirmed COVID-19 cases in Latin America. Data were obtained either through publicly available information from Ministries of Health, published journal reports and/or unpublished datasets. We analyzed data from SARS-CoV-2 positive patients evaluated at healthcare centers and hospitals of 8 countries including Brazil, Peru, Mexico, Argentina, Colombia, Venezuela, Ecuador, and Bolivia, between March 1^st and July 30^th, 2020. These countries consist of a total population that exceeds 519 million. Demographics, comorbidities, and clinical symptoms were collected. Statistical descriptive analysis and correlation analyses of symptoms, comorbidities and mortality were performed.

RESULTS

A total of 728,282 COVID-19 patients were included in this study. Of these, 52.6% were female. The average age was 48.4 years. Peru had the oldest cohort with 56.8 years and highest rate of females (56.8%) while Chile had the youngest cohort (39 years old). Venezuela had the highest male prevalence (56.7%). Most common symptoms were cough with 60.1% (Bolivia had the highest rate 78%), fatigue/tiredness with 52.0%, sore throat with 50.3%, and fever with 44.2%. Bolivian patients had fever as the top symptom (83.3%). GI symptoms included diarrhea which was highest in Mexico with 22.9%. Hypertension was among the top (12.1%) comorbidities, followed by diabetes with 8.3% and obesity at 4.5%. In multivariate analyses, the leading and significant comorbidities were hypertension (r = 0.83, p = 0.02), diabetes (r = 0.91, p = 0.01), and obesity (r = 0.86, p = 0.03). Mortality was highest in Mexico (16.6%) and lowest in Venezuela (0.9%) among the analyzed cohorts.

CONCLUSION

Overall, COVID-19 patients in Latin America display cough, fatigue, and fever as main symptoms. Up to 53% of patients with COVID-19 have GI manifestations. Different clinical symptoms were associated with COVID-19 in Latin American countries. Metabolic syndrome components were the main comorbidities associated with poor outcome. Country-specific management and prevention plans are needed and can be established from this meta-analysis.

Clinical characteristics, gastrointestinal manifestations and outcomes of COVID-19 patients in Iran; does the location matters?

BACKGROUND

Coronavirus disease 2019 (COVID-19) started in Asia, and Iran was one of its first epicenters.

AIM

To study the gastrointestinal (GI) symptoms and comorbidities associated with this pandemic in four different regions of Iran.

METHODS

We analyzed data from severe acute respiratory syndrome coronavirus 2 positive patients evaluated at four hospitals of Iran (n = 91), including South (Shiraz), Southeast (Dezful), Rasht (North), and Northwest (Mashhad) between April and September 2020. Demographics, comorbidities and clinical findings including GI symptoms were collected. Statistical descriptive analysis and correlation analyses of symptoms, comorbidities, and mortality were performed.

RESULTS

The average age of COVID-19 patients was 51.1 years, and 56% were male. Mortality rate was 17%. Cough with 84.6%, shortness of breath with 71.4%, fever with 52.7%, and loss of appetite with 43.9% were the main symptoms. Overall cardiac disease was the most common comorbidity with an average of 28.5% followed by hypertension (28.5%) and diabetes (25.2%). The highest comorbidity in North (Rasht) was diabetes (30%) and in South (Dezful) hypertension (37%). Shiraz leads cardiac disease with 43.4%. The most reported GI symptoms included nausea, diarrhea, vomiting, and abdominal pain, with 42.8%, 31.8%, 26.8%, and 12% prevalence, respectively. In addition, albumin, alkaline phosphatase, aspartate aminotransferase, and alanine aminotransferase were elevated in 26.3%.

CONCLUSION

Our results show hypertension and diabetes as the most common comorbidities, but their distribution was different in COVID-19 patients in the four studied regions of Iran. Nausea, diarrhea, and elevated liver enzymes were the most common GI symptoms. There was also a high mortality rate that was associated with high infection rates in Iran at the beginning of the pandemic.

