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BACKGROUND: Intra-arterial infusion of yttrium-90 (Y-90) microspheres is locoregional radiation therapy for unresectable hepatic neoplasms. Literature on GI complications of this novel therapy is sparse. OBJECTIVES: Clinically and pictorially characterize selective internal radiation therapy (SIRT)-induced GI injury and review the published literature. DESIGN: Retrospective chart analysis. SETTING: Single-center tertiary referral community hospital. PATIENTS: One hundred three patients treated with SIRT for hepatic neoplasms between 2006 and 2008. INTERVENTIONS: SIRT for unresectable hepatic neoplasms followed by upper endoscopy with biopsy in symptomatic patients. OUTCOME MEASURES: GI ulcers after SIRT. RESULTS: Five patients with suspected GI injury after SIRT were identified. Significant postprocedural symptoms included nausea/vomiting, odynophagia, hematemesis, and melena. Radiation ulcers occurred mostly in the gastric antrum, pylorus, and duodenum. Biopsy specimens of ulcer margins in 4 patients showed pathognomonic radiation microspheres. Angiographic review of the fifth patient revealed a previously unrecognized arterial branch supplying the corresponding region of GI ulceration noted on endoscopy. LIMITATIONS: Small retrospective study and follow-up limited by terminal disease states in most patients. CONCLUSIONS: The reported incidence of GI complications after SIRT for hepatic neoplasia varies from 3% to 24% of patients. Incidence can be minimized by strict adherence to published SIRT protocols. Diagnosis requires a high degree of clinical suspicion along with endoscopy and biopsy of ulcer margins. Characteristic radiation microspheres in biopsy specimens are pathognomonic. Gastroenterologists and pathologists must be cognizant of this complication. [ABSTRACT FROM AUTHOR]

Deaf and mute patients may require minimal extra attention to establish trust and allay anxieties before minor medical maneuvers such as rectal examination. An extreme case is reported of the consequences from failure to accomplish this. A generally cooperative deaf and mute patient struggled and suffered a rectal tear and perforation during enema insertion that required emergency colorectal surgery; his nurse had failed to establish a trusting relationship before enema insertion. Ironically, the patient's physician had earlier easily performed digital rectal examination, a similar medical maneuver, with patient cooperation after establishing patient rapport. This report demonstrates the importance of treating individuals with disabilities like everyone else in addressing anxieties before medical maneuvers. The health care worker has the same responsibility of calming the patient, whether deaf or not; the sole difference is that communication between deaf and hearing requires greater skill and patience. [ABSTRACT FROM AUTHOR]

