Early-onset colorectal cancer (CRC) has been on the rise since the start of the twenty-first century. While the etiology behind this increase remains unclear, the United States Preventive Services Task Force (USPSTF) has decreased the recommended age to begin screening for CRC to 45 years. This case report reviews the literature on CRC in the young population while presenting a case of a 21-year-old male with early-onset metastatic colorectal cancer without a hereditary etiology.
According to the ACC/AHA/HRS guidelines, cardiac pacing is reasonable in patients with bifascicular block (BF-B) and syncope when other causes have been excluded. The purpose of this study was to assess the long-term outcome of patients with BF-B and unexplained syncope following cardiac pacing.Between 2009 and 2015, we identified 43 consecutive patients (mean age of 78 ± 12 years, 64% males) who presented with syncope and BF-B and had received a pacemaker (PM). During a mean follow-up period of 31 ± 21 months, syncope recurred in seven patients (16%): 7% (95% standard error [SE] ± 3%) at 1 year and 18% (95% SE ± 7%) at 5 years. At univariable analysis, the only predictor of syncope recurrence was empiric pacing (P = 0.03). There were no syncope recurrences in the 12 patients who received a PM following a positive electrophysiological study (EPS) and the five patients with documentation of paroxysmal atrioventricular block (AVB) during cardiac monitoring (insertable loop recorder [ILR]), (EPS/ILR Group, n = 17) compared to seven of 26 (27%) patients who received empiric pacing (Empiric Group, n = 26; P = 0.02). Progression to high-degree AVB was documented during follow-up in 16 (37%) patients: nine of 17 (53%) patients in the EPS/ILR Group and seven of 26 (27%) patients in the Empiric Group (P = 0.11). There were no injuries reported during ILR monitoring.We have shown that syncope recurs not infrequently in patients with BF-B who received pacing for syncope. Nearly one in four patients who had empiric pacing suffered syncope recurrence compared to no recurrences in patients who received a PM following a positive EPS or documentation of transient AVB.
Acid exposure time (AET) <4% on ambulatory reflux monitoring definitively rules out pathologic gastroesophageal acid reflux, while AET >6% indicates pathologic reflux per the Lyon Consensus, leaving AET of 4-6% as borderline. We aimed to elucidate the borderline AET population and identify metrics that could help differentiate this group. A total of 50 subjects in each group, AET <4, 4-6, and >6% on pH-impedance monitoring between 2015 and 2019, were retrospectively reviewed. In addition to demographic and clinical information, the extracted data included mean nocturnal baseline impedance (MNBI) on reflux study and high-resolution manometry (HRM) parameters and diagnosis. After excluding patients with prior foregut surgery, major esophageal motility disorder, or unreliable impedance testing, a total of 89 subjects were included in the analysis (25 with normal AET < 4%, 38 with borderline 4-6%, 26 with abnormal >6%). MNBI in borderline AET patients was significantly lower compared to normal AET (1607.7 vs. 2524.0 ohms, P < 0.01), and higher than abnormal AET (951.5 ohms, P < 0.01). Borderline subjects had a greater frequency of ineffective esophageal motility (IEM) diagnosis per Chicago classification v3.0 (42.1 vs. 8.0%, P = 0.01), but did not demonstrate any differences compared to abnormal subjects (34.6%, P = 0.56). Patients with borderline AET had an average MNBI that was in between normal AET and abnormal AET. Borderline AET patients also commonly demonstrate IEM on HRM, similar to those with abnormal AET. Our findings can be potentially useful in assigning higher clinical significance for patients found to have borderline AET with concomitant low MNBI and IEM on manometry.