Trends in the Incidence of Hepatocellular Carcinoma in Washington DC: A Single Institutional Cohort Study (1959-2013)

The African American (AA) community in Washington DC is at an elevated risk for hepatocellular carcinoma (HCC) that has a dismal prognosis. The recent rapid increase in the incidence and diagnosis of HCC and liver metastases (LM) in DC prompted us to evaluate the past six decades of this incidence and some of its underlying causes using a single institutional cohort in a hospital located in the center of the city. Electronic medical and pathology records of 454 liver cancer patients from 1959 to 2013 at Howard University Hospital (HUH) were reviewed. Demographic, clinical and pathology characteristics were examined, and statistical analysis was performed using Wilcoxon rank-sum test. Incidence of HCC rose substantially between 1959 and 2013, increasing eight-fold from 1.05 to 8.0 per 100,000 AAs. The rate of increase in the last decade was highest at 550%. Cases were disproportionately male (67.2%), and median age at diagnosis was 57 years. Towards the last decade, the most common etiology for HCC was nonalcoholic fatty liver disease (NAFLD) followed by NAFLD/HCV combination. Liver cancer was clustered in the eastern region of DC in wards 4, 5, 7, and 8. Cases of liver metastases clinically diagnosed and confirmed by biopsies increased 96.4% from 1959 to 1968 to 2009-2013. This study confirms that HCC incidence has been increasing (initially driven by HCV, and NAFLD in the latter decades) more rapidly in DC than previously believed, highlighting the impact of case definitions especially regarding NAFLD in the context of changing diagnostic approaches including the revised ICD10. The rising burden, disproportionate population distribution, and low survival rate among AAs emphasize the importance of prevention and early detection as a public health imperative.

A case of rectal stricture associated with the use of a fecal management system

Fecal management systems are widely used to prevent complications of fecal incontinence such as skin breakdown and pressure ulcers. However they are occasionally associated with complications such as bleeding and pressure necrosis of rectal mucosa. We present a patient with Clostridium difficile colitis with a prolonged hospital stay requiring the use of Flexi-Seal Fecal Management System who developed abdominal pain and distention with obstipation. Computed tomography of abdomen showed dilatation of small and large bowel loops with a transition point at rectosigmoid junction. Flexible sigmoidoscopy revealed the presence of a severe stricture at the rectosigmoid junction that was not amenable to endoscopic dilation. Surgical resection with an end-colostomy was performed to relieve the obstruction. To the best of our knowledge, this is the first reported case of a high-grade stricture due to use of bowel management system that needed bowel resection surgery.

A Comprehensive Analysis of COVID-19 Impact in Latin America

Background

Latin America has now become the epicenter of the global coronavirus disease 2019 (COVID-19) pandemic. In the ongoing COVID -19 pandemic, a profound burden of SARS-COV-2 infection has been reported in Latin America. In the present study, we aim to determine the profiles that are associated with this disease in Latin America. We analyzed symptoms, morbidities and gastrointestinal (GI) manifestations by country.

Methods

We analyzed data from SARS-CoV-2 positive patients evaluated at healthcare centers and hospitals of 8 Latin American countries including Brazil, Peru, Mexico, Argentina, Colombia, Venezuela, Ecuador, and Bolivia between March 1 and July 30, 2020. These countries consist of a total population that exceeds 519 million. Demographics, comorbidities and clinical symptoms were collected. Statistical descriptive analysis and correlation analyses of symptoms, comorbidities and lethality were performed.

