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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 Endoscopic retrograde cholangiopancreatography (ERCP) is often unsuccessful in patients with duodenal stenosis or malignant ampullary infiltration. While endoscopic ultrasound-guided biliary drainage (EUS-BD) has been proposed as an alternative, EUS-guided gallbladder drainage (EUS-GBD) is an attractive option when both approaches fail. We aimed to assess the effectiveness and safety of EUS-GBD as rescue therapy for malignant distal bile duct obstruction. Methods A multicenter retrospective study was performed on patients with unresectable malignant distal bile duct obstruction who underwent EUS-GBD between 2014 and 2019 after unsuccessful ERCP and EUS-BD. Clinical success was defined as a decrease in serum bilirubin of > 50 % within 2 weeks. Results 28 patients were included, with a lumen-apposing metal stent used in 26 (93 %) and a self-expandable metal stent in two (7 %). The technical success rate was 100 %. The clinical success rate was 93 %, with an improvement in bilirubin (7.3 [SD 5.4] pre-procedure vs. 2.8 [SD 1.1] post-procedure; P = 0.001). Delayed adverse events included food impaction of the stent (n = 3), with a further two patients developing cholecystitis and bleeding. Conclusion This study demonstrates the feasibility of gallbladder drainage to relieve malignant distal bile duct obstruction in patients with failed ERCP and EUS-BD.

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.

Nonalcoholic fatty liver disease remains a major cause of liver-related morbidity and mortality worldwide. It is a complex disease associated with obesity, diabetes, and dyslipidemia but is increasingly recognized in normal-weight individuals. Its progressive inflammatory phenotype, nonalcoholic steatohepatitis (NASH), currently has no effective treatment apart from lifestyle interventions. Multiple pathogenic pathways are involved in disease progression, and targets for intervention have been identified. These targets mediate glucose, lipid, and bile acid metabolism; inflammation; apoptosis; and fibrosis. Novel therapeutic agents are being developed in each of these pathways, and several have shown promise in early phase testing. Given the complexity of the disease, intervention trials are large and long and require histologic confirmation as a primary endpoint for disease improvement or regression. We highlight active Phase 2 and 3 therapeutic trials for NASH as this field rapidly expands in development.

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.

There is an urgent as yet unmet need to develop highly effective and safe therapeutics for nonalcoholic fatty liver disease (NAFLD). The remarkable progress in understanding NAFLD pathogenesis allowed the identification of injury pathways which may be recruited as therapy targets. Areas covered: This article reviews the safety and tolerability data of the NAFLD therapies and explains the mechanistic basis for each of the established and investigational drugs. Treatment targets include: weight loss, anti-metabolic agents such as lipid lowering and anti-diabetic drugs, inflammation, fibrosis and others such as targeting gut microbiota, immune modulation and apoptosis. Expert opinion: Current therapies continue to remain suboptimal. Weight loss is effective but hard to achieve. Traditional and endoscopic bariatric procedures are promising although more randomized trials are needed and the long-term safety remains to be established. Clinical trials have demonstrated the efficacy of several drugs for the treatment of NASH. Of these, there remains some uncertainty about the long-term safety of vitamin E. Pioglitazone is associated with osteopenia, fluid retention and weight gain. Obeticholic acid causes pruritus in a substantial proportion of subjects and elafibranor has been associated with transient rises in creatinine. Several exciting therapies are under development and results of clinical and post-marketing trials will help elucidate their safety.

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.

Background: Intravenous 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. Methods: Patients 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. Results: Sixty-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 (3-9) vs 8 (7-16) days, respectively, 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. Conclusions: Azithromycin infusion before endoscopy for upper GIB was associated with better visualization than that of erythromycin. Randomized trials are needed to validate these findings. Funding: None. Declaration of Interest: All authors report no conflict of interest in relation to this study. Ethical Approval: The study protocol was approved by the Institutional Review Board of Virginia Commonwealth University.

BACKGROUND Non-alcoholic steatohepatitis (NASH) is an advanced and aggressive form of non-alcoholic fatty liver disease (NAFLD), which remains difficult to diagnose without a liver biopsy. Hyperferritinemia has increasingly been associated with the presence of NASH. Hence, we sought to explore the relationship between ferritin and NASH and to develop a composite model based on ferritin to predict the presence of NASH. METHODS A total of 405 patients with biopsy-proven NAFLD were enrolled in the study. Comparison was explored to assess differences between patients with and without NASH, upon which a scoring model was established using variables found to be independent predictors of NASH. RESULTS Among all patients with NAFLD, 291 (72%) had biopsy-proven NASH, and 114 (28%) had non-NASH. Mean age was 48 ± 12 years, and 56% were female. Ferritin was significantly higher in NASH compared with non-NASH patients (184 vs 126, respectively; P

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.

The use of performance-enhancing drugs has increased dramatically in the last decade with high prevalence reported among the young athlete population. Many of these drugs contain anabolic steroids and may carry potential significant side effects and health risks. We report a case of anabolic steroid-induced acute pancreatitis (AP) that recurred after the reuse of the same drug by the patient, confirming the causative relationship.A 24 year-old male presented with severe epigastric pain. His past medical history was significant for two hospitalizations during the last year with AP. During his hospital admissions, extensive workup was performed ruling out the common and uncommon causes of AP. Upon further pressing, the patient admitted to a history of past and current anabolic steroid use for athletic performance enhancement. He began this use four years ago and most recently started using trenbolone acetate (TA). The correlation between the timing of the anabolic steroids administration and the attacks of AP, along with ruling out other causes, confirmed TA as the cause of pancreatitis.The side effects associated with the use of these increasingly prevalent drugs are difficult to study in clinical trials due to the unethical nature of their consumption. In addition, these medications are difficult to study due to the varied usage cycles and patterns, unknown origin and source, as well as often high dose ingestion. Physicians and body builders need to be aware of the possible serious consequences of their use.

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.

GOALS To analyze the frequency and trend of liver transplantation (LT) for nonalcoholic steatohepatitis (NASH) cirrhosis in young adults aged 18 to 40 years and to assess post-LT outcomes in this age group. BACKGROUND NASH is currently the fastest-growing indication for LT in US adults. It is believed that NASH is a rare indication for LT among young adults. STUDY Using the United Network for Organ Sharing database, we performed a retrospective cohort analysis of all LTs in young adults between 2002 and 2012. Incidence rate ratio was calculated for each indication. RESULTS A total of 5157 young adults underwent LT over the study period-54% were male, 23% obese. Mean (±SD) age and body mass index were 31.6±6.7 years and 26.3±6.1 kg/m, respectively. The incidence of LTs performed for NASH cirrhosis increased from 0.53% in 2002 to 4.46% in 2012. NASH was the most rapidly growing indication for LT among all other etiologies with a 14% increment per year (incidence rate ratio, 1.14; 95% confidence interval, 1.09-1.20, P