Aim: Critically review approximately 2 years afterward the effectiveness of revolutionary changes at an academic gastroenterology division from coronavirus disease-2019 (COVID-19) pandemic surge at the metropolitan Detroit epicenter from 0 infected patients on March 9, 2020, to >300 infected patients (one-quarter of) in-hospital census in April 2020 and >200 infected patients in April 2021., Setting: GI Division, William Beaumont Hospital which had 36 GI clinical faculty who used to perform >23,000 endoscopies annually with a massive plunge in endoscopy volume during the past 2 years; fully accredited GI fellowship since 1973; employs >400 house staff annually since 1995; predominantly voluntary attendings; and primary teaching hospital, Oakland-University-Medical-School., Methods: Expert opinion, based on: Hospital GI chief >14 years until September 2019; GI fellowship program director, at several hospitals for>20 years; author of 320 publications in peer-reviewed GI journals; and committee-member Food-and-Drug-Administration-GI-Advisory Committee for >5 years. Original study exempted by Hospital Institutional Review Board (IRB), April 14, 2020. IRB approval is not required for the present study because this opinion is based on previously published data. Advantageous changes: Division reorganized patient care to add clinical capacity and minimize risks to staff of contracting COVID-19. Affiliated medical school changes included: changing "live" to virtual lectures, meetings, and conferences. Initially, virtual meetings usually used telephone conferencing which proved cumbersome until meetings were changed to completely computerized virtual meetings using Microsoft Teams or Google Zoom, which performed superbly. Some clinical electives were canceled for medical students and residents because of the need to prioritize car for COVID-19 infection during the pandemic, and medical students graduated on time despite partly missing electives. Division reorganized by changing "live" GI lectures to virtual lectures; by four GI fellows temporarily reassigned as medical attendings supervising COVID-19-infected patients; postponing elective GI endoscopies; and drastically reducing an average number of endoscopies from 100/weekday to a small fraction long-term! GI clinic visits were reduced by half by postponing nonurgent visits, and physical visits were replaced by virtual visits. Economic pandemic impact included a temporary, hospital deficit initially relieved by federal grants and hospital employee terminations. GI program director contacted GI fellows twice weekly to monitor pandemic-induced stress. Applicants for GI fellowship were interviewed virtually. Graduate medical education changes included weekly committee meetings to monitor pandemic-induced changes; program managers working from home; canceling annual ACGME fellowship survey, ACGME site visits, and national GI conventions changed from physical to virtual. Dubious changes: Temporarily mandated intubation of COVID-19-infected patients for EGD; temporarily exempted GI fellows from endoscopy duties during surge; fired highly respected anesthesiology group employed for 20 years during pandemic leading to anesthesiology shortages, and abruptly firing without warning or cause numerous senior respected faculty who greatly contributed to research, academics, and reputation., Conclusion: Profound and pervasive GI divisional changes maximized clinical resources devoted to COVID-19-infected patients and minimized risks of transmitting infection. Academic changes were degraded by massive cost-cutting while offering institutions to about 100 hospital systems and eventually "selling" institutions to Spectrum Health, without faculty input., Competing Interests: Conflict of interest The author declares no conflict of interest. Dr M.S. Cappell, as a member of the United States Food and Drug Administration (FDA) Advisory Committee for Gastrointestinal Drugs, 2013 to 2018,(35) affirms that this paper does not discuss any proprietary, confidential, pharmaceutical data submitted to the FDA and reviewed by Dr M.S. Cappell. Dr M.S. Cappell was >4 years ago a member of the speaker’s bureau for AstraZeneca and Daiichi Sankyo, co-marketers of Movantik. Dr M.S. Cappell had one-time consultancies for Mallinckrodt and Shire >3 years ago. This work does not discuss any drug manufactured or marketed by AstraZeneca, Daiichi Sankyo, Shire, or Mallinckrodt., (Published by Elsevier Inc.)

Profound and pervasive GI divisional changes maximized clinical resources devoted to COVID-19-infected patients and minimized risks of transmitting infection. Academic changes degraded by massive cost-cutting while offering institution to about 100 hospital systems and eventually "selling" institution to Spectrum Health, without faculty input., Competing Interests: Conflicts of interest The author declares no conflict of interest. In particular, Dr M.S. Cappell, as a member of the United States FDA Advisory Committee for Gastrointestinal Drugs, 2013 to 2018,(21) affirms that this article does not discuss any proprietary, confidential, pharmaceutical data submitted to the FDA and reviewed by Dr M.S. Cappell. Dr M.S. Cappell was more than 3 years ago a member of the speaker’s bureau for AstraZeneca and Daiichi Sankyo, comarketers of Movantik. Dr M.S. Cappell had one-time consultancies for Mallinckrodt and Shire more than 3 years ago. This study does not discuss any drug manufactured or marketed by AstraZeneca, Daiichi Sankyo, Shire, or Mallinckrodt. Dr. M. S. Cappell dedicates these two related special critical review articles in this issue to Dr. Anthony Fauci, the Head of Infectious Diseases at the National Institutes of Health, who has served selflessly in this capacity or other positions as a public servant at the National Institutes of Health over a long career, and who despite this dedicated service was the subject of vitriol because of advocating vaccination for the pandemic that has been proven to have saved millions of lives throughout the world. Disclaimer Dr. M. S. Cappell is employed as a gastroenterologist at the Aleda E. Lutz Veterans Administration Hospital in Saginaw, MI and by the United States Government. These institutions do not have an opinion on the views expressed by Dr. Cappell herein., (Published by Elsevier Inc.)