Results

A total of 728,282 patients tested positive for COVID-19 across all the 8 Latin American countries. Of these, 52.6% were female. The average age was 48.4 years. Peru had the oldest cohort with 56.8 years old and highest rate of females (56.8%) while Chile had the youngest cohort (39 years old). Venezuela had the highest male prevalence (56.7%). Most common symptoms were cough with 60.1% (Bolivia had the highest rate 78%), fatigue/tiredness with 52.0%, sore throat with 50.3%, and fever with 44.2%. Bolivia had fever as the top symptom (83.3%). GI symptoms including diarrhea (highest in Mexico with 22.9%), nausea, vomiting, and abdominal pain were not associated with higher mortality.Hypertension was among the top (12.1%) comorbidities followed by diabetes with 8.3% and obesity 4.5%. In multivariable analyses, the leading and significant comorbidities were hypertension (r=0.83, p=0.02), diabetes (r=0.91, p=0.01), and obesity (r=0.86, p=0.03). Asthma (r=0.37, p=0.54) and increasing age (0.13 p=0.81) were not independently associated with higher mortality. Lethality was highest in Mexico (16.6%) and lowest in Venezuela (0.9%) among the analyzed cohorts.

Conclusion

Nearly, 10.5%-53% of patients with COVID-19 have GI manifestations. Differential clinical symptoms were associated with COVID-19 in Latin America countries. Metabolic syndrome components were the main comorbidities associated with poor outcome. Country-specific management and prevention plans are needed. Country-specific management and prevention plans can be established from this meta-analysis.

Association of Patients' Perception of Quality of Healthcare Received and Colorectal Cancer Screening Uptake: An Analysis of 2 National Surveys in the USA

OBJECTIVE

It is not known whether patients' ratings of the quality of healthcare services they receive truly correlate with the quality of care from their providers. Understanding this association can potentiate improvement in healthcare delivery. We evaluated the association between patients' ratings of the quality of healthcare services received and uptake of colorectal cancer (CRC) screening.

SUBJECTS AND METHODS

We used 2 iterations of the Health Information National Trends Survey (HINTS) of adults in the USA. HINTS 2007 (4,007 respondents; weighted population = 75,397,128) evaluated whether respondents were up to date with CRC screening while HINTS 4 cycle 3 (1,562 respondents; weighted population = 76,628,000) evaluated whether participants had ever received CRC screening in the past. All included respondents from both surveys were at least 50 years of age, had no history of CRC, and had rated the quality of healthcare services that they had received at their healthcare provider's office in the previous 12 months.

RESULTS

HINTS 2007 data showed that respondents who rated their healthcare as good or fair/poor were significantly less likely to be up to date with CRC screening compared to those who rated their healthcare as excellent. We found comparable results from analysis of HINTS 4 cycle 3 data with poorer uptake of CRC screening as the healthcare quality ratings of respondents reduced.

CONCLUSION

Our study suggests that patients who reported receiving lower quality of healthcare services were less likely to have undergone and be compliant with CRC screening recommendations. It is important to pay close attention to patient feedback surveys in order to improve healthcare delivery.

Inflammatory polyps occur more frequently in inflammatory bowel disease than other colitis patients

BACKGROUND

Colitis is generally considered a risk factor for colon neoplasia. However, not all types of colitis seem to have equal neoplastic transformation potential.

AIM

To determine the prevalence of colorectal polyps in a predominantly African American population with inflammatory bowel disease (IBD) and Non-IBD/Non-Infectious Colitis (NIC).

METHODS

We retrospectively evaluated medical records of 1060 patients previously identified with colitis at Howard University Hospital, based on ICD-10 code. Among these, 485 patients were included in the study: 70 IBD and 415 NIC based on a thorough review of colonoscopy, pathology and clinical reports. Logistic regression analysis was applied to estimate the risk of polyps in patients with IBD compared to those with NIC after adjusting for age and sex. A subgroup analysis within the IBD group was performed.

RESULTS

Of the 485 patients, 415 were NIC and 70 were IBD. Seventy-three percent of the NIC patients and 81% of the IBD patients were African Americans. Forty six percent of IBD and 41% of NIC cases were male. IBD patients were younger than NIC patients (median age of 38 years vs. 50, P < 0.001). The prevalence of all types of polyps was 15.7 and 8.2% in the IBD and NIC groups, respectively (P = 0.045). Among patients with polyps, the prevalence of inflammatory polyps was higher in the IBD group (55%) compared to the NIC group (12%). After adjusting for age, sex and race, odds ratio of inflammatory polyps in IBD patients was 6.0 (P = 0.016). Adenoma prevalence was 4.3% (3/70) in IBD patients and 3.9% (16/415) in the NIC patients (p = 0.75). The anatomic distribution of lesions and colitis shows that polyps occur predominantly in the colitis field regardless of colitis type. More polyps were present in the ulcerative colitis patients when compared to Crohn's disease patients (27% vs. 5%, P < 0.001) within the IBD group.