INTRODUCTION: Studies have shown Visual Gaze Patterns (VGP) differ between experienced and non-experienced endoscopists and may correlate with adenoma detection rate (ADR). It is unclear if VGP changes with training and experience. Our aim was to assess whether GI fellows’ VGP change over the course of their training. METHODS: GI fellows at a single academic training program had VGP recorded while watching three 2 min videos of colonoscopy withdrawal on two separate sessions (S1, S2). S1 occurred during fellowship training. S2 occurred during the 3rd year of fellowship or within the first 2 years as faculty. The screen was divided into a 3 × 3 grid (1 center box, 8 periphery boxes segmented into top, bottom, left, right zones of interest (ZOI)). VGP recorded using a commercial eye tracker. Videos were shown on a 23” TFT-LCD monitor (1024 × 1280 pixels). Eye fixations (FIX) were determined by software algorithm. Percentage of overall gaze time (%GT) and the number and duration of FIX in each ZOI was recorded. %GT and FIX between ZOIs and between S1 and S2 were compared using the Wilcoxon signed-rank test. RESULTS: 9 fellows were enrolled (66% M); 2 were excluded (incomplete recordings). S2 was mean 2 yr (range 1.6–2.3yr) after S1. At the time of S2, 2 were faculty. In both sessions, mean %GT and #FIX were 2–2.5× higher in the periphery than the center (Table 1). While there was no significant difference between the center and top, left and right ZOI, the bottom ZOI %GT and #FIX were 0.25× and 0.30× the center, respectively (P = 0.02, Tables 1 and 2). When comparing S1 and S2, there were no significant differences in %GT spent in central, peripheral, left, right, top, bottom ZOIs. Compared to S1, subjects in S2 had significantly fewer peripheral FIX (mean 331 v 253, P = 0.05), though there were no differences with any specific ZOI. Mean FIX duration was longer in S2 (0.27s v 0.35s, P = 0.02). There was no difference in mean FIX duration between central and peripheral ZOIs for either session, but mean FIX duration was longer in S2 for both central and peripheral ZOIs (0.29s v 0.36s, P = 0.02; 0.28s v 0.36s, P = 0.02). CONCLUSION: Fellows’ VGP appear to consistently exclude the bottom third of the screen. Through training, their central and peripheral %GT do not significantly change but they have fewer peripheral fixations and increased mean fixation duration suggesting a more focused search. Confirmation of these findings in prospective studies and identification of correlations with ADR are needed.Table 1.: Comparison of Percentage Total Gaze Time (%GT) Per Zone of Interest (ZOI) Between Session 1 and Session 2Table 2.: Comparison of Mean Number of Fixations (#FIX) Per Zone of Interest (ZOI) Between Session 1 and Session 2Table 3.: Comparison of %Gaze Time Between Central and Peripheral ZOI
Introduction: Arteriovenous malformations (AVMs) are abnormal congenital or idiopathic connections between arteries and veins. The lack of a capillary bed between these vessels leads to increased blood flow through veins, resulting in a steal phenomenon. Ischemic colitis secondary to mesenteric AVMs is exceedingly rare with only a few cases published in literature. Case Description/Methods: A 67-year-old man with past medical history of myasthenia gravis presented with abdominal pain, continuous mucous rectal discharge, and tenesmus with associated 25 lb weight loss. Routine laboratory tests were remarkable for hemoglobin of 12 g/dL, CRP 22 mg/dL, and infectious stool studies including Clostridioides difficile, stool culture, ova and parasites were negative. Abdominopelvic CT with IV contrast revealed moderated colitis of the descending and sigmoid segments through at least the level of the mid rectum. Colonoscopy showed significantly congested and diffusely erythematous mucosa extending from the rectum to the descending colon with an abrupt transition to normal appearing mucosa (Figure 1A). Biopsies of the abnormal mucosa were consistent with healing ischemic colitis. He subsequently underwent CT angiography which revealed a tuft of arterial and venous vessels that have an appearance most suggestive of an AVM that appears to be supplied by the sigmoidal artery of the inferior mesenteric artery (IMA) with chronic occlusion of the inferior mesenteric vein (Figure 1B, C). Inferior mesenteric angiogram identified 5 feeding arteries into the nidus. One branch from the superior hemorrhoidal artery, 2 branches from the sigmoid artery, and 2 branches from the left colic artery. Early draining vein noted in the form of large parallel superior hemorrhoidal vein and sigmoid vein. Attempts at embolization of the AVM were unsuccessful due to complex anatomy and inferior mesenteric vein occlusion (Figure 1D). He subsequently underwent robotic descending and sigmoid colectomy with Hartman pouch. Discussion: AVM induced ischemic colitis is a rare entity. Symptoms include bloody diarrhea, mucous discharge, tenesmus, and abdominal pain. Mesenteric AVMs can be easily missed on CT abdomen and require CTA, MRA, and confirmation with mesenteric angiography for diagnosis. Treatment includes embolization of the AVM or more commonly resection of the affected portion of the colon.Figure 1.: A: Colonoscopy demonstrates significantly congested and diffusely erythematous mucosa of the descending colon. B: Coronal CTA shows a tuft of arterial and venous vessels that has an appearance most suggestive of an AVM (circle). C: Axial CT shows AVM (circle) and sigmoid colitis (arrow). D: Mesenteric angiography delineating 5 feeding arteries into the nidus and draining vein noted in the form of large parallel superior hemorrhoidal vein and sigmoid vein.
Ingestion of non-food entities poses a critical risk, particularly in children and young adults. Mostly foreign bodies can safely pass through the gastrointestinal tract if they traverse the pylorus; however, ingestion of Orbeez beads can present as a unique challenge. Orbeez beads have the potential to absorb water and can expand in the stomach and small intestine, and can result in complications including constipation, intestinal obstruction, perforation, and peritonitis. Timely diagnosis and management are crucial to improve patient outcomes. We present a case of a 19-year-old male who ingested Orbeez beads and presented with nausea, vomiting, and abdominal pain. A non-contrast CT scan of the abdomen confirmed the foreign bodies. Fifty to seventy beads were successfully removed via esophagogastroduodenoscopy (EGD) without any complications, and the patient is currently doing well.
