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BackgroundIntravenous erythromycin prior to endoscopy for upper gastrointestinal bleeding (GIB) improves outcomes but requires immediate preparation delaying administration in emergency cases. Azithromycin is readily available and does not require prolonged preparation. The aim of the study was to assess the effect of azithromycin in improving the quality of endoscopic visualization in upper GIB compared to erythromycin.MethodsPatients admitted with upper GIB who received erythromycin or azithromycin before urgent endoscopy were included. Primary outcome of the quality of visualization was assessed by two gastroenterologists, blinded to the choice of infusion, using a scoring system ranging from 0 to 8, with a maximum of 2 points assigned to the fundus, body, antrum and bulb.ResultsSixty-six patients were included; 25 received azithromycin and 41 received erythromycin. Mean total visualization score was significantly higher with azithromycin compared to that with erythromycin (6.8±1.4 vs. 5.5±2.2, respectively; P=0.01) and remained significant after adjusting for confounders (Diff: 0.01, 1.88; P=0.05). Secondary outcomes analyses showed a shorter LOS when given azithromycin compared to erythromycin [6 (3 to 9) vs. 8 (7 to 16) days, respectively, 95% CI: 1.03, 3.89; P=0.04]. Time between initiating the infusion and endoscopy was longer with azithromycin (Diff: 40.64 min; 95% CI: 7.23, 74.05; P=0.02). Need for second look endoscopy, procedure time, blood transfusion requirements and procedure-related complications did not differ between the groups.ConclusionsAzithromycin infusion before endoscopy for upper GIB was associated with better visualization than that of erythromycin. Randomized trials are needed to validate these findings.

Video Video 1 EUS-guided stent placement for afferent limb and gastrojejunal obstruction in a patient with pancreatic cancer.

BACKGROUND AND AIMS: The treatment of submucosal (T1b) esophageal adenocarcinoma (EAC) remains in evolution with some evidence supporting endoscopic management of low-risk lesions. Using a multicenter cohort, we evaluated outcomes of patients with T1b EAC and predictors of survival. METHODS: Patients diagnosed between 2001 and 2016 with T1b EAC were identified from 3 academic medical centers in the United States. Demographic, clinical and outcome data were collected. Outcomes studied included overall and cancer-free survival. Cox proportional hazards models were constructed to assess independent predictors of survival. RESULTS: One hundred forty-one patients were included, of whom 68 (48%) underwent esophagectomy and 73 (52%) were treated endoscopically. Most (85.8%) patients had high-risk histological features. Thirty-day operative mortality was 2.9%. Median follow-up in the esophagectomy and endoscopic cohorts was 49.4 and 43.4 months, respectively. Patients treated endoscopically were older with higher comorbidity scores. 46 (63%) patients treated endoscopically achieved histologic remission. Nineteen (26.0%) patients also received chemoradiation. Five-year overall survival rates in the surgical and endoscopic cohorts were 89% and 59% respectively whereas 5-year cancer free survival rates were 92 and 69%. Presence of high-risk histological features was associated with reduced overall survival. CONCLUSIONS: In this large multicenter study of patients with T1b EAC, esophagectomy was associated with improved overall but not cancer-free survival. High-risk histological features were associated with poorer survival.

Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease in the Western world, affecting about 1/3 of the US general population and remaining as a significant cause of morbidity and mortality. The hallmark of the disease is the excessive accumulation of fat within the liver cells (hepatocytes), which eventually paves the way to cellular stress, injury and apoptosis. NAFLD is strongly associated with components of the metabolic syndrome and is fast emerging as a leading cause of liver transplant in the USA. Based on clinico-pathologic classification, NAFLD may present as isolated lipid collection (steatosis) within the hepatocytes (referred to as non-alcoholic fatty liver; NAFL); or as the more aggressive phenotype (known as non-alcoholic steatohepatitis; NASH). There are currently no regulatory agency- approved medication for NAFLD, despite the enormous work and resources that have gone into the study of this condition. Therefore, there remains a huge unmet need in developing and utilizing pre-clinical models that will recapitulate the disease condition in humans. In line with progress being made in developing appropriate disease models, this review highlights the cutting-edge preclinical in vitro and animal models that try to recapitulate the human disease pathophysiology and/or clinical manifestations.

Background and Aims Gastric peroral endoscopic myotomy (GPOEM) is a promising treatment for refractory gastroparesis. Initially, endoscopists performed GPOEM along the greater curve of the stomach. We, herein, present a novel modification with a lesser curve approach that offers the advantages of shorter tunnel and possibly better myotomy. Methods Three patients with refractory gastroparesis underwent GPOEM by use of the lesser curve approach. Two of the patients had a prior GPOEM by the traditional greater curve approach. All procedures were performed with the patient under general anesthesia. The specific tools used for incision, dissection, and myotomy are described. The patients were followed up closely, and the gastroparesis cardinal symptom index (GCSI) was calculated before, and 4 weeks after, the procedure. Results The pyloric ring was exposed very well with the lesser curve approach. The mean procedure time was 48 ± 12 minutes. No immediate or late adverse events were observed. All patients had significant improvement in the GCSI 4 weeks after GPOEM, with resolution of gastroparesis symptoms. The mean follow-up time was 6 months. Conclusion The lesser curve approach to GPOEM provides an excellent exposure to the pyloric ring and can be used as a primary or a salvage technique for the treatment of refractory gastroparesis.