CONCLUSION

Our study shows that inflammatory polyps are more common in IBD patients when compared to NIC patients. Most polyps were in the same location as the colitis.

Abstract 4003: Colon sessile serrated polyps associate with endometrial polyps

Background: Colon and endometrial polyps are current health issues and their incidences are on the rise. Due to conflicting reports of higher colon polyps in patients with endometrial polyps, we aimed to evaluate if there is such an association in African Americans, a population at high risk for colorectal cancer.

Method: We retrospectively reviewed all female patients who had endometrial (EN) presentations (n=3,600) and colonoscopy (n=14,888) at Howard University Hospital from January 2004 to December 2015. We selected cases with endometrial poly and control without this diagnosis who underwent colonoscopy. Clinical [Body Mass Index (BMI), diabetes (DM), hypertension (HTN), Tamoxifen intake, age] and pathological (histology, location, type of lesions) features of Cases and Controls were collected. Association between EN and colon polyp was tested using multivariable logistic regression analysis. We excluded the patients with endometrial cancer.

Results: We recruited 664 cases and 118 controls. Cases were statistically significant older (median age of 60 vs. 57 in controls) and had higher rates of smoking and DM than controls. However, the overall colon polyp prevalence in the two groups was not statistically different (54% vs 52% in controls and cases, respectively). In subgroups of subject with colon polyp, sigmoid and rectal polyps were more prevalent in controls than cases. Sessile serrated polyps/adenomas (SSPs) were more frequent in cases (8% vs. 2%, p=0.03) while benign mucosa was more so in controls. Whether considering the overall study population or just those with colon polyps, SSPs lesions associated with an Odds Ratio of 4.6 (p=0.02) for EN polyp occurrence, after adjusting for confounder.

Conclusion: Our study shows that the overall colon polyp’s prevalence was similar in endometrial polyp patients compared to endometrial-polyp free controls. However, a significant association between SSP with endometrial polyps was noted. Females with colon lesions of the SSP type might benefit from a screening for endometrial polyp in an age-independent manner.

Note: This abstract was not presented at the meeting.

Citation Format: Hassan Brim, Taraneh Tarjoman, Shirin Ganjali, Saman Azam, Negin Farsi, Edward Lee, Babak Shokrani, Farshad Aduli, Carla Williams, Adeyinka Laiyemo, Akbar Soleimani, Zaki Sherif, Mehdi syed Nouraie, Hassan Ashktorab. Colon sessile serrated polyps associate with endometrial polyps [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 4003.

Rheumatologic Diseases and the Liver

A variety of rheumatologic disorders may affect the liver. There is a significant epidemiologic, genetic, and immunologic overlap between immune-mediated rheumatologic disorders and autoimmune liver diseases. There is an increased frequency of autoimmune liver diseases, such as primary biliary cholangitis, autoimmune hepatitis, primary sclerosing cholangitis, or overlap syndrome, in patients with systemic lupus erythematosus, rheumatoid arthritis, Sjögren syndrome, systemic sclerosis, vasculitis, and other immune-related diseases. Non-immune-mediated rheumatologic diseases such as gouty arthritis may also have hepatic manifestations. Furthermore, medications used to treat rheumatologic diseases occasionally cause liver dysfunction. Conversely, primary immune-mediated and non-immune-mediated liver disorders may present with rheumatologic manifestations.

FIBROVASCULAR POLYP: AN UNUSUAL MASS IN THE ESOPHAGUS CAUSING DYSPHAGIA

We present a case of a 56-year-old Caucasian women with long-standing gastroesophageal reflux disease complicated with non-dysplastic Barrett's esophagus and stricture presented with difficulty in swallowing.