The global coronavirus disease-2019 (COVID-19) pandemic has caused significant morbidity and mortality, thoroughly affected daily living, and caused severe economic disruption throughout the world. Pulmonary symptoms predominate and account for most of the associated morbidity and mortality. However, extrapulmonary manifestations are common in COVID-19 infections, including gastrointestinal (GI) symptoms, such as diarrhea. Diarrhea affects approximately 10% to 20% of COVID-19 patients. Diarrhea can occasionally be the presenting and only COVID-19 symptom. Diarrhea in COVID-19 subjects is usually acute but is occasionally chronic. It is typically mild-to-moderate and nonbloody. It is usually much less clinically important than pulmonary or potential thrombotic disorders. Occasionally the diarrhea can be profuse and life-threatening. The entry receptor for COVID-19, angiotensin converting enzyme-2, is found throughout the GI tract, especially in the stomach and small intestine, which provides a pathophysiologic basis for local GI infection. COVID-19 virus has been documented in feces and in GI mucosa. Treatment of COVID-19 infection, especially antibiotic therapy, is a common culprit of the diarrhea, but secondary infections including bacteria, especially Clostridioides difficile, are sometimes implicated. Workup for diarrhea in hospitalized patients usually includes routine chemistries; basic metabolic panel; and a complete hemogram; sometimes stool studies, possibly including calprotectin or lactoferrin; and occasionally abdominal CT scan or colonoscopy. Treatment for the diarrhea is intravenous fluid infusion and electrolyte supplementation as necessary, and symptomatic antidiarrheal therapy, including Loperamide, kaolin-pectin, or possible alternatives. Superinfection with C difficile should be treated expeditiously. Diarrhea is prominent in post-COVID-19 (long COVID-19), and is occasionally noted after COVID-19 vaccination. The spectrum of diarrhea in COVID-19 patients is presently reviewed including the pathophysiology, clinical presentation, evaluation, and treatment., (Published by Elsevier Inc.)

The novel coronavirus pandemic of COVID-19 has emerged as a highly significant recent threat to global health with about 600,000,000 known infections and more than 6,450,000 deaths worldwide since its emergence in late 2019. COVID-19 symptoms are predominantly respiratory, with mortality largely related to pulmonary manifestations, but the virus also potentially infects all parts of the gastrointestinal tract with related symptoms and manifestations that affect patient treatment and outcome. COVID-19 can directly infect the gastrointestinal tract because of the presence of widespread angiotensin-converting enzyme 2 receptors in the stomach and small intestine that can cause local COVID-19 infection and associated inflammation. This work reviews the pathopysiology, clinical manifestations, workup, and treatment of miscellaneous inflammatory disorders of the gastrointestinal tract other than inflammatory bowel disease., (Published by Elsevier Inc.)

COVID-19 infection is an ongoing catastrophic global pandemic with significant morbidity and mortality that affects most of the world population. Respiratory manifestations predominate and largely determine patient prognosis, but gastrointestinal (GI) manifestations also frequently contribute to patient morbidity and occasionally affect mortality. GI bleeding is usually noted after hospital admission and is often one aspect of this multisystem infectious disease. Although the theoretical risk of contracting COVID-19 from GI endoscopy performed on COVID-19-infected patients remains, the actual risk does not seem to be high. The introduction of PPE and widespread vaccination gradually increased the safety and frequency of performing GI endoscopy in COVID-19-infected patients. Three important aspects of GI bleeding in COVID-19-infected patients are (1) GI bleeding is often from mucosal erosions from mucosal infalammation that causes mild GI bleeding; (2) severe upper GI bleeding is often from PUD or stress gastritis from COVID-19 pneumonia; and (3) lower GI bleeding frequently arises from ischemic colitis associated with thromboses and hypercoagulopathy from COVID-19 infection. The literature concerning GI bleeding in COVID-19 patients is presently reviewed., (Published by Elsevier Inc.)