INTRODUCTION: Telemedicine has become an essential tool that allowed physicians to continue to provide care during the coronavirus disease 2019 (COVID-19) pandemic The use of telemedicine among gastroenterologists has peaked recently but questions remain regarding the future implication of this technology within the field We aimed to evaluate providers' experience with telemedicine in a large academic health system with a broad geographic reach and quantify variations and factors that influenced this experience METHODS: We developed a 22-item survey instrument based on literature review, conceptual models of physician behavior, pilot testing by colleagues and discussions with academic and community gastroenterologists The survey was emailed to practicing providers in the Division of Digestive Diseases at a major university-based health system RESULTS: Thirty-five out of 83 (41%) gastroenterologists responded to the survey within the first week of distribution, of whom 32% were female, and 68% were #44 years old Sixty-four percent practiced general gastroenterology, 59% have been in practice for ≥10 years, and 18% for ≥20 years The majority reported positive (46%) and very positive (29%) experience, and only 6% reported a negative experience with telemedicine 63% felt telemedicine was more efficient than traditional visits, and 58% consider adding telemedicine visits between endoscopic procedures Lack of physical exam was felt to be critical in 27%, and 25% thought in-person visits would change management plan compared to telemedicine Age or gender were not associated with having a positive providers' experience {74% for age 45, P = 0 940;82% for female vs 70% for male;P = 0 68} Similarly, the importance of physical exam was not associated with age (22% vs 36%, P = 0 4), gender (18% for female vs 30% for male, P = 0 6), or years of experience (36% for < 10 years vs 20% for ≥10 years;P = 0 1) 91% plan to integrate telemedicine into practice after the COVID-19 outbreak;however two-thirds stated they will use it only if appropriate insurance payment, equal to office visits, is provided CONCLUSION: The emerging use of telemedicine among gastroenterologists is perceived as a positive experience The vast majority of our survey participants plan to integrate telemedicine into routine practice following the COVID-19 pandemic Future efforts should focus on improving the technology's user interface, overcoming billing/payment hurdles, and techniques to compensate for the lack of physical examination (Figure Presented)

Non-alcoholic fatty liver disease (NAFLD) is a leading cause of liver-related morbidity and mortality in the United States and globally (1,2). A large body of literature currently exists to suggest at the clinical burden of NAFLD is not only confined to liver but may rather represent a major part of a multisystem disease (3). Along with the well-known association with metabolic syndrome (MetS), NAFLD has proven to strongly correlate with cardiovascular disease (CVD), chronic kidney disease (CKD), type 2 diabetes (T2D) and potentially osteoporosis and extra-hepatic malignancies (4,5).

Eosinophilic esophagitis (EoE) is a rare disease of the esophagus that is characterized by eosinophilic infiltrate within the esophageal mucosa resulting in chronic inflammation and stenosis. It typically presents with symptoms of esophageal dysfunction with dysphagia and food impaction being the most common presenting complaints. Herein we describe a rare case presentation of a young patient with spontaneous esophageal perforation in the setting of undiagnosed EoE. We suggest that the placement of a covered esophageal stent can provide full closure of the perforation and restoration of the integrity of the GI tract without the need for more invasive open repair. The patient had a short recovery time with no reported postoperative complications upon 30 months follow up. We believe that it’s important to consider and rule out EoE in patients with a history of dysphagia and esophageal perforation.

Hepatocellular carcinoma (HCC) is the most rapidly increasing cause of cancer-related mortality in many countries including the United States (1). In 2012, primary liver cancer was estimated to be the overall second cause of cancer related death in the world (2). These alarming reports stress the desperate need for better understanding of the risk and prognostic factors as well as the screening and treatment methods of HCC.

Outcomes and long-term survival rates after liver transplantation have significantly improved over the last 5 decades, but the improved longevity is accompanied by long-term complications such as metabolic syndrome, obesity, cardiovascular disease, cancer, and bone disease. After the first year, the primary care physician assumes a greater role and provides most of the patient's care. This review provides a source for primary care physicians in managing the long-term medical complications seen in these patients.

Non-alcoholic fatty liver disease is a leading cause of chronic liver disease and can lead to cirrhosis, hepatocellular cancer and end stage liver disease. It is also associated with increased cardiovascular and cancer related morbidity and mortality. The pathogenesis of non-alcoholic fatty liver disease includes metabolic stress to the liver associated with insulin resistance with downstream cell stress from reactive oxygen species and unfolded protein response with activation of inflammatory and fibrotic pathways. There are currently no approved therapies for non-alcoholic fatty liver disease. This review summarizes ongoing efforts to establish the treatment of non-alcoholic steatohepatitis the progressive form of non-alcoholic fatty liver disease. Therapies are currently directed towards improving the metabolic status of the liver, cell stress, apoptosis, inflammation or fibrosis. Several agents are now in pivotal trials and it is expected that the first therapies will be approved in 2-3 years.