Rare Synchronous Gastrointestinal Plasmacytomas of Colon and Stomach

Gastrointestinal (GI) plasmacytomas, though relatively uncommon, can occur with or without multiple myeloma. The small intestine is the most commonly involved GI site, followed by stomach, colon, and esophagus. Synchronous plasmacytomas involving 2 anatomically distinct regions of gastrointestinal tract have never been reported in the literature. We report a case of a multiple myeloma patient who had acute-onset hematochezia and was found to have synchronous plasmacytomas of the colon and stomach.

Endoscopic management of post-liver transplant biliary complications

Biliary complications are being increasingly encountered in post liver transplant patients because of increased volume of transplants and longer survival of these recipients. Overall management of these complications may be challenging, but with advances in endoscopic techniques, majority of such patients are being dealt with by endoscopists rather than the surgeons. Our review article discusses the recent advances in endoscopic tools and techniques that have proved endoscopic retrograde cholangiography with various interventions, like sphincterotomy, bile duct dilatation, and stent placement, to be the mainstay for management of most of these complications. We also discuss the management dilemmas in patients with surgically altered anatomy, where accessing the bile duct is challenging, and the recent strides towards making this prospect a reality.

Helicobacter pylori-negative Russell body gastritis: does the diagnosis call for screening for plasmacytic malignancies, especially multiple myeloma?

Russell body gastritis (RBG) is a rare entity with unestablished pathophysiology, endoscopic findings, clinical manifestations and treatments. Literature is scarce on this clinical entity with unclear clinical significance. Of 18 cases reported, 12 tested (+) for Helicobacter pylori and improved with treatment, but it remains unclear whether this link is coincidental or bears some clinical significance. We describe a case of elderly woman who had a follow-up oesophagogastroduodenoscopy for chronic peptic ulcers, and biopsy showed positive immunohistochemical stains for κ and λ, indicating a polytypic population of plasma cells. Immunostaining for H pylori was negative. Biopsies were also (-) for gastric carcinoma, lymphoma and plasmacytoma. Considering her RGB-suggestive histology and her symptoms of bone pains and anaemia, multiple myeloma screening was considered clinically relevant. The purpose of this review was to educate clinicians and gastroenterologists about this unique entity and explore its association with multiple myeloma or other plamacytic malignancies.

Manometric measures of head rotation and chin tuck in healthy participants

The primary aim of this study was to investigate the immediate effects of partial versus complete head rotation and chin tuck on pharyngeal swallowing pressures and durations in the pharynx and UES of normal, healthy adults. Ten individuals (3 men and 7 women; age range 54-76 years) served as participants. Solid-state intraluminal manometry was performed with the participants in the upright position while performing swallows with the head in the normal position, head rotated (partial and complete), chin tucked, and chin down. A cervical range of motion (CROM) inclinometer was used to accurately measure the degree of head rotation and chin tuck. The CROM inclinometer has not been used before so this is the first study to our knowledge to quantify degree of head rotation and chin tuck. Manometric data derived from these healthy participants indicate both partial and complete head rotations can increase the duration of UES relaxation and decrease UES residual pressure. Chin tuck may be effective in increasing durations in the upper pharynx. Partial chin tuck (chin down) decreases UES residual pressure. Complete head rotation and chin tuck provide more overall benefit than partial maneuvers. However, for patients with limited head and neck mobility, partial posture changes impact the pharynx in similar ways and may provide clinically meaningful benefits. Additional research on patient populations is warranted.

Gastric metastasis of merkel cell cancer--uncommon complication of a rare neoplasm

Merkel cell cancer is an aggressive cutaneous malignancy of neuroendocrine cell lineage which carries a poor prognosis. It usually affects elderly Caucasians and presents as a firm, painless, nodular lesion on the sun exposed areas of the body. Though it is highly metastatic, metastasis to the gastrointestinal tract is rarely reported. We describe a case of gastric metastasis from merkel cell cancer presenting with upper gastrointestinal bleeding. To our knowledge, only 8 such cases have been reported in English literature so far.