Aim: To report revolutionary reorganization of academic gastroenterology division from COVID-19 pandemic surge at metropolitan Detroit epicenter from 0 infected patients on March 9, 2020, to > 300 infected patients in hospital census in April 2020 and > 200 infected patients in April 2021., Setting: GI Division, William Beaumont Hospital, Royal Oak, has 36 GI clinical faculty; performs > 23,000 endoscopies annually; fully accredited GI fellowship since 1973; employs > 400 house staff annually since 1995; tertiary academic hospital; predominantly voluntary attendings; and primary teaching hospital, Oakland-University-Medical-School., Methods: This was a prospective study. Expert opinion. Personal experience includes Hospital GI chief > 14 years until 2020; GI fellowship program director, several hospitals > 20 years; author of > 300 publications in peer-reviewed GI journals; committee-member, Food-and-Drug-Administration-GI-Advisory Committee > 5 years; and key hospital/medical school committee memberships. Computerized PubMed literature review was performed on hospital changes and pandemic. Study was exempted/approved by Hospital IRB, April 14, 2020., Results: Division reorganized patient care to add clinical capacity and minimize risks to staff of contracting COVID-19 infection. Affiliated medical school changes included: changing "live" to virtual lectures; canceling medical student GI electives; exempting medical students from treating COVID-19-infected patients; and graduating medical students on time despite partly missing clinical electives. Division was reorganized by changing "live" GI lectures to virtual lectures; four GI fellows temporarily reassigned as medical attendings supervising COVID-19-infected patients; temporarily mandated intubation of COVID-19-infected patients for esophagogastroduodenoscopy; postponing elective GI endoscopies; and reducing average number of endoscopies from 100 to 4 per weekday during pandemic peak! GI clinic visits reduced by half (postponing non-urgent visits), and physical visits replaced by virtual visits. Economic pandemic impact included temporary, hospital deficit subsequently relieved by federal grants; hospital employee terminations/furloughs; and severe temporary decline in GI practitioner's income during surge. Hospital temporarily enhanced security and gradually ameliorated facemask shortage. GI program director contacted GI fellows twice weekly to ameliorate pandemic-induced stress. Divisional parties held virtually. GI fellowship applicants interviewed virtually. Graduate medical education changes included weekly committee meetings to monitor pandemic-induced changes; program managers working from home; canceling ACGME annual fellowship survey, changing ACGME physical to virtual site visits; and changing national conventions from physical to virtual., Conclusion: Reports profound and pervasive GI divisional changes to maximize clinical resources devoted to COVID-19-infected patients and minimize risks of transmitting infection., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Bariatric surgery leaks result in significant morbidity and mortality. Experts report variable therapeutic approaches, without uniform guidelines or consensus., Objective: To review the pathogenesis, risk factors, prevention, and treatment of gastric sleeve leaks, with a focus on endoscopic approaches. In addition, the efficacy and success rates of different treatment modalities are assessed., Design: A comprehensive review was conducted using a thorough literature search of 5 online electronic databases (PubMed, PubMed Central, Cochrane, EMBASE, and Web of Science) from the time of their inception through March 2020. Studies evaluating gastric sleeve leaks were included. MeSH terms related to "endoscopic," "leak," "sleeve," "gastrectomy," "anastomotic," and "bariatric" were applied to a highly sensitive search strategy. The main outcomes were epidemiology, pathophysiology, diagnosis, treatment, and outcomes., Results: Literature search yielded 2418 studies of which 438 were incorporated into the review. Shock and peritonitis necessitate early surgical intervention for leaks. Endoscopic therapies in acute and early leaks involve modalities with a focus on one of: (i) defect closure, (ii) wall diversion, or (iii) wall exclusion. Surgical revision is required if endoscopic therapies fail to control leaks after 6 months. Chronic leaks require one or more endoscopic, radiologic, or surgical approaches for fluid collection drainage to facilitate adequate healing. Success rates depend on provider and center expertise., Conclusion: Endoscopic management of leaks post sleeve gastrectomy is a minimally invasive and effective alternative to surgery. Their effect may vary based on clinical presentation, timing or leak morphology, and should be tailored to the appropriate endoscopic modality of treatment., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is a diagnostic/therapeutic endoscopic procedure for numerous pancreaticobiliary diseases. Data regarding performing ERCP on weekend (WE; Saturday/Sunday) versus postponing ERCP to first two available weekdays (WD; Monday/Tuesday) are scarce. ERCP requires costly resources including specialized nurses, endoscopy room equipped with fluoroscopy, anesthesia services, and highly trained therapeutic endoscopists. Hospitals frequently do not have these resources readily available during WE, leading to postponing ERCPs to WD., Aims: This study analyzes the effect of performing ERCP on WE versus postponement to WD on hospital efficiency, and on patient safety/outcomes., Methods: A computerized search of electronic medical records, January 2011-December 2016, at four Beaumont Hospitals retrospectively identified all gastroenterology consults performed on Friday or Saturday before 12:00 noon, which resulted in ERCP performed for any indication on WE versus postponing ERCP to WD. Length of stay (LOS), hospital costs, hospital charges, and hospital reimbursements were compared between both groups, as were quality of care measures., Results: Among 5196 patients undergoing ERCPs, 533 patients were identified, including 315 patients in the WE group and 218 patients in the WD group. Comparing WE versus WD groups, median LOS was shorter (4.5 days vs. 6.9 days, p < 0.0001); median hospital costs were less ($9208 vs. $11,657, p < 0.0001); and median hospital charges were less ($28,026 vs. $37,899, p < 0.0001). Median hospital reimbursements were not significantly different in WE versus WD groups ($10,277 vs. $10,362, p = 0.65). Median hospital charges were lower than median hospital reimbursements (net profit) in WE but not in WD. WE versus WD had no significant differences in morbidity, mortality, ≤ 30-day readmission rates, need for repeat ERCP ≤ 30 days, or post-ERCP complications., Limitations: This is a retrospective study., Conclusions: Performing ERCPs during weekends significantly reduced LOS, hospital costs, and hospital charges compared to postponing ERCP to WD and resulted in net hospital profits, without impairing quality of medical care.

