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Eosinophilic esophagitis (EoE) is a chronic and progressive immune-mediated esophageal disorder. Given its increasing incidence, it is now a leading cause of dysphagia and food impaction in the United States. Eosinophilic esophagitis is most common in adult White men and has a high concurrence rate with other atopic conditions like allergic rhinitis, bronchial asthma, and eczema. The initial presentation includes symptoms of esophageal dysfunction, classically solid-food dysphagia. Without treatment, inflammation can progress to fibrosis with the formation of strictures, leading to complications such as food impaction. It is a clinicopathologic disease requiring compatible clinical symptoms and histologic evidence of eosinophil-predominant inflammation of the esophageal epithelium with more than 15 eosinophils per high-power field. The mainstay of management includes the 3 d’s (diet, drugs, dilation): dietary modifications to eliminate trigger food groups; medications including proton pump inhibitors, swallowed topical glucocorticoids, and dupilumab; and esophageal dilation to manage strictures. Various elimination diets have been found to be effective, including 1-food, 2-food, 4-food, and 6-food elimination diets. Dupilumab, a humanized monoclonal antibody that regulates interleukin 4 and 13 signaling pathways, has shown promising results in clinical trials and was approved by the Food and Drug Administration in 2022 for use in EoE. Symptom alleviation, although important, is not the sole end point of treatment in EoE as persistent inflammation, even in the absence of symptoms, can lead to esophageal fibrosis and stricture formation over time. The chronic nature and high recurrence rates of EoE warrant maintenance therapy in patients with EoE after initial remission is achieved.

Disorders of gut-brain interaction, previously known as functional gastrointestinal disorders (eg, functional dyspepsia and irritable bowel syndrome), are commonly encountered in both the primary care and gastroenterology clinics. These disorders are often associated with high morbidity and poor patient quality of life and often lead to increased health care use. The management of these disorders can be challenging, as patients often present after having undergone an extensive workup without a definite etiology. In this review, we provide a practical five-step approach to the clinical assessment and management of disorders of gut-brain interaction. The five-step approach includes (1) excluding organic etiologies of the patient’s symptoms and using Rome IV criteria for diagnosis, (2) empathizing with the patient to develop trust and a therapeutic relationship, (3) educating the patient about the pathophysiology of these gastrointestinal disorders, (4) expectation setting with a focus on improving function and quality of life, and (5) establishing a treatment plan with central and peripherally acting medications and nonpharmacological modalities. We discuss the pathophysiology of disorders of gut-brain interaction (eg, visceral hypersensitivity), initial assessment and risk stratification, as well as treatment for a variety of diseases with a focus on irritable bowel syndrome and functional dyspepsia.

Gastrointestinal bleeding is a common clinical problem encountered in both the inpatient and outpatient settings. Although the evaluation of upper and lower gastrointestinal bleeding is often straightforward, bleeding from the small bowel may pose a clinical challenge. In this article, we review the indications, modalities, and differential diagnoses of small bowel bleeding. On completion of the article, clinicians should be able to identify common causes of small bowel bleeding, understand the advantages and disadvantages of the modalities used to evaluate small bowel bleeding, and enact a stepwise management approach to the patient with presumed small bowel bleeding.

Microscopic colitis (MC) is an inflammatory disease of the colon and a common cause of chronic watery diarrhea, predominantly in older patients. Microscopic colitis encompasses 2 different subtypes, lymphocytic colitis and collagenous colitis. The colon typically appears normal endoscopically in MC, and the diagnosis requires histologic evaluation. Whereas recent studies suggest that the incidence of MC has plateaued, given the aging of the population, the prevalence of MC will likely increase. Risk factors for MC include increasing age; female sex; presence of other autoimmune diseases; and possibly use of certain medications, including proton pump inhibitors, nonsteroidal anti-inflammatory drugs, selective serotonin reuptake inhibitors, and statins. The clinical presentation of MC is nonspecific and includes watery nonbloody diarrhea, nocturnal stools, fecal urgency, abdominal pain, arthralgias, and weight loss. The disease course of MC is variable; some patients experience occasional, intermittent symptoms, and others demonstrate more chronic and even progressive symptoms. The approach to treatment is similar for both lymphocytic colitis and collagenous colitis and should be guided by the severity of the patient’s symptoms. Offending medications highly associated with MC should be eliminated as clinically possible. In patients with mild symptoms, antidiarrheals such as loperamide are the initial choice; for moderate-severe disease, budesonide is recommended for induction of clinical remission. In those with recurrent symptoms, low-dose budesonide may be required for maintenance therapy with close monitoring for potential adverse effects. In rare cases, immunomodulators may be required.

Barrett’s esophagus (BE) is the only known precursor to esophageal adenocarcinoma (EAC), a cancer with increasing incidence and poor survival. Risk of EAC in patients with BE is higher compared with the general population. Endoscopic screening for BE is performed to identify patients earlier in the metaplasia-dysplasia-carcinoma sequence from BE to EAC to enable eradication therapy. BE screening should be considered in individuals with multiple risk factors for BE and EAC. Challenges to BE screening include the absence of a cost-effective, widely applicable minimally invasive screening tool, gastroesophageal reflux disease centric screening recommendations, and limitations of current endoscopic surveillance practice.

Narrowed-spectrum imaging (NSI) technologies, also known as digital or virtual chromoendoscopy, use optical or digital filters to modify the visible light spectrum and thereby enhance mucosal surface and vascular features. Following the introduction of narrow band imaging over a decade ago, NSI technologies have progressed in image resolution and brightness and are now an intricate part of modern diagnostic endoscopy. This review highlights the application of NSI for the diagnosis and characterization of a wide range of upper gastrointestinal disorders with an emphasis on the diagnostic performance of validated classification systems.