Mesenteric vein thrombosis treated successfully with ultrasound augmented thrombolysis

Mesenteric vein thrombosis is a potentially fatal condition that is associated with better outcomes with early diagnosis and intervention. A 32-year-old-man with Down syndrome presented with abdominal pain and was found to have extensive porto-splenomesenteric thrombosis with early bowel ischemia on computed tomography. He was treated successfully with ultrasound augmented thrombolysis. Ultrasound can improve efficiency of thrombolysis, decreasing the time required for thrombolysis by half, decrease thrombolytic dose and monitoring time and thus reduce overall costs and complications seen with long thrombolysis times.

Strongyloides duodenitis: case report and review of literature

Strongyloides stercoralis affects 30 to 100 million people worldwide and is a common cause of abdominal pain and diarrhea. Strongyloidiasis is a chronic and limited disease; however, in immunocompromised patients, hyperinfection syndrome can occur. Diagnosing strongyloidiasis early is important, as almost all deaths due to helminths in the United States are due to S stercoralis hyperinfection. Patients infected with human immunodeficiency virus (HIV) do not appear to be at an increased risk for S stercoralis hyperinfection. We report a case of an HIV-infected Hispanic woman presenting with dyspepsia, emesis, abdominal pain, and diarrhea diagnosed with S stercoralis on an esophagogastroduodenoscopy biopsy of the duodenum. The diagnostic workup had been inconclusive and deciding to biopsy the small bowel based on the nonerythematous boggy appearance of the duodenal folds was the key step in making the correct diagnosis. Early diagnosis and treatment thwarted the developing hyperinfection syndrome and likely prevented further morbidity and probably saved her life.

Giant gastric hyperplastic polyp: not always a benign lesion

Giant gastric hyperplastic polyps constitute of around 76% of all gastric polyps found. They are often found incidentally on upper GI endoscopy. They often present with occult GI bleeding causing iron deficiency anemia or partial gastric outlet obstruction. Although mostly benign, they do have potential for malignant transformation and hence must be excised endoscopically or surgically, whichever may be feasible. We hereby present a couple of cases of gastric hyperplastic polyps in an attempt to add to the current literature on this rather rare entity.

Rare case of dysphagia

Wound botulism is exceedingly rare and occurs almost exclusively among injection drug users. In 2008 there was a case of wound botulism in a noninjecting drug user reported to the Centers for Disease Control and Prevention (CDC). We report a case of a Caucasian male developing dysphagia due to wound botulism after having a motorcycle accident that left him with open fractures. The CDC was contacted and the patient was transferred to medical intensive care unit to be emergently started on hepatavalent Clostridium botulinum antitoxin. Early suspicion of wound botulism is essential for effective therapy with antitoxin in this life-threatening disease. If not suspected, this patient would likely have died. Nevertheless, the delay in diagnosis and treatment resulted in the patient's suffering dysphagia and neurological deficits. The patient required a percutaneous endoscopic gastrostomy tube and months of dysphagia therapy, supportive care, and rehabilitation. Our aim is to increase the awareness for wound botulism when a patient presents with dysphagia and diplopia after suffering open wounds. If suspected early, the morbidity and mortality from this disease can be prevented.