Background: Previous literature on epidural pneumatosis (pneumorrhachis, or air in epidural cavity) associated with forceful vomiting in a patient with diabetic ketoacidosis (DKA) has consisted of individual case reports without comprehensive syndrome characterization due to syndromic rarity, with the largest previous literature review comprising 6 cases. Presumed pathophysiology is air escaping from alveolar rupture from forceful vomiting via tissue planes to cause epidural pneumatosis., Aim: Systematically review literature to facilitate syndromic diagnosis, evaluation, and treatment. A new illustrative case is reported., Methods: Systematic review of literature using 2 independent readers, 2 computerized databases, and the following medical terms/keywords: ["epidural pneumatosis" OR "pneumorrhachis"] AND ["diabetes" OR "diabetic ketoacidosis" or "DKA"]. Discrepancies between 2 readers were resolved by consensus using prospectively developed study inclusion criteria. Two readers independently abstracted case report. Prospective review protocol and patients, problems, intervene, comparison group, outcomes discussed in Methods section of paper., Results-Systematic-Literature-Review: Revealed 10 previously reported cases plus 1 new case (see below) that shows this syndrome presents rather stereotypically with the tentatively proposed following pentad (% of patients fulfilling individual criterion): 1-forceful vomiting (100%), 2-during DKA (100%), 3-pneumomediastinum from forceful alveolar rupture (100%), 4-epidural pneumatosis from air escape from pneumomediastinum (100%), and 5-no complications of Boerhaave syndrome or of focal neurological deficits (100%). Pentad is pathophysiologically reasonable because forceful vomiting can cause alveolar rupture, pneumomediastinum, and air entry into epidural space., Results-Illustrative-Case-Report: Epidural pneumatosis occurred in a 33-year-old-male with poorly controlled diabetes mellitus type 1 who presented with forceful vomiting while in DKA. Radiologic findings also included subcutaneous emphysema, pneumomediastinum, and small pneumothorax. The patient rapidly improved while receiving acute therapy for DKA, and was discharged after 2 hospital days., Study Limitations: Limited number of analyzed, retrospectively reported cases. Case reports subject to reporting bias. Specificity, positive predictive value, and negative predictive value not meaningfully analyzed in this homogeneous population., Conclusions: Based on systematic review, syndrome is tentatively proposed as a pentad with: 1-forceful vomiting, 2-during DKA, 3- pneumomediastinum, 4-epidural pneumatosis, and 5-no complications of Boerhaave syndrome or focal neurological deficits. Proposed pentad should be prospectively tested in a larger population including patients with this versus closely related syndromes.

Aim: To systematically review clinical presentation, diagnosis, and therapy of achalasia, focusing on recent developments in high-resolution esophageal manometry (HREM) for diagnosis and peroral endoscopic myotomy (POEM) for therapy., Methods: Systematic review of achalasia using computerized literature search via PubMed and Ovid of articles published since 2005 with keywords ("achalasia") AND ("high resolution" or "HREM" or "peroral endoscopic myotomy" or "POEM"). Two authors independently performed literature searches and incorporated articles into this review by consensus according to prospectively determined criteria., Results: Achalasia is an uncommon esophageal motility disorder, usually manifested by dysphagia to solids and liquids, and sometimes manifested by chest pain, regurgitation, and weight loss. Symptoms often suggest more common disorders, such as gastroesophageal reflux disease (GERD), thus often delaying diagnosis. Achalasia is a predominantly idiopathic chronic disease. Diagnosis is typically suggested by barium swallow showing esophageal dilation; absent distal esophageal peristalsis; smoothly tapered narrowing ("bird's beak") at esophagogastric junction; and delayed passage of contrast into stomach. Diagnostic findings at high-resolution esophageal manometry (HREM) include: distal esophageal aperistalsis and integrated relaxation pressure (trough LES pressure during 4 s) > 15 mmHg. Achalasia is classified by HREM into: type 1 classic; type 2 compartmentalized high pressure in esophageal body, and type 3 spastic. This classification impacts therapeutic decisions. Esophagogastroduodenoscopy is required before therapy to assess esophagus and esophagogastric junction and to exclude distal esophageal malignancy. POEM is a revolutionizing achalasia therapy. POEM creates a myotomy via interventional endoscopy. Numerous studies demonstrate that POEM produces comparable, if not superior, results compared to standard laparoscopic Heller myotomy (LHM), as determined by LES pressure, dysphagia frequency, Eckardt score, hospital length of stay, therapy durability, and incidence of GERD. Other therapies, including botulinum toxin injection and pneumatic dilation, have moderately less efficacy and much less durability than POEM., Conclusion: This comprehensive review suggests that POEM is equivalent or perhaps superior to LHM for achalasia in terms of cost efficiency, hospital length of stay, and relief of dysphagia, with comparable side effects. The data are, however, not conclusive due to sparse long-term follow-up and lack of randomized comparative clinical trials. POEM therapy is currently limited by a shortage of trained endoscopists.

Following publication of the original article [1], due to miscommunication during proofing, the author notified us the bellow corrections. In this Correction, correct and incorrect versions are shown.

Background: Gastroenterology fellowship candidates may strive to improve their qualifications for this extremely competitive fellowship., Objective: To analyze whether extreme competitiveness of gastroenterology fellowship positions has affected fellowship interview selection by statistically analyzing 13 parameters of interviewees to identify statistically significant time changes during last 10 years., Methods: Retrospective time-trend-analyses (performed 2018) on thirteen prospectively-obtained-parameters of 47 interviewees (2009-2011) vs. 53 interviewees (2016-2018) for gastroenterology fellowship., Setting: William-Beaumont-Hospital, Royal-Oak: academic fully-accredited gastroenterology fellowship, teaching hospital of Oakland-University-William-Beaumont-School-of-Medicine, tertiary-care hospital, GI fellowship since 1973., Results: Statistically significant increases occurred from 2009 to 2011 vs. 2016-2018 in number of publications, including mean number of: abstracts (1.69 ± 0.37 vs. 7.54 ± 1.16, p < 0.0001); peer-reviewed articles (1.48 ± 0.30 vs. 6.13 ± 1.29, p < 0.0001); and total publications (3.17 ± 0.48 vs. 12.76 ± 1.99, p < 0.0001). Increased publications were associated with graduating from foreign medical schools (correlation coefficient = 0.26, p = .03), and were, surprisingly, correlated with lower letters-of-recommendation-scores (Kruskal-Wallis-statistic = 5.82, p = .002). USMLE-Step-1 scores significantly increased from 2009 to 2011 to 2016-2018 (235 ± 14.1 vs. 244.9 ± 13.5, p = 0.001) (previously reported finding). Nine other parameters did not significantly change with time., Conclusions: Current report of >four-fold-increase in publications by gastroenterology fellowship interviewees at one academic-medical-center is novel. Increased focus on scholarship by applicants may be explained by their having only three parameters to improve their credentials during residency: publications, letters-of-recommendation, and honors awarded during residency (other parameters determined before residency and immutable). Current findings may benefit medical residents/medical-residency-program-directors by focusing more on publications for applications. Association between research productivity and medical promotions likely strongly motivates medical research of residents and may motivate academic faculty. Increased exposure to research/publications may improve the clinical acumen of GI fellowship applicants by enhancing their skills in critically reading the medical literature.