Background & Aims Even though propofol use for gastrointestinal endoscopic procedures has increased over the past decade, there is a perception that it causes a higher rate of cardiopulmonary adverse events. The aim of this study was to compare the sedation-related adverse events associated with use of propofol vs nonpropofol agents for endoscopic procedures. We also wanted to determine the influence of duration or complexity of the procedures and endoscopist-directed (gastroenterologist) vs non–gastroenterologist-directed sedation on the outcomes. Methods A search was conducted using Medline, EMBASE, and the Cochrane controlled trials registry. The following cardiopulmonary adverse events were assessed: hypoxia, hypotension, and arrhythmias. The procedures were divided into 2 groups based on the procedure length: a nonadvanced endoscopic procedure group consisting of esophagogastroduodenoscopy, colonoscopy, and sigmoidoscopy, and an advanced endoscopic procedures group including endoscopic retrograde cholangiopancreatography, endoscopic ultrasonography, balloon enteroscopy, and endoscopic submucosal dissection. Pooled odds ratios for complications were calculated for all the procedures combined and then separately for the 2 groups. Random-effects models were used for 2-proportion comparisons. Results Of the 2117 citations identified, 27 original studies qualified for this meta-analysis and included 2518 patients. Of these, 1324 received propofol, and 1194 received midazolam, meperidine, pethidine, remifentanil, and/or fentanyl. Most of the included studies were randomized trials of moderate quality and nonsignificant heterogeneity (Cochran Q, 26.07; P = .13). Compared with traditional sedative agents, the pooled odds ratio with the use of propofol for developing hypoxia for all the procedures combined was 0.82 (95% confidence interval [CI], 0.63–1.07), and for developing hypotension was 0.92 (95% CI, 0.64–1.32). In the nonadvanced endoscopic procedure group, those who received propofol were 39% less likely to develop complications than those receiving traditional sedative agents (odds ratio, 0.61; 95% CI, 0.38–0.99). There was no difference in the complication rate for the advanced endoscopic procedure group (odds ratio, 0.86; 95% CI, 0.56–1.34). A subgroup analysis did not show any difference in adverse events when propofol was administered by gastroenterologists or nongastroenterologists. Conclusions Propofol sedation has a similar risk of cardiopulmonary adverse events compared with traditional agents for gastrointestinal endoscopic procedures. Propofol use in simple endoscopic procedures was associated with a decreased number of complications. When used for gastrointestinal endoscopic procedures of a complex nature and longer duration, propofol was not associated with increased rates of hypoxemia, hypotension, or arrhythmias. Administration of propofol by gastroenterologists does not appear to increase the complication rates.

To The Editor: We read with great interest the article by Hong et al. published in August 2013 in the online version of Hepatology. Hong et al. report an increased risk of nonalcoholic fatty liver disease in patients with lower muscle mass. Here we take the chance to share the results of a study we conducted to investigate the presence of sarcopenia in patients with Nonalcoholic steatohepatitis "NASH" and NASH-related cirrhosis. NASH is an aggressive form of nonalcoholic fatty liver disease. It is widely accepted now that NASH is associated with insulin resistance(1), and can progress to cirrhosis in 21–28% of patients(2). Pro-inflammatory cytokines and insulin resistance result in muscle catabolism leading to muscle wasting "sarcopenia" in obese patients(3). In addition, sarcopenia is being more frequently described and addressed in cirrhotic patients(4). In our study, we divided the subjects into three groups, each one included 25 individuals; control group, NASH and NASH-cirrhosis groups. The diagnosis of NASH was proven by liver biopsy. To assess the presence of sarcopenia, we evaluated the muscle mass by measuring the cross-sectional area of the psoas and paraspinal muscles at the level of the midpoint of L4 vertebra on computed tomography (CT) scan (5). Total psoas and paraspinal muscles densities were also measured. Analysis of covariance was performed to assess differences in muscle area while adjusting for age and gender. Our results showed that patients with NASH and NASH-related cirrhosis were older and had higher body mass index than the control group. There was a stepwise significant decrease in total psoas area "TPA" from the control group to NASH group to cirrhosis group (29.3 ± 0.88 cm2, 24.8 ± 0.8 cm2, and 19.3 ± 0.93 cm2, respectively, p< 0.001). This difference remained significant after adjusting for age, gender and height(Figure). Similar findings were noted for the paraspinal muscle area. The density of the muscles as assessed by Hounsfield units was lower in patients with NASH or cirrhosis suggesting fatty infiltration (controls 36.9 ± 2.6 HU, NASH 31.2 ± 2.3, cirrhosis 18.5 ± 2.7). Figure Age and Gender Adjusted Means (95% Confidence Limits) for TPA/Height2 and Paraspinal Muscle Area/Height2 In conclusion, our data suggest that there is progressive muscle wasting in patients with NASH that precedes the development of cirrhosis and worsens with progression to cirrhosis.