Recurrent spontaneous gastrointestinal graft-versus-host disease in autologous hematopoietic stem cell transplantation

Acute graft-versus-host disease (GVHD) is a major complication after allogeneic stem cell transplantation (SCT). A similar manifestation involving skin, gastrointestinal (GI) mucosa, and liver can occur after autologous hematopoietic SCT (autoHSCT), either spontaneously or after treatment with cyclosporine or interferon. Severity of spontaneous GI GVHD among patients treated with autoHSCT is variable. Recurrent spontaneous GI GVHD induced by succeeding cycles of chemotherapy has rarely been reported and is poorly understood. Enteric-coated budesonide has been studied extensively in Crohn's disease, and beclomethasone has been studied in GI GVHD. There are no comparative studies between these drugs for GI GVHD. Furthermore, GI GVHD has to be considered when microbiologic workup remains negative during the workup of persistent diarrhea in autoHSCT. Endoscopic appearances can be normal, and pathologic diagnosis is essential. Further research into risk factors involving type of chemotherapy, interval between chemotherapies, and gene polymorphisms have to be considered for better understanding of autologous GVHD. We report for the first time a patient with spontaneous recurrent GI GVHD after autoHSCT for multiple myeloma with predominant lower GI symptoms and excellent response to enteric-coated budesonide therapy.

Corrosive injury to the GI tract in adults: a practical approach

Corrosive injury to the GI tract still poses great challenges with regards to the initial evaluation triage, as well as the optimization of medical management. Although relatively uncommon in the adult population, these injuries can cause significant morbidity and serious sequelae of complications, such as esophageal strictures and cancer. Prompt recognition of the process and aggressive measures towards the stabilization of the patient are key to a favorable outcome.

Carcinosarcoma of the colon: a rare cause of colovesical fistula

Carcinosarcomas are relatively rare tumors composed of both carcinomatous and sarcomatous components. The most common sites involved by this tumor are the head and neck, respiratory tract, uterus, ovaries, and fallopian tubes. Within the gastrointestinal tract this tumor most often occurs in the esophagus, followed by the stomach. Carcinosarcomas are very aggressive tumors associated with a poor prognosis. The first case of carcinosarcoma of the colon was reported in 1986. The case reported here is the only one involving an associated colovesical fistula.

Carcinosarcoma of the Colon: A Rare Cause of Colovesical Fistula

Carcinosarcomas are relatively rare tumors composed of both carcinomatous and sarcomatous components. The most common sites involved by this tumor are the head and neck, respiratory tract, uterus, ovaries, and fallopian tubes. Within the gastrointestinal tract this tumor most often occurs in the esophagus, followed by the stomach. Carcinosarcomas are very aggressive tumors associated with a poor prognosis. The first case of carcinosarcoma of the colon was reported in 1986. The case reported here is the only one involving an associated colovesical fistula.

Pancreatic plasmacytoma presenting as variceal hemorrhage: life threatening complication of a rare entity

CONTEXT

Pancreatic plasmacytoma is a rare entity and presents with features of mass lesion of pancreas.

CASE REPORT

We present an interesting case of pancreatic plasmacytoma with life threatening gastrointestinal bleeding secondary to isolated gastric varices.

CONCLUSION

This case highlights the importance of considering it in differential diagnosis of patients with anemia, recurrent pancreatitis or jaundice and isolated gastric varices, prompting a CT scan to evaluate for any pancreatic mass lesions.

Isolated tuberculosis of the pancreas: a case report

CONTEXT

Pancreatic tuberculosis is a rare entity. Only a few cases have been reported in the medical literature. We hereby describe a case of pancreatic tuberculosis in an immunocompromized individual.

CASE REPORT

A fifty-year-old African-American gentleman with history of HIV non-compliant on anti-retroviral therapy presented with epigastric pain for five weeks duration. CT scan of abdomen showed large necrotic node on the posterior aspect of the head of pancreas and multiple cystic masses adjacent to the pancreas. Acid fast bacilli were found on staining of CT guided biopsy of the node. Cultures grew Mycobacterium tuberculosis. Anti-tubercular therapy was initiated and resulted in gradual resolution of symptoms.

CONCLUSION

Pancreatic tuberculosis is rare and is frequently confused with pancreatic cancer on clinical presentation as well as on imaging studies. Since it is a curable disease, accurate diagnosis is paramount CT or ultrasound guided biopsy is cornerstone of diagnosis. Endoscopic ultrasound is now increasingly being used for obtaining tissue for diagnosis. Anti-tubercular therapy is curative in majority of the cases.