Advanced endoscopy (AE) fellowship interviews during the 2020 application cycle were held virtually due to COVID-19 pandemic. This study aimed to characterize the application experience with virtual interviews.

Volumetric laser endomicroscopy (VLE) is an advanced imaging modality used in Barrett's esophagus (BE) surveillance. VLE interpretation relies on identification of specific features associated with BE dysplasia and can be enhanced by intelligent real-time image segmentation (IRIS). The diagnostic performance of established VLE interpretation systems has not been validated. This study uses a dataset of histology-matched regions of interest (ROI) to determine the diagnostic performance of VLE with and without IRIS enhancement.

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Esophageal adenocarcinoma (EAC), the primary form of esophageal cancer in the United States, is a lethal cancer with exponentially increasing incidence. Screening for Barrett esophagus (BE), the only known precursor to EAC, followed by endoscopic surveillance to detect dysplasia and early-stage EAC and subsequent endoscopic treatment (to prevent progression of dysplasia to EAC and to treat early-stage EAC effectively) is recommended by several society guidelines. Sedated endoscopy (the primary current tool for BE screening) is both invasive and expensive, limiting its widespread use. In this review, we aim to provide a comprehensive review of recent innovations in the nonendoscopic detection of BE and EAC. These include swallowable cell sampling devices combined with protein and epigenetic biomarkers (which are now guideline endorsed as alternatives to sedated endoscopy), tethered capsule endomicroscopy, emerging peripheral blood–sampled molecular biomarkers, and exhaled volatile organic compounds. We also summarize progress and challenges in assessing BE and EAC risk, which is an important complementary component of the process for the clinical implementation of these innovative nonendoscopic tools, and propose a new paradigm for the strategy to reduce EAC incidence and mortality.

Background:Prior studies have not examined national trends and characteristics of unintentional non–health care facility (HCF) medication errors associated with cardiovascular drugs. Objective:To investigate non-HCF medication errors associated with cardiovascular drugs reported to poison control centers in the United States. Methods:A retrospective analysis of non-HCF medication errors associated with cardiovascular drugs from 2000 to 2012 was conducted using the National Poison Data System database. Results:There were 278 444 medication errors associated with cardiovascular drugs reported to US poison control centers during the study period, averaging 21 419 exposures annually. The overall rate of cardiovascular medication errors per 100 000 population increased 104.6% from 2000 to 2012 (P< 0.001) and the highest rates were among older adults. Most cases (83.6%) did not require treatment at a HCF. Serious medical outcomes were reported in 4.0% of exposures. The cardiovascular drugs most commonly implicated in medication errors were β-blockers (28.2%), calcium antagonists (17.7%), and angiotensin-converting enzyme inhibitors (15.9%). Most of the 114 deaths were associated with cardiac glycosides (47.4%) or calcium antagonists (29.8%). Most medication errors involved taking or being given a medication twice (52.6%). Conclusions:This study describes characteristics and trends of non-HCF cardiovascular medication errors over a 13-year period in the United States. The number and rate of cardiovascular medication errors increased steadily from 2000 to 2012, with the highest error rates among older adults. Further research is needed to identify prevention strategies for these errors, with a particular focus on the older adult population.

Supplemental digital content is available in the text.

Helicobacter pyloriis a common bacterial pathogen responsible for substantial gastrointestinal morbidity worldwide. Helicobacter pyloriinfection can be clinically challenging, given the numerous diagnostic and therapeutic options available. In this article, we provide a systematic review of H pyloriepidemiology and pathogenesis. In addition, we provide a simplified approach to the diagnosis and treatment of H pyloriinfection, suitable for application in the primary care setting. On completion of this article, one should be able to (1) state the indications for H pyloritesting; (2) identify noninvasive and invasive tests to diagnose H pyloriinfection; and (3) describe the advantages and disadvantages of various treatment regimens.

Nausea and vomiting are common presenting complaints in the outpatient and inpatient settings. These symptoms can be associated with high morbidity and poor quality of life, particularly in those with chronic symptoms. The clinical approach to nausea and vomiting can be challenging, given the numerous possible underlying etiologies as well as vast array of diagnostic and therapeutic options. In this concise review, we provide a practical five-step approach to the clinical evaluation and treatment of nausea and vomiting, suitable for application in the primary care and subspecialty settings. The five-step approach includes 1) defining what the patient means by nausea and vomiting, 2) determining whether symptoms are acute versus chronic, 3) considering medication or toxin side-effects, 4) using the patient’s presentation, severity of symptoms, and physical exam findings to formulate a differential diagnosis and guide evaluation, and 5) directing treatment based on knowledge of neurotransmitters and receptors involved in the emetic pathways. We discuss the pathophysiology (neuronal pathways and neurotransmitters), differential diagnosis (medication/toxin side effects, neurologic causes, gastrointestinal diseases, metabolic/endocrine conditions, and psychogenic etiologies), initial evaluation and risk stratification, as well as management and treatment options. Management of symptoms that are acute in onset or mild in severity may involve an empiric trial of anti-emetics without extensive testing. In contrast, when symptoms are chronic or moderate-severe, testing for an underlying etiology should be performed and 1) medication side-effects, 2) neurologic causes, 3) gastrointestinal diseases, 4) metabolic or endocrine conditions, and 5) psychogenic disorders should be considered in particular.

To describe the clinical, endoscopic, and histologic features in patients with acute esophageal necrosis (AEN).