Endoscopic-retrograde-cholangiopancreatography (ERCP) is now a vital modality with primarily therapeutic and occasionally solely diagnostic utility for numerous biliary/pancreatic disorders. It has a significantly steeper learning curve than that for other standard gastrointestinal (GI) endoscopies, such as esophagogastroduodenoscopy or colonoscopy, due to greater technical difficulty and higher risk of complications. Yet, GI fellows have limited exposure to ERCP during standard-three-year-GI-fellowships because ERCP is much less frequently performed than esophagogastroduodenoscopy/colonoscopy. This led to adding an optional year of training in therapeutic endoscopy. Yet many graduates from standard three-year-fellowships without advanced training intensely pursue independent/unsupervised ERCP privileges despite inadequate numbers of performed ERCPs and unacceptably low rates of successful selective cannulation of desired (biliary or pancreatic) duct. Hospital credentialing committees have traditionally performed ERCP credentialing, but this practice has led to widespread flouting of recommended guidelines ( e.g ., planned privileging of applicant with 20% successful cannulation rate, or after performing only 7 ERCPs); and intense politicking of committee members by applicants, their practice groups, and potential competitors. Consequently, some gastroenterologists upon completing standard fellowships train and learn ERCP "on the job" during independent/unsupervised practice, which can result in bad outcomes: high rates of failed bile duct cannulation. This severe clinical problem is indicated by publication of ≥ 12 ERCP competency studies/guidelines during last 5 years. However, lack of mandatory, quantitative, ERCP credentialing criteria has permitted neglect of recommended guidelines. This work comprehensively reviews literature on ERCP credentialing; reviews rationales for proposed guidelines; reports problems with current system; and proposes novel criteria for competency. This work advocates for mandatory, national, written, minimum, quantitative, standards, including cognitive skills (possibly assessed by a nationwide examination), and technical skills, assessed by number performed (≥ 200-250 ERCPs), types of ERCPs, success rate (approximately ≥ 90% cannulation of desired duct), and letters of recommendation by program director/ERCP mentor. Mandatory criteria should ideally not be monitored by a hospital committee subjected to intense politicking by applicants, their employers, and sometimes even competitors, but an independent national entity, like the National Board of Medical Examiners/American Board of Internal Medicine., Competing Interests: Conflict-of-interest statement: None for either Dr. Cappell or Dr. Friedel. In particular, Dr. Cappell, as a consultant for the United States Food and Drug Administration (FDA) Advisory Committee for Gastroenterology Drugs, affirms that this paper does not discuss any proprietary confidential pharmaceutical data submitted to the FDA and reviewed by Dr. Cappell. Dr. Cappell was until 1 year ago a member of the speaker’s bureau for AstraZeneca and Daiichi Sankyo, co-marketers of Movantik. Dr. Cappell has had one-time consultancies for Mallinckrodt and Shire. This work does not discuss any drug manufactured or marketed by AstraZeneca, Daiichi Sankyo, Shire, or Mallinckrodt.

Voriconazole-induced hepatotoxicity is a relatively rare but serious clinicopathologic entity. This drug is frequently used for invasive aspergillosis and other fungal infections. We report a patient with alcoholic cirrhosis who developed hepatic encephalopathy due to voriconazole administered for invasive pulmonary aspergillosis and subsequently showed marked improvement in mental status with dose adjustment of the drug. The patient eventually underwent an uneventful liver transplant. Histopathologic examination of the diseased liver specimen revealed numerous rhomboid-shaped crystals, deemed secondary to liver injury after voriconazole-induced hepatotoxicity. Additionally, this article briefly reviews the available data on voriconazole-induced hepatotoxicity with special emphasis on plasma drug concentration monitoring., (© 2019 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.)

Aim: To systematically review safety/efficacy of therapeutic endoscopic-retrograde-cholangiopancreatography (ERCP) performed during pregnancy, considering fetal viability, fetal teratogenicity, premature delivery, and future postpartum development of the infant., Methods: Systematic computerized literature search performed using PubMed with the key words "ERCP" and "pregnancy". Two clinicians independently reviewed the literature, and decided on which articles to incorporate in this review based on consensus and preassigned priorities. Large clinical trials, meta-analyses, systematic reviews, and controlled trials were assigned higher priority than review articles or small clinical series, and individual case reports were assigned lowest priority. Dr. Cappell has formal training and considerable experience in conducting systematic reviews, with 4 published systematic reviews in peer-reviewed journals indexed in PubMed during the last 2 years, and with a PhD in neurophysiology that involved 5 years of training and research in biomedical statistics., Results: Advances in imaging modalities, including abdominal ultrasound, MRCP, and endoscopic ultrasound, have generally obviated the need for diagnostic ERCP in non-pregnant and pregnant patients. Clinical experience with performing ERCP during pregnancy is burgeoning, with > 500 cases of therapeutic ERCP reported in the literature, aside from a national registry study of 58 patients. These studies show that therapeutic ERCP has a very high rate of technical success in clearing the bile duct of gallstones, and has a relatively low and acceptable rate of maternal and fetal complications. The great majority of births after therapeutic ERCP are full-term, have normal birth weights, and are healthy. A recent trend is performing ERCP without radiation to eliminate radiation teratogenicity. Systematic literature review reveals 147 cases of ERCP without fluoroscopy in 8 clinical series. These studies demonstrate extremely high technical success in endoscopically removing choledocholithiasis, favorable maternal outcomes with rare maternal ERCP complications, and excellent fetal outcomes. ERCP without fluoroscopy generally confirms proper biliary cannulation by aspiration of yellow bile per sphincterotome or leakage of yellow bile around an inserted guide-wire., Conclusion: This systematic literature review reveals ERCP is relatively safe and efficacious during pregnancy, with relatively favorable maternal and fetal outcomes after ERCP. Recommendations are provided about ERCP indications, special ERCP techniques during pregnancy, and prospects for future research., Competing Interests: Conflict-of-interest statement: All authors have no conflicts of interest to report.

Aim: To systematically review liver disease associated with hemophagocytic lymphohistiocytosis (HLH), propose reasonable contraindications for liver transplantation for liver failure in HLH, and report an illustrative case., Methods: Systematic review according to PRISMA guidelines of hepatic manifestations of HLH using computerized literature search via PubMed of articles published since 1980 with keywords ("hemophagocytic lymphohistiocytosis" or "HLH") AND ("liver" or "hepatic"). Two authors independently performed literature search and incorporated articles into this review by consensus. Illustrative case report presented based on review of medical chart, and expert re-review of endoscopic photographs, radiologic images, and pathologic slides., Results: A 47-year-old Caucasian male, was hospitalized with high-grade pyrexia, rash, total bilirubin = 45 g/dL, moderately elevated hepatic transaminases, ferritin of 3300 ng/dL, leukopenia, and profound neutropenia (absolute neutrophil count < 100 cells/mm³). Viral serologies for hepatitis A, B, and C were negative. Abdominal computed tomography scan and magnetic resonance imaging revealed no hepatic or biliary abnormalities. Pathologic analysis of liver biopsy revealed relatively well-preserved hepatic parenchyma without lymphocytic infiltrates or macrophage invasion, except for sparse, focal hepatocyte necrosis. Bone marrow biopsy and aspirate revealed foamy macrophages engulfing mature and precursor erythrocytes, consistent with HLH. Interleukin-2 receptor (CD25) was highly elevated, confirming diagnosis of HLH according to Histiocytic Society criteria. Patient initially improved after high-dose prednisone therapy. Patient was judged not to be a liver transplant candidate despite model for end stage liver disease (MELD) score = 33 because liver failure was secondary to severe systemic disease from HLH, including septic shock, focal centrilobular hepatocyte necrosis from hypotension, bone marrow failure, and explosive immune activation from HLH. The patient eventually succumbed to overwhelming sepsis, progressive liver failure, and disseminated intravascular coagulopathy. Systematic review reveals liver injury is very common in HLH, and liver failure can sometimes occur. Data on liver transplantation for patients with HLH are very limited, and so far the results have shown a generally much worse prognosis than for other liver transplant indications. Liver transplantation should not be guided solely by MELD score, but should include liver biopsy results and determination whether liver failure is from intrinsic liver injury vs multisystem (extrahepatic) organ failure from HLH., Conclusion: This case report illustrates that liver transplantation may not be warranted when liver failure associated with HLH is primarily from multisystem failure from HLH. Liver biopsy may be very helpful in determining the severity and pathophysiology of the liver disease., Competing Interests: Conflict-of-interest statement: None for all authors. In particular, Dr. Cappell, as a consultant of the United States Food and Drug Administration (FDA) Advisory Committee for Gastrointestinal Drugs, affirms that this paper does not discuss any proprietary confidential pharmaceutical data submitted to the FDA. Dr. Cappell is also a member of the speaker’s bureau for Astra Zeneca and Daiichi Sankyo, co-marketers of Movantik, and has received one-time consulting fees from Mallinckrodt and from Shire. This work does not discuss any drug manufactured or marketed by Astra Zeneca, Daiichi Sankyo, Mallinckrodt or